The biopsychosocial model of pain and beyond…
The biopsychosocial model includes three domains in which potential influences of pain can occur.
An important note: the division in three clear spheres is somewhat arbitrary, as so many elements of our lived experience are interconnected. One example: our thoughts, beliefs, actions, and feelings are considered within the psychological realm, which might be construed as individual. However, they result from an interaction of biological contributors (e.g. genetics, temperament) and social contributors (e.g. experiences of adversity, oppression and external resilience factors such as access to resources, safety, and caring relationships). Another example: the relational aspect of our lives encompasses both the psychological and the social realms.
Additionally, as I’ve shared elsewhere, human beings are integrated mind, body, spirit, and social, relational beings, and our existence is part of a vast web of beings, human and non-human, and is also connected with land. From this understanding, everything we experience in the realm of health and illness is biopsychosocial + spiritual + ecological in nature, though the weighing of each aspect in terms of experiences of health, illness, pain/symptoms and recovery may vary for any given person at any given time. If we can act on one aspect of a complex system, this will have an impact in the others, and it means we have multiple possible approaches.
Bearing this in mind, here is a simplified description of contributors in the different realms:
Biological contributors: bodily events that activate nociceptors (pain receptors) or drive tissue states outside the safe homeostatic zone, including genetics, inflammation, injury, excessive load, tissue pathology, and system dysfunction; epigenetic changes in response to environment; temperamental disposition.
Psychological contributors: the things we think, say, believe, predict, feel and do; our relationship with ourselves; our attachment templates, learned through early experiences and relationships; our personality traits, more or less stable ways in which we respond or relate.
Social contributors: any interactions you have with others and the roles you play in your social world, involving family, friends, work environment, access to care, community, culture and society.
According to the biopsychosocial model of pain, “Pain involves the intricate, variable interaction of biological factors (genetic, biochemical, etc.), psychological factors (mood, personality, behavior, etc.), and social factors (cultural, familial, socioeconomic, medical, etc.).” Moseley, G.L. & Butler, D.S. (2017)
In my experience, the way we experience and relate to pain also involves the spiritual realm. By spiritual I mean how we integrate meaning and purpose in life through a sense of connectedness with self, other human beings, other-than human beings, community, nature, Earth, art, and something greater than ourselves (whether secular or religious). And as beings in a complex and intricate ecological web, this dimension also plays into our experience of pain and wellbeing.
The more I learn, the longer I’ve been practicing medicine, the more I realize how little we know and how complex we are. Like my friend Deb Burgard says, what we know is akin to one star in the midst of the whole universe, or one grain of sand in the vast expanse of a beach. And speaking of health, pain, and complexity, Betsan Corkhill has written about it so articulately. Below is a short excerpt, and you can read the full text here.
“Getting to grips with complex systems can make your head hurt […] it becomes easier to simplify, safer to compartmentalise, and we can go so far down this route we lose sight of the complexity. People and life are messy […] We’ve thankfully moved into an era where anyone taking a purely biomechanical approach is considered outdated. However, even the bio-psycho-social model doesn’t grasp it all. As Cabaniss says, ‘It chops the patient into three neat packages.‘ These artificial boundaries can result in silos of fragmented care that distract attention away from the person as a dynamic whole embedded in their environment. As a result those living with long-term medical conditions often acquire multiple labels and go down individual pathways of care […] It’s clear that we need to change our thinking to create new approaches […] Health and Social Care systems that aim at nurturing health and promoting recovery. Humans are complex beings. The human body consists of a range of systems from cell to whole, plus trillions of microbes that all interact in complex ways, embedded in complex environments in an uncertain, complex world.”
I know that, as we lean into a more complex understanding, the confusion and uncertainty can feel daunting, and we can find ourselves yearning for simple and straightforward explanations or prescriptions. And yet… this space of unknowing, of uncertainty, opens up possibilities for unlearning that which no longer serves us well, or for learning new concepts, skills and practices that can help us grow in ease and wellbeing. It also engenders an expansiveness for curiosity, awe, wonder, hope, faith, and reassurance, because there is still so much to explore and discover, so much that is yet to be known.