biopsychosocial model

Questioning: a skill for health
I must have driven my parents mad as a child: I’m the eternal 4 year old asking ‘Why’! It’s got me into a lot of trouble over the years when I can’t seem to sit with the status quo, just need to ask the question, understand the reasons things are the way they are – or at least ask why they are the way they are!

In my work, I use Socratic questioning as I work with participants in both group and individual pain management. Socratic questioning is a method of enquiry ‘to challenge accuracy and completeness of thinking in a way that acts to move people towards their ultimate goal.’ It can be used poorly to almost ‘bully’ someone to come around to a specific point of view (ever watched one of those law shows where the lawyer neatly traps the witness into admitting that part of their testimony without the explanation?) – but used well, it can take you and the person on a journey to discover how they have arrived at their point of view.

I came across this interesting paper by Cary Brown, Katrina Bannigan and Joanna Gill, written for occupational therapists about the place of Socratic questioning not simply for therapy but to question the assumptions about health care. They’re arguing from a postmodernist framework, which I won’t really go into today (but watch this space!), in which they suggest that the assumptions that there is One Single Truth, and it’s biomedical, needs to be questioned. Now I won’t argue with that at all! But what I will argue with is throwing the idea of all underlying principles and science (especially empiricism) out along with the biomedical model.

I can see some of my readers rolling their eyes at the philosophy here – but hold on it does make sense!

Brown, Bannigan & Gill argue that the biomedical model of health is incomplete. I totally agree! It doesn’t include all those social and psychological factors that influence whether someone is living well or is unwell. They state ‘A postmodernist perspective of health and well-being underlines that the illness experience is not a linear, cause-and-effect equation’. They go on to say that life experiences and social, cultural, physical and economic contexts influence individual experience – you can’t really work in pain management without appreciating how much these aspects of life influence how one person lives well with pain, while another has great difficulty.

Postmodernism in health has lead to questioning the assumptions of the biomedical model – again this isn’t new, Engel’s biopsychosocial model has been used in pain management for many years (that link is to a 2002 article on the place of interviewing and relationships in heatlh). It’s almost a truism that in nonmedical management of pain, the biopsychosocial model is the one we turn to. I wish I could say that the medical practitioners I work with also recognise that model, but it’s not quite there yet for some of them!

Brown, Bannigan & Gill suggest that questioning is a strategic tool for occupational therapists so they are equipped to deal with the complexities of current healthcare practice. I don’t know where they’ve been practicing, but I can’t think of a time when my practice in pain management hasn’t been complex! But I guess if you’re working in acute orthopaedic rehabilitation, you might find it difficult to argue with the prevailing ‘give em a toilet seat on Day 2 and they can be discharged on Day 4’ attitude!

Anyway, they suggest that Socratic questioning should be used to ‘frame a critical exploration of the relationships between elements of a given issue’.

The six categories of Socratic questioning are:

  1. Clarification – what is the real issue here? what are the parameters, exceptions, inclusions?
  2. Assumption probes – what are the the presuppositions and unquestioned beliefs for treatment/decisions?
  3. Reason and evidence probes – is there a clearly-thought-out rationale fora treatment or approach? What is the evidence for it?
  4. Viewpoints and perspectives – what if we took another viewpoint, what if we had a look from the perspective of a consumer, a purchaser, a referrer?
  5. Implications and consequences probes – a viewpoint may have logical implications that can be forecast. Do these make sense? Are they desirable?
  6. Questions about the question – why did we start asking these questions? Where are they leading to? What does this mean for practice?

The rationale for using Socratic questions with people experiencing pain is to help them take another look at how they are viewing their pain problem – what are their assumptions? what happens if they adopt one action over time? when might one viewpoint hold true and when might another?

By exploring actions and beliefs in this way, we can develop a more robust point of view that can be not only ‘true for me’ (ie constructivist), but also ‘true for others’ (empiricist).  The questioning part seems to me to be essential (well, I would say that, it’s all I ever do!), the finding out why and what’s behind it is one way to help define key issues.  I hope that patients also get trained in how to question.

I also hope that occupational therapists don’t throw out the empiricist approach altogether.  Empiricism simply means ‘can be known by experience’ – in other words, we can test ideas out and see what happens.  I think this is a critical part of case formulation – once we’ve understood the underlying assumptions and relationships between various parts of a person’s presentation, then we may start to directly influence one of those factors – and then watch to see what happens. 

In a very real way, we are experimenting in pain management, because we don’t know the exact mechanisms that are in play so we need to carefully influence one thing at a time to discern the effect – and use Socratic questioning on our own practice to ensure we’re aware of consequences we hadn’t originally thought about.

