Riverland

What does biopsychosocial practice really mean?


It’s still a bit of a buzzword, biopsychosocial. I’ve argued before that in pain, it’s more of a biopsychological model in practice (and here).*

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:

  1. Why is this person presenting in this way at this time?

  2. 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

44 comments

  1. Bronnie, I am with you (almost) all the way. I would like to comment on your post-script:

    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.

    Would you accept the following?

    ps the biopsychosocial model isn’t really a “testable” scientific model, it’s more of a heuristic or framework for the clinician and patient to think about, discuss and together integrate various aspects of human life to formulate a plan of management.

    You may wish to modify it.

    1. I guess I’d like to argue that I think ANY and ALL formulations must be developed in collaboration with the person, or they won’t make sense! I understand what you’re suggesting, and (largely) agree, although on reading Engel’s 1977 Nature paper he doesn’t mention it. I think that apart from the usefulness as a discussion framework, the BPS has also prodded people into considering a wider narrative of illness and disease, and also as a result has prompted greater attention to researching those other aspects of health vs nonhealth. For all its lack of scientific rigour, as a heuristic it has generated some testable models such as the Biopsychosocial model of pain communication. Engel developed the approach to shore up psychiatric treatment against an invasion by biologically-driven models. I can see a very similar situation in pain, but the paradigm is even more complicated by the muddied waters wrought by knowing there IS a BPS approach but it not being integrated into many pain clinicians’ approaches.

      1. Bronnie, if I can trust my failing memory, you might like to check Engel’s 1978 paper [The biopsychosocial model and the education of health professionals. Ann N Y Acad Sci 1978; 310: 169-78] and view his hierarchical conceptualisation of the “model”. He included a distinct level for the patient, but when pioneering pain theorists (John Loeser and Gordon Waddell) adapted his model, unintentionally they left out the patient. Take a look at their onion-skin diagrams!

        As you say, Engel did indeed try to rescue psychiatry and in so doing was very much influenced by his discussions with Austrian-born biologist Karl Ludwig von Bertalanffy, one of the founders of General Systems Theory.

  2. thanks I’ll look that paper up. I knew he was influenced by GST (rather unfortunate abbreviation!), as am I (it’s a useful approach!). And I totally agree that the person seeking help must also be part of the formulation, though not sure how they could ever have been omitted!

    1. Bronnie, we did point out this unfortunate omission in our 2008 paper, Pain Medicine and its Models: helping our hindering? This has been played out in clinical practice where the much-vaunted biopsychosocial “model” all to often defaults to the biomedical reductionist model. The most recent consequence of what we see as a historical mistake has been the promulgation of the idea that “chronic pain” can be a disease in its own right. Yes, we swim in muddied waters!

  3. “What does biopsychosocial practice really mean?”

    From the look of the Cochrane review cited, it means no improvement in people’s ability to work, and only self-report measures for non-blinded trials being used to support claims of efficacy.

    “It’s a great business model – but not so good for living a life that is half-way normal.”

    There are a lot of manipulative ways of making money from other people’s health problems.

    1. I think there’s a difference between interdisciplinary programmes and biopsychosocial framework or model. The outcomes for ANY approach to chronic pain and associated disability are poor. This possibly reflects the long time (usually years) before people are referred to programmes, the complex situations they are in, and the fact that the approach requires commitment and practice before profound changes are achieved. I think one of the most important things we can learn from the 30 years of research into interdisciplinary pain management programmes is that a single programme will not, and cannot, address the entire range of concerns people living with chronic pain are faced with. And it certainly doesn’t help when ill-informed clinicians who are probably doing it inadvertently but nevertheless offer “quick fixes” that require no personal effort and undermine an individual’s confidence in his or her own coping strategies.
      My question is: what is the alternative? Pain reduction using single modality interventions but no attention to ways of living, beliefs or attitudes towards pain? Outcomes for single modality interventions often don’t even begin to measure work disability or confidence to manage pain.
      It’s an incredibly complex problem, disability attributed to chronic pain, and I don’t pretend using a biopsychosocial model will alleviate all the problems, but at least the approach identifies that there might be some and attempts to address them.

