The biopsychosocial model gets bandied about a lot in pain management – but often it’s recognised as ‘bio’ and ‘psychosocial’, as if the social part doesn’t really exist outside of the psychological. I have to say at the outset I’m not a sociologist but it does seem to me that to conflate psychological and social could very well miss some important aspects of the model, and that this might not be the best for the people we work with.
Over the past couple of weeks I have been reading more about the social aspects and while I’m not yet entirely certain of all the elements that could be encompassed by it, I’m starting to get a feel for at least some of them.
The first observation I have is that often the biopsychosocial model gets broken down into ‘biophysical’ then ‘psychological’ with ‘social’ being a bit of a poor cousin. I don’t think this is what Engel intended, certainly as I read Engel’s papers, I find many references to the value of the biophysical aspects – “as a scientific framework within which to elaborate the disordered bodily mechanisms involved in disease the biomedical model has been extraordinarily fruitful” (Engel, 1976). But Engel was extremely clear that this model has limitations and, as we know, when using any model, it constrains the way we think about and identify problems.
Engel cited a large study ofthe type of patients that family physicians saw in which only 7% had “problems with psychologic and social origins and psychologic or social manifestations,” but found that when these cases were reviewed, they included “only depression, marital problems and anxiety neurosis, hardly even representative of psychiatric morbidity”.
Engels view of the ‘other’ parts of the biopsychosocial reflect his concern that when patients complaints about doctors and health system were really listened to, the areas they thought weren’t addressed well were “that doctors don’t communicate well, that they don’t really listen, that they seem insensitive to personal needs and individual differences, that they neglect the person in the zeal to pursue diagnostic and treatment procedures.” How much has changed?
He goes on to say “they stress the unavailability of the physician and health services, often as much indicative of psychological remoteness as of economic barriers or geographical distances”. I’d suggest both economic barriers and geographical distances are social aspects that continue to make accessing health care really difficult for some.
So far, while looking through Medline and PsychInfo, I’ve had trouble identifying articles that are specifically ‘social’ in orientation. In my own mind, ‘social’ equates to the following:
- interpersonal communications
- pain behaviours (facial expressions, guarding, rubbing the area, spoken words)
- roles in life – friend, partner, child, parent, worker etc
- family of origin relationships
- extended family relationships
- community networks
- socio-economic factors
- interactions with the physical environment including access to buildings and transport
- cultural aspects – across multiple cultures, not simply ethnicity
- legislative policy and practices for healthcare delivery
- legislative policy and practices for sickness and support for being unwell
And obviously many more – but it’s less common to find discussion of these factors by comparison with those that discuss biophysical and psychological aspects.
Engel makes a lovely point in his 1976 paper. He suggests that the biomedical model thinks in a linear ’cause’ – leads to ‘effect’, and if the ’cause’ is cured, the ‘effect’ has gone and the person returns to normal. I’ve been told by one doctor that ‘once the pain has been abolished, the person is back to normal and there is no need to consider psychosocial factors’. Needless to say, I beg to disagree! Engel’s suggestion is that the biopsychosocial model is a systems model that involves ongoing interactions between all three aspects, and that, in his words,
“every change becomes part of the history of each system, rendering it different at every successive point in time… there can be no return to status quo ante. Health restored is not the former state of health but represents a different intersystemic harmony than existed before the illness, with characteristics based on all the system changes incurred during the illness. By virtue of the illness not only is the individual changed as a person, but so too may be changed others in relationship to him, in the family as well as the community.” (emphasis mine)
Every event has some flow-on effect for the person involved. Even if the tissues heal – the person processes and develops an understanding about ‘what happens when’, and this understanding is shaped not only by the effects on the tissues, but also on the responses and expectations of the greater system within which the person lives. Contextual factors always have an effect – we simply can’t see people as ‘the back pain’ or ‘the CRPS’, treat only that part and think we haven’t had some effect on the person-in-context.
What does this mean for me?