Brown, C., Bannigan, K., & Gill, J. (2009). Questioning: A critical skill in postmodern health-care service delivery Australian Occupational Therapy Journal, 56 (3), 206-210 DOI: 10.1111/j.1440-1630.2008.00756.x

If you’re new to pain management – ii

Now it’s time to turn to the details of the biopsychosocial model as it is applied to pain. There are some excellent resources available to look at this in both a simple way, and in much greater detail.

This site is written by a physiotherapist – and contains some well-written and reasonably simple information both about pain and more especially about low back pain. I’d suggest heading to this page on biopsychosocial model for a quick overview.

As far back as 1953, pain has been seen as more than simply either body or mind…
Pain is no longer considered exclusively either as a neurophysiological or a psychological phenomenon. Such a rigid dichotomy is obsolete, because pain is now recognised as the compound result of physiopsychological processes whose complexity is almost beyond comprehension.
The Management of Pain J Bonica Lea & Febiger 1953 (more…)

If you’re new to pain management – i

I posted last week on some of the basic domains of knowledge that I personally think are important when you’re new to pain management.  For more detailed curricula, the best place to go is IASP, where you can see some older but still relevant examples of curricula such as this one for occupational therapy and physiotherapy.

To break the area down a bit, because it really is quite a daunting list of topics, I thought about some of the basic conceptual material as being quite helpful to organise learning.  The first topic that I think is fundamental to understanding pain is the biopsychosocial model, and a quite nice summary of the model is this one by Dr Shaheen Lakhan.  A lightly longer, albeit older couple of papers are here.  A much more recent paper is briefly summarised here, and the paper referenced in this new item is Fava, G.A. and Sonino, N. The Biopsychosocial Model Thirty Years Later. Psychother Psychosom 2008;77:1-2 (more…)

Case formulation: A simplified example continues

My final post on case formulation illustrates the slightly simplified case study that I presented here.
I will be simplifying his presentation again today, to make sure this post isn’t too enormous!

Firstly, we identify the relatively stable phenomena:

  • Pain-related anxiety and avoidance
  • Work disability
  • Depression
  • Pain behaviours

Selected biophysical contributing factors:

  • Initial scaphoid fracture
  • Complex regional pain syndrome type i
  • Reduced range of movement and strength
  • Central sensitisation (more…)

Case formulation: A simplified example

Over the past few days I’ve been posting about case formulation. While I’ve presented the abductive theory of method (ATOM) which is a process of inferring from phenomena to underlying causal mechanisms, it’s not the only way to develop a formulation.  I posted on some of the other ways formulations can be developed, and today I’m going to describe a simplified formulation to show how it can work in practice. Don’t forget that when I write about patients I make sure details that can identify the individual are changed – or I describe a composite of several patients.

Robert is a 39 year old previously self-employed electrician who sustained a fracture of a his nondominant hand when he fell from a ladder two years ago.  This fracture developed into a complex regional pain disorder type i which had been slowly resolving with the use of medication, functional restoration (graded daily use of the hand), and mirrorbox therapy.  Robert presented for pain management assessment when his progress plateaued, and he became increasingly distressed.

He was assessed in a three-part comprehensive pain assessment in which he was seen by a pain management medical specialist, a functional assessor and a psychosocial assessor.  He completed a set of questionnaires prior to the assessment which were used to ‘flag’ areas for closer investigation.  Information was made available from the referrer (the GP), the case manager (clinical notes from the orthopaedic surgeon and initial physiotherapy treatment provider), and an initial workplace assessment which provided details of his work demands.

The medical assessment consists of reviewing his previous medical history, a full musculoskeletal examination, general ‘systems’ examination, current and past medications used for pain management, and pain specific examination.  The purpose is to identify whether all the appropriate investigations have been completed, the appropriate medical treatments have been pursued, and the medication regime is rationalised. (more…)

Case formulation – the next few steps

Over the past few days I’ve been writing about case formulation because in pain management, it’s rare to find only one single causal factor that is influencing either the pain or the disability. Most times we are looking at many factors coming from all three areas of the biopsychosocial model.

In each person, the relationships between and combinations of these factors will be unique. And that’s the value of a case formulation as opposed to a diagnosis, which is more like ‘shorthand’ for a group of symptoms that go together and are supposedly linked by a causal mechanism (in the case of non-mental health problems).

After identifying stable phenomena (symptoms that are present over time and in different places), the next step is to identify the underlying biopsychosocial causal factors that produce the phenomena we see, and the relationships between these factors as they interact. (more…)