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Rehabilitation Matters

About all rehabilitation

B-2 Using the biopsychosocial model

Learning to use the biopsychosocial model of illness is difficult because the biomedical model is culturally dominant and is ingrained from early childhood, reinforced by early education and training in most healthcare professions. Nonetheless, it is possible, and teaching and learning strategies can help. The primary way to make it second nature is through daily use and practice; it needs to become the default model, the dominant personal model. I am not suggesting that the biomedical model should be abandoned; it should be reserved for use in appropriate circumstances and within a broader use of the biopsychosocial model. This page discusses how and why this competency can be achieved.

Table of Contents

The competency

The competency is “Able to use and explain the biopsychosocial model of illness in all situations relating to rehabilitation.”. This document gives the details of indicative behaviours, knowledge, and skills. In addition, it provides some references.

Introduction

Being competent and excellent in using the biopsychosocial model of health is crucial for all rehabilitation experts. The biopsychosocial model is to rehabilitation as the biomedical model is to traditional medical practice; it is the vital underlying theory for all rehabilitation decisions and analysis.

Many pages on this site discuss the model and its application in rehabilitation. A search today (20-Nov-2022) found it on 58 (31%) of the 185 pages and posts on the site. Moreover, I have published articles about the model since 1987, when I wrote about its use in neurological rehabilitation. This page will focus on why this competency is essential and the evidence that training can help.

Context – why?

Rehabilitation concerns the consequences of a person’s disease, tissue damage, or condition. I have discussed the terminology in a post where I suggest that malady may be an appropriate term. Whatever word is used will refer to the presumed primary cause for their health problem.

Another perspective is to consider the illness, which has two components. One is the single underlying cause, often summarised as the diagnosis. This may be tissue damage (pathology), but it might be a psychological, cognitive, or affective dysfunction without any known direct tissue damage; anxiety and obsessive-compulsive disorders are two examples.; The second component of an illness is the myriad consequences of the malady on their life. Rehabilitation concerns these consequences.

The consequences of a malady will be determined to a limited extent by the underlying cause. More importantly, a host of other factors will influence the consequences and choose the best way to minimise the impacts. The actual influences will differ across all people, even people with the same malady. Thus the healthcare professional needs a structured framework to guide data collection, formulation, and planning of interventions.

When making the original biomedical diagnosis of a primary cause, the healthcare professional, usually a doctor, will use the biomedical model to provide a structure. This model has proved effective when diagnosing the cause and considering treatments. It is of limited value when considering the consequences.

Fortunately, the biopsychosocial model of illness provides the necessary framework. I have reviewed the evidence concerning its validity in several journal articles, notably on many pages on this site, such as here and in the following pages.

Moreover, I have shown, in an empirical investigation into effective rehabilitation, that using the biopsychosocial approach is the central feature of effective rehabilitation. The need for all members of a multi-professional rehabilitation team to base all their individual and team processes on the biopsychosocial model cannot be doubted.

Evidence on training

There are studies on training healthcare professionals to use the biopsychosocial model of illness. Those I have found concern healthcare professionals in a particular field of practice, such as musculoskeletal rehabilitation, although some concern doctors in psychiatry or general practice. There is no reason to believe that the findings from these studies would not apply generally.

Tina McClain and her colleagues studied biopsychosocial formulation in psychiatry residents (trainees) in centres across the United States. They found that few residents reached a basic level of competency in making a biopsychosocial formulation of a case; worryingly, there was a trend towards lower competency as trainees gained more experience.

More optimistically, an intervention to increase competency led to measurable improvement in the centres implementing the intervention. The intervention included:

  • Highlighting the low competency of residents at grand rounds (presumably in a supportive, developmental manner)
  • The programmes director meets with faculty members to ask for increased attention to training the skill
  • The programme director meets with residents to emphasise the importance of learning the skill

Ingrid Scholten and her Australian colleagues reported twelve tips for teaching the biopsychosocial approach, presumably based on their experience. The ones I think are relevant are:

  • The trainer needs to improve their understanding and use
  • The skill needs to be a way of thinking and practising a worldview
  • Learning needs to occur in all parts of the curriculum
  • Fostering inclusive partnerships, which seems to mean talking about it with others
  • Incorporate teaching into all other teaching activities
  • Undertake education in both uni-professional and multi-professional contexts
  • Incorporate its use in clinical activities

Phoebe Simpson and her multinational colleagues recently published a scoping review on training physiotherapists (psychical therapists) to treat people with pain using individualised interventions based on the biopsychosocial model. Their findings revealed 36 studies. Only 24 gave information about the training content, which was very varied. Only 12 studies included any competency assessment, and the methods used varied. They summarised the findings “There was a large disparity in the biopsychosocial interventions and training approaches, ranging from didactic educational “top-ups” to training with experiential learning, feedback, supervision, and posttraining mentoring.

