Tauhou "New arrival"

Pain management and the political

There are only a few more weeks before a general election in New Zealand. This means the usual rounds of promises, muck-racking, hoardings and defaced hoardings. As I browse the research into chronic pain, and bemoan the lack of attention to the SOCIAL of the biopsychosocial model, I find myself looking at factors that almost entirely depend on a political solution. Let me explain.

Social. What is meant to fit into this part of Engel’s model? Drawing from one of his earlier works, Engel stated in his Cartwright Lecture at Columbia University College of Physicians and Surgeons (1977), that

“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…”

I interpret this segments of Engel’s work, and in particular the diagram he included in the published version of this speech, as a clear indication that while a biomedical model looks at the levels from quarks to systems, a biopsychosocial systems approach looks beyond this and into the person right up to society and nation.

biopsychosocialAnd this is where it gets political. While individuals reappraise their self worth, learn new skills, develop new living patterns (well within the contributions of most allied health including occupational therapists), Governments and economic policy have a direct influence on what occurs in the interaction between what the individual does and the effect on the family, community, culture and subculture (however you define this), and ultimately society-nation.

Here’s some recent research illustrating how these factors interact.

When a person develops chronic pain, clinicians are likely to ask “How did it begin? What happened?” The person will probably talk about an event in the last few months or years that may have triggered the most relevant experience of pain. What clinicians may not think to ask about, and the person with pain may not even consider, is what happened in early life.

Goosby (2013) looked at socioeconomic disadvantage and maternal depression in individuals during their teenaged years, and found that the probability of chronic pain increases in magnitude over life in those adults who had parents with less education, and in those who had mothers who were depressed. She points out that mothers who live in low-income households (e.g. single mothers on a benefit?) are “especially vulnerable to psychological distress and disorders such as depression” (p. 77). She calls this “intergenerational transmission”, and goes on to describe “risk amplification” that occurs for children with low socioeconomic status who continue to experience deprivation as they become adults, while those who are not disadvantaged continue to maintain their health and wellbeing at least in part because of economic stability.

She continues by describing that childhood disadvantage increases the risk of depression and pain in adulthood and that adult socioeconomic status is a key factor through which adult health and wellbeing emerge. Interestingly, she found that adult depression is influenced by fewer factors than adult chronic pain – in fact, she found that all indicators of childhood socioeconomic status had significant interactions with the RR of adult chronic pain relative to no conditions, and particularly for those who had mothers who were depressed.

A similar finding was made by Lacey, Belcher, & Croft (2013) in a study looking at life-course socioeconomic position influencing chronic pain in older adults.

It doesn’t take a rocket scientist to see that this is political. In a climate where single parents (most often women) are told they are “welfare dependent”, receive a tiny sum of money or are asked to return to work when the child is 5 years old, often to work that is poorly paid (because more senior and well-paid positions rarely allow workers time to attend to children’s needs, mind you neither are poorly paid jobs), life is stressful and anyone vulnerable to depression and/or chronic pain is at high risk.

A sense of injustice can exist where individuals feel that circumstances are not fair, and that they are the victims of an injustice. In New Zealand there is a mitigating factor in that all accidental injuries are covered by the state-owned and tax-payer funded Accident Compensation Corporation. BUT, and this is a big one, there are incentives for those case managers to encourage and support people to return to work, while those who are injured while not working may receive far fewer entitlements and will not receive rehabilitation to return to work. This shouldn’t matter because access to rehabilitation is available to all – but in practice, does it?

McParland & Eccleston (2013) found that a sense of injustice can affect emotions, cognitions and behaviours. A particular point they raise is that when there is inequality between two people in a relationship, ie where one has money but the other does not (one is working, while the other is unwell with chronic pain) there may be adverse responses between the individuals. In New Zealand, if one person in a longterm relationship becomes unwell, while the other person is employed there is very little if any financial support for the couple. If the earner is only receiving a minimum wage, this presents a huge obstacle even to attending treatment.

