BIOPSYCHOSOCIAL MODEL

The biopyschosocial model as it was originally proposed ‘dispenses with the scientifically archaic principles of dualism and reductionism and replaces the simple cause-and-effect explanations of linear causality with reciprocal causal models’ (Engel 1978, p. 175).

The WHO model of health and disability (WHO 2001; see also Chapter 22) reflects this biopsychosocial perspective whereby patients’ clinical presentations (their body functions and structures or physical status; their capacity and performance of functional activities of life; and their subsequent ability to participate in their family, work and leisure roles) are portrayed as the result of influences (both positive and negative) of their health condition, environment and personal factors. Importantly, the contributions of the physical/biomedical, environmental and psychosocial influences to a particular patient are individual and complex. That is, the individual factors not only combine in determining a patient’s disability experience, they also directly influence each other (Borrell-Carrió et al 2004).

However, some clinicians’ personal and professional philosophies of practice are clearly more biomedically than biopsychosocially based, leading either to a lack of attention to these influences on patients’ presentations (for example the view that ‘psychological’ aspects of patients’ problems are separate from the physical and it is not the clinician’s role to manage psychological issues) or to an overly superficial and hence less effective assessment, reasoning and management of psychosocial barriers. This may also be associated with a view that psychosocial factors only become relevant when working with patients in chronic pain and disability and are not relevant to the more acute patient presentations. Further, while health professionals may claim to be biopsychosocially oriented in their assessment, reasoning and management, espoused philosophies of practice do not always reflect actual practice attitudes and behaviours (Argyris & Schön 1978, Jorgensen 2000, Mattingly & Hayes Fleming 1994). In a critical review of cognitive-behavioural theory and practice, Sharp (2001) argued that the cognitive dimension of cognitive-behavioural therapy for chronic pain as reported in the literature is inadequate and that behavioural management inappropriately dominates the cognitive-behavioural interventions. The conception of biopsychosocial for some remains dualistic, in that either (a) the patient’s presentation is viewed as a combination of biomedical and psychosocial problems, rather than construing biopsychosocial as a genuine integration of mind and body where each influences the other (Borrell-Carrió et al 2004, Duncan 2000, Engel 1978, Pincus 2004), or (b) appreciation and focus are given to psychological factors without appropriate recognition and attention to the social circumstances that have contributed to shaping those cognitions and that remain as barriers to change (Osborn & Smith 1998, Sim & Smith 2004).

PSYCHOSOCIAL FACTORS CONTRIBUTE TO THE DISABILITY EXPERIENCE

In the biopsychosocial and WHO models of health and disability, patients’ thoughts, feelings, self-efficacy and coping strategies contribute (positively and negatively) to their disability experiences (Craig 2006, Flor & Turk 2006, Gottlieb et al 2001, Jones & Edwards 2006, King et al 2002).

Psychosocial factors, of course, involve more than just the patient’s own thoughts and feelings; the expressed or perceived thoughts and feelings and the behaviour of others (healthcare practitioners, family, friends, acquaintances and service representatives such as insurers and resource providers) also influence an individual’s disability experience. For example, in a qualitative study investigating the personal experience and psychological processes involved in maintaining pain, distress and disability in subjects presenting with benign chronic low back pain, Osborn & Smith (1998) used an interpretative phenomenological analysis to identify four themes common to the participants: (a) searching for an explanation; (b) comparing this self with other selves; (c) not being believed; and (d) withdrawing from others. The frustrations regarding inadequate explanation from the medical system reported by these participants is well recognized as an iatrogenic contributing factor to maintained disability (e.g. Main et al 2000, Main & Watson 2002). The effect of these subjects’ self-image was evident in their continuing comparisons to others and to their memory of their past selves while also projecting who they were likely to be in the future (Osborn & Smith 1998, p. 72):

Sim & Smith (2004) noted that this loss of a former self is a common finding in people suffering with chronic disability and pain, and described the circumstances that leave these people with a fundamental choice of trying to maintain their former self in spite of the pain, to suspend the former self in the hope that it can be regained once the pain is gone, or to come to terms with a new painful self.

The third theme identified by Osborn & Smith (1998) of not being believed created for the participants a continual need to justify their pain, and the incongruity of being mobile or appearing healthy created a sense that they should appear ill in order to conform to the expectations of others. The participants’ tendency to withdraw from others was the final theme. The researchers related this to participants’ fear of misunderstanding and rejection, highlighting the various and complex forms which fear-avoidance may take (Phillips 1987). In other words, fear-avoidance may have a social basis and not just a biomedical one.

With recognition that the thoughts, feelings and behaviours of patients and others influence disability, healthcare practitioners clearly need strategies and skills in assessing and managing these influences within the limits of their professional training. The level of education health practitioners receive in this area varies enormously, both across and within professions. Although it is not realistic to refer all patients to healthcare practitioners with more extensive education in psychosocial assessment and management (e.g. psychologists), superficial assessments leading to superficial judgements and inappropriate management are equally inappropriate. All healthcare professions have their own body of literature to assist their members’ understanding and application in this important area. For example, there is now very helpful physiotherapy literature providing suggestions on assessment and management strategies specifically targeting patients’ unhelpful thoughts, feelings and behaviours (e.g. Harding 1998, Johnson & Moores 2006, Keefe et al 2006, Kendall & Watson 2000, Main & Watson 2002, Muncey 2002, Strong & Unruh 2002). However, as discussed above, many clinicians either have not incorporated this approach into their philosophy and application of practice or have acknowledged its importance but take a superficial approach to psychosocial assessment and management.

It is not uncommon to find recommended management strategies that selectively ignore patients’ maladaptive coping behaviours while reinforcing their adaptive responses without providing practitioners with explanation as to how judgements of adaptive versus maladaptive should be made. It is as though there is an assumption that maladaptive thoughts, statements and behaviours can be defined out of context and some sort of universal truth exists that defines for everyone what is normal versus abnormal. For example, praying is classically given as an example of a passive coping behaviour that should be challenged and ideally replaced with something more active. However, judgements such as this simply cannot be made out of context. Whereas for one person praying may well be a passive coping behaviour linked to an excessively negative perspective, for another it may function as an active coping mechanism with links to positive thoughts, providing a source of strength and conviction to fight on. We certainly take issue with such a positivist position regarding judgements about normality and motivation. Any assessment of a patient’s beliefs, emotions and behaviours cannot be made without a deeper understanding of the person (including personal perceptions and social influences) and the basis for their perspectives. Kleinman et al (1992, p. 6) highlight the challenge this creates to the epistemological premise that underpins traditional biomedical theory and research, ‘namely that there is objective knowledge, knowledge apart from subjective experience’. Although it may not be the intent of those promoting cognitive-behavioural therapy, it is very common to see such superficial judgements being made in practice.