A Bio-Psycho-Social Approach; of Clouds and Clocks

A healthy joyful life is found somewhere in the middle when all three components are in check. 

A healthy joyful life is found somewhere in the middle when all three components are in check. 

A Bio-Psycho-So....... what?? What is it and what's the alternative?

It's a good question and it is an important one to understand. A "Bio-Psycho-Social" (BPS) approach is really the brainchild of George Engel, an american psychiatrist who challenged the conventional "Biomedical" framework that dominated western medicine since the mid 20th century. 

In a 1977 article in Science, George Engal called for the need for a 'new medical model'. Doctor Engal felt that in order to truly understand and respond accordingly to a patients suffering, clincians must attend simultaneously to the biological, psychological and social dimensions of their illness. 1 He had offered an 'alternative' to the prevailing biomedical model.

Critics of the 'biomedical model' had a couple of main issues with the then conventional approach that they felt de-humanized care: 2

  • Dualism
  • Reductionism

A dualistic perspective views the body and mind as distinctly separate entities, first traced back to Descartes and perhaps inappropriately so. This conceptualisation included an implicit privileging as the former [body] as more "real" and therefore more worthy of a scientific clinicians attention. Engal argued, persuasively, that medicine needed desperately to bridge the two realms - that treating a persons' disease as somehow independent of the person experiencing that disease was illogical and ill-founded. 

Dualism perceives the body and mind as distinct separate entities where the former is held as more “real”, consequently receiving more scientific attention.
— George Engal (1977)

The next major issue was the reductionist way of thinking in the biomedical model. Anything that could not be objectively verified and explained at the cellular level and molecular processes was ignored and devalued. Engal's primary critique of the reductionist method - that in fact it was an impersonal and cold approach to medical care, may largely have been to do with distress he felt at the professions' desuetude of human suffering, and not their actual philosophy. Humans are complex integrated systems where reductive reasoning simply does not work, take the following example:

Robert Sapolsky is an American neuroendocrinologist, Professor of biology, neuroscience and neurosurgery at Stanford University, as well as prolific researcher and best selling author - all around incredible guy and someone who has had a profound influence on my studies. Professor Sapolsky has a series of twenty-four free Stanford lectures available on youtube from his course Human Behavioural Biology. There is approximately 36 hours listening in the series that is so fascinating, I have listened three times. Each sitting there is something new I immediately integrate into my writing and practice. I have taken the following extract from lecture twenty-one entitled "Chaos & Reductionism", which is actually credited to James Gleick insightful book "Chaos: Making a New Science".3

Lecture 21 from Chaos & Reductionism (at approximately 45 mins in):

"Take a clock. A clock is a simple, non-complex system. If a clock breaks, we can open it up, take it apart and find the cog, or part that is broken. If we replace that part then put all the pieces back together in an additive way we will fix the clock. A clock can be fixed with reductive, point for point knowledge. 

Human beings are clouds, NOT clocks
— Robert Sapolsky (2010)

If we take a new problem, a cloud, and say for example this cloud is not raining enough, we have a drought. How are we going to figure out what is wrong with the cloud? Reductionist reasoning would be too find some way of dividing the cloud in half, and then those halves divide again, then more complex tools to divide each part again, over and over until we have a molecule of cloud. Once we have billions of these molecules and understand how they all work, we can put them all back together and then have an understanding of why the cloud is not raining, why we have a drought. The problem is, it does not work this way. Reductive reasoning can be used to fix clocks,  it cannot be used to understand why clouds don't rain".

It was these lines of reasoning that underpinned Engal's criticism of the biomedical model, human beings are clouds, not clocks. As a health professional, I unfortunately have to pick up the pieces of reductionist reasoning in management of chronic low back pain (cLBP) all to often. Failed-back-surgery-syndrome (FBSS)5 is becoming more and more common and with the rising trend of low back surgery being offered for back pain this unfortunate outcome is an inevitable consequence of treating clouds like clocks. There is now a clear body of evidence illustrating that scans simply do not correlate with pain6,7,8 and often even make things worse!9

This hopefully makes some sense when you consider that a disc bulge or some spinal degeneration on a scan is synonymous to a broken cog in our clock. We go in with a knife and try to fix the broken part [disc bulge] in the hope that things piece back together like a clock. This issue then leaves extremely frustrated patients with FBSS that could have been avoided if we managed them like clouds, Bio-Psycho-Socially. 