      1. “I don’t pretend using a XXX model will alleviate all the problems, but at least the approach identifies that there might be some and attempts to address them.”

        Couldn’t that also be said for reiki and many other forms of medical nonsense?

        “My question is: what is the alternative?”

        Give patients direct control over resources and access to to data which will allow them to decide how they want to live their lives – don’t just funnel resources to those claiming to have expertise of value when those claims are not supported by good quality evidence. Some patients may care about non-blinded trials showing improvements in subjective self-report measures but not more objective outcomes (even after the problems with this have been explained to them): they might try reiki if they don’t want to put too much of their own time or effort into something (or if it just sounds nice), or they might try a biopsychosocial approach if that appeals to them. Maybe they’d rather just buy a few good books or a big TV? Who knows. I think that real empowerment come from real power and control, not just training people to answer more positively on a questionnaire.

    1. Eindt, I would not categorise Reiki as a form of medical nonsense. Have you forgotten that “knowledge is power”? Would could then argue the point over what level of knowledge may be useful.

      1. I’m not sure if you mean reiki is not ‘medical’, or is not ‘nonsense’. I meant it was ‘medical’ only in so much as it claims to be able to treat health problems. Knowledge is power, and nonsense is harmful – the claims made by reiki practitioners are nonsense.

      2. Reiki doesn’t purport to be “medical”, and any effects of Reiki are surely engendered by a meaning response (Moerman), or expectation generated by context and interpersonal relationships.

      3. Eindt, now that we are beginning to understand the concept and actuality of our peripersonal space and how it can be manipulated experimentally to relieve pain, in my opinion it is not beyond the realms of possibility that Reiki techniques will find a place in evidence-based pain management.

      4. Reiki purports to be able to improve people’s health by the manipulation of their energy flows. It is being claimed to be an effective treatment for pain: http://www.everydayhealth.com/pain-management/can-reiki-help-your-chronic-pain.aspx It can be argued that alternative medicine is not ‘medicine’, but I do not think that this is an important point in this context. It’s simply an illustration of the fact that all manner of immoral nonsense can be used to manipulate people into reporting improved symptoms in non-blinded trials.

      5. Almost anything is possible, and sadly the standards of evidence based pain management often seem rather low, but nonetheless the belief that reiki therapists have learnt how to improve people’s health through the careful manipulation, channelling and unblocking of ch’i is a pretty good example of nonsense.

      6. The explanation for how Reiki might work may currently be rubbish, but as John points out, interpersonal interactions in the context of healing have been shown to produce pain relief. Best book I know to explain our current knowledge is Benedetti’s book The Patient’s Brain.

  4. “interpersonal interactions in the context of healing have been shown to produce pain relief”

    Compared to what control? Measured how? One can refer to quantum mechanics to offer a scrap of a defence for homeopathy but I don’t think that should prevent us from describing it as nonsense.

    To me it seems that some people, including Benedetti, can get over-excited by the mighty power of placebo when it’s effect is largely indistinguishable from biased reporting: http://www.ncbi.nlm.nih.gov/pubmed/20091554

    Reiki, along with any other experience, will affect the functioning of people’s bodies and brains. That’s just how humans work. It’s still nonsense and quackery.

