What goes in to the “social” part of biopsychosocial?

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