Judging by the response to last week’s post on the Biopsychosocial (BPS) Model, it is clearly a subject that is exercising the minds of a lot of physio/physical therapists. Not wanting to play a kind of ‘dog-whistle’ politics – where someone lights a torch under an incendiary issue and then walks away – I wanted to take in the flavour of the discussion before coming back to the blog to compose some reflections.
So firstly, thanks to everyone who took the time to share their thoughts on the subject last week. The conversation felt thoughtful, courteous and respectful of people’s different positions.
In answer to the question of whether last week’s blogpost was just lofty philosophy with no practical use, I would have to disagree. Firstly, to my mind, all good theory/philosophy is practical – it deals with the eternal question of how we should/might live – or in this case, how we might ‘practice’. Every facet of practical physiotherapy is underpinned by some sort of philosophy. The question is perhaps more about how much we are prepared to make these particular ways of thinking and acting overt. Most physiotherapists have been trained in a positivistic tradition that doesn’t generally acknowledge its underpinning belief systems, but that doesn’t mean that they’re not there, or wouldn’t benefit from a bit of an airing now and then.
Another criticism of last week’s blogpost was that it didn’t really offer a practical alternative to the BPS model. This is true, but I should sat that I did not argue that “the BPS model is flawed, and here’s a better model” for some quite deliberate reasons:
- Philosophically speaking, I don’t believe my job, or indeed our job as collaborators in this conversation, to tell people the answer. For one thing, I don’t believe there is one answer. I believe in a plurality of right answers; a more complex picture than a simple linear model that might suggest that what’s right for me is also right for you. I don’t believe that an English-trained physiotherapy lecturer in New Zealand has any justification for saying that you should definitely use Mason Durie’s Whare Tapa Wha model instead of the BPS Model, for instance.
- What’s more, I don’t believe there is a model that is any less flawed than the BPS model. Most of the alternatives, including Trevor Hancock’s Mandala of Health, Cheryl Cott et al’s Movement Continuum, Broberg et al’s conceptual framework, the Norwegian model of psychomotor physiotherapy (Dragesund & Råheim 2008), or the model of embodiment Barbara Gibson and I critiqued in 2008, struggle because they often over-reach themselves. In the act of being ‘holistic’ they exclude as much as they include, and they leave no room for physiotherapists to identify their own point of difference. The same criticism could be leveled at Shirley Sahrmann’s recent call for physical therapists to embrace ‘The Human Movement System’.
- Models like the BPS, also completely fail to acknowledge the diverse and often contradictory and competing ideologies that make up the model’s segments and parts. The BPS model, for instance, attempts to reconcile a biomedical view of the body, which says that the body can be understood as a connected network of systems and structures (reductionism); that fail and lead to sickness, madness and disability, which constitute (labelling, taxonomy) various forms of deviation from the norm (normalisation), that can be located (specific aetiology), by suitably trained medical practitioners (professionalisation, objectivity, science), with the disorder remedied or repaired through medical intervention, with ‘social’ and ‘humanistic’ aspects that come from completely different belief systems. To position oneself within a social or humanistic paradigm is, in many cases, to oppose many of the principles of biomedicine. So any model that neatly juxtaposes these often conflicting and contradictory positions, in the belief that they can sit neatly together in one basket, is perhaps both critically naive and deeply problematic.
So the question raised by the BPS model is as much about models themselves as it is about this particular iteration. It is perhaps no surprise that physiotherapists are increasingly interested in models and frameworks – given that we are increasingly looking to broader, more meaningful ways of expressing the complexity of the work we do. I think the search for new models also underpins the interest in more complex health problems like chronic pain. Clearly the days of routine post-op leg exercises and low-grade treatments are coming to an end for physiotherapists, and the future for the profession looks increasingly specialised and complex. So not surprisingly, approaches that try to capture this shift are appealing. I have to say though, for all the reasons above, I’m nervous about any and all models that attempt to ‘capture’ physiotherapy in these ways.