Pain is a complex phenomenon, as is health. A simple join the dots, reductionist intervention for a complex system is no longer considered appropriate in evidence informed practice. A BPS approach is what current best evidence advocates in both health and disease. A BPS approach transcends the modality in which care is delivered, whether you are being managed by a Chiropractor, Medical Doctor, Physiotherapist, Osteopath or even Personal Trainer.

A Bio-Psycho-Social approach transcends the modality in which care is provided, be it Chiropractic, Medicine, Physiotherapy, Osteopathy or Personal Training
— Luke R. Davies

The FBSS example described above is a clinical one but the same also holds true in health and training. An example of reductionism here might be to advise that everyone needs to get as strong and muscular as they can to achieve health. There is emerging evidence that those who take this approach to their training are significantly more likely to suffer eating disorders and body image dysmorphia (think bodybuilders and stage athletes).10 The pursuit of physiological perfection has come at the detriment of their psychological well being. Anyone who has been around people in these circles will also recognise the obvious social implications of these life choices. Do I think most people will benefit from getting stronger? Absolutely. Just not as a consequence of mental well being or social status.

SOME CLOSING THOUGHTS

If you are in any doubt as to whether your care is actually BPS in nature simply ask your provider, any professional who endorses patient-centred current best practice will welcome your enquiry and advise accordingly. If they don't, or are unclear, maybe seek help elsewhere. 

If you would like to be part of a comprehensive Bio-Psycho-Social community outreach, preventative health program, contact Luke R. Davies. There is an upcoming 12 week programme in Mid-Wales early 2017. If you would like to discuss bringing a programme to your area also get in touch where this could be discussed.

Clouds, not clocks.

Luke R. Davies :)

 


 

REFERENCES

1. Engal, G. (1977). The Need for a New Medical Model: A Challenge for Biomedicine. Science, 196, P.129-136. 

2. Borrell-Carriò, F., Suchman, A. L. and Epstein, R. M. (2004). The Biopsychosocial Model 25 Years Later: Principles, Practice and Scientific Enquiry, Annals of Family Medicine, 2 (6), P.576-582.

3. Gleick, J. (1987). Chaos: Making a new Science. Penguin Books, New York, USA.

4. Sapolsky, R. (2010). Stanford lecture 21 accessible at: https://www.youtube.com/watch?v=_njf8jwEGRo ACCESSED ON: 29.10.16

5. Hussain, A. and Erdek, M. (2013). Interventional Pain Management for Failed Back Surgery Syndrome, Pain Practice, 14(1), P.64-78.

6. Videman, T., Battié, M. C., Gibbons, L. E., Maravilla, K., Manninen, H. and Kaprio, J. (2003).  Associations Between Back Pain History and Lumbar MRI Findings, Spine, 28(6), P.582-8.

7. Endean, A., Palmer, K. T. and Coggon, D. (2011). Potential of MRI Findings to Refine Case Definition for Mechanical Low Back Pain in Epidemiological Studies: A Systematic Review, Spine, 36(2), P160-9.

8. Brinjikji, W., Diehn, F. E., Jarvik, J.G., Carr, C. M., Kallmes, D. F., Murad, M. H. and Luetmer, P. H. (2015). MRI Findings of Disc Degeneration are More Prevalent in Adults with Low Back Pain than in Asymptomatic Controls: A Systematic Review and Meta-Analysis, American Journal of Neuroradiology, 36(12), P2394-9.

9. Webster, B. S. and Cifuentes, M. (2010). Relationship of Early Magnetic Resonance Imaging for Work-related Acute Low Back Pain with Disability and Medical Utilization Outcomes, Journal of Occupational Environmental Medicine, 52(9), P. 900-7.

10. Helms, E. R., Aragon, A. and Fitschen, P. J. (2014). Evidence-based Recommendations for Natural Bodybuilding Contest Preparation: Nutrition and Supplementation, Journal of the International Society of Sports Nutrition, 11(20).