The Biopsychosocial Model
Published on The FIX website
*Note: Though this blog is written in the first person as the physical therapist Jeff Frankart, I wrote this blog as if I were him
Biopsychosocial: What is it and how does it work?
The FIX treatment system uses not only physical but psychological techniques to retrain the body’s interpretation of pain. To conquer the psychological tactics, I use the biopsychosocial (BPS) model to reprogram a patient’s view on pain by integrating the biopsychosocial model into the pain treatment regimen. The physical therapy world undergoes mass confusion about how to treat pain because our training looks to treat tissues of the body and then the rest will follow. But the central nervous system and peripheral nervous system are all tissues in the body, yet we ignore them in treatment! Using the biopsychosocial model in treatments allows for a patient to reflect on their environmental factors, understand pain differently, and take another step closer to regaining function. I get the mind and body to work together by making a patient aware of pain interpretation based on his or her psyche.
What is the biopsychosocial model?
George Engel originally developed the biopsychosocial theory to understand how a person’s biological makeup, psychological interpretations, and social factors influence his or her pain interpretation for chronic physical illnesses. Essentially, a person’s environmental factors impact the way pain affects him or her. For example, based the rigorous training a Navy SEAL encounters, a SEAL will have an increase in pain tolerance than that of a general person. When it comes to physical therapy, if a patient doesn’t know they can increase their pain awareness, then they will not heal to a greater extent.
I met a young PT, and he was up to date on the most current PNE and functional rehab, but he could not figure out how we as PT’s could implement the psycho component of BPS treatment model into a health care system that doesn’t reimburse for psychoeducation. PT’s and other medical providers, outside of the behavioral health arena, do not get reimbursed for treating the brain. The new International Association for the Study of Pain (IASP) definition of pain—an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage—opens a door for PT’s and others to get reimbursed for BPS pain treatments.
So, what exactly do the “bio,” “psycho,” and “social” components have to do with understanding pain?
“Bio”
In order to treat pain, people in pain and medical providers must first be on the same page and understand pain. Humans are binary thinkers by nature, meaning we view complex ideas as being one side or another. I consulted Dr. Howard Rankin, expert of psychology, cognitive neuroscience, and neurotechnology, and author of I Think Therefore I Am Wrong, and he explained how humans are most effective at binary thinking. We break thoughts down into two options, then make the choice (good/bad, right/wrong, yes/no). For example, a leader of a country could say, “You’re either with us or with them.” Two options. One outcome.
In 2012, based on the most current science on treating chronic low back pain, my mentor Dr. James Rainville, Dr. Mosely and I broke pain down into two parts: Bio and Psycho, where Bio refers to “Pain Threshold,” how fast stimuli acknowledges pain, and Psycho refers to “Pain Tolerance,” how much pain a person can handle. These two concepts, “threshold” and “tolerance,” act as the foundational ideas I teach my patients so that we both understand the physical therapy and recovery process. I approach these two components by teaching people that, just like animals, the human bio and psycho are biologically and genetically predisposed. For example, according to research from Dr. Rainville, most people openly accept that genetic predisposition refers to height, hairline, balding, and graying of hair, but people find it hard to accept that back pain is 76% genetics and 2% job related. Genetics have just as much of an impact on pain as one does to go bald.
Genetics are not the only “bio” influence on pain. Hormones and past injuries also contribute to the way someone experiences pain.
“Psycho”
The mind is a powerful tool. The “psycho” component challenges the thoughts a patient has about pain and the influence specific thought patterns have on injury; these emotions people have control the pain tolerance within. However, the ways in which we think about pain comes from the environments we surround ourselves in daily.
For example, if a person thinks negatively towards living every day with depression, those psychological battles can lead to other health related issues based on heavy alcohol intake or an addiction to drugs that make the person feel happy for a moment before plummeting back into a depressive state. With physical injuries, if someone thinks the pain he or she experience possesses unbearable agony, then the person will not move in any way to potentially flare up that injury. Therefore, other health-related concerns could occur such as blood clots. It all comes from what the mind tells a person.
