silent angel comfort me

What does using a biopsychosocial framework mean in practice?


A good friend of mine told me that during her training (as a physiotherapist), psychosocial factors were “what you blame when your treatment doesn’t work”. It’s something I’ve heard more than once. I’ve also been asked many times “…but are you sure you’re not doing something outside your scope of practice?” when I talk about using cognitive behavioural principles and ACT (Acceptance and Commitment Therapy) and other psychological strategies. And some of you might have seen earlier posts of mine where I ask “How social is your biopsychosocial model?”

Today’s medical students are trained in using a biopsychosocial framework in their undergraduate years. They leave medical school, begin their hospital and advanced training, and I guess I wouldn’t be alone in asking “what happened to the psychosocial?” when we see them working.

So today’s post is a bit of a reflection and a musing on what I think using a BPS approach might mean in pain practice.

BPS is, I think, less of a “model” than a way of thinking. Thinking that is based on a systems approach – every factor affects and is affected by every other factor. In fact, Engel, the originator of this way of viewing human health, was strongly influenced by general systems theory which was developed by Ludwig von Bertalanffy, a biologist who lived between 1901 – 1972. General systems theory was a model describing processes thought to be common in many different fields of knowledge. General systems theory is based on these five beliefs:

(1)  There is a general tendency towards integration in the various sciences, natural and social.

(2)  Such integration seems to be centred in a general theory of systems.

(3)  Such theory may be an important means of aiming at exact theory in the nonphysical fields of science.

(4)  Developing unifying principles running ‘vertically’ through the universe of the individual sciences, this theory brings us nearer to the goal of the unity of science.

(5)  This can lead to a much-needed integration in scientific education.

Engel then applied this to a model of the influences on human health. At the time he wrote his seminal article (Engel, 1977), psychiatrists were being challenged by reductionism on the one hand, particularly around approaches to mental health – the distinction between “diseases” where biological causal factors are influential, such as neurological disorders, and “problems of living” such as alcoholism, where the relevance of biology was, at the time, hotly debated; and concern that psychiatrists might lose ground to nonmedical practitioners such as psychologists. It’s an argument that continues today: should, for example, nonspecific low back pain be the domain of medical practitioners or should physiotherapists, occupational therapists, psychologists and others pick up primary responsibility for its management? (For a very interesting discussion of socio-political debates about this, read Wilson, N., Pope, C., Roberts, L., & Crouch, R. (2014). Governing healthcare: Finding meaning in a clinical practice guideline for the management of non-specific low back pain. Social Science & Medicine, 102(0), 138-145. doi: http://dx.doi.org/10.1016/j.socscimed.2013.11.055)

Back to the story. The broad BPS “model” can’t be tested, and to some, was never intended to be a “scientific” model but rather a discussion tool. A way of shaping a dialogue between the person seeking help, and the clinician wanting to understand what was influencing how and why this person was presenting in this way at this time. I like to think of it as a way to remember that the person seeing you is a person-in-context.

We can argue the toss about exactly which factors belong in which “bit” of a biopsychosocial approach, but broadly speaking, we want to understand biological influences on health. Some of these are genetic (a bit hard to investigate for most of us), some of these are environmental (rickets? Vit D deficiency?), some are other organisms (M. leprae and M. lepromatosis? – Leprosy to you and me). Some are associated with what people do – tripping, jumping off things; while some are associated with what people don’t do – manage diabetes, exercise. The bio part is far more readily assessed and addressed than the other messy bits and pieces, so I won’t deal with that any further.

The psychosocial, on the other hand, is messy. It’s muddled and hard to measure and changes over time and geography and culture.

To me, it means remembering that when two people get together, it’s not just about the words we use, it’s about what we both bring to the setting in terms of experience, habits, expectations, vulnerabilities. It’s about where we meet. It’s about the purpose of meeting. It’s about recognising that everything we say and do is imbued with meaning – but it’s also about not necessarily knowing what we know, or what we don’t know.

So if I’m practicing in a biopsychosocial framework, I’m going to have to know a great deal about myself and my assumptions, my attitudes, habits, how others see me, and even what I don’t know. And the same applies to my knowledge about the person I’m seeing – only because I’m usually the “treatment provider”, I need to shape my conversation so that it’s OK for that person to tell me about this stuff, and this means knowing a bit about how people tick. I especially need to know how to hear what the person coming to me is saying – and not saying.

I see much that is called “psychological” as being about how we communicate and what we know about helping people change behaviour. I’m not “doing psychology” when I teach my child how to tie shoelaces, yet I’m using psychological techniques – modeling, reinforcement, verbal instructions and so on. Likewise when I’m helping someone feel OK about driving their car when they have back pain, I’m using psychological techniques such as verbal instruction, grading the difficulty, encouraging, supporting and so on. To suggest we can’t use psychological techniques to enable normal function is unthinkable.

Using CBT or ACT or motivation interviewing simply means refining my interpersonal skills so that I can optimise the chances that the person feels heard, can understand what I’m on about, and begins to feel OK about taking steps towards the life they want and being themselves. It’s about learning ways of explaining things, learning how to show that I’m listening, learning about the right level of support and challenge that will enhance the chances of success. Most people who live with chronic pain probably don’t need to see a psychologist – they need someone to help them make sense of pain, to show they’re there as they find their way through, and celebrate when they’re doing what’s important in their lives. I think all health professionals should be doing this.

