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How much attention to psychosocial issues?


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:

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.

 

6 comments

  1. Bronnie, my understanding of Engel’s approach is that these various bits of information (bio-psycho-social factors) are arrived at as a result of negotiation between clinician and patient. Those that are agreed upon then form the framework for the therapeutic engagement. Have I missed the point?

    1. My take on the way biopsychosocial considerations work most effectively is for information collection across a broad range of relevant factors (personally I refer to the scientific literature about relevant factors as a starting point). Using abductive reasoning, these are assembled into some sort of relationship to one another – and this usually works most effectively when it’s carried out by both a clinician/clinicians and the client. If you like, they’re a formulation (rather than a diagnosis) of the various factors that contribute to answer the question: Why has this person presented in this way, at this time, to this provider? And the second important question is: what can be done to alleviate distress and disability?
      Patients like clinicians don’t always have insight into what is and isn’t relevant – not only do we all defend our own positions, we’re all inclined to have cognitive biases that we’re completely unaware of, and there may be factors influencing our presentation/beliefs/behaviour that we don’t know about. So this is why I don’t completely hold with the notion that patients must always agree on the relevance of certain factors. At the same time, patients, like clinicians, will only be motivated to continue with self management behaviours if they believe the goals are important, and they’re confident they can do things successfully. So it’s important to spend time listening to and building confidence and importance with the patient.
      I suppose when I’m working with someone I use their own words and awareness to generate the answers to develop a formulation that “fits” with the client’s own experiences. I don’t think this is a job for an acute/emergency situation, but certainly with longer-term problems it’s well worth the investment in time. And GP’s typically have a longitudinal knowledge and relationship of their patients, so they can have many of the building block for developing biopsychosocial awareness. Not just GP’s but other specialties like rheumatology can also have long-term relationships, so there is time to develop the awareness of relevant factors IF the clinician has a mind to do so.
      To me it’s more than just the information, the biopsychosocial model (for want of a better term!) means thinking about the person in context and taking a patient-centred view of “what it is like” to have the health condition under scrutiny. This means looking beyond the list of signs and symptoms and into the impact they have on the occupations, beliefs, attitudes and decisions a person has, within their normal social context.
      So, for example, if a woman who is a single parent, with two small children, has a vulnerability to depression, pushes herself to get things done because she holds strong beliefs about looking after her kids, presents with low back pain, I’d also be asking her “what do you think is going on? What’s your theory about your back pain?”
      I’d be asking about how she’s managing her everyday activities and what effects she’s experiencing from her back pain.
      I’d want to know how easily she feels she can modify her activities while her back pain’s present, and if she’s OK with being kind to herself so she has enough energy to do what’s important for her kids.
      I’d want to know what her family think she should be doing, and what their history of back pain (and attitudes towards pain) is, and I’d be interested in what she’s learned from previous times she’s had back pain – what “sticky” back beliefs does she hold?
      I’d particularly want to know what her concerns are, her main concern, so I could make sure my advice addressed this main concern.
      I already know a bit about the community context and Western beliefs about back pain tend to be, but I’d want to know more about her take on things.
      And I’d love to know about her resources and strengths, as well as her vulnerabilities. I’d use a range of assessment approaches including physical examination, questionnaire, observation and talking/listening to her.
      And yes, it might take 15 minutes to go through all of this – but this is an investment into ensuring she’s going to (a) feel she’s being listened to (b) recognising any risk factors and actively managing them and (c) ensuring I can build her resilience by recognising her strengths. And in the face of recurrent back pain which is the norm, this might help reduce the likelihood that she becomes disabled long term.
      I’d ask her to contact me in a week or so, or earlier if she’s bothered a lot by her pain. I’d then review her progress and particularly help her set goals that keep her focused on what she can do rather than what she can’t.
      That’s the difference between responding only to distress by giving injections or using diagnostic language, and really listening to her story and coming alongside her. And I think that’s biopsychosocial as I think Engel saw it. I’m just not sure that we pay nearly enough attention to the social as a general rule.

      1. I am sure Engel would agree with you. As I see it, when the opinion leaders in the field of pain management adopted his framework, they did not understand his important contribution to medical practice. The “onion skin” cartoons of Loeser and Waddell were incomplete – they did not factor in the contribution/influence of the clinician/observer to therapeutic outcome.

  2. I think Loeser and Waddell were both products of their context! I’ve seen many diagrams showing the final “ring” as socio-environmental, and I’ve amended the model myself to fit emerging concepts over the years. Mine has “neuromatrix” at the centre instead of nociception, I remove “suffering” and call this “judgement” because it can be suffering or not depending on the appraisal, and the final ring is “socio-environmental” including the people and culture within which the individual is located.
    I’m particularly keen on us recognising the socio-environmental because it’s this part that is often missed, yet has such an incredibly potent influence on individual beliefs and behaviours.

    1. Bronnie, my point is that we need two “onion skins” – one for patient and one for the clinician/observer.

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