With the “psycho” component, the pain tolerance someone experiences influences the way a person thinks about pain. Someone with a low pain tolerance will find something as simple as a prick in the arm excruciating whereas someone with a high pain tolerance wouldn’t even bat an eye after breaking a bone. The state of the mental fortitude conditioned into us impacts our psychological viewpoint on pain. Simply put, if a person thinks, “I am never going to get better,” then that person will never get better because he believes what he tells himself. On the contrary, if someone says, “I will get better!” then she will achieve what she believes. If a soldier with extreme pain WANTS to get better versus another who looks for excuses why they won’t get better, which do you think develops a greater probability of recovery?
“Social”
The “social” aspect takes surrounding environments that influence the way we interpret pain and our responses to that pain. This comes from family and friends, cultural influences, societal pressures, etc. Why do we cry if we break a bone? Could it be because it hurts that bad? Maybe. Or could it be that our social norms trained us to react in a specific scenario, usually involving tears?
Social aspects can influence people either negatively or positively. For example, those born into a family with a member labeled as “disabled” and acts like and believes he is disabled and who receives financial support, have an 80% chance of becoming disabled themselves. In comparison, a person born into a family who has a disabled family member (lost limb or trauma) but still works and doesn’t let the disability define who that person should be, the family member becoming disabled becomes less. Depending on the social settings you surround yourself in will alter your perspective on pain.
Integrating BPS into The FIX
To get patients to connect with this process, I use several metaphors and real-life success stories as examples. Each metaphor discussed here will be covered in-depth in later articles. The first metaphor I use is “Be the Deer.” Shortly explained, if a deer gets hit on the side of the road and breaks a leg, it doesn’t sit there and wait for medical help. It will move and when the deer gets to a safe place, it will slowly put weight on its leg until and builds enough strength to put all its bodyweight on its limb. This metaphor puts my patients in a new psychological state, painting a new picture on the difference between natural healing versus our conditioned surgery, opioid, rest induced society.
Along with Be the Deer, other metaphors I use are redlining the PainTachometer to recalibrate the biological system, or the “threshold,” where we should move to the pain and then taper back.
I then explain that scar tissue is only 80% the strength of the original tissue, just as a weld on metal isn’t as strong as the original structure. This means that post-injury, our recovered tissue will never reach 100%, but with proper care, the scar tissue can be as strong as possible by keeping the tissue three-dimensionally mobile and hydrated. These metaphors challenge our cultural shaping of pain and pain management and alter the biological hindrances that affect pain.
To integrate the “social” component of pain into The FIX system, I took the metaphors and applied them to real-life patients who went through the program with some of the worst injuries someone could ever experience.
One of my patients back at Landstuhl Regional Medical Center in Germany suffered an incredibly terrible injury. His name is Renn, and during a High Altitude-Low Opening (HALO) jump, his companion went through Renn’s parachute, causing the two to crash to the ground. Renn’s friend died upon impact. As for Renn, he woke up two weeks later in the hospital to find out that parts of his spine essentially exploded upon impact. Using The FIX program, I could rehabilitate him where he could go through the exercises, including the inchworm and burpee. With a man who basically doesn’t have a spine, I use this example to reconstruct the way other patients think about their pain. The typical societal structure that “Pain=Broken” does not bear scrutiny with the results Renn had. I use pictures and videos of Renn to wipe away the belief that if he had pain he was broken. Basically, if a guy with no spine can run, ride his Harley, and play with his kids, how can he be broken?
The philosophy challenges the patient’s mind, posing the question, “If Renn can do it, I should at least give it a try.”
Conclusion
I’m not here to say pain isn’t real or that someone’s pain isn’t there just because it wouldn’t be there for another person. But getting people to think about their pain, where it comes from, how to suppress pain, and then challenge our societal norms can alter a person’s thoughts to the point where that person may take his or her body to a new level so the body can take over and heal itself. In essence, we compartmentalize the BPS treatment model into binary constructs of: Bio=Pain Threshold, Psycho=Pain Tolerance, and Social=Pain Training. Training here indicates the sense that we get “socially trained” by our family, peers, and the media we consume or propaganda placed in our minds by society. Those messages include such ideas as Pain=Broken and you should not have any pain to function. However, reconstructing the BPS model incorporates an alternate route to interpret pain.