My final review today (and believe me, there are SO many more than I’ve touched on!) comes from Antao, Shaw, Ollson, Reen and colleagues (2013).  They looked at intermittent work incapacity and how this influenced the way we can support people to sustainably remain working despite having times where their chronic pain interferes with this ability.  They draw on Bronfenbrenners Ecological Systems Theory which views child development within a context of social and interpersonal environments. Antao and colleagues used the environmental framework to analyse the workplace: .Micro level issues are defined as issues within the individual and personal realm and include factors such as cognitive deficits. Meso level issues are related to the workplace, such as workplace policies and accommodations. Finally,macro level issues are related to socio-cultural or political issues, such as benefits and insurances. (p. 13).

What these researchers found was there is considerable literature discussing micro-level support for people with pain. These are things like the individual learning about his or her condition, maintaining physical fitness, working on routines that can maintain or support work. Education, for example, focused on giving individuals information about worker’s rights, how to maintain quality of life through coping changes.

Meso-level strategies were rather more scarce in the literature, but they were present – things like educating employers and supervisors, modifying tasks or workstations, ensuring people are aware of the benefits of working on the individual and so on. I guess some of these fit into the “ergonomics” category.

Macro-level strategies were even less often presented, but included using flexible work practices (shifts, glide time, sharing tasks), providing timely financial support during times when an individual is unable to work, anti-discrimination laws and similar.

Meso- and Macro-level strategies are about social change and political will.

Where does this leave me?

When I consider the influence socioeconomic deprivation has on people, right from childhood through to the flow-on effects in adults, I worry about the effects of policy on people in New Zealand. There is an increasing disparity between those earning above $100,000 per annum, and those on the minimum wages of $14.50 or so. Worse for those on a benefit who are also labelled “benefit dependent”.

I’m worried that very often there is an outcry if a policy is introduced to support the situation of workers – employers complain that this is unsustainable, that they won’t remain in business and there will be economic fall-out because of this. I’m concerned at labelling that occurs if a person is on a benefit. Being on a benefit is not a life of luxury, yet benefit fraud is pursued more vigorously than so-called “white collar” crime, and in research conducted by Victoria University in 2011 “22 per cent of tax offenders received a custodial sentence” while “approximately 60 per cent of welfare fraud offenders received a custodial sentence.” Sophie Rule, Report Writer, Youth Parliament 2013, Ministry of Youth Development.

I am unhappy that the “trickle down” of economic growth hasn’t trickled, and that people who have few resources in so many ways are in a very real situation of social injustice. It’s a brave person who challenges an employer who decides to fire a worker who, having been in the same job for 20 years, has a heart attack and needs three months time off work. True story. Or a woman who, since the business she works for has moved from town to Rolleston, now has to travel by bus for an hour, then cycle for another 30 minutes to work in a job that pays minimum wage. And do the same again in the evening, despite her chronic obstructive pulmonary disease. In Christchurch. In winter. Oh and she lives with the man who had the heart attack. She doesn’t get paid when she needs a week or two off work because of her COPD as happened recently.

The social is largely, I think, a political matter. And chronic pain affects one in six New Zealanders. And they all vote.


Antao, Lilian, Shaw, Lynn, Ollson, Kaitlyn, Reen, Kavleen, To, Flora, Bossers, Ann, & Cooper, Lynn. (2013). Chronic pain in episodic illness and its influence on work occupations: A scoping review. Work: Journal of Prevention, Assessment & Rehabilitation, 44(1), 11-36.

Goosby, Bridget J. (2013). Early life course pathways of adult depression and chronic pain. Journal of Health and Social Behavior, 54(1), 75-91. Goosby, Bridget J. (2013). Early life course pathways of adult depression and chronic pain. Journal of Health and Social Behavior, 54(1), 75-91.

Lacey, Rosie J., Belcher, John, & Croft, Peter R. (2013). Does life course socio-economic position influence chronic disabling pain in older adults? A general population study. European Journal of Public Health, 23(4), 534-540.

McParland, Joanna L., & Eccleston, Christopher. (2013). “It’s not fair”: Social justice appraisals in the context of chronic pain. Current Directions in Psychological Science, 22(6), 484-489.


  1. Bronnie, I think we would all agree that improving the “social” domain is the primary responsibility of our respective governments.