    1. Read the book. I can’t cite the many studies Benedetti refers to, but you may wish to refer to the following:
      Arnold, M. H., Finniss, D. G., & Kerridge, I. (2014). Medicine’s inconvenient truth: the placebo and nocebo effect. Internal Medicine Journal, 44(4), 398-405.
      Benedetti, F. (2014). Placebo effects: from the neurobiological paradigm to translational implications. Neuron, 84(3), 623-637.
      Carlino, E., Piedimonte, A., & Frisaldi, E. (2014). The effects of placebos and nocebos on physical performance. Handbook of Experimental Pharmacology, 225, 149-157.
      Elsenbruch, S. (2014). How positive and negative expectations shape the experience of visceral pain. Handbook of Experimental Pharmacology, 225, 97-119.
      Evers, A. W., Bartels, D. J., & van Laarhoven, A. I. (2014). Placebo and nocebo effects in itch and pain. Handbook of Experimental Pharmacology, 225, 205-214.
      Flaten, M. A. (2014). Pain-related negative emotions and placebo analgesia. Handbook of Experimental Pharmacology, 225, 81-96.
      Klinger, R., & Flor, H. (2014). Clinical and ethical implications of placebo effects: enhancing patients’ benefits from pain treatment. Handbook of Experimental Pharmacology, 225, 217-235.
      Meissner, K. (2014). Placebo responses on cardiovascular, gastrointestinal, and respiratory organ functions. Handbook of Experimental Pharmacology, 225, 183-203.
      Vase, L., Petersen, G. L., & Lund, K. (2014). Placebo effects in idiopathic and neuropathic pain conditions. Handbook of Experimental Pharmacology, 225, 121-136.
      Wendt, L., Albring, A., & Schedlowski, M. (2014). Learned placebo responses in neuroendocrine and immune functions. Handbook of Experimental Pharmacology, 225, 159-181.

  5. You mentioned a finding which you seemed to think was important, and I asked you to clarify what you meant by it. If you cannot do so, that’s fine but this is not an area I feel an urgent desire to devote further hours of reading to.

  6. Well, I’ve provided a range of research papers and a book that provides a very modern understanding of placebo which may explain how nonsensical therapies can have real effects. If you’re not keen on reading through a lot of material, that’s fine, but I have responded to your question. Placebo or meaning responses have been found in pain and other conditions, demonstrating the power of context and expectancies. A number of measures have been used, including fMRI, cortisol and neuroedocrine and immune responses, along with self-reported pain and disability measures. The studies range from hidden/revealed administration of opioid with hidden/revealed naloxone, to manipulations of expectancies and of interpersonal behaviour of the clinician. Words can influence how strongly a placebo response is enacted.
    I’m not advocating Reiki, but offering a potential explanation for its purported effects. To give you a comprehensive answer for your questions is well beyond the scope of my blog – but I’m happy to discuss placebo in another post. I think what John was suggesting is that to discount an effect on the basis that the explanation is implausible risks throwing the baby out with the bathwater. I personally don’t recommend Reiki (and acupuncture, or any other therapy requiring ongoing attendance to administer the treatment) because my approach is to work with a person to help them develop strategies they can employ without my being present.

    1. Lots of different things can affect how people report symptoms, and there are many potential sources of bias here. People’s attention can easily be shifted by short-term distractions. Lots of experiences can have strong short-term impacts on our bodies and brains. Changing people’s cognitions, narratives and expectations will often have some impact on the words they use to describe their symptoms. This does not seem to add up to any real benefits of placebo on people’s health though. That’s why I posted the link to the Cochrane review on placebo. The new Cochrane review of biopsychosocial rehabilitation for chronic back pain seems to present similar results.

      Lots of quack interventions can claim to have some value through the ritual of therapeutic interactions, but I don’t think that this means that they cannot be fairly classed as nonsense. Even if that did go on to lead to some long-term improvements in disability, so long as they are enacted without informed consent they’re still immoral quackery. As it is, it seems that the only health outcome they reliably improve is self-report measures in non-blinded trials. This is the sort of evidence that has a long history of leading to quackery.