Engel, G.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

15 comments

  1. Bronnie, thanks for a very much-needed and timely distillation of the elements subsumed by the term bio-psycho-social.

    1. My pleasure – have been doing loads of thinking about this – so keen to help people understand that people need people not scalpels, magic hands, or techniques. These help but only when we’re being human with one another.

  2. “…should, for example, nonspecific low back pain be the domain of medical practitioners or should physiotherapists, occupational therapists, psychologists and others pick up primary responsibility for its management?”

    This, to me, is the key. The best model is that which enables an individual to take responsibility for their own management

    1. Exactly! Though people can take a little while before they realise they need to, and can, look after their own health. That’s why some support to change is good, and then we can increase the challenge!

    2. Wendy, I cannot agree with your “best model” – “that which enables an individual to take responsibility for their own management.” I see the responsibility as being a shared one between the clinician and person in pain. Implicit in Bronnie’s formulation is that of the “level playing field” where neither party is striving for dominance. But I accept that it can be extremely difficult in practice for a health care professional to admit to not knowing the answers to specific questions posed by the person in pain.

      1. I think where chronic conditions are concerned, and especially when most of the daily “management” is about what people do (behaviour) in the end it IS about a person learning to do what helps them live the life they want. Sometimes this means not doing what the health professionals want – like having radiation therapy for cancer. As someone said on Twitter yesterday, “a helpful mindset shift for me was seeing referral as seeking professional opinion rather than for Rx”. The decision-making responsibility must always lie with the person living with pain. People may need more, or less, support to take this on, and it requires great care from the health professional.

  3. Bronnie, I am reminded that our 2008 paper – Pain Medicine and its Models: Helping or Hindering? – was written in an attempt to get these very same messages across to help clinicians engage more meaningfully with people in pain. But it has become painfully obvious that our current health care systems, with their emphasis on time-based consultations, are far from being “friendly” to these people, as well as to others presenting with chronic conditions.

    1. I agree – structural changes, systems changes, remuneration changes are all social aspects of healthcare that impact on our practice and ability to work this way. It’s not just about “what” we know and “how” we interact, it’s also whether the practice is supported within context. Hey, clinicians are also “in context”!

  4. Bronnie, your post should be made compulsory reading for all those doctors who have the ear of the New Zealand Accident and Compensation Corporation.

    When assessing women who have developed cervicobrachial pain syndromes in an occupational context, they tend to advise the ACC to reject their claims for compensation on the grounds that they do not harbour demonstrable tissue damage.

    Such highly influential opinions can be arrived at without these doctors ever needing to physically examine a particular claimant. It would appear to me that they are not familiar with the pain-oriented physical examination. If this is so, implementing an educational programme becomes an urgent priority, for reasons that are obvious.

    This very same phenomenon of fallacious reasoning was observed in Australia during the “RSI” epidemic of the 1980s, when what I termed “psychalgic fundamentalism” rose to prominence on a national scale and swept all other explanations before it.

    In this particular reformulation of Engel’s “biopsychosocial model,” psycho-socio-cultural factors are being blamed, without any evidence, for the pathogenesis and persistence of pain and other positive sensory phenomena, as well as for any associated disability.

    The point I wish to make here is that Engel’s biopsychosocial approach to the patient can so easily default to body/mind dualistic thinking: “If we can’t find the cause in your body, ipso facto it must reside in your mind.”

    New Zealand, you do have a problem!

    http://insultandinjury.org/2015/04/29/no-coverage-by-acc-in-new-zealand-for-rsi-type-disorders/#comments

    1. I have a great deal of empathy for your position, John, but the legislation is written in such a way as to reinforce dualist thinking. I hope someone will take notice!!

      1. Bronnie, let me assure you that people ARE taking notice.

        What has always irked me is that some members of the medical profession are ever so eager to “fall into bed” with insurance companies, and corporations like your ACC. However, in so doing, they run the risk of losing their professional independence, as well as their scientific credibility.
        Their behaviour reflects badly upon the whole medical profession.

        Conflicts of interest appear to go unnoticed, which suggests to me that our respective societies have effectively stigmatised those people in pain who receive (or even apply for) workers’ compensation benefits. Legislation can always be changed, but the damaging consequences for people in pain that follow from your current ACC legislation cannot be redressed.

        There is no excuse for supporting workers’ compensation legislation that may have been more appropriate to the working conditions of the 19th century. Clearly, the use of such legislation is glaringly inappropriate to properly address work-related medical problems in the 21st century.

  5. I like the idea of the BSP model being a way of thinking. The clinician may not have the answers, but that is okay- we often don’t. But acknowledging that to the patient is surely better than concocting an answer to fit the bio approach. If we start the encounter thinking in BSP terms then we may achieve more. It also allows the clinician, when appropriate, to the frame the symptoms as being normal for someone experiencing their current bio, psycho and social “soup”

    1. Exactly! And it avoids turf protection as well because everyone can identify the various aspects and if they don’t have the skills to address things, it’s far easier to help the person find another clinician who might be able to help. Far more collaborative.

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