the retreat ii

How “social” is your biopsychosocial model?
It’s called the biopsychosocial model, but how much attention do we really pay to the social part of this model? While we know the medical model has its limitations (especially when we’re looking at how people respond to having health problems), in pain management I wonder whether we now have a ‘psychological’ model of pain rather than a biopsychosocial model?

The first time I started pondering this was when a large purchasing body in New Zealand removed the word ‘social’ from what is called a ‘Comprehensive Pain Assessment’. This is an assessment that has medical, functional and psychosocial components – but without the social part it seems to omit some of those really important aspects of the experience of both pain and disability…

I’ve pondered this issue of ‘social’ for a long time. What does it actually mean? There doesn’t appear to be a particularly clear definition of ‘social’ in the biopsychosocial model. I returned to Engel’s (1996) work on biopsychosocial model – and this is what he said: “As the name suggests, its intent is to provide a framework within which can be conceptualized and related as natural systems all the levels of organization pertinent to health and disease, from subatomic particles through molecules, cells, tissues, organs, organ systems, the person, the family, the community, the culture, and ultimately the biosphere.” He goes on to say “processes at the cellular level are subordinate to those at the tissue or organ level, which in turn are subordinate to those at the person or community level“.

Engel shows great compassion towards the people who seek help from the medical profession. He points out that the biomedical model is disease-oriented rather than patient-oriented, and that psychosocial is often thought to be “problems primarily of concern to the psychiatrist or the social worker.” By contrast, he states “For the patient the ultimate criteria [for wellness] are psychosocial, even when the complaint is physical. Patients’ criteria have to do with how one feels, how one functions, how one relates; with the ability to love, to work, to struggle, to seek options and to make choices. The physician, in contrast, while ostensibly attentive to such concerns, nonetheless is wont to consider such criteria as merely subjective… Even the organization of health care delivery is predicated on the assumption that the doctor, that is, the laboratory, is right and the patient is wrong.”

I couldn’t agree more when it comes to the way in which pain is conceived, especially pain where “the cause” can’t be found!

Engel’s vision was that “general competency for all health professionals would derive from their shared understanding that all three levels, biological, psychological and social, must be taken into account in every health care task.”  Not the ascendency of any one of the three.

What does the “social” consist of?  This diagram might help:

How often do you assess or report on roles and the changes that have occurred in a family as a result of the person you’re seeing having difficulty with their pain?  How often is their economic stress acknowledged? Their communication patterns identified?  What about the influence of the community – things like unemployment, the ways in which the Government or insurers fund various treatments or even income replacement/benefits, the actions of case managers, other health care providers, the effect of various policies on the individual?

Do we see these aspects of health as even relevant for health care?

My clinical focus has been on return to work for people who have persistent pain.  Sadly I’ve found that it’s often not even touched on in assessment or management – and if the person has lost a job, or feels they can’t return to work, the aim is not on how to help them feel more confident, but instead, on how quickly they can be pushed through a system that can ‘determine’ the kind of work they are physically fit for – as if physical fitness or capacity is the major determinant of return to work.

A more recent paper than Engel’s excellent theoretical one discusses the way in which members of chronic pain centres discuss their work. Harding and colleagues have published several papers from a qualitative study of people and clinicians in chronic pain centres. This paper refers to a study of 25 clinicians drawn from seven pain centres across the UK.

In the study, there was a very strong belief by all team members in the biopsychosocial model. They talked about it often, believed they were delivering a biopsychosocial model and backed each other up with regard to the importance of a biopsychosocial model. But – you knew there would be one! – did they use the entire model? In the assessment of Harding and colleagues, no. The majority of interventions were biomedical or psychological – the social got left behind.

One of their concluding comments is “pain clinic practitioners we interviewed readily embraced cognitive/behavioural based management strategies but reported relatively little if any consideration of the impact social factors played in managing chronic pain for patients failing to respond to interventions or for whom interventions were deemed appropriate.”

What would ‘consideration of the impact [of] social factors’ look like?
Well, recognising that most people with chronic pain will continue needing to interact with health care providers, I think learning how to be health literate – that is, learning what to ask about treatments, how to respond to suggestions, how to effectively and assertively interact with health professionals would be a good start.