      1. I suspect we will only really understand placebo once consciousness has been explained. In the meantime I await more research into placebo, but recognise that everything I say, everything I do, and the context in which I do it will influence how a person responds. Yes, outcomes from interdisciplinary pain management are not wonderful, but then neither is anything else. At this point I’m not sure how one would mitigate placebo within the context of healthcare interactions – given the mechanisms are unknown I’m not sure how one would give informed consent, do you?
        The distinction between quackery and the approaches I endorse is that everything that I use is subject to scientific examination. Quackery is typically not investigated. And unfortunately, as the review I referred to, neither do interventionist procedures measure meaningful outcomes, apart from considering that if pain is “abolished” the person is considered to “return to normal”, whatever that is.

  7. Bronnie, I am not talking about contextual (placebo) effects. There is a steadily growing body of scientifically respectable literature dealing with the peripersonal space. It could even form the subject of one of your next blogs.

  8. “given the mechanisms are unknown I’m not sure how one would give informed consent, do you?”

    When an intervention is not clearly more effective than placebo this should be explained in advance to the patient. A brief explanation of problems like response bias should be provided, along with information on the sort of outcomes that placebo have been shown to change and those that they have no affect upon. It should then be left to the patient to judge whether they think that such an intervention would be worthwhile for them or whether they would rather use the available resources on something else.

    “The distinction between quackery and the approaches I endorse is that everything that I use is subject to scientific examination. Quackery is typically not investigated.”

    That’s a pretty weak distinction, and anyway, a lot of quackery does have some good quality research into it which fairly consistently shows that it’s of no greater value than placebo. In the couple of decades, when sceptics and rationalists came to take an interest, it became much harder for alternative therapists to get away with the poorly controlled nonblinded trials of the past. There is (rightfully) little funding in this area, but the involvement and interest of those without a vested interest in these treatments has meant that there’s been some unusually rigorous research. With biopsychosocial interventions, decisions about how trials and reviews are conducted and presented are often taken by those whose careers are tied to this model. There’s an old quote: “It is difficult to get a man to understand something, when his salary depends upon his not understanding it”

    I think that the big 2005 Ioannidis paper ‘Why Most Published Research Findings Are False’ expresses some of my concerns more clearly than I can, and especially the section “Claimed Research Findings May Often Be Simply Accurate Measures of the Prevailing Bias”
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1182327/

    1. Eindt, according to Richard Gregory (Editor of The Oxford Companion to the Mind) scientists have generally been more concerned to justify their theories than run the risk of falsifying them with counter-evidence. As you would be well aware, this is a criticism of science which has been argued most powerfully by the late Sir Karl Popper, philosopher of science. He tackled the difficult and perennial problem of demarcating science from non-science. In my opinion, your comments here are both apt and timely.

    2. That’s a great paper, the Ioannidis one, and I’m fully aware of bias etc in scientific study. I broadly support a Popperian falsification approach to science, but I have found there are a great number of weak hypotheses being tested against a null hypothesis as opposed to two strong hypotheses being tested against one another. I also see that there are many people who fail to understand the BPS because by doing so their position on biomedical interventions is less positive. I do think the BPS provides a more parsimonious explanation for disability and distress than a biomedical one. Until, that is, we know more about some of these complex ideas such as consciousness and subjective experience. Maybe it will all boil down to neurobiology, maybe not, but I’m not comfortable with airy fairy explanations of “energy” or “vibrations” and so on. I draw on the BPS simply because it provides a pragmatic framework for me and my client to have a common language.
      My remarks about informed consent relate to placebo – if a good part of placebo is about expectations, and the context of a “healing ritual”, then it’s not really possible to ask for or give consent, it’s part of what people bring with them to any healthcare encounter. There was one study, I can’t recall it exactly, showing that even when a person is told they’re being given a placebo, there is still an effect. I can’t remember the details, but I thought it intriguing. People seek help for many reasons, and there are even more reasons for people returning for ineffective treatment. I think the explanations for this lie in social psychology and sociological theory as well as psychological and neurobiological ones. I don’t have other answers – but in my own practice I think I work hard to collaborate with, inform as much as possible, and am guided by the values of the person seeing me. Unfortunately the alternatives to BPS model are biomedical approaches, and these have also consistently not shown good results for many.

