The Biopsychosocial Model
Understanding the Whole Person
Many people seeking care for chronic dizziness, chronic pain, functional neurological disorders, and functional movement disorders, find themselves moving from one health care practitioner to another, to find answers, insight, and treatment to decrease their symptoms.
The barrier with our current biomedical model is the separation and poor collaboration of the health and wellness providers. The medical community focuses primarily, if not solely, on the biological aspects of health and illness. This community includes most medical doctors, nurses, rehab professionals, and audiologists. On the other hand, psychologists, counselors, and some social workers, often remain solely in the mental health care sector. And finally, a large portion of social workers, community, family and children service agents are primarily in government agencies and sectors with poor collaboration and/or poor direct communication with the healthcare providers. Peer support groups, exercise groups, wellness groups, community groups, religious and culture
This current biomedical model of how disease and illness are conceptualized lies in the fact that such definition is paramount to understand the boundaries and scope of responsibility associated with medical work.1 How health the health care community addresses the health, disease, illness, injury, and wellness of the community it serves, must be reconsidered.
The biopsychosocial model, on the other hand, is gaining momentum and awareness in the health care community, particularly in pain management when treating chronic pain and pelvic floor dysfunction. Outside of those subspecialties, there is a significant knowledge gap in the rehabilitation world and the entire health care community.
So What is the Biopsychosocial Model?
The biopsychosocial model was conceptualized By George Engel in a series of papers between 1960-1980. It views a health condition as products of:
Bio: biological characteristics/variables
physiological pathology
Psych: behavioral factors
emotions
lifestyle
stress
health beliefs and behaviors such as psychological distress
fear/avoidance beliefs
current coping methods and attribution
Social: social conditions
socio-economical
socio-environmental
cultural influences
social support such as work issues
family relationship/circumstances
benefits/economics).
This model differs from the traditional (current) biomedical model of healthcare, discussed earlier. The biomedical model is characterized by a reductionist approach that attributes illness to a single cause located within the body and that considers disturbances of mental processes as a separate and unrelated set of problems.2 It does not take into account the social, psychological, and behavioral dimensions of illness. 1
Engel discussed in a paper published in 1977:
‘the existing biomedical model does not suffice. To provide a basis for understanding the determinants of disease and arriving at rational treatments and patterns of health care, a medical model must also take into account the patient, the social context in which he [sic] lives, and the complementary system devised by society to deal with the disruptive effects of illness, that is, the physician role and the health care system. This requires a biopsychosocial model’.4
It is important for clinicians in all realms of health care to have the capacity to support the whole person. Although each area of health care has its role, specialty, and, scope there is a significant need for Interdisciplinary support and collaboration.
So Why Aren’t All Healthcare Providers Shifting to this Model?
The short answer is, changing the culture of healthcare is a big undertaking, when you consider the entries long practice of western medicine. Major cultural shifts, even as remarkable as understanding and utilizing DNA and gene coding took several decades before they were standard practice. mountain of evidence and knowledge translation task forces are often needed to support clinical practice translation. So, while the biopsychosocial approach to healthcare and wellness has drawbacks for application, primarily in how to standardization and implementation methods to determine consistency and efficacy to generate repeated outcomes. There is a lot of emerging evidence, particularly in the field of pain science and pain management, in which the current biomedical model has repeatedly failed, which has sought to develop and improve “patient-centered interview questions” that address the biopsychosocial aspects of the health condition or illness.
How to Start Implementing the Biopsychosocial Model:
1. Intentional subjective interview questions at the consultation or at the initial medical exam that seek to better understand not just the symptoms but the beliefs, perceptions, and functional limitations that are impacting the person. These questions can look like…
Cause/meaning:
What do you think is the cause of the problem*(pain, dizziness, balance, walking, tremor, weakness, fatigue, headache, fogginess)?
Consequences
Where do you see yourself in the future?
Vigilance
How much is your mind on your problem* (pain, dizziness, balance, walking, tremor, weakness, fatigue, headache, fogginess)?
Self-efficacy
How confident are you with your problem* (pain, dizziness, balance, walking, tremor, weakness, fatigue, headache, fogginess)?
How confident are you to do the things in life that you value?
Problem interference/disability
How has the problem (pain, dizziness, balance, walking, tremor, weakness, fatigue, headache, fogginess) impacted your life?
Coping with the problem
How do you cope with your problem (pain, dizziness, balance, walking, tremor, weakness, fatigue, headache, fogginess)?
Have you avoided important activities or modified the way you do them because of your problem (pain, dizziness, balance, walking, tremor, weakness, fatigue, headache, fogginess)?
Catastrophic thoughts
What do you think will happen if you ________(challenging activity)?
Where do you see yourself in the future?
