Towards an ethical multiplicity in low back pain care: Practising beyond the biopsychosocial model

Abstract

The biopsychosocial model is currently considered by most researchers and clinicians to be the best approach to low back pain (LBP) care. The model was popularised in LBP care in response to some clear deficiencies in earlier biomedical approaches and is now widely recommended in clinical guidelines and policy statements. Yet the biopsychosocial approach has also been critiqued for its narrow conceptualisation and application. In this article, we explore how attending to the multidimensionality of LBP in practice goes beyond a biopsychosocial approach. We engaged with 90 ethnographic observations of clinical practices, 22 collaborative dialogues with clinicians, and eight consultatory meetings with people with experience of LBP to consider the sociomaterialities of clinical practices in two settings: a private physiotherapy practice and a public multidisciplinary pain clinic. Drawing on the work of Annemarie Mol and Rosi Braidotti, our analyses suggest that sociomaterial practices, involving human and non‐human actors, produced multiple objects of clinical attention and ethical concerns about how to attend to this multiplicity well. We argue that the multiplicity of LBP is attended well by reimagining: (1) clinical settings as ‘becoming more‐than‐sterile environments’ where objects, furniture and elements such as tears and laughter help to provide a relational, welcoming and comfortable space to all bodies with LBP; (2) differences through ‘becoming minoritarian’ where considering power relations allows actions towards connectiveness and belonging; and (3) disciplinary boundaries through ‘becoming interdisciplinary within’ where actions expand traditional scopes of practice. The flux of these multiple becomings moves clinical practice and conceptualisations beyond the biopsychosocial approach to consider a new ethico‐onto‐epistemological approach to LBP care. They invite clinical practices that engage with an ethical multiplicity of LBP care, providing a better understanding of how places, objects, emotions, power, bodies and professions are interconnected and come together in everyday practice.

INTRODUCTION

Low back pain (LBP) is a condition that affects millions of people worldwide and has received considerable research attention in attempting to alleviate its burden (GBD 2017 Disease and Injury Incidence and Prevalence Collaborators, ²⁰¹⁸). LBP is broadly recognised as being multidimensional and shaped by biological, psychological, experiential, social, cultural and material factors (Hartvigsen et al., 2018; Waddell, ¹⁹⁹²). For example, research suggests that most people with LBP do not have a known pathoanatomical cause for their pain (Maher et al., 2017), and that multiple factors such as psychological factors, disability, social isolation, social stigma and socioeconomic status are intertwined with peoples’ pain experiences (Karran et al., 2020; Maher et al., ²⁰¹⁷). Further, people with ongoing LBP often report feeling disempowered by experiences related to their pain, including having unsatisfactory relationships with health‐care professionals, and not being listened to when seeking care for their pain (MacNeela et al., 2015; Rodrigues‐de‐Souza et al., ²⁰¹⁶). Engel’s (1977) biopsychosocial model is one of the most advocated models, attempting to explicate the intersection between biological, psychological and social dimensions in the process of ill health. Although originally from psychiatry, the biopsychosocial model is considered by clinicians, researchers, and leading health organisations around the globe to be the best approach to providing care for people with LBP and has been adopted widely in policy statements (Department of Health, 2019) and clinical guidelines (National Institute for Health and Care Excellence, 2016).

Despite its uptake, the biopsychosocial model has faced critique. For example, Stilwell and Harman (2019) argue that the model takes a fragmented approach, while Bolton and Gillett (2019) assert that it lacks a clear theoretical foundation. Such critiques are scarce in LBP literature, but one critical review of researcher discourses suggests that its use can lead to an under exploration of multiple other factors important to LBP care and restrict how care is provided in clinical practices (Mescouto, Olson, Hodges, & Setchell, 2022). In this article, we engage with critiques of the biopsychosocial model by analysing ethnographic observations of a fee‐for‐service physiotherapy clinic and a publicly funded multidisciplinary pain clinic, collaborative dialogues with clinicians and consultatory meetings with people with lived experience of LBP. We explore how the care of people with LBP goes beyond a biopsychosocial approach to argue that—in practice—there are multiple dimensions outside the trifecta of bio, psycho and social dimensions of care. We establish a sociomaterial perspective that considers the entangled social and material aspects shaping clinical interactions. This approach adds further layers for clinicians, researchers, educators and policymakers attending to the multidimensionality of LBP care.