      1. “I do think the BPS provides a more parsimonious explanation for disability and distress than a biomedical one.”

        That is certainly the case when it comes to insurance companies and social security systems, and it seems to be here where to BPS model has had the biggest impact. It is difficult to present this as being a good thing for those with health problems.

        “I draw on the BPS simply because it provides a pragmatic framework for me and my client to have a common language.”

        Along with: “The distinction between quackery and the approaches I endorse is that everything that I use is subject to scientific examination. Quackery is typically not investigated.”

        Those seem like two very weak justifications of the biopsychosocial approach.

        “My remarks about informed consent relate to placebo – if a good part of placebo is about expectations, and the context of a “healing ritual”, then it’s not really possible to ask for or give consent, it’s part of what people bring with them to any healthcare encounter.”

        If you were asking how people can give informed consent for unknowing manipulation, then they cannot. That is why the more manipulative approaches that have been put forward as part of the biopsychosocial model can be so readily condemned as an immoral abuse of power. I suppose that patients could be asked to give very broad consent for a wide range of dishonesty and manipulation, but it’s difficult to see why anyone would give informed consent for such an approach, other than perhaps in a research setting.

        In an article on return to work for chronic pain (Are you ready?) you wrote:

        “In the first session, participants are asked to indicate how
        important work is to them on a line where at one end it is
        “not at all important” while at the other end it is “extremely
        important”. Participants are then asked “Why have you put
        your mark so high?” or “Why is your mark here (pointing to the
        mark) and not down here (pointing to zero)?” In answering this
        question, participants generate personal reasons for working,
        and are encouraged to write down the top five reasons for
        work being important to them. It’s important to note that
        people are not asked why their mark is so low, because this
        results in reasons for not making change.”

        In order to avoid that being manipulative patients should be informed in advance what you were intending to do and why.

        “There was one study, I can’t recall it exactly, showing that even when a person is told they’re being given a placebo, there is still an effect. I can’t remember the details, but I thought it intriguing.”

        I think that would be this rather over-hyped study: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0015591

        Patients were told that they would receive “placebo pills made of an inert substance, like sugar pills, that have been shown in clinical studies to produce significant improvement in IBS symptoms through mind-body self-healing processes”.

        So the study shows that patients told that they are receiving an intervention which had been found to be effective are more likely to go on to report improvements in subjective self-report measures. I don’t think it was worthy of the headlines.

        “but in my own practice I think I work hard to collaborate with, inform as much as possible, and am guided by the values of the person seeing me.”

        When you are seeing a patient, and there is not good evidence that your approaches are of any greater value than placebo, do you have a responsibility to inform them of this in advance? When the evidence indicates that your approaches are of no value in helping people to return to work are you clear about this at the start? Do you explain the potential problems with response bias in non-blinded trials, or do you just claim that there’s evidence your approaches lead to improvements in symptoms?

        “Unfortunately the alternatives to BPS model are biomedical approaches, and these have also consistently not shown good results for many.”

        You’re assuming that it’s required that health professionals be making money from claiming to have valuable expertise in helping treat people’s health problems. I think that we need to be more honest about our limited to worthless ability to help many patients. Where the effects of available treatments are not clearly better than placebo, patients themselves should have direct control over how additional resources are used to try to improve their quality of life, to use however they see fit. It should not be assumed that ill health justifies spending on healthcare. The BPS model should not be promoted simply because there are areas where biomedical approaches have little to offer – this is the same justification used for all manner of forms of quackery.

      2. Eindt, I am with you on this matter. Bio-psycho-social (BPS) was never a scientific model, and the theory upon which it was based – General Systems Theory – failed in this respect. As far as I can tell, exactly how the heirachical levels from atom to biosphere might be linked was never explained.