Emotional factors (feelings about problem)
Emotional response to the problem
How does the problem (pain, dizziness, balance, walking, tremor, weakness, fatigue, headache, fogginess) make you feel?
How does the problem (pain, dizziness, balance, walking, tremor, weakness, fatigue, headache, fogginess) affect you emotionally?
Anxiety
Do you worry about the problem (pain, dizziness, balance, walking, tremor, weakness, fatigue, headache, fogginess)?
Depressed mood
Does it get you down? In what way?
Frustration/anger
Does the problem (pain, dizziness, balance, walking, tremor, weakness, fatigue, headache, fogginess) make you feel frustrated? What is it that frustrates you?
Influence of emotions on the problem
Does how you feel (mood, worry, stress, fatigue) influence your problem (pain, dizziness, balance, walking, tremor, weakness, fatigue, headache, fogginess)?
Fear of damage
How do you feel when you ________ (challenging activity)?
Fear of problem
How do you feel about the problem (pain, dizziness, balance, walking, tremor, weakness, fatigue, headache, fogginess)?
Problem predictability
Does the problem (pain, dizziness, balance, walking, tremor, weakness, fatigue, headache, fogginess) feel predictable to you?
Problem controllability
Do you feel in control of the problem (pain, dizziness, balance, walking, tremor, weakness, fatigue, headache, fogginess)? Are there things you can do to control your problem (pain, dizziness, balance, walking, tremor, weakness, fatigue, headache, fogginess)?
(Interview Prompts Adapted from O’Sullivan et al, 2018)
2. Motivation interviewing can be a great catalyst to empower and promote self-efficacy for goal setting for the person seeking care.
“Motivational Interviewing is a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.” (Miller & Rollnick, 2013, p. 29)
“Motivational Interviewing is a guiding style of communication, that sits between following (good listening) and directing (giving information and advice).” 9
3. CFT: Cognitive Functional Therapy
For CFT, an individual is interviewed and key thought patterns and behavioral responses to pain are identified ( see intentional interview question above) and Four main methods are employed to change the cognitive and functional aspects of an individual’s response to the problem
Making sense of the problem
Functional integration
Exposure with control (graded exposure)
Lifestyle change.10
Graded exposure, Sympathetic responses to pain, safety behaviors, and functional tasks are targeted during CFT, which allows individuals to understand the feeling of pain and their physical response to it. As a result, individuals gradually adopt levels of conditioning to that stimuli as time goes on, with the goal of ablating fear-avoidance beliefs and behaviors. Avoidance of certain tasks or movements, due to fear of exacerbating their problem, should be addressed immediately as they occur. These methodologies of CFT eventually lead to a lifestyle change.10
4. CBT: Cognitive Behavioral Therapy
CBT focuses on maladaptive cognitions that contribute to emotional distress and functional limitations that result from painful conditions. There is abundant evidence for the use of CBT in the literature, so much so that multiple meta-analyses have been conducted with frequently positive outcomes.10
Brain Changing = Life Changing. Live Beyond! 🧠
References:
Farre A, Rapley T. The New Old (and Old New) Medical Model: Four Decades Navigating the Biomedical and Psychosocial Understandings of Health and Illness. Healthcare (Basel). 2017;5(4):88. Published 2017 Nov 18. doi:10.3390/healthcare5040088
Physiopedia: https://www.physio-pedia.com/Biopsychosocial_Model
Wade DT, Halligan PW. The biopsychosocial model of illness: a model whose time has come. Clinical Rehabilitation. 2017;31(8):995-1004. doi:10.1177/0269215517709890
The need for a new medical model: a challenge for biomedicine. Engel GL. Science. 1977 Apr 8; 196(4286):129-36.
Peter B O’Sullivan, J P Caneiro, Mary O’Keeffe, Anne Smith, Wim Dankaerts, Kjartan Fersum, Kieran O’Sullivan, Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain, Physical Therapy, Volume 98, Issue 5, May 2018, Pages 408–423, https://doi.org/10.1093/ptj/pzy022
Miller, W.R. & T.B. Moyers (2017) Motivational Interviewing and the clinical science of Carl Rogers. Journal of Consulting and Clinical Psychology, 85(8), 757-766
Miller, W.R. & Rollnick, S. (2013) Motivational Interviewing: Helping people to change (3rd Edition). Guilford Press
Miller & Rollnick (2017) Ten things MI is not Miller, W.R. & Rollnick, S. (2009) Ten things that MI is not. Behavioural and Cognitive Psychotherapy, 37, 129-140
https://motivationalinterviewing.org/understanding-motivational-interviewing
Hadley, G., Novitch, M.B. CBT and CFT for Chronic Pain. Curr Pain Headache Rep 25, 35 (2021). https://doi.org/10.1007/s11916-021-00948-1
