I’m a relative newbie to Twitter and have been reading with interest the posts about the BioPsychoSocial model and its use in Physiotherapy.
I have tried to understand what the BioPsychoSocial model means for me as a physiotherapy patient by following two main avenues of thought. First, what would ‘psycho-social’ mean in my own profession (or rather ex profession) of school teaching, and secondly what has been my experience of physiotherapy thus far and do I think I have been treated mainly within the BioPsychoSocial model or mainly within the Medical model.
I have then considered what I might expect to be different if being treated in the BioPsychoSocial model in the future.
I’ve entered this new and interesting Twitter world with a background of teaching, latterly in special schools where I worked as part of a multidisciplinary team with physiotherapists and other healthcare professionals, experience of running a mental health charity, some current working alongside physiotherapists, GPs, consultants and other clinicians, and perhaps most importantly with 10 years personal experience of persistent pain.
The ‘EduPsychoSocial’ Model
Teachers don’t work within the BioPsychoSocial model. Our core work is to teach a curriculum, whilst physiotherapists core work, I think, concerns a person’s physical body, the ‘Bio’ part of BioPsychoSocial. (I know this is simplistic!) However, it is often impossible to teach young people well without considering the psycho-social aspects of a young person. These aspects affect a young person’s ‘readiness’ to learn and their ‘ability’ to learn, as well as affecting their thinking and understanding. I’m going to suggest therefore that you can think of teachers working within an ‘EduPsychoSocial’ model. Although the core of the two professions are different (physical body vs curriculum), I think there are many overlaps in terms of consideration of the psycho-social aspects of a person, and the intertwining of these psycho-social aspects with either the ‘Bio’ or ‘Edu’ side, and their impact on them.
The following are some of the ways I think I considered and worked with a child’s psycho-social factors in my teaching.
Making a connection
Most people attended school as a child. If you think back to who you thought were your best teachers, there is a good chance that you had some kind of personal ‘connection’ with them. In my experience the good teachers are interested in their pupils as individuals and get to know them and understand a little about their backgrounds and interests. They will notice when a young person enters school in a distracted, unhappy state and will take time to listen. They will take time to listen to a pupil who wants to tell them about the positive things going on in their life and they will celebrate their successes. Most importantly a good teacher will ‘connect’ with their pupils, and this ‘connection’ will enhance the ability of the pupil to learn, and most importantly enjoy learning.
Beliefs and attitudes
Some young people will enter the classroom with a willingness to learn, and a positive attitude. Others are entirely different! Whilst I was teaching Secondary School mathematics, one of the biggest challenges for me was turning an ‘I can’t do maths, I hate maths’ attitude round. This attitudinal state was a huge blocker to progression, and often had its roots in parents telling their children they hated maths at school and couldn’t do it! To address these beliefs and attitudes I had to first listen to them, understand them and then usually discuss them with the young person. I then had to use my teaching expertise to work out ways to progressively change these views and so better move the pupil forward in their learning. If ignored, then the student may disengage and perform less well.
Considering home circumstances and relationships
Children are hugely impacted on by their home circumstances and their relationships with both family and friends. Children fortunate to live in loving, calm homes in which there is enough food to eat, enough warmth and enough other human basics are more likely to be able to engage and progress well with their learning. Those who experience difficulties in their home circumstances are more likely to find engaging and learning that bit harder. Bullying remains a large problem within schools, as it does in the workplace, and inevitably impacts on a child’s ability to concentrate and learn. Difficult family dynamics will also impact. Good teachers will recognise the impact home circumstances and relationships can have on a young person’s learning, take time to listen and talk, and adapt learning experiences as needed.
Considering life experiences
In my experience, and view, you cannot teach successfully if you expect the pupil to leave their life experiences, whether good or bad, at the classroom door. Some pupils may have experienced severe trauma, for example sexual, physical or emotional abuse. Some pupils may have witnessed domestic violence, others may have been involved in a bad accident. These experiences become part of who those children are and cannot be disaggregated from the child. These experiences will inform how a child views and understands parts of the curriculum and will inform how they learn. Good teachers will take time to listen to and understand a child’s past experiences, and how they have affected the child, and modify the curriculum and/or the way they are teaching to best support that individual child.
Some children find any kind of trauma difficult, and enter a downward spiral, whilst others build resilience and then seem more able to deal with later life experiences. Some have a naturally positive outlook on life, whilst others more negative. Some children become extremely difficult to teach and present as a behaviour challenge or may become anxious and withdrawn. To be able to teach these more troubled children successfully then the better teachers are likely to invest increased time getting to know them better as people, listening to them, and adapting the curriculum accordingly. The less successful teachers, who do not invest this time, may experience some very difficult lessons! For the children that are more positive and resilient then their confidence can be improved and built on by teachers that celebrate these qualities and reinforce them.
Considering mental health difficulties
Some children enter a classroom with mental health difficulties, either diagnosed or otherwise. Some are depressed, and/or anxious and may be self-harming. Some may be showing early signs of psychosis. Some may be struggling with their gender identity and some may be struggling with eating disorders. It is impossible for a child to be experiencing any type of mental health difficulty and for this not to impact on their learning in some way. I wasn’t formally trained in mental health, but I was very experienced at dealing with it! Sometimes giving a child an opportunity to talk helped, sometimes I needed to seek advice from other professionals so that I could better support the child and sometimes I needed to refer the child on to someone with more specific expertise than me.
What has this all got to do with physiotherapy?
In the same way that children entered my classroom with a complex mix of personal and intellectual differences, social and life experiences, and mental health, adults enter their physiotherapy sessions.
In the same way that this complex mix of experiences and differences affect a child’s readiness and ability to learn, and their educational progression, an adult’s complex psycho-social mix will affect their physical condition and their ability to engage, progress and rehabilitate through their physiotherapy sessions.
