Capability 1: BPS model
This page shows how someone would show they had expert rehabilitation capability number one: “Able to use the biopsychosocial model of illness as a structure and framework for all rehabilitation–related clinical, academic, and management activities.“ The biopsychosocial model of illness is summarised in a publication here and is described in pages on this site (e.g. here and here). This description of the capability sets out the context (the dominance of the biomedical model) and then gives the attitudes needed. Then it sets out behaviours expected of someone with this capability. These behaviours will not just occur ‘naturally’, so some guidance is given on the needed knowledge and skills. This is only a guide; the interested person will need to explore this site and read many articles. Nevertheless, the basic ideas are relatively simple, but much practice is required to embed the capability into day-to-day practice. This capability needs to be set in the context of the other six specialist rehabilitation capabilities (here) and the seven generic rehabilitation capabilities (here).
Table of Contents
Context: biomedical model dominance
The concepts underlying the biopsychosocial model of illness are simple and can easily be understood by a patient or family. Yet the model is not all that widely used, and many people who know it still need to improve to use it to its full effect. Why?
The reason is simple. We are all (well, nearly all; there may be exceptions) brought up in a culture that bases its understanding of illness upon the biomedical model. This model is so inbuilt that it appears self-evidently true to most people. Although used by most organisations and people, there is no standard text or other exposition of the biomedical model; most descriptions are within articles on the biopsychosocial model. Overcoming the influence of the biomedical model is a great struggle, one that I certainly need to work on from time to time.
One prominent manifestation of the dominance of the biomedical approach arises when considering functional illnesses. For example, despite the extensive evidence that chronic low back pain is primarily associated with psychological and social factors, many patients and their professional advisors still behave as if problems with the back are the primary cause. Even the funders still pay for treatments aimed at the back, including surgery, despite a wealth of evidence that it is ineffective.
Some groups of doctors and patients now accept that functional illnesses are multifactorial, do not have a primarily biological cause (though there may be associated changes), and need a different approach. For example, functional neurological disease is a rapidly expanding area of interest, and professionals and patients recognise it as a common illness. [here, here, here] Other patient groups representing people with functional disorders are more resistant to the idea that a condition can be multifactorial and complex, preferring to continue a search for a unique, single biological cause.
In summary, the difficulty in using the biopsychosocial model of illness in healthcare does not arise from any problem in understanding it or how it can be used when analysing illness. The difficulty arises because the model is the opposite of the biomedical model, which is based upon the premise of a single biological cause for each illness. The biomedical model is culturally dominant and deeply embedded in the thinking of almost all people. A change in attitude is needed.
Attitudes required for capability 1: BPS model
The key attitudes required to achieve this capability are:
- being willing to think well outside areas of biomedical knowledge and focus
- acceptance that the patient’s viewpoint is central
- flexibility and adaptability, setting aside desire to explain and control everything
- recognition that rehabilitation is only a small part of the patient’s life
This capability requires the professional to have a good knowledge and understanding of the biopsychosocial model of illness and to incorporate that understanding into their everyday professional work. It is the actual use of the model that is needed. Just as a patient may be capable of some activity but not undertake it, a professional who fully understands the model but does not use it is no better than someone who does not understand. Decisions about capability must be made based on actual, observed behaviours.
A list of behaviours expected of someone with the capability also illustrates how knowledge and use of the biopsychosocial model of illness might influence (and hopefully improve) professional practice. It gives the professional a reason for learning; it shows that there is some purpose behind the knowledge. Learning becomes a means towards an end; it becomes goal-directed learning.
The list given here is not prescriptive, and it is not comprehensive. It is illustrative, giving common and essential examples.
The first set of behaviours relates to using the framework in all areas of professional practice, not solely (for example) when assessing a patient. They are that the professional:
- Uses the holistic, biopsychosocial model of illness framework in all areas of professional practice:
- discussing a patient’s formulation with the patient and family;
- discussing a patient’s formulation with clinical colleagues;
- writing about a patient in notes, letters, summaries and reports;
- developing an audit and quality improvement project;
- teaching professional colleagues, students and other clinicians;
- reading about and evaluating, and if it occurs, in designing and undertaking clinical research studies
- designing and developing services, record systems, data-management systems.
The second set of behaviours relates to the more detailed aspects of its use in the clinical rehabilitation process with individual patients. They are that the professional:
- Uses the holistic, biopsychosocial model of illness framework in all activities within the clinical rehabilitation process:
- when assessing, considers factors from all domains that may influence or affect the particular function,
- when formulating, does so using the model
- in planning, considers what interventions might be possible in all domains, not just those relevant to professional or service expertise
- focuses on patient-centred functional and social outcomes.
Knowledge and skills
What the model is – its structure – is the basic knowledge required. Still, it is essential to read about and discuss the model to use it effectively and avoid becoming entangled in irresolvable debates about the precise categorisation of some phenomena. Diagrams look simple and alluring, but talking about them and using them throws up many questions that need to be worked through. It is also essential to be fully aware of the biomedical model’s strengths and weaknesses. Patients and other clinical staff usually base their analysis and decisions on the biomedical model.
It is only possible to set out some of the literature available. The article that initially set out the model should be read: it sets it in a historical context, and it is a very well-written article explaining the concepts. (here) The model has inevitably evolved, and a second article published 40 years after the first sets out the current version and gives evidence supporting its validity. Much more is also available on this site, including a section expanding on its influence on rehabilitation. (here)
An indicative list of some of the areas of knowledge that are likely to help includes having or knowing about:
- a clear understanding of its structure – the domains (and hierarchical levels) and what phenomena lie outside (e.g. quality of life, choice);
- insight into underlying concepts such as complexity and general systems theory;
- examples of measures and data collection tools based on the framework (e.g. WHO ICF, INTERMED – see compendium);
- the biomedical model of illness and significant contrasts with the biopsychosocial model;
- familiarity with the debate about each of the constructs, significantly differentiating between activities and social participation; (see compendium)
- how it can help assess the validity of a measure.
The skills needed help translate knowledge into valuable behaviours. They demonstrate that the knowledge is being or has been embedded, influencing clinical and other professional activity. They are that the clinician can:
- use and talk about the model without slipping into the use of jargon,
- demonstrate its utility through the use
- structure letters and reports using it without evident labelling
- explain why it necessitates a multi-disciplinary team approach.
Summary and MindMap
This page has set out a brief but valuable indicative set of behaviours, items of knowledge, and skills that would enable a clinician to be capable and behavioural items that would show that a clinician is an expert. The content is summarised in the MindMap shown below and downloaded from here.