Wednesday 5 December 2012

In the Middle : Biopsychosocial Model

 This is an interesting topic for me as a medical student and a disabled person, because both groups use the phrase to mean different things, one is seen as a positive thing and the other a negative. I thought I would write this post as a 'translation' of sorts - because I have seen it lead to misunderstandings or arguments. It is almost a 'false friend' situation for the linguists amongst you.

The biopsychosocial model (henceforth BPS) has an understandably bad reputation amongst disabled people. It has been used by many to suggest that people are not impaired by biological disease, but rather by psychological beliefs that they are sick, and therefore as an excuse to deny medical treatment, insurance coverage or benefits applications. These alleged psychological beliefs are of course not deemed 'proper disease' enough to merit psychological treatment, so people are left being told that their illness is 'all in their head' and therefore they just need to pull themselves together.

Before my diagnoses I was frequently told that fatigue, joint pain, dizziness etc was all in my head and therefore that I should ignore it and push through. I asked on several occassions why, if I had a psychological disease I was not being given psychological treatment. (Doctors need to get better at saying 'I don't know'.) There is obviously a lot of hurt and frustration felt by sick/disabled people who have been dealt with in this way. Or, people are 'diagnosed' with social problems, which often intertwines with the 'illness behaviour' narrative - e.g. you are not working therefore you sit at home and worry yourself into being ill, for which the obvious cure is to threaten people on benefits to the point that they no longer live the comfortable, shelterd life which the government seems to think benefit claimants have.

It is however, used in another way. The BPS model has been introduced into some medical schools / postgraduate training as a way to remind doctors that there is more to caring for a patient than the medical model. The medical model is basically 'you have broken your arm, we need to pin it and put it in a cast' or 'you have an infection, you need antibiotics'. It is very much the model that you want doctors to be using when you are being resuscitated after a car crash, but once the immediate danger has passed there are other aspects to consider.

So, as a reminder that a biological disease process (let's say Parkinson's) will have more than purely biological effects. It has psychological effects - in the case of Parkinson's both psychological symptoms such as depression and the general 'reactive' psychological effects that can come with any chronic illness - adjustment to new symptoms, traumatic medical experiences etc. There are also many social effects that come from having a chronic illness - the stigma of appearing drunk for example, as some with Parkinson's can do, the fact that the world is not accessible and is therefore disabling (so we include 'social model' thinking which states that people are not intrinsically disabled, they are disabled by their environment - e.g. stairs with no lift alternative disable some folk with mobility impairments, expectations that a normal working day is 9-5 5 days a week disables folk with chronic fatigue or frequent hospitalisations/medical appointments).

The BPS model was introduced in this context to remind doctors that it is not necessarily enough to give folk some tablets and send them away. The multidisciplinary team (ooh, I get points for using the buzzwords!) is given the recognition it deserves in this context - OTs, Social Workers, chronic illness psychologists (yes, I'm told they do actually exist but I've never seen one in the wild).

In my mind the BPS model as applied this way is a very good thing for chronically sick/disabled people, because it is a much more 'holistic' model than the medical model used in isolation (and I hope it's clear that I think the 'it's all in your head' use of the BPS model is very damaging).

Any thoughts?


  1. Interesting and at some point soon i will finish wrting my musings on it.

    In the context you give, i whole heartedly agree, we have something very wrong with how people with a chronic illness are treated.

    Its a bit like you have x off you pop and life with it, no proactive care plans or any recognistion that you need to see other disciplines or agencies.
    You ar eleft to totally navigate the system and very often fall through the cracks.

    If there was recognistion that actually being diagnosed with a chronic illness needs more imput and not just an 8 week manage your pain course that at best is a sticking plaster and at worst just re-enforces an attitude you are developing illness behaviours and some how its your fault.

    I have no idea what medical training is like or even if medics have much training with peope, or how to work in partnership etc?

    sadly my experience like many is they arnt and you simply feel like a ball in a pin ball machine - pinged from serivce to service with no resolution or plan

  2. At the age of 22, whilst combing my long hair, I suffered an incredible pain that went from my neck to my hand and also up into my head, I also heard a loud cracking sound and thought I had either been shot or struck by lightening. I was unable to let go of the comb and couldn't turn my head and the slightest of movements resulted in searing pain. The doctor was called and he was not pleased to see me, sitting sobbing but looking otherwise unscathed. I was prescribed some cream for my neck and some Valium. Many years later and after being diagnosed as having cerebral spondylosis in my early thirties, I had an MRI followed by a CT scan which showed up an old fracture in my neck and the neurologist said that he could only assume this had been the cause of my continued neck pain, as it hadn't healed properly. I felt like punching the air because I did have a "real" reason for my pain and yet cheated of a life without pain for all those years. However the scans proved that I had no other anomalies other than my cerebral and lumbar spondylosis, neither of which could account for my inability to walk because my right leg wouldn't do what I wanted [I have since come to the conclusion that it was a muscular spasm in my groin]. So the nice neurologist explained that sometimes pain has a psychological base and asked if I would be willing to undergo psychotherapy and I said "Yes please!" as I was desperate to get off anti depressants and had had success with psychotherapy before but my GP fobbed me off and so I never had it. I'd suffered an horrific trauma 23 years ago and as a result suffered two breakdowns and general ill health but every illness was attributed to my depression until proven otherwise. I also have CFS and fibromyalgia and at last was referred to a specialist a year ago and have since had some physiotherapy and hydrotherapy but to be honest it's taken far too long and if I'd have had this help years ago, I might not be in the position I am today............housebound, often bed ridden, in constant pain and depressed.

  3. About pain psychologists: I am a CRPS patient @ the University of Pennsylvania. My team includes Dr. Chetal, who is one of the mythical beasts!
    You can see his influence in the patient survey given each time you attend clinic. The questions groups are "what is your pain doing", "how are you feeling", and "what effect are these having on your life". As a chronic (10 yr) patient, this validates that those variables can and may change...thus is "normal". As my PT says, "Your normal isn't the same as other people's normal!" Yet so soothing to know that I have one :-)

  4. Thanks for the blog post buddy! Keep them coming... best rated pediatric stethoscope