        As I have said repeatedly, BPS simply provided a framework or aide memoire for negotiation between the clinician and patient. This was indeed a big advance for clinical medicine.

        The fall-out from failed attempts to apply BPS as if it was a scientific model has reinforced body/mind substance dualism (either of the body or of the mind|) and thereby increased the risk of stigmatisation of those who suffer chronic pain without a discernable lesion.

        There is now at least one way of escaping the trap of dualistic thinking. I hope that our 2008 paper (see above) has stimulated discussion along these lines.

      3. I absolutely let people I work with know that I don’t know whether my intervention will be useful – it’s an experiment (N=1), and we treat it as such. A formulation we develop together is really a set of hypotheses about the relationships between variables. I usually like to pit two hypotheses against one another – eg are sleep problems associated with worrying at night or are they associated with drinking coffee? To test this I use a single subject experimental design – A-B-A-B with a baseline recording and either alternating an approach, or using a multiple baseline approach. I don’t claim that my approach will, or won’t work. Grouped data will obscure the responses in individuals – for example, when using TCAs for chronic pain, some people respond very quickly and with good pain reduction, while others don’t respond at all. Grouped data obscures the number of people who do respond, so ultimately it’s an experiment to establish empirically whether this treatment will be effective for this person, and whether they can tolerate the side effects.
        with regard to the RTW motivational interviewing approach – yes, I absolutely tell people the reason for using this approach. Why wouldn’t I? The MI approach uses known psychological principles (drawn from behavioural theory) to reinforce behaviour change. I agree that used unethically it’s possible to abuse this approach. I hope I don’t.
        From what you’ve said it seems your major gripe with the BPS approach is that you feel that it doesn’t have evidence to support it, it’s manipulative, and you would prefer people to have the cash and spend it as they will on ways to help them feel better/have better quality of life. You’d rather clinicians were honest about the limitations of their treatments, and you’re doubtful about placebo and think the effects are hyped. I believe the biomedical model fails to recognise the active stance people take in interpreting their situation and what happens to and around them. A biomedical model also fails to recognise that societal attitudes influence what is and isn’t considered ill health. By at least considering the effects of factors drawn from biological, psychological and social domains, I think there is a greater chance of understanding how and why a person presents in the way he or she does, provided the person is a collaborator in the process (because some information is subjective and only accessible by the individual experiencing it). I don’t claim to work wonders. I don’t know whether any particular strategy or approach will be useful, but I can offer something that is based on what is currently the best evidence – and an advance on repeating the same thing again and again but hoping for a different result.
        I’m closing this discussion now because I have some important deadlines to meet. Thank you for engaging in this discussion and although we disagree, I hope we’ve been able to at least understand where one another is coming from. What I don’t want to be accused of is engaging in quackery, manipulation or deceit. I don’t think I am any of these things.

      4. @John Quintner

        “As I have said repeatedly, BPS simply provided a framework or aide memoire for negotiation between the clinician and patient. This was indeed a big advance for clinical medicine.”

        I’m not convinced that it was a big advance. It led to psychosocial matters being discussed more in papers, but it does not seem to me that prior to this, or amongst those who rejected the BPS model since then, there was a rejection of, or ignorance to, the importance of (what are classed as) psychosocial factors in people’s lives. Previously there was more wariness of professionalising the management of psychosocial matters in all but the most extreme of cases, and it seems that this caution was well placed.

        The routine expansion of health care into the psychosocial aspects of peoples lives seems to me to have done more harm that good, and come long before we have sufficient understanding as to how biological, social and psychological factors do interact and affect people’s lives.

        “The fall-out from failed attempts to apply BPS as if it was a scientific model has reinforced body/mind substance dualism (either of the body or of the mind|) and thereby increased the risk of stigmatisation of those who suffer chronic pain without a discernable lesion.

        There is now at least one way of escaping the trap of dualistic thinking. I hope that our 2008 paper (see above) has stimulated discussion along these lines.”

