E-15 Psychosocial competency
Psychosocial factors cover a ballpark range of psychological (emotional and cognitive) and social items. This makes it difficult to delineate precisely what constitutes psychosocial interventions or support. Despite this, psychosocial issues are the most important influences to discover and understand when analysing someone’s illness, and actions to affect their impact will often be crucial. Therefore, every rehabilitation professional must acquire competency in looking for opportunities to help the person by influencing their psychological state (emotions, beliefs, expectations etc.) or social state (social contacts, networks, interactions, roles etc.). This requires familiarity with interventions such as cognitive behavioural therapy, Acceptance and Commitment Therapy (ACT), and Mindfulness, as well as more social interventions such as social prescribing and Behavioural Activation Therapy. A document you may download gives some indicative behaviours, knowledge, and skills associated with competence and suggests further reading.
Table of Contents
Psychosocial competency
The competency is that the rehabilitation professional is “Able to assess for and recognise the presence of emotional and social factors that are impacting on the patient, and to identify the interventions that may help.” You will notice a significant emphasis on detecting when psychosocial factors are relevant. Except for psychologists, no rehabilitation professional has psychosocial problems as their speciality, and some psychologists remain focused on cognition. The tendency is to avoid psychosocial factors and therapies because they are less concrete than most other therapies and often challenging to articulate, discuss, find, and fund.
Introduction
Two-thirds of the biopsychosocial model of illness is psychosocial. Yet, most attention is paid, directly or indirectly, to the biologically-determined aspects of most illnesses, including the specific cognitive sequelae such as amnesia or visuospatial neglect. This disparity in attention does not reflect a discrepancy in importance or influence. Psychological and social factors are influential. Unfortunately, they are also less easy to define, encapsulate, categorise, diagnose, and treat. The continuing dominance of the biomedical model and the stigma associated with mental health difficulties add to the lower priority given to psychosocial factors.
There are other reasons. Despite the obvious and strong link between health and social factors, rehabilitation is within healthcare, and social factors are not considered within their remit. Research into psychological and social interventions is complex, so the evidence behind treatments is difficult to accrue. Moreover, the terminology could be more precise; for example, psychology encompasses cognition, belief systems, emotions and possibly more.
The portmanteau term is helpful because most people will understand the concept. However, when considering a specific example, one should specify the factor or intervention being researched as clearly as possible, avoiding less precise terms such as psychological, social, psychosocial, or any other label.
Psychosocial factors and treatments.
I have not found any widely-used definition of psychosocial. Further, the content depends upon the speciality so that people managing patients with psychotic illnesses have a different perception from people covering musculoskeletal disorders, emotional disorders, or cancer.
Sonora Gennarelli and colleagues reviewed psychosocial interventions in people with musculoskeletal injuries and suggested the following categories of psychosocial intervention:
- Relaxation and guided imagery
- Positive self-talk and cognitive restructuring
- Goal setting
- Counselling
- Emotional written disclosure
- Modelling
However, this is only a tiny proportion of all the possible interventions. Other interventions include cognitive behavioural therapy, mindfulness, mind-body treatments such as Tai Chi or yoga, treatment to increase self-efficacy, social prescribing, group therapies, peer support and mentoring, etc. The reviews and articles suggested for this competency will introduce you to some of the vast range of treatments.
Acquiring psychosocial competence.
Awareness of psychosocial aspects of illness and well-being is integral to understanding and using the biopsychosocial model of illness. I have published many pages and posts on this site about that, and they should increase your awareness and understanding. For example, the page on the model’s validity and the page on analysing social participation. Other posts on subjects such as humanities in rehabilitation and loneliness will increase your understanding. The humanities post refers to a poem on the distinction between empathy and sympathy. It would be best if you strived for empathy.
Thus, you must focus on listening to and asking about a person’s values, social roles and networks, beliefs, understanding of their illness, worries and concerns. Using a scale such as the Oxford Case Complexity Assessment Measure to summarise your patient’s state after completing your assessment would remind you of what you have not asked about. You must always be curious about each person you see to get a feel for who they are and what they think. This is a person-centred assessment.
Once you understand the person and their situation well, you will often immediately appreciate what psychological or social actions might help. The range is vast; you should expect to know only a small proportion. You will soon learn the common areas in your practice area, but you will often need to use your Research and Scholarship competency.
Many of the actions needed will be unique to the person. There is no ‘treatment’ for loneliness. Instead, it would be best to explore why they are lonely, elicit their interests, and draw on your knowledge of local resources to suggest some actions the person might take.
Evidence
There is overwhelming evidence confirming that psychosocial factors influence health and well-being.
For example, Michael Nicholas and colleagues collated many systematic reviews of yellow flags used in patients with low back pain, identifying psychological risk factors for poor prognosis and some evidence for intervention on some risk factors.
Mohammad Auais and colleagues investigated the role of social factors after stroke, identifying ten factors that had been studied, which they categorised into three groups, social support, socioeconomic, and living arrangements. The data showed that social factors affected functional recovery and mortality in older adults after hip fractures.
Equally, there is evidence of the effectiveness of some psychological interventions. For example, a systematic review found moderate evidence of the efficacy of cognitive behavioural therapy for depression in people with multiple sclerosis. Many other systematic reviews show effectiveness, including one on behavioural activation therapy for depression and another on psychosocial intervention for treating fatigue in people with rheumatoid arthritis.
The evidence for interventions focused on social factors is limited. Because each person’s situation is different and the options for intervention will be specific to their circumstances, randomised group studies will always be challenging. Moreover, funding the interventions with research grants is unlikely.
On the other hand, almost every rehabilitation professional will have known patients whose lives have been transformed by changes in social networks or social support or living arrangements. We should not let the absence of evidence stop us from considering achievable social changes. I am unaware of randomised trials of prosthetic legs against wheelchairs or no intervention, yet we routinely provide them.
Conclusion
Competency in psychosocial matters is nearly synonymous with being fully capable of rehabilitation, so trainees must circumscribe their efforts. The main characteristic indicating competency is always an awareness of the illness’s psychological and social aspects. Associated with this is having some knowledge of the many possible psychological interventions without trying to have extensive or detailed knowledge unless the trainee is a clinical psychologist or training in rehabilitation psychiatry. The primary skill is to elicit relevant information. Last, the expert professional will be ready to improve the social factors impinging on their patient.