We begin by exploring the shortcomings of the biopsychosocial model and discussing the potential benefits of engaging a sociomaterial theorisation in the context of LBP health care. We then introduce how bringing together Annemarie Mol’s concept of multiplicity and Rosi Braidotti’s nomadic ethics offers a conceptual framework that broadens how LBP care can be understood and practised. We conclude by discussing the implications of our approach for the advancement of pain research, practice and theory.

Shortcomings of the biopsychosocial model

The biopsychosocial model, it is argued, limits and fragments the body into biological, psychological and social dimensions. Although important, these dimensions are deemed insufficient to account for the complexities of ill health processes. For example, others have suggested the model should add spiritual (Sulmasy, 2002), ethical (Bolton & Gillett, 2019), cultural (Pham, 2015), digital (Ahmadvand et al., 2018) and technical dimensions (Card, 2022). Furthermore, the term ‘sociopsychobiomedical’ has been advocated (Department of Health, 2019) to decrease the overwhelming focus on biomedical aspects. Our past work suggests that physiotherapy research (Mescouto, Olson, Hodges, & Setchell, 2022), physiotherapy practice (Dillon et al.; Mescouto, Olson, Hodges, Costa, et al., ²⁰²²) and multidisciplinary practice (Mescouto, Olson, Costa, et al., 2022) continue to focus on biological and narrow ‘psychological’ aspects of LBP, with little consideration of the multiple other relevant dimensions. Although some have counter‐argued that psychosocial matters have been overemphasised (Hancock et al., 2011; Jull, ²⁰¹⁷), the underlying assumption within the biopsychosocial model seems to lie within a biomedical paradigm despite being established to counter it (Mescouto, Olson, Hodges, & Setchell, 2022). The unintended effect is the fragmentation of dimensions, which is reinforced in the way health care attends to conditions.

The resulting fragmentation is underpinned by the model’s lack of philosophical/theoretical clarity. Although Engel considered General System Theory as a philosophical base for the biopsychosocial model (Engel, 1977), he provided limited elaboration, prompting critiques that the biopsychosocial model lacks a theoretical foundation (Benning, 2015; Bolton & Gillett, ²⁰¹⁹; Borrell‐Carrió et al., ²⁰⁰⁴). Furthermore, a dominant (often implicit) positivist biomedical approach guides the application of the biopsychosocial approach (Hatala, 2012). These philosophical discussions have mainly occurred within psychiatry; to our knowledge, only Stilwell and Harman (2019) have proposed a different theoretical foundation for the biopsychosocial model in the context of pain. Their enactive approach to pain involves a more relational and interconnected framework between brain‐body‐world, incorporating the environment and the phenomenological first‐person experience of pain (Stilwell & Harman, 2019). That is, an enactive approach considers peoples’ pain experiences, or the sense‐making of pain, as an active and interrelated process of a physical body (e.g., the brain and nervous systems’ role and bodily movement and orientation in pain representations) and the environment (e.g., peoples’ social contexts, relationships and their engagement with the world). Although enactivism is a promising approach, it focuses on cognition based on phenomenological assumptions about the body and the world, foregrounding the human experience. A sociomaterial approach could add to this approach, helping to move beyond anthropocentric understandings of pain.

A sociomaterial approach to low back pain care

Sociomaterial theorisations can lead to more comprehensive and multidimensional conceptualisations of bodies and social worlds. Although diverse in nature, sociomaterial approaches share two overarching understandings: (1) that phenomena and the world are shaped by social and material forces; and (2) that boundaries between social/material, body/mind/world, human/things are artificial (Barad & Alice, 2007; Braidotti, ²⁰¹³; Latour, ²⁰⁰⁵). The material and social are ontologically entangled. For example, a sociomaterial approach illuminates how physical spaces and geographical places interact with people’s wellbeing and health, and their affect on social dis/advantage (Fox & Powell, 2021). It can also provide in‐depth insight into how technology influences clinician‐patient interactions (Asan & Montague, 2014), and how COVID‐19 restrictions impact how people interact with places, other people and conflicting emotions (Lupton & Lewis, 2021). Taken together, these examples illustrate the emerging agency of multiple elements, their interconnectedness and their direct impact on people’s health. Thus, sociomaterial theories can assist in reassembling, following the fragmentation imposed by the biopsychosocial model; they can provide different ways of approaching the multidimensionality of health conditions, including LBP, and bodies beyond ontologically distinct bio‐psycho‐social entities.