        I wrote the above before reading this paper. Have just read it now, thanks. I thought that you straw-manned the biomedical approach a bit in that paper, eg:

        “When applied to the problem of clinical pain,
        the biomedical model posits a predictable and
        linear relationship between identifiable tissue
        damage and the report of pain, thereby presuming
        a neurobiologically hard-wired connection
        between the site of that damage and the brain.”

        I’ve found that most of those committed to reductionist biomedical explanations of ill health are deeply aware of how much we do not yet know about the human body. Furthermore, I do not think that such an approach requires dualism or a denial of of the importance of factors currently classed as being psychosocial. A simple and honest acknowledgement of the current gaps in our knowledge seems like a preferable solution to the problems with the biomedical model that the BPS model claims to have identified and improved upon.

        You may well be better informed on this than I, but I feel as if a lot of overviews of the history of medicine can slip into talking as if the views of those who have managed to have themselves seen as world experts, or published widely cited papers, are more influential on medical practice than they often are. I’ve found that doctors as a group are quite sceptical of medical research, and are quite aware of the history of trends, hype and exaggeration. In your paper you cite approaches that “privilege the “objective” view of the clinician when observing the “subjective” experience of the person in pain”, and I wonder how much that reflects real medical practice, and how much it just reflects the way in which those most willing to exaggerate their own abilities are sadly most likely to end up on committees of experts. It is so clearly nonsensical for doctors to assume that their inability to explain a patient’s pain meant that they were not in pain that I find it difficult to believe that this was ever the approach most doctors took – I’ve certainly seen lots of historical examples of doctors talking honestly about their lack of understanding here.

        I agreed more with your criticisms of other approaches and desire to avoid hubris than with the ideas of an alternative approach – although I’m not sure I really took in all you were saying in some sections. If the patient has a condition for which there is good evidence of an effective treatment, the clinician should make them aware of this and let the patient decide how they wish to proceed. I don’t think there need be any reason for give and take or jazz improvisations!

        I’ve seen that you are aware of, and concerned about, the political aspects of medicine and the way in which the power given to clinicians can be used to serve the interests of those with power in society. To me, this seems good reason to try to limit the purview of clinicans to those area where there is good evidence that their interventions will benefit patients. It looked to me as if your proposal for a way forward over-emphasises the role of the clinician and I worry that, like Engel, you can write as if clinicians are, or can be, a uniquely pure breed solely concerned with doing what is best for their patients. I think it’s safer to assume that those working in healthcare are as self-interested as other professions, and that the authority they have over others should be limited to that justified by good quality evidence.

        It was good to see some of the matters that concern me about BPS being expressed in a pain paper though, albeit rather more gently that I would have liked.

        @ adiemusfree: You don’t need to respond if you have deadlines, but I thought I should point out that you answer:

        “I absolutely let people I work with know that I don’t know whether my intervention will be useful – it’s an experiment (N=1), and we treat it as such.”

        didn’t really follow on from my questions:

        “When you are seeing a patient, and there is not good evidence that your approaches are of any greater value than placebo, do you have a responsibility to inform them of this in advance? When the evidence indicates that your approaches are of no value in helping people to return to work are you clear about this at the start? Do you explain the potential problems with response bias in non-blinded trials, or do you just claim that there’s evidence your approaches lead to improvements in symptoms?”

        If we have a treatment which has been shown under the most exacting of conditions to cure 95% of people, we would still not know whether this intervention will be helpful for the patient sitting in front of us. Equally, a homoeopath could state that “I absolutely let people I work with know that I don’t know whether my intervention will be useful – it’s an experiment (N=1), and we treat it as such.” That doesn’t provide enough information to people about the evidence of efficacy to allow them to make an informed decision about whether they wish to proceed.

