I’ve had my wrist firmly slapped when I’ve suggested that a group of medical practitioners doesn’t really practice biopsychosocial pain management. I’m not the only person to point out how unidimensional some pain management practice is, as Roth, Geisser & Williams (2012) point out. This paper argues that interventional pain management focuses narrowly on nociception as an exclusive target, challenges this biomedical view of peripheral nociception as a primary source of pain and discusses the potential that this viewpoint has to foster unhelpful beliefs about pain, discourage using pain coping strategies, and (my addition) may even reinforce fear of pain.
I originally thought I’d discuss just this paper, but in mulling things over, I want to extend my discussion beyond this one example, and think more deeply about what it means to practice biopsychosocial pain management.
So what makes me biopsychosocial?
Someone once said “You don’t always need a team of people to help someone with chronic pain, you just need to think biopsychosocially“. I can see their point. But what does that mean in my practice?
To me, practicing in a biopsychosocial framework means answering two questions:
Why is this person presenting in this way at this time?
What can be done to reduce distress and disability?
The first question is about this unique individual and the choices that have led to them seeing me, today. It’s also about the social context and attitudes that mean this person frames their situation as a problem. When I read that so many people have chronic pain but continue to work, or don’t seek treatment, I want to understand how and why this person has found it necessary to look for help. The different motivations for seeing me will influence how we work together. For example, if someone has decided they can do more than they have been, but don’t quite know how to go about it, this will lead me to one set of “tools” from my toolbox (sorry Jason!). If, on the other hand, they’ve been sent to me by a compensation funder, they may not even want to do more than they currently can – or that may not be their priority at present. A different set of tools will be required.
I want to understand their problems as they see them. I want to look at the various factors that influence their problems, that may also influence any changes we make. I want to look at how the problems first arose, and then how they’re being maintained – these may not be the same! And it may take time to work through the various aspects to develop a case formulation that can explain why this person is presenting in this way at this time.
It’s only once I’ve taken some time to listen to the person and generate this case formulation that I can then begin to work on the second question. Distress and disability. Both of them, together. You see, it’s easy to address one or the other. Most health professionals want to reduce distress, it’s part of our reason for choosing healthcare as a job. If someone is distressed, our belief is that they’re suffering, and we have a duty to alleviate suffering. But if we’re not careful, we can treat distress but actually perpetuate disability, and disability can mean prolonged suffering. For example, if we give someone short-term relief through acupuncture (or massage, manipulation, medication or even empathy) the effect is to reduce distress immediately – but if and when the same situation comes up again, what do you think that person will do? Yes – head straight for you. It’s a great business model – but not so good for living a life that is half-way normal.
We need to think about how this person can begin to take the reigns him or herself to reduce disability, or the interference value of pain (and treatments and coping strategies and exercise associated with the pain). How can we as health professionals help this person do what’s needed to let pain interfere less?
And I guess that’s part of my frustration with needle jockeys, or people who push procedural pain management without considering that humans make sense of whatever happens to them. If managing pain means attending a treatment clinic every three months for a series of injections, when does that begin to interfere with life? At the end of one year? Two years? What about in 10 or 15 years? When do we call it quits?
And what do I do if I’ve been “trained” to go back for more jabs when my pain returns? And what do I now believe about my ability to deal with pain by myself? How much do I now fear having pain because I’ve been taught I need a quick fix? And from a social perspective, if I need to go to a clinic every three months for life, after a while, how are they going to see any new patients? At what point do they need to stop seeing new patients, or do they need to stop seeing old patients? And if they stop seeing old patients, what happens to me now?
You see, when a person doesn’t know there are any alternatives for managing their pain, how will they do anything differently? If the clinician doesn’t take the time to understand the person inside the pain, and doesn’t take a responsible stance towards what they offer as treatment, I think we end up with unethical practice. By selectively reporting outcomes, failing to assess psychosocial factors, and attending only to nociception and “identifying the source”, perhaps some clinicians are inadvertently creating dependence. Is this OK?
*ps the biopsychosocial model isn’t really a “testable” scientific model, it’s more of a heuristic or framework for thinking and integrating various aspects of human life.
Deyo, Richard A. (2015). Biopsychosocial care for chronic back pain. BMJ, 350. doi: 10.1136/bmj.h538
Engel, George L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196(4286), 129-136. doi: http://dx.doi.org/10.1126/science.847460
Kamper, Steven J, Apeldoorn, A T, Chiarotto, A, Smeets, R J E M, Ostelo, R W J G, Guzman, J, & van Tulder, M W. (2015). Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis (Vol. 350).
Roth, R. S., Geisser, M E, & Williams, D. A. (2012). Interventional pain medicine: retreat from the biopsychosocial model of pain. Translational Behavioral Medicine, 2(1), 106-116. doi: 10.1007/s13142-011-0090-7