Living with chronic structural vulnerability: A biopsychosocial-structural formulation of a patient exhibiting “medical noncompliance” in the setting of historical trauma and social suffering

Background

This qualitative case study explores the potential for operationalizing the social science framework of structural vulnerability through integrating it into the classic 4P model of biopsychosocial case formulation.

Methods

Through phenomenological analysis of data from a series of longitudinal in-depth interviews with the case study participant, a middle-aged Native American man recently initiated on buprenorphine-naloxone for opioid use disorder after undergoing below-the-knee leg amputation, the study developed a biopsychosocial-structural case formulation identifying predisposing, precipitating, perpetuating, and protective factors contributing to the participant's deteriorating health.

Results

Key findings from this case formulation facilitate reconceptualization of the participant's acute symptomology and high-risk behavior as manifestations of structural violence and historical trauma.

Conclusion

Adopting the diachronic approach inherent to the 4P factor model allowed for temporal expansion of analysis, which emphasizes the cumulative and compounding health effects of living with chronic structural vulnerability.