The current healthcare system functions within a behavioral model premised on the biopsychosocial theory (BPS Theory). Yet, all healthcare disciplines observe a narrow application of the BPS Theory. One specific challenge within the physical therapy discipline is the historical instruction to be psychologically informed. The suggestion to be psychologically informed parallels the criticized reductionistic approach of the Cartesian model of dualism. The physical therapy discipline has been silently directed away from the social determinants of our patient’s health and disability. The context of our patient’s existence is consistently deferred. The ultimate challenge of the BPS Theory is the contextualization of the psychosocial factors around biological factors when attempting to fully understand the neuromusculoskeletal impairments associated with maladaptive movement patterns and behaviors. The psychological focus has been specifically directed toward understanding fear and avoidance proclivities, the Fear Avoidance Model (FAM). Understanding fear was an excellent place to start. But, the conditions of fear still require distinctions to be fully psychologically informed. It’s time for a comprehensive application of BPS Theory.
The problem with focusing on fear
Being psychologically informed is a big ask that implies an understanding of affective and cognitive domains. It is not so easy to understand one’s feelings and the thoughts behind those feelings. Regarding musculoskeletal pain, the focus on fear was the perfect place to start as it exemplifies the threat response we instinctively obey. And, within the context of [chronic] pain, fear may have been the only place to start. Regardless, a unilateral focus on being psychologically informed may be both a powerful tool for understanding and a profound directional bias. We have focused on fear avoidance at the expense of investigating coping and resilience as well as social and cultural factors. The suggestion of focusing on a single substrate of the BPS Theory biases the understanding of the interdependent relationships between internal and external factors influencing the context of our patient. Let’s investigate the concept of fear a little further and discuss required distinctions.
We have focused on fear avoidance at the expense of investigating coping and resilience as well as social and cultural factors.
Clinical framing of fear
Interestingly, the FAM has evolved to include learning motivation and self-regulation, which demand even more psychological distinctions. No doubt, the fundamentals of fear occur with layered emotional and mental domains. For example, where does concern, catastrophizing, stress, anxiety, doubt, and despair exist within our clinical framing of fear? How does it affect learning and self-regulation? The intensity of these cognitions and emotions offers either positive or negative influence over the outcome, which is based on personal appraisals of circumstances. Investigating fear allows an understanding of some cognitions and behaviors. However, we cannot understand the context of those cognitions and behaviors without delving into distinctions and underlying premises. Therefore, the context of fear requires investigation into the social and cultural reinforcements, particularly knowing that social well-being is critical to physical and psychological health.
Social determinants of health
The World Health Organization (WHO) defines social determinants of health as: “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.” The social determinants of health also include income, support system, childhood development, education, employment, housing, and gender. The argument in this blog is for a broader yet more efficient manner for this line of questions to discover a place to start and a direction to go when evaluating our patients. My suggestion for the best way to consider a meaningful totality and a contextual direction of our patient is to inquire about a factor that bridges both psychology and social determinants.
Bridging the gap with self-efficacy
Self-efficacy bridges the gap between the psychological and social factors by drawing from Social Cognitive Theory (SCT). SCT is a psychosocial blend of cognitive, emotional, behavioral, and environmental factors. Self-efficacy is defined as “a belief in one’s capabilities to organize and execute the courses of action required to manage prospective situations” (Bandura, 1995). An individual’s subjective assessment of their internal and external resources to cope is an expression of competence of control and self-regulation leading to self-efficacy. In this way self-regulation and control provide the contexts of self-efficacy that vary with personal experiences and dynamic interactions. Self-efficacy offers insight into one’s judgments of their own capabilities to execute a definitive performance and provides the most influential understanding of psychosocial considerations (Keedy, Keffala, Altmaier, & Chen, 2014). Overall, self-efficacy mobilizes specific skills toward a desired behavior and outcome. One’s self-efficacy is seen through their behavior rather than task completion. Understanding one’s behavior emphasizes the importance of an individual’s beliefs of their ability to successfully meet the demands of a particular situation, which explains how and why people either orchestrate or fail to orchestrate existing abilities in the pursuit of a goal or outcome. Social influences help an individual to create, develop, and reinforce self-efficacy. The constructs of self-efficacy are reinforced or compromised through personal control of somatic and emotional states related to anxiety, stress, distress, and depression (Keedy, 2014; Pajares & Schunk, 2001). Self-efficacy, as a positive psychosocial construct, has developed considerable traction to explain the development of chronic pain and disability. The ultimate suggestion is that self-efficacy plays a mediating role toward the development of resilience or disability.
Self-efficacy mediates the relationship between pain related fear and chronic pain outcomes & disability (Woby, Urmston, & Watson 2007). Self-efficacy mediates the relationship between depressive symptoms and pain (Skidmore, Koenig, Dyson, Kupper, Garner, & Keller, 2015). Self-efficacy mediates the effects of negative cognitions on post-traumatic distress (Cieslak, Benight, & Lehman, 2008). Self-efficacy mediates the impact of pain catastrophizing and disability (Shelby, Somers, Keefe, Pells, Dixon, & Blumenthal, 2008). My research identified the potential for self-efficacy to mediate the relationships between fear, catastrophizing, and depression with reported disability. In fact, my research found that for every digit increase on the pain self-efficacy questionnaire there was a nearly symmetrical corresponding decreased digit in reported disability. It seems that an individual’s cognitive appraisal and integration of their experiences ultimately determine self-efficacy and disability. It is time to start measuring self-efficacy of our patients as a quintessential marker reflective of the BPS Theory and behavior. The physical therapy evaluation that aims to understand this may better discern what needs to be investigated further and the direction to endeavor as we guide our patient through their rehabilitation.