      5. Eindt, please bear in mind that the 2008 paper expressed our views relevant to the emerging speciality of Pain Medicine. We were clinicians who were struggling to understand the issues you rightfully raise. Our subsequent papers have attempted to build upon the theoretical insights we gained from undertaking this exercise. There is still much to be done! Thank you for your insightful response.

      6. I have to admit that I wasn’t being mindful of the date it was released when reading, and responded to it as if those were your current views.

  9. Thank you.

    “scientists have generally been more concerned to justify their theories than run the risk of falsifying them with counter-evidence”

    I find this so frustrating. It’s also something which a lot of the processes around academia seem to actively encourage. I don’t think I’ve read the Richard Gregory piece yet but will have to add that to my list. It’s been disappointing how little progress has been made with these issues in the last decade.

  10. Bronnie
    An interesting read. What occurs to me having read these thoughts comes about from my experience as a health social worker, more specifically in the mental health and refugee trauma sectors.
    While you allude to the “why now?’ question in your first consideration, what is missing for me is any focus on the power within the decision to seek support. This for me, out of Narrative Therapy training, raises the enormous potential for the client being enabled to better manage their own pain management (or whatever issues bring them to support seeking) rather than being reliant on the expert therapist diagnosing and treating. Your article implies that the information gathering your assessment process outlines (and I agree with the importance of understanding the biopsychosocialogical aspects) has as its purpose the development of a treatment plan. I would argue that it has as its primary purpose helping the client understand their own functioning and how to access their power for self-management. This may or may not involve clinical/medical interventions; the issue is “who decides?”. Consequently, your second consideration, “what can be done..?” risks disempowering the client in favour of the empowering therapist. The therapeutic partnership becomes distorted.
    Also my assumptions about the “why now” most frequently come out of the realisation that “staying put” is more risky/scary/painful than seeking help. This, I would suggest, is part of the (1st world) human condition, and not restricted to the “client” world.
    Comments?

    1. Thanks for your thoughts Alan. The “why now” is a neutral question. Very often people come for treatment because someone else has sent them – perhaps a partner, or a case manager. So the question is a neutral one and perhaps phrased more like “what are the factors that have led to this person being here right now?”, and this can incorporate gender roles, societal influences (health/pain beliefs), assertiveness, learned responses from prior experience etc. These two questions are intended to be answered or figured out collaboratively. The person is always at the centre of this dialogue – what can be done includes what does this person think needs to be done? What does this person want to do? What does this person expect from me? What can I do for them? What can we discover together?

      1. Bronnie, think carefully about what is meant when you say that “the person is always at the centre of this dialogue.” Surely the most important feature of an ideal “third space” dialogue is that a centre no longer exists. “I” and “Thou” merge to become “We”.

      2. I suppose what I mean is that as the healthcare professional we have a responsibility to value the client’s/patient’s voice above our own needs or desires. Yes, it is a “third space”, a dialogue, or a communal ground, but I think we have a greater responsibility to develop that relationship in a way that honours the person seeking help rather than elevate our own agenda.
        Can we truly become a “we”? I’d have to think about that, because I think “we” suggests it’s bidirectional, and I’m not sure all my clients want this. Your thoughts?

      3. Bronnie, by definition such an ideal engagement must be bidirectional. Why not ask your “clients” about this matter?

  11. Or…. do they present to a pain clinic because all they’ve had is ‘massage, manipulation, medication and empathy?’ (non specific treatment)

    I see too many msk pains in our service caught up in the definition of chronic pain.

    Possibly a failing of the educational system, or private practitioners profiteering?.

    Is there a distinction between acute and chronic pain?

    Some of the best long term outcomes I’ve seen are from ‘needle jockeys’ – time to stop war with them and work together.

    1. James, there is no war going on. The NNT of the various spinal interventional procedures are now available for perusal. Some are little more than lucrative “theatrical placebos”. I am referring of course to injections of corticosteroid preparations into lumbar zygapophyseal joints. They are still very popular in my country.

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