    This responsibility is accorded a place in Engel’s highly influential hierarchical framework, which was based upon the then popular General Systems Theory.

    But Engel did not explore how perturbations at each level might interact with any or all of the other levels, which in my view precludes his theorising from being further developed into a scientific model.

    When the discipline of Pain Medicine adopted Engel’s framework, it made the fundamental error of leaving out the person in pain. Take a look at the “onion skin” diagrams of Loeser and Waddell and you will see what I mean.

    To obtain some different and I feel more worthwhile socio-political insights, I suggest that you might like to read the essay “Autopoiesis, Culture and Society” by Humberto Mariotti, a very astute psychiatrist. It is freely available at: http://www.oikos.org/mariotti.htm

    1. I’m not so sure that Loeser and Waddell did leave the person out of their depiction of the model. After all, it’s the person who has the experience of pain, the person who has the judgements, carries out the pain behaviours, lives within a social environment. Engel may not have examined the mechanics of interaction between each level, but other researchers have – vis the papers I’ve quoted here, and other examples such as Hadjistavropoulos and colleagues paper on a biopsychosocial communications model of pain (2011); and the Pain, Mind and Movement III Symposium of IASP 13th World Congress in Montreal.

      What I think has been missing is discussion on the privileging of various viewpoints. To date the views of people interested in biological mechanisms, and those who are exploring psychological mechanism, have been published. There is less attention paid to the “what it is like” to be a person experiencing chronic pain (or indeed pain of any type). And even less of the influence of mechanisms such as legislation, responses from family, attitude change in the community, and even within defined cultures such as the body suspension culture, or extreme sports culture.

      >But this situation is changing – and just like any area of research, the answers are incomplete, acknowledged as such, and work continues<<
      There is more published on first person narratives, and on studies using qualitative methodologies. There are people such as myself and others with a "lived experience" of pain who are willing to explore and write about aspects of living with and dealing with chronic pain.

      Assembling these bits together takes time – but it is happening, and I think the papers I've cited from today begin to uncover some of the mechanisms involved. I guess it's a bit like ecological science. Firstly researchers had to show that changes in ecology were happening. Then the effects of those changes on organisms, and now some of the mechanisms involved in responding to climate change or deforestation or draining swamps and so on are being uncovered.

      I also agree we can't continue to use a linear line of reasoning. Life's far more complex than this, and I think Hadjistavropoulos' paper demonstrates this rather well. Do we, as humans, have the capacity to understand or represent this level of complexity? I'm not sure – maybe not, but we can still look at it!

      The questions for me are how we can continue exploring this messy business called life, and even messier business called pain. How can we incorporate social factors – in all its complexity. Should I privilege my thoughts and beliefs just because I have them? Even if they're valid for me? Or should I attempt to find others who have similar views, and on this begin to trace an aspect of reality that exists – all the while acknowledging that it's an incomplete picture of an incomplete context? Because while I acknowledge my own idiosyncratic understanding of my experience, there are others who have similar experiences. There are commonalities amongst people. Or should I give up on recognising similarities because they are not exactly the same, just similar?
      Somehow I don't think that's the answer – but I also know that if I privilege what I think I experience, I could very well be completely wrong, just because I'm also aware of the range of cognitive biases that I, and everyone else in this world, holds.
      My answer is that we need all of these perspectives, and that none of them should be privileged with the exception that if a phenomenon is seen repeatedly, it might represent a pattern. And humans are especially good at making something out of random patterns. Some of those "somethings" are pretty profound and make for a better life for more people than other things.

      Hadjistavropoulos, Thomas, Craig, Kenneth D., Duck, Steve, Cano, Annmarie, Goubert, Liesbet, Jackson, Philip L., . . . Fitzgerald, Theresa Dever. (2011). A Biopsychosocial Formulation of Pain Communication. Psychological Bulletin, 137(6), 910-939.

      1. Bronnie, I can only access the abstract to the paper you mention but it refers to a framework and not to a scientific model.

        As for the “onion skins” of Loeser and Waddell, the other point I needed to make is that the observer is entirely left out of the cartoons.

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