Dear BPS,
You were good to me. You helped me formalize my thoughts around pain. I felt validated in my humanistic philosophies with you. But Venn diagrams offer me no guidance in my care delivery. I tried to make it work for so long. But it is time for us to part ways. You were helpful, but you weren’t “right” enough. I have found a different model to replace you. One that I think puts an important piece into perspective. One that encourages me to reflect in ways I hadn’t before. I wish you well. I know we will see each other often, as we move in the same circles. You were a valuable companion.
With respect for our time together,
Devra
Engel’s Biopsychosocial Model (BPS), is the most prevalent framework for understanding pain. But has not done for us what the architects had perhaps hoped. In spite of Engel’s advocacy to the contrary, we continue to more heavily weight what we perceive to be objective information, when assessing validity of pain expression. I regularly encounter clinicians who have familiarity with BPS. When asked how the implement it, I am sometimes told that they offer the addition of some outcome measure or screening. But when you ask them what do they do with that information that those measures collect, I hear crickets. BPS is not something to be placed upon a patient, and yet it is. BPS does not offer us a basis to understand the interaction of the biological, psychological, and social factors, only to consider that the factors exist. It’s popularity has increased awareness of the complexity of pain beyond pathology. And that is incredibly important and not to be minimized. However, it doesn’t offer enough to guide, to predict, or to influence and thus inform our practice. And if it can’t do those things, is it even a model in a true sense? BPS accurately notes that psychosocial factors are present across all existence. However, we still frame the patient as being in a bubble unto themselves. And I, the practitioner, view them as a specimen to be examined, like a butterfly in a bell jar. Never acknowledging that my putting them under the glass, may have had an effect.
Medical systems frame clinicians as the experts with an assumption of impartiality. How can we rationally believe that we examine all factors related to the human before us, understand their full complexity and influence, and use that to impart what we believe to be best care. We can’t ever really know. We can only think we know. Such that we as practitioners feed into our own confidence in knowing and ego as identified experts. I can only “know”, if the patient relays their reduced suffering. Which relies on their own self-evaluation and all the nuances of humans reconcile our ought, actual, and idealized selves and dwindling affordances. “I am not who I was and who I want to be.” Versus, “I will never again be who I was, but I am engaging with things that are important to me.” If I observe progress as I define it based on engagement, and they do not as they define it based on identity, then what have I achieved as their carer? We are systematically disconnected from our patients. And that needs consideration.
We must look relationally, and at ourselves as healthcare practitioners.
To better inform practice, we need a model that includes our actions as medical providers. The Social Communication Model of Pain (SCMP) shows us how pain is interconnected to care provision. It integrates the evolutionary development of social intelligence and group dynamics into the theoretical model of the experience of pain.
Prior to the pain experience is foreknowledge. What we know, health, economics, social status, family, medications, stress, etc. all contribute to expectation and prediction for all parties. There begins an initial manifestation of pain from which a pain experience emerges. The experience is informed by these expectations, predictions, knowledge, emotions, thoughts, the environment, social factors, and specific circumstances of the immediate context. From this, the expression follows. The presence of others as observers, leads to the need for pain communication to express the experience and need for help. But, can the observer be trusted? Is their support necessary? Are they a gate keeper to care? How can they help? Who they are, to the person experiencing pain, changes the purpose of expression. It doesn’t end there, SCMP is bidirectional and has a feedback loop. Observers respond to their perception of the pain expression. The observer makes a determination of meaning of the expression and takes action or inaction that is received by the suffering person. The reliance on a caregiver’s recognition and response to the expression, impacts the pain and suffering itself.
SCMP recognizes pain expression as a call to action, a call for support from an “other”. This feature of the model requires us as caregivers to reflect on how our interactions with the person in pain, may impact the person before us. Differentiating intrapersonal factors, from context dependent ones. Intrapersonally “...the experience of pain reflects the biological substrates, as well as the totality of the individual’s life experience predisposing to particular patterns of experience and expression.” (Craig 2009) Interpersonal influences may change expression based on audience and social setting in the moment. These dynamics are specific targets of the model. Who is the observer reading the expression, to the person experiencing pain? How do those relationships change the purpose of pain expression? Is the observer “...in a position to influence the suffering person’s pain.”(Craig 2009) Observers too bring their past experiences, perceived roles in the encounter, and judgements to the encounter. Observers are not immune to social and environmental contexts.
If a sufferer doesn’t sense that a recipient of their expression has understood them, what would you expect to happen? When I don’t think someone has heard me, I repeat myself and talk louder. SCMP helps us to understand some of the underpinnings to patients urgency in their communication. They want to be heard, and aren’t sensing that they have been.
The thing we as care providers have influence over in SCMOP, is what the model calls “action”. Our response to the person experiencing the suffering. Note that “treatment” is not solely what is highlighted here. Included in “action,” is our communicative response. This offers us an important consideration, irrespective of interventions offered or not.
Let us look at the example of an individual seeking care for unexplained widespread pain. To illustrate we will reflect on the communication of test results. “We have found no serious pathology. As there are no findings or diagnosis, there is no treatment we can offer you.” Versus: “The good news is that we found nothing serious to be worried about in your work up. But we recognize that you are still suffering and we will continue to work to help this.” Our interaction can be as important as the findings. Dare I say, maybe even more important?
Consider your relationship and communication, as the intervention that fosters a sense of safety. If instead of being worried by the limited time I have with a patient, what if I changed my focus to behaviorally demonstrate that I care, validate, and recognize the suffering they are communicating to me. Dose yourself.
De Ruddere L, Goubert L, Vervoort T, Prkachin KM, Crombez G. We Discount the Pain of Others When Pain Has No Medical Explanation. J Pain. 2012;13(12):1198-1205. doi:10.1016/j.jpain.2012.09.002