I’ve been asked, from time to time, to give some sort of screening questions or questionnaires that medical practitioners can use in their practice, so that I can avoid covering so much psychosocial material, especially in my teaching job. I’ve struggled with this for many reasons, and have had a hard time pinning down why I’m not all that keen to do it. Now I don’t want to stop medical practitioners from considering psychosocial factors when they’re assessing pain, far from it – quite the opposite in fact! But at the same time I worry about developing a “Dummies Guide”.
Psychosocial factors can seem incredibly complicated and difficult to understand. Some practitioners think it’s well outside their scope of practice – yet they’re working in pain management where the biopsychosocial model is widely accepted. Some practitioners think it’s way too woolly to come to grips with, all this “soft” stuff about beliefs and emotions, yet some of the crunchiest statistical and neurobiological mechanisms are used to understand it. Some practitioners still see psychosocial factors as relevant only as reactions to the real stuff going on in the tissues, which is a particular concept developed in the 1890’s by Strong, one of the American Psychological Associations presidents.
He divided the experience of pain into two parts: the physical sensation and the psychic reaction to this sensation (Strong 1895). Researchers maintained this view until the 1940’s, thinking that pain could be separated into the perception of pain, and the reaction to pain. In this view of pain, perception of pain was a neurophysiologic process involving relatively simple and primitive neural mechanisms while the reaction to pain was a complex psychophysiological process involving cognitive, learned experience, culture and other psychological factors to produce a variable reaction pain threshold (Bonica and Loeser 2001). While psychosocial factors were incorporated into the model, neurophysiological processes involved in transmitting “pain signals”, or nociception were believed to be the primary mechanisms. Thankfully Melzack & Wall (1965) began the revolution showing that pain is intimately connected with our brain’s way of determining bodily threat. Nervous systems including the brain are needed for pain to be experienced, but it’s a judgement call that is considered amongst the other competing goals relevant to the individual in that context.
There are some very good reasons, IMHO, for maintaining the complexity of the psychosocial concepts as we understand them today. These are my thoughts:
- Without truly grasping the idea that pain is an emergent experience and the sum of biological, psychological and social factors, it can become only too easy to focus only on psychological risk factors. By this I mean that although clinicians may learn about psychosocial yellow flags (risk factors for chronic disability), they way they’re construed is that they’re the reason for physical treatments failing. So, if the person doesn’t respond to usual treatment using physical modalities (including pharmacology and needles and exercises) then clearly the issue is now psychosocial – and that means “I don’t have to deal with this”. (Thanks to a very good physiotherapist for telling me that this is how she learned it until she studied more). This viewpoint clearly reverts to the Cartesian dualist model.
- By only considering psychosocial factors as risk factors, clinicians are likely to forget that everything that is said, done and even the treatment context has an influence on outcome. Risk factors may be what the person with pain brings with them into a treatment setting, but if clinicians forget that treatment is an interaction between at least two people, they may forget that they too have beliefs, come from a particular culture, have developed a clinical/professional persona, and that all of these things and including what they say and how they say it affect the patient. These things matter – they affect what the person with pain understands about what is happening to them, and also what might happen to them in the future.
- Sometime when risk factors alone are considered, clinicians can fail to recognise individuals bring strengths with them as well. After all, people who come to see a clinician have got themselves up, traveled to an appointment, and carried out the tasks of everyday even though they have pain: they have coped at least to a degree. If we only attend to risk factors, we probably don’t think about how well a person is doing, or what they can do to enhance their wellbeing, or build on what’s already working for them.
- Psychosocial factors are definitely complex. That’s not necessarily a reason to try to dumb them down. After all, human body systems are also complex, and we don’t see attempts to simplify things like motor control, or bone remodeling or neurobiological systems and their response to pharmaceuticals. I’m sure that if I asked a medical practitioner to sum up the “things I need to know about prescribing” in a “dummies guide” I’d be shot down in flames, and rightly so. Frankly there just are some complicated things we need to learn if we’re going to work effectively with people who have pain, and particularly people who have chronic pain.
- Finally, I’m loathe to simplify psychosocial concepts because I don’t know where the clinicians I teach (or blog to) practice. I don’t know their contexts, and I don’t know what they already know. I don’t think it’s right to assume that everyone works in primary care, or secondary care. I don’t want to assume that everyone has a team to refer to. I don’t think I should decide what is and isn’t relevant to a clinician. And I think clinicians are smart enough to work out what they want to do with psychosocial material. I also know from learning theory that by processing and using information, we begin to integrate that knowledge rather than treating it as some sort of “add-on” to daily practice.
The fact is that for most health professionals, with the exception of those working primarily in mental health, psychosocial concepts are not taught nearly as thoroughly as biological ones. I can assume that most clinicians working in pain management know anatomy, physiology of normal healthy bodies, understand concepts like inflammation or bone remodeling or nerve transmission.
Unfortunately, I can’t say that most clinicians remember Psych 101 from first year, and so I need to go through basics like operant and classical conditioning. I need to review things like measurement concepts. I need to help people recall attention and social learning theory and become familiar with self efficacy as a concept, along with internal and external locus of control. And that’s before beginning to look at constructs like catastrophising.
Because if I don’t do a good job, the idea of catastrophising, for example, becomes yet another pejorative label to give to someone who doesn’t respond to “normal” treatment. Another way to place the blame on the individual with pain rather than thinking about what and how clinicians do their job. I’d rather that people became more familiar with the complexity of pain and began to attend to what they do.