Well the first thing is that when I ask about the history of both the onset of the pain problem and the treatments the person has had, I’m not simply cataloguing events in some sort of timeline. I’m looking to see how the person interprets these events, and what meaning they have made from it. After all, something occurred for the person to look for treatment in the first place – and it’s not simply the pain, it’s what the pain means to them. At each successive interaction, the person will interpret it in some way. This makes our encounters incredibly potent, even when we think we’re ‘not doing anything’.
Each health care interaction is a social exchange. That means the health provider and the person are within a social context, there are rules (or folkways and mores) that influence behaviour and also influence what is discussed and what is not. The person going to see a health care provider lives in a community, has people around him or her – even if they’re not directly living with or interacting with those social factors – they’re geographically situated near or far from health care, they’re in an economy that places value on certain activities and roles, they’re in a community and culture that shapes the way they view what is healthy and what is not.
I think that means I need to learn a whole lot more about social and cultural and political aspects of health than I ever thought necessary, for to ignore them is to be blind to some of the most powerful influences on individual health. You can bet I’ll be writing more about my explorations!
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
Great to see you blogging about this! It’s a nice follow up to our chat a few weeks ago.
Hi there – yes it’s a really important part of thinking about healthcare, and as you can see, I think it’s one that gets missed so often. More about it again soon!
May I suggest the Area of Occupation – “Social Participation” in OTPF 2008 as a good indicator of what goes into the “social” part of biopsychosocial? 🙂
Hi there! Nice to see you on the blog! That’s a great idea – social participation is definitely part of the ‘social’ aspect of the biopsychosocial model, although doesn’t encompass all that ‘social’ means to me – I’m not overly familiar with the ‘social participation’ concept, but some of what I’m thinking about includes things like the unwritten ‘rules’ of conduct between people in different roles; the assumptions that we make about what we should do (or not do); the policies that we make in local and national government and so on. I’ll be writing more about it, so I can make it clearer both to myself (first!) and the people who read this. It’s all food for thought anyway!
Thanks for taking the time to visit and comment!
Thank you for this! I’ve been thinking a lot about this in the context of clients I’ve seen for a long time, as a massage therapist, who have a sort of revolving door of pain — it’s always something: one thing gets more or less fixed but another steps right it to take its place — and I’m thinking, you know, maybe it’s this person’s relationships and work stress that need to get fixed. All this pain may be ultimately a symptom of not having enough time and not having enough caring interaction. Maybe we can fix this shoulder pain or this pseudosciatica, but something else is going to move right in to replace it.
But of course that’s wildly out of the scope of my practice.
I think that the psychosocial aspects of a person’s life need to be considered right alongside the rest of their health presentation, and while it may not be within your scope of practice, it’s something you can discuss with the person and/or refer to another health provider. It can also inform your practice so that you can decide whether it’s worthwhile (in the bigger picture) to carry on with your treatment. For me it makes it difficult to carry on with treatment if I think the areas that I’m working on don’t appear to be changing for the better, or if the effects we’re achieving get undermined by another condition. For example, if the person is being seen by me for pain management and part of what I’m working on is organising a daily routine, but this is getting disrupted by the person’s poorly controlled diabetes, or sleep apnea, then it would be my responsibility to discuss it with the person then inform the GP.
That’s how i’m seeing it today – but I am still just starting to look at this in more depth!
Yes. Though I’m also somewhat reluctant to second guess people: if they’re choosing massage, is it because it actually *is* indirectly addressing what they need addressed? How do I know that talk therapy, or whatever I might refer to, would really be more effective? So many unknowns. But certainly I don’t want to be part of the problem: I don’t want to be fostering expectations of “cures” that I don’t really think I have in packed away in my linens bag 🙂
The main reason I’d not support ongoing use of massage is that it means people have to take time out of their day, and attend for therapy – self management means they can integrate the skills into daily life, and hopefully not be as focused on being a patient. Massage can certainly meet many needs (not to mention feeling fabulous!) and one of those needs could well be social. I recall a patient many years ago who had no family and lived alone and quite isolated – she described herself as ‘touch starved’, and used to get massage regularly to fulfill that need. The difference between her use of massage and what I believe would be a negative feature was that she was aware of the choice she was making: it was a conscious decision fo rher to meet her needs this way.