Principle 2: Adopt a biopsychosocial approach
Key messages
- Healthcare professionals must consider the biological, psychological and social factors that influence a person’s health as part of their assessment and treatment interventions.
- A biopsychosocial approach improves function, facilitates recovery and maximizes independence, while minimising the risk of long-term activity limitation, participation restriction, or persistent pain.
- The early identification and management of risk factors helps to address issues that can impact on an optimal outcome.
A healthcare professional adopts a biopsychosocial approach when he/she considers the biological, psychological and social determinants of health during the assessment and treatment of an injured person.1 For example, the healthcare professional treats the injured tissue or mental health problem, and also assesses whether the person has psychosocial risk factors that may hinder recovery. These could include unhelpful beliefs, issues with their work situation and other barriers to returning to work.
A biopsychosocial approach is based upon the management of the multiple factors that can affect function and participation at home, work and in the community. The WHO International Classification of Functioning, Disability and Health reflects a biopsychosocial approach.2
Current evidence indicates that the biopsychosocial approach to injury management is effective in improving function, facilitating recovery and maximising independence.
Early phase of injury management
Early injury management should focus on educating the injured person about their injury, reassuring them about the natural history of the injury, and emphasising the importance of early participation in home, work and community life despite the injury. By focusing on these areas early in the management of an injury, there is reduced risk of developing long-term activity limitations, participation restrictions and persistent pain.
Identifying risk factors
The early identification of risk factors across the biological, psychological and social domains is important during the assessment phase as it informs and guides treatment.
Poor or delayed outcomes from an injury can sometimes be explained by biological factors, such as serious medical complications or conditions. However, psychosocial risk factors (including unhelpful beliefs about an injury, job disatisfaction and low expectations about return to work) often contribute to poor outcomes for injured people.3
Risk factors can be classified according to the flags model, which describes the factors that can impede recovery and independence.
Table 2: The flags model4
| Biological Factors | Red Flags | Serious pathology Other serious medical conditions Failure of treatment |
|---|---|---|
| Mental Health factors | Orange Flags | Mental health disorders Personality disorders |
| Psychological Factors | Yellow Flags | Unhelpful beliefs about injury Poor coping strategies Passive role in recovery |
| Social Factors | Blue Flags | Low social support Unpleasant work Low job satisfaction Excessive work demands Non-English speaking Sense of injustice Problems outside of work |
| Other Factors | Black Flags | Threats to financial security Litigation Compensation thresholds |
Flags or risk factors can be identified by healthcare professionals using standardised risk assessment tools or through comprehensive history taking in the assessment phase. To ensure flags are addressed early, there are several questions the treating healthcare professional should ask themselves and the injured person:
- what factors are becoming a barrier and are preventing the injured person from improving their function, participating at home, work or in the community today?
- how can these barriers be addressed?
- is the current treatment having the expected effect on the injured person’s health, function, participation at home, work and in the community?
- would other healthcare professionals, health services (such as multidisciplinary services) or evidence-based treatments improve the injured person’s rate of recovery?
Developing a treatment plan to address these biological, psychological and social risk factors, and shape behaviour, is an important aspect of effectively preventing or managing persistent pain, activity limitation and participation restriction. It is also important to monitor flags or risk factors and adjust the treatment plan as an injured person’s experiences change. Some psychosocial factors cannot be changed, but a person’s perceptions and responses may be amenable to positive change. An effective biopsychosocial approach is usually based on good communication among stakeholders and often includes the involvement of multiple healthcare professionals.
The impact of personality and considerations for mental health professionals
Sometimes personality characteristics (such as obsessional traits) and poor coping styles add complexity to the provision of treatment and can impede an injured person’s progress. Considering these characteristics during the design of treatment plans, particularly psychology treatment plans, can help to reduce the risk of activity limitations, participation restrictions, persistent pain or chronic mental health problems. However, it must be remembered that before their injury the person had the same personality and coping style.
Generally, personality characteristics should not become the focus of treatment. The exception is where personality characteristics are associated with an ongoing lack of response to treatment or a high risk of relapse. In these instances referral to specialist mental health professionals or services should be considered.
References
1. Engel, G 1977, ‘The need for a new medical model’, Science, vol 196, pp.129-136.
2. World Health Organization 2001, International Classification of Functioning, Disability and Health, World Health Organization, Geneva.
3. Based on Waddell, G, Burton, AK, Main, CJ 2003, Screening to identify people at risk of long-term incapacity for work: A conceptual and scientific review, The Royal Society of Medicine Press, London.
4. Based on Main, CJ, Sullivan, MJL and Watson, PJ 2008, Pain Management: practical applications of the biopsychosocial perspective in clinical and occupational settings, Churchill Livingstone, Edinburgh, New York.
