Mansel Aylward said:
Biopsychosocial models
None of the above models on its own succeeds in taking account of the range of factors which can influence the nature and extent of physical or psychological dysfunction. They all fail in one way or another to acknowledge attitudes and beliefs, psychological distress, social, and cultural influences, and personal experiences brought to greater or lesser extent by an individual person to the display of functional limitations and restrictions in its social context. A better understanding of chronic low back pain and disability, and management, is best provided by a
biopsychosocial model which considers all the physical, psychological, and social factors which may be involved (Engel 1977; Waddell 1987; Mendelson, Chapter 17). Many patients with medically unexplained symptoms do not have psychiatric disorders; these may be the result of minor pathology, physiological perceptions, and other factors including previous experience of illness (Nimnuan et al. 2000).
According to the attractive biopsychosocial model developed byWaddell (1998) and Main and Spanswick (2000), an initiating physical problem or perception, when filtered through the affected individual’s attitudes, beliefs, coping strategies, cultural perspectives, and social context, may be experienced as magnified or amplified and predispose to illness behaviour. Thus, the development and maintenance of chronic pain and fatigue, chronic disability and, indeed, long term incapacity for work, particularly in the context of low back pain and chronic fatigue states, rests more on psychological and psychosocial influences than on the original benign and mild forms of physical or mental impairments.
Waddell (1998) further argues that disability is not static but a dynamic process which evolves through distinct phases over time: the relevant model of disability may be different at various stages of this process. Waddell (2002) argues that the medical model may well be the most appropriate for most patients in the immediate aftermath of a physical injury, acute illness or disease. But within a few short weeks psychosocial issues start to predominate, and following the lapse of 1 or 2 years the initiating physical or psychological dysfunction will bear little, if any, relevance to the manifest illness behaviour. Psychosocial factors, expectations, and behaviours are thus very different at the acute, sub-acute, and chronic stages in the development of chronic disability. Capacity for work deteriorates and the chances of effective rehabilitation and return to work recede. Social Security statistics also demonstrate that some 40 per cent of new claimants for incapacity benefits return to work within 6 months, but those on benefit at 6 months have a very strong likelihood of remaining on benefit for years. Of those beginning a claim in 2000 around 30 per cent will be on benefit for at least 4 years (Aylward 2002).
Illness behaviour itself is not considered to be a formal diagnosis but is a melange of an affected individual’s observable activities, conduct and performance to express, and to transmit to others, his/her self-perception or interpretation of an altered state of health. Nor should it be defined in terms of a continuum of pathology. The manifestations of illness behaviours according to this model do not necessarily provide information about the initiating biomedical stimulus whether this be pain, fatigue or psychological distress. Nonetheless, in keeping with the traditional medical model, the biopsychosocial model recognizes that psychological and behavioural change are secondary to pain, fatigue or some other distressing complaint that most frequently has its origins in musculoskeletal and neurophysiological processes. As pointed out by Sharpe and Carson (2001), biopsychosocial models offer the potential (and indeed a danger) for an explanation and re-medicalization of unexplained symptoms around the notion of a functional disturbance of the nervous system. A paradigm shift indeed, or just a return to some of the competing theories offered to explain neurastheria in the nineteenth century (Aylward 1998)?
Is there any place for volition and or intentionality within the constraints of biopsychosocial models of disability? (See Halligan et al., Chapter 1, and Malle, Chapter 6.) For the most part, the assumption is that ‘patients cannot help how they react to pain’. Emotions are outside our conscious control and most illness behaviour is involuntary. Our professional role is not to sit in judgement but to understand the problem with compassion to provide the best possible management for each patient’ (Waddell 1998). This view reflects the philosophy that humans are not freely determined creatures: thought, behaviour, actions, and apparent free will are determined by factors beyond the individual’s control. And yet, if evolutionary psychology defines the human as the moral animal endowed with a capacity to make value-driven choices and an intentional approach to life then the emergence of a moral sense in human consciousness drives us away from genetically programmed behaviour, instinctive responses and the overriding effect of emotion. No doubt, we are creatures who are in conflict with ourselves; creatures in whom the life-force has started observing itself (Holloway 2001). Frankl (1963) called this our ‘ultimate freedom’—the potential freedom to exercise individual choice about one’s attitudes, behaviours, and responses to a given situation (see Halligan et al., Chapter 1).
