One way of using a biopsychosocial framework in pain management – v


Theories are an important part of scientific development. Theories are essentially a collection of propositions or hypotheses that build a picture of what is in order to predict or control or somehow explain what’s going on. The extent to which a theory’s predictions represent what actually happens, given a set of circumstances, allows us to place more or less faith in the adequacy (or perhaps accuracy) of that theory. The problem with social theory is that there are so many complex interactions between variables that it’s very hard to generate hypotheses that represent what actually goes on in the world – so we end up with skinny theory that explains very little, and in turn this allows naysayers to argue “oh but it isn’t so”.

A biopsychosocial framework is one of those messy, complex theoretical models of “the way people are” that beg for people to argue against it. “It’s too complex”, “it’s too broad”, “it’s too reductionist”, “it’s not clinically useful” – all points against this way of viewing people. Yet, after years of using this model, I still find myself unable to find an alternative way of attempting to understand my two clinical questions: why is this person presenting in this way at this time (and what is maintaining their situation), and what can be done to reduce distress and disability?

Social theories are not something many health professionals are introduced to during their undergraduate training. We’re not trained to understand topics like structure of societies, organisations, groups and everyday lives and how they come about. We don’t typically get trained to think about power and who defines what is normal and abnormal, or who generates names for things – classifications, taxonomies, diagnoses. We rarely get to unpack the hidden discourse of who holds power in healthcare delivery, policy development – even social spending on health.

The people I typically see, living with persistent pain, are often from what posh folks call “the wrong side of the tracks”. Many people don’t have good employment histories. They may not have savings, they may live off a benefit. They are often not well-educated, having left school to do manual work. Their daily routines might be chaotic, and the idea of “keeping fit” or “eating well” doesn’t occur to them because their lives are about getting through the day, loving the family they have, and maybe looking towards a tomorrow where things might be different.

In pain management, we’ve not really spent much time examining the kinds of social relationships or social structures in which the people who really struggle with managing pain come from.  I’m not sure I’ve read very much research exploring, for example, whether people who have two jobs and live on a minimum wage experience greater difficulty developing skills in pacing their activities. I’ve not heard much from the people who live in this way expressing their understanding of what contributes to their distress and disability. I don’t see much about how uncertainty of employment pushes people into unsuitable work – while work is good for most people, what about those minimum wage jobs with unsavoury work environments, precarious employment tenure, cold, wet, smelly and physically demanding jobs with little prospect for the future? I don’t see very much about the effect of someone living on the bare bones of their threadbare trews going to see a medical specialist dressed immaculately in a bespoke suit and silk tie, with the handmade shoes and a language of healthcare that is incomprehensible to anyone other than another similarly clad specialist.

For a sociopsychobiological model of pain (yes, that’s a word, and no I haven’t got it backwards – see this) to gain traction, I think it’s timely to ponder the way our communities view persistent pain. Communities include our own healthcare communities – the manual therapy, physical therapy, occupational therapy, nursing, medical enclaves that use special language and dress in certain ways to demonstrate that we know our stuff. And we need to take a minute to understand the communities the people we hope to help come from.

At the stroke of a keyboard, the labels we give to someone – fibromyalgia, “degenerative changes”, “pre-existing condition”, “depression” – alter the treatment that person receives within healthcare. No question about it – if a person is receiving accident compensation (in NZ it’s ACC) and someone gives that kind of label to them, they’re going to the bottom of the health queue. The vagaries of our system mean that person doesn’t receive work-related rehab, they’re disentitled from ACC, no more weekly compensation, and oh yes they now go through the dehumanising process of attending the “Ministry for Social Development”.

I’m not arguing against the way our ACC legislation is written. And I’m not certain that receiving compensation is always a good thing. What I am pointing out is that when health professionals view the person in front of them as “other” – beneficiary, ACC claimant, pain patient – we are issuing a social declaration. And that means we’re exerting a degree of power over them and their lives. The labels we give have power. And this has a significant impact on the way that person views their pain, and the treatment they may receive.

I think until we begin to include, extend, and invite people living with pain to co-investigate their experience and to contribute to our health professional education (including scientific meetings), we’ll carry on thinking of ourselves as somehow superior to, and certainly more powerful than, the people we hope to treat. Hats off to Rajam Roose for developing the San Diego Pain Summit where this year she’s included a patient panel to give an insight into what it means to hear “your pain is just an output of your brain”. Can we have more please.

What can we do to reduce distress and disability? One thing we can do is begin a conversation about persistent pain being something that anyone can experience. It’s just that people without resources end up dealing with not only pain but also lack of power to change the way it’s treated.

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4 comments

  1. Great article and a subject I have long thought about.I work in the NHS inthe UK and therefore see people from every walk of life. The evidence shows there is better care delivered to the intelligent middle classes, than the poor who often have lower educational attainment.
    This might be due to kinship, the feeling you are dealing with someone from your tribe, more engagement because you feel your message is being understood better (and therefore you feel better about yourself) or perhaps more fear you might get your arse sued by the middle classes.
    Also if you perceive the lack of ability/ motivation to create behavioural/ cognitive change your own enthusiasm starts to wane.
    I have been thinking about rather than using a BPS approach, what about using phenomenological inquiry as a “treatment”approach.By this I mean the embodied inquiry, where the interview is the treatment.Of course this would need at least 45 mins and ideally 60-90 mins, but to allow people to experience a felt sense of being listened to by the practitioner.
    I think it is an honest approach for those who you say have lives that are chaotic and harsh.
    To have their story validated by someone taking a compassionate / empathetic stance would I believe be of great value. No labelling, no trying to help fix things, just listening hard.
    I say this because I am at the start of a research project for a Masters (in Mindfulness) and have been very taken by phenomenology as a qualitative approach to research.I immediately thought of my chronic pain patients and thought how it would suit them well.

    1. Thanks for your lovely comment. And yes I hadn’t thought of using phenomenological inquiry as a treatment approach – but of course the “interview” is about exploring what it’s like to be this person in this situation seeing me at this time. I usually do allow an hour for my first assessment because it’s such an important first step. It’s not easy because time is always precious, but what a gift to the person living with pain!

    2. Very interesting Graham. That finding doesn’t surprise me much. As someone who grew up in a mixture of working class and middle class environments, I noticed that middle class people are much more likely to challenge what they perceive as inadequate treatment, to research and direct treatment options themselves, and, yes, to hint at legal action when they deem it would be useful or necessary. This was really eye-opening to me. And, sadly, my experience of the NHS is that this is often necessary because many (most?!) GPs and even consultants simply seem to wait for the patient to ask for what they want, rather than suggesting options, and some are very keen to just get the patient out of the door if they aren’t on death’s door.

  2. Very good points I think. The patient voice does seem largely absent to me, and I think that is a great failing (something I’m trying to redress in a small way through some of my blog posts e.g. the latest one and by interacting with the blogs of physios and other medical professionals. That said, I can’t speak for the group you work with most. It would definitely be interesting to hear more about that though… a great gap for some Sociology phD student to fill perhaps…

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