Capability 1: BPS model

This page sets out how someone would show they had expert rehabilitation capability one: “Able to use the biopsychosocial model of illness as a structure and framework for all rehabilitationrelated 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’, and so some guidance is given on the knowledge and skills needed. This is only a guide, and the interested person will need to explore this site and read many articles as well. Nevertheless, the basic ideas are relatively simple, but much practice is needed 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).

Context:
dominance of the biomedical model

The concepts underlying the biopsychosocial model of illness are in fact fairly 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 the model still fail to use it. Why?

The reason is simple. We are all (well, nearly all; there may be exceptions) are brought up in a culture that bases its understanding of illness upon the biomedical model of illness. This model is so inbuilt that it appears self-evidently true to most people. Although used by most organisations and people, there is no formal 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 fail from time to time.

One obvious manifestation of the dominance of the biomedical approach arises when considering functional illnesses. For example, despite the very large body of 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 is the primary cause. Even the funders still pay for treatments aimed at the back, including surgery, despite a wealth of evidence that it is not effective.

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 both 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 an illness 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 difficulty in understanding it or its use in the analysis of illness. The difficulty arises because the model is the polar 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.

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


Behaviours

This capability requires the professional both to have a reasonable knowledge and understanding to the biopsychosocial model of illness and to incorporate that understanding into his or her 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 nonetheless not undertake it, a professional who has a full understanding of the model but does not use it is no better than someone who has no understanding. Decisions about capability must be made on the basis of 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 the reason for learning, it shows that there is some purpose behind the learning. 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 important examples.

The first set of behaviours relate to the use of 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, student 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 relate 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 process,
    • 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 & Skills

What the model is – its structure – is the basic knowledge required, but in order to use it effectively, and in order not to become entangled in irresolvable debates about the precise categorisation of some phenomena, it is essential to read about and discuss the model. Diagrams look simple and alluring, but talking about it and using it throws up many questions that need to be worked through. It is also important to be fully aware of the biomedical model’s strengths and weaknesses. Most of the time, patients and most other clinical staff will be basing their analysis and decisions upon the biomedical model.

It is not possible to set out all 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 in support of its validity. There is much more 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);
  • biomedical model of illness, and major contrasts with biopsychosocial model;
  • familiarity with the debate about each of the constructs, especially 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 useful behaviours. They demonstrate that the knowledge is being or has been embedded, influencing clinical and other professional activity. They are that the clinician is able to:

  • use and talk about the model without slipping into use of jargon,
  • demonstrate its utility through use
  • structure letters and reports using it, without obvious labelling
  • explain why it necessitates a multi-disciplinary team approach

This page has set out a brief but, hopefully, useful indicative set of behaviours, items of knowledge, and skills that would both enable a clinician to be capable and behavioural items that would show that a clinician is capable. The content is summarised in the MindMap here.

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