This review was focused on teaching professionals how to undertake a specific treatment using the model rather than training professionals how to use the model in all areas of practice.

A study in students investigated, as far as I can understand, how training in the model as applied to patients with low back pain altered the attitudes and beliefs of the students. It did change their attitudes –more an evaluation of a patient intervention programme than a programme intending to transform practice.

Last, a recent systematic review by Wendy Ng and her Australian colleagues investigated barriers and facilitators affecting the adoption of a biopsychosocial approach to pain. They classified these factors into three groups:

  1. The micro-level factors relate to the individual practitioner. They covered a range, from personal beliefs and knowledge through misunderstandings of guidelines to concerns about the time involved.
  2. The meso-level meant organisational influences such as how guidelines were formulated, funding arrangement and workforce training.
  3. The macro-level concerning national health policy and social factors.

This is remarkably similar to the influences on implementing patient-centred care.

In summary, there are very few studies on training competency in using the biopsychosocial approach to healthcare, and most of those I found are concerned with managing pain.

How to learn (be trained)

There is little specific one can take from the available research. The main points I extract for the publications reviewed are:

  1. Competency is considered essential but is generally found to be low
  2. Attention to learning and training probably improves competency
  3. Success is more likely if the competency is used in all settings and is shared with others
  4. Success depends upon a culture of valuing and using the model

I can report how I learned. From about 1990 for about ten years, I constantly discussed the model for up to 3-4 hours a week with my friend and colleague Peter Halligan, and we debated solid points and weaknesses. Dialogue and debate are potent ways of learning. Second, I used it to structure my clinical letters, reports, patient data collection, research applications, research articles, documents presented to management, and several national guidelines I wrote. Third, I taught about it to many audiences from many different professions. Last I used it regularly with patients and families when discussing their problems.

In other words, it became wholly internalised and remains central to how I see any clinical, research, or service matter. Furthermore, the questions asked, comments made, and new ideas proposed by the audience all helped immensely.

There are some general principles:

  • You learn and improve through practice, especially using the knowledge and skills in as many different circumstances as possible
  • Constructive critical feedback is essential, which can be formal or informal and includes reflection on your performance.
  • Being in a supportive culture and environment where the model is used and valued increases knowledge and skills

I would recommend that you:

  1. Read the articles referred to in the pages on this website and read as many of the pages as you can over time to see how the model can be used
  2. Discuss patients with your peers, colleagues, and seniors, basing your discussion around this model
  3. Arrange multi-professional teaching sessions with your rehabilitation teams to discuss the model and how it might help teamwork
  4. Write a detailed formulation on at least three or four patients each month.
  5. Use it to structure explanations and information given to patients
  6. Try to develop a culture based on the model within your rehabilitation service
  7. Teach and lecture about it, especially to doctors from other specialities

Last, you could use the Oxford Case Complexity Assessment Measure to measure the complexity of the patients you see in your service. When we developed it, we found that if you undertook a complete biopsychosocial assessment for about 25-35 minutes, you could usually fill in the form from the information you garner. If you find areas you always need to catch up on, you will be getting feedback on your use of the model. The paper and some forms can be seen and downloaded.

 

Conclusion

People have done little research into training healthcare workers in using the biopsychosocial approach to rehabilitation or within healthcare generally, despite its central importance in rehabilitation and other specialities such as geriatrics, paediatrics, and psychiatry. The limited available evidence suggests that knowledge about and use of the approach is low but educational interventions can benefit professionals. Most of the advice given here is based on general academic principles. The most important feature is to make the biopsychosocial approach and mindset the cultural norm for all rehabilitation team members.

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