I think it would be great if body language and those ‘illness behaviours’ or ‘pain behaviours’ that health providers notice were identified to the individual, and each person helped to review how much those behaviours influence how they are seen in the community. Even little things like the Mobility sticker on the car!

Communication skills, like assertiveness, would be useful. So would acknowledging changing roles and how the family adapt to the person coping with pain – and perhaps bringing some of those ‘invisible’ changes out into discussion, so families and individuals can decide what changes to hold onto, and those they want to review.

Looking at the impact of various labels, like ‘invalid’s benefit’ or ‘sickness benefit’, ‘disabled’ or ‘beneficiary’ or ‘compensation claimant’. And discussing the impact of systems that people interact with when they have chronic pain – like government agencies, or insurance agencies and the legal system.

The problem with doing this is – we start to step along a slightly more political path than we have traditionally had in healthcare. Once the effect of various systems is made clear, we can be sure that not everyone will like being made aware of this! Most notably, systems like insurance don’t tend to like having their systems critiqued – even when the critique is based on evidence. I’m not sure whether this is something we can ignore, though.

So – back to my original question: how “social” is your biopsychosocial model?

Engel, G. (1979). The biopsychosocial model and the education of health professionals General Hospital Psychiatry, 1 (2), 156-165 DOI: 10.1016/0163-8343(79)90062-8
Harding G, Campbell J, Parsons S, Rahman A, & Underwood M (2010). British pain clinic practitioners’ recognition and use of the bio-psychosocial pain management model for patients when physical interventions are ineffective or inappropriate: results of a qualitative study. BMC musculoskeletal disorders, 11 PMID: 20298540

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  1. That was an excellent observation. I totally agree. I use the ICF as my evaluation tool with the ICF core set for chronic widespread pain as I feel this actually uses the “social” in the biopsychosocial model. I did my masters research in mapping the IMMPACT recommended questionnaires for the assessment of chronic pain in clinical trials tin 2010 and the questionnaires did very poorly on the activities and participation, and did not assess environmental issues which really have an impact on the social aspect of a patient’s life. I agree with you that the questionnaires used omit many aspects of the evaluation of chronic pain patients especially social aspects being the activities and participation in the ICF framework.

    1. Hi Lesley, I’d be really grateful if you could summarise your findings on IMMPACT – I agree, I thought the recommendations just miss out on function and social almost completely. While pain is a personal event, it’s influenced and influences the social environment (and is influenced by the wider environment and systems as well). I haven’t used the ICF framework particularly, but it’s high time I did!! Drop me a line if you’re keen (go to the ‘About’ page!).

    1. It is a great paper, although it didn’t help with the topic I was writing about at that time – but it does tap into much of what I’m mulling over currently. Thanks for the link!

  2. Fascinating topic! With regard to the social aspect of the model, I find myself thinking a great deal about the doctor-patient (or provider-patient or even clinic-patient) relationship. How are we interacting with the patient? Does he feel that we truly hear him and understand him? In other words, I constantly remind myself that we are a part of the patient’s social domain, as well. I hear a lot in this article about assessing the patient’s family and interactions with other social groups/agencies, or doing CBT with the patient or teaching him to communicate effectively with us. That is all critically important, I agree. But I also want to make sure that we are being reflexive and looking at our own role and impact on the patient.

    I highly recommend the following chapter, which elaborates the biopsychosocial model with self psychology (not directly applicable to chronic pain, however): A Self-Psychological Approach to ADHD in Adults: A Paradigm to Integrate the Biopsychosocial Model of Psychiatric Illness by H. Baker and M. Baker. It appears in Progress in Self Psychology, V. 12 Basic Ideas Reconsidered, Edited by Arnold I. Goldberg.

    1. Hi Liz
      Thanks for your comments – I think we are coming to quite similar conclusions! I’ve written more recently on the behaviour of health providers and the effect this has on people coming to see us. What we say is so incredibly important. I also think we need to consider the social world that we bring to any healthcare encounter – especially the health systems and perhaps even compensation systems we interact with, and how this affects the person too. If you get a chance to take a look at some of my more recenlt posts, I hope I’ve been able to address some of your concerns about this article in these ones.
      Thanks for the reference, I’ll take a look at it, looks very interesting.

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