I do think these models can serve a purpose though. If they highlight previously underdeveloped or underexplored aspects of physiotherapy, then that can be a very good thing. If we return to the BPS model, for example, it mirrors most other ‘holistic’ models in identifying physical, existential/experiential (a much broader concept than ‘psychological’) and socio-cultural aspects of people’s health and wellbeing. Physiotherapists have always been strong in the physical domain, but are increasingly exploring the existential and experiential aspects of practice, particularly in Scandinavia – where the work on the embodiment of pain is groundbreaking. I think, though, that we are much less well developed in the soci0-cultural aspects of our practice. And this is, perhaps, one of the most exciting and fertile areas of growth for physiotherapy in the future – because it has been so underdeveloped.
So, for example, a physiotherapist that chooses to align themselves and their practice with an overtly social and cultural paradigm might choose to:
- Locate their clinic in the poorer areas of town where people experiencing the greatest social determinants of health live
- Look for remuneration that doesn’t disadvantage poor people – government assistance programmes, community support funding, etc., instead of direct or indirect user-pays models
- Remove the all-too-common images of young, fit, white, semi-naked bodies from their clinic signage and promotional material and, instead, use more inclusive pictures of real people, people in the community they work in, etc.
- Perhaps even dispense with the idea of having a clinic that people have to travel to at all; taking the clinic out to the community where the people are
- Devolve all of their professional power and authority to the community itself: allowing community elders or groups of locals to set the treatment priorities and determine how and when we work to best meet the needs of the community
- Move away from bio-centric, evidence-based justifications for practice, to embrace whatever explanatory frameworks are meaningful to the community
- Live and work in and for the community: offer free sessions; group therapy; family appointments; move away from individual one-to-one treatments
- Reject behaviourism and victim blaming, focusing instead on community activism and tackling the structural barriers to good health (safe walking spaces, tackling violence against women and children, campaigning for better paid work, etc.)
- Use their professional power and social standing to become a vocal advocate for the needs of the people in their community – lobbing for more funding and government assistance and greater recognition of community needs
These are only some of the practical ways that a philosophical shift towards just one dimension of many of the ‘holistic’ models of health could be worked through by physiotherapists. Hopefully, its possible to see how some of these actions are at odds with some of the principles and aspirations of biological and existential/experiential approaches and cannot be easily reconciled, but completely available to practitioners like physiotherapists if they choose to shift their philosophical position.
So to sum up, it has been wonderful to see the flourishing of ideas around the BPS model. I had an email this morning from a colleague in America who took the time to send me his own explanatory framework. It was very different to my own and all the more interesting to me as a result. I’ll enjoy following the conversation with him off line (his choice). His framework is strongly grounded in Anglo-American analytical philosophy and held some really interesting ideas for new ways to think and practice. We will need so much more of this kind of debate and discussion in the future if the profession is to make sense of the changes taking place in healthcare. I say ‘hallelujah’ and ‘bring it on!’
Broberg, C., Aars, M., Beckmann, K., Emaus, N., Lehto, P., Lähteenmäki, M. -L., . . . Vandenberghe, R. (2003). A conceptual framework for curriculum design in physiotherapy education – an international perspective. Advances in Physiotherapy, 5(4), 161-168. doi:10.1080/14038190310017598.
Cott, C. A., Finch, E., Gasner, D., Yoshida, K., Thomas, S. G., & Verrier, M. C. (1995). The movement continuum theory of physical therapy. Physiotherapy Canada, 47(2), 87-95.
Dragesund, T., & Råheim, M. (2008). Norwegian psychomotor physiotherapy and patients with chronic pain: Patients’ perspective on body awareness. Physiotherapy Theory and Practice, 24(4), 243-54.
Hancock, T., & Perkins, F. (1985). The mandala of health: A conceptual model and teaching tool. Health Education, 24(1), 8-10.
Nicholls, D. A., & Gibson, B. E. (2010). The body and physiotherapy. Physiotherapy Theory and Practice, 26(8), 497-509.
Sahrmann, S. A. (2014). The human movement system: Our professional identity. Physical Therapy, 94(7), 1034-1042. doi:10.2522/ptj.20130319.