I entered my physiotherapy sessions with my own unique and complex mix of biological, psychological and social factors.
My experience of physiotherapy
I have had a number of episodes of physiotherapy care during my 10-year journey with pain. Some have been more successful than others.
I have detailed in another blog the episode of physiotherapy care which followed a Cognitive Functional Therapy approach, which I believe changed my life. Cognitive Functional Therapy has been designed to consider psycho-social factors as an integral component. This blog includes a more detailed description of how some of my psycho-social factors were considered within this episode of care and can be accessed HERE.
My most successful episodes of care have taken place when a physiotherapist has taken the time to listen to me, has taken an interest in what is important to me, and has got to know me as a person. They have formed a ‘connection’ with me, a therapeutic bond, which has supported both my engagement and my ability to progress.
Appointment time constraints must have limited some of my physiotherapists being able to sufficiently get to know me and to sufficiently consider my psycho-social factors and how they impacted on my persistent pain presentation. Some of my physiotherapy appointments have seemed quite short, and sometimes I have had a short number of sessions. My ‘connection’, and therapeutic bond, with these physiotherapists were the weakest of all.
I have experienced some trauma in my life which has resulted in me having a high level of resiliency, and which I believe serves me well dealing with my persistent pain condition. The best physiotherapists acknowledged both my resilience and my positivity. Doing this has helped me value and build on these features to support my persistent pain condition. It has also helped develop my therapeutic alliance with my therapist and improved my confidence and ability to progress.
In terms of mental health, I don’t think I was ever depressed going through my persistent pain journey, but I did find the journey very difficult emotionally at times. It helped me when physiotherapists and clinicians acknowledged this and listened.
I returned to work almost immediately after my accident 10 years ago, with varying amounts of success. I have been very grateful for the support I have been given by physiotherapists, and other clinicians, to remain in work. I am sure that if the physiotherapists had been operating purely in a medical model then this support would not have been offered, but I would say being able to continue in work has been key in terms of me being able to live well with persistent pain.
In terms of understanding my pain and acceptance of my situation, I am sure I have needed a great deal of support, in fact I know I have (sorry!). To learn to self-manage my condition, I have needed to understand that some of my psycho-social factors were likely impacting on my experience of pain, and to be given encouragement and support to make some changes.
Living with persistent pain is incredibly difficult. It affects every part of your life and impacts on the lives of your family and friends. It is impossible to disaggregate the pain from your social and emotional being. For a physiotherapist to understand my pain condition sufficiently well and to help me move forward both in terms of reduced pain and increased function, then I need to be considered as a ‘whole person’. I was fortunate that overall my physiotherapists took the time to consider both my physical presentation and my psycho-social presentation, consider how they intertwined and affected each other, and supported me to move forward.
Across the range of physiotherapy care I have experienced I think that overall I have been treated within a BioPsychoSocial Model. Some physiotherapists were better than others at taking into consideration my psycho-social factors, and some physiotherapists had more time within appointments to do so.
Looking back and comparing my experiences as a patient with that of my experiences as a school teacher, I don’t think the way my psycho-social factors were considered as a patient were entirely different to the way I used to consider the psycho-social factors of the children I taught (happy to be corrected!).
In the same way that if I wanted to get the best out of the children I taught, and help them to progress further, I would need to do more than just stand at the front and ‘deliver’ a lesson, the physiotherapists who got more out of me, and helped me progress did more than just treat my physical body. They listened to me and took account of me as a ‘whole person’, considering both the positive and negative aspects of my personality, my pre-dispositions, my current and past life experiences, my relationships and all the other things that make me the person I am. In particular they took account of how these factors might be impacting on my persistent pain.
Physiotherapists aren’t extensively trained in mental health, or social work etc, in the same way that I wasn’t as a teacher. If I had needed more specialist expertise, then my physiotherapist could have referred me on. All the physiotherapists I encountered had the personal skills necessary to engage well with me and facilitate the disclosing and discussion of the psycho-social factors I presented with. I don’t know whether all of them had the expertise to sufficiently utilise this information in their clinical reasoning and so work out the best way to support me with my persistent pain condition. Some of them certainly did.
I can’t remember being specifically trained to consider a child’s psycho-social factors in my teaching, I don’t know if physiotherapists are specifically trained in this or not, but I think it would be helpful. I’m guessing that most physiotherapists already have the skills to undertake work within a BioPsychoSocial model, that many are probably doing so, and some will have been doing this for years.
Looking to the future, and as the profession develops, I wonder if there is anything majorly different I can expect when being treated by a physiotherapist working within the BioPsychoSocial model?
In the same way that I was free to identify which children needed more time and input, and to allocate my time accordingly, I wonder if physiotherapists will be able to offer differing appointment times according to need. Maybe they already can? I wonder if basic appointment times will be increased to facilitate more in-depth discussions?
I wonder if all the physical spaces that physiotherapists operate in will be made more private to facilitate more personal discussions?
I assume that as science advances and knowledge about the interrelationship between a person’s presenting physical condition and their psycho-social factors is furthered, that physiotherapists skills and knowledge will increase, and they will be better able to utilise the information given by their patients in their clinical reasoning. I wonder if this means I could have improved outcomes?
Thinking through my experiences, both within teaching and within my own physiotherapy care, there doesn’t seem to me to be anything mystical or magical about the BioPsychoSocial model. Unless I am misunderstanding or missing something key, then I think the model has been utilised reasonably well overall in my physiotherapy care, better by some physiotherapists than others, and isn’t in essence very different to the way I worked with psycho-social factors in my teaching. I hope the BioPsychoSocial model is further embraced by physiotherapists and all clinicians.