While sharing the commonalities discussed above, sociomaterial approaches are many: actor‐network theory (Latour, 1996, 2005), feminist new materialism (Barad & Alice, 2007; Haraway, ¹⁹⁸⁷) and posthumanism (Braidotti, 2013). To provide a theoretical avenue for the multidimensionality of LBP and think/act beyond the confines of the biopsychosocial model and enactivism, we engage with the sociomaterial work of medical anthropologist and actor network theorist Annemarie Mol and posthuman scholar Rosi Bradotti. In her ethnographic work in a Dutch hospital, Mol (2002) explores how health‐care practices enact atherosclerosis as a ‘more than one’ condition. Practices not only produce different perspectives but also produce different realities. Atherosclerosis is multiple: it is blood test results, pain while walking and plaque in a dissected artery. Although not specific to LBP, Mol’s concept of multiplicity emphasises how the biological and psychosocial realities, which are often dualised, are interconnected in practice and should be considered together with other seemingly ‘mundane’ things. According to Mol:

The humane does not reside exclusively in psychosocial matters. However important feelings and interpretations may be, they are not alone in making up what life is all about. Day‐to‐day reality, the life we live, is also a fleshy affair. A matter of chairs and tables, food and air, machines and blood. Of bodies.

(Mol, 2002, p. 27)

Mol moves away from a solely phenomenological/humanistic notion of the body (such as in the biopsychosocial and enactivist approaches) to consider furniture, sustenance and technology as part of ‘the life we live’. Together with other Actor‐Network Theory scholars (Latour, 1996; Law & Mol, ²⁰⁰²), Mol highlights how human and non‐human actors interact in networks to create different realities. This relational ontology allows a consideration of bodies beyond only experiences, feelings and thoughts. The body is multiple, and its multiplicity is made of sociomaterialities.

If the body (and reality) is multiple, then which reality/body should we focus on when thinking/practising the multidimensionality of LBP? Mol (2002) does not answer the question but asks how a body multiple can be done well, leaving readers with the resources to acknowledge a condition’s multiplicity but not how to attend to it. A similar concern has been discussed within the biopsychosocial model: Ghaemi (2009) argued that it shows you what to see, but not how to act. The plurality of this model leads to the ultimate paradox: ‘Free to do whatever one chooses, one enacts one’s own dogmas (conscious or unconscious)’ (Ghaemi, 2009, p. 3). This paradox could explain why researchers tend to use the biopsychosocial model to focus on biological and psychological aspects of LBP (Mescouto, Olson, Hodges, & Setchell, 2022) while maintaining positivist assumptions (Hatala, 2012). Mol’s concept of multiplicity brings light to health care’s ‘ontological politics’ (Mol, 1999, 2002) by recognising that although a condition is more than one, or multiple, it is less than many (Mol, 2002). Certain practices—and therefore certain realities—are prioritised over others. The concept of multiplicity does not discuss such prioritisation in depth, making it insufficient for unpacking how the multidimensionality of LBP can be done well. Here is where posthumanist accounts of the body can be useful.

Posthumanism shares Actor‐Network Theory’s relational ontology, with some scholars drawing attention to an ethical engagement with multiple others. Unlike biomedical bioethics, where a person is conceptualised as an autonomous, disembodied, fixed subject expected to engage with principles and act under a common and shared morality (Beauchamp & Childress, 2019; Olson, ²⁰²¹), posthumanist ethics rejects universalism. For example, Braidotti’s (2006) posthuman nomadic ethics, drawing from Deleuze and Guattari’s (1986) earlier conceptualisations, is concerned with relationality, praxis and sustainable affirmative ways to act on positive and creative changes without assuming an a priori moral subject. According to Braidotti (2006, p. 343):

This posthuman ethics rests on a multilayered form of relationality. It assumes as the point of reference not the individual but the relation. This means openness to others, in the positive sense of affecting and being affected by others, through couples and mutually dependent corealities. Containment of the other occurs through interrelational affectivity and the construction of common planes of actualization of alternative subjects, projects and communities.

(Braidotti, 2006, p. 343)

Therefore, a posthuman perspective takes a much more contextual and dynamic approach to ethics. From this perspective, ways of being (ontology) and knowing (epistemology) about and in the world are inseparable from ethical concerns, also exemplified in Barad’s term ‘ethico‐onto‐epistem‐ology’ (Barad & Alice, 2007). A nomadic vision of the subject recognises complex socio‐political, historical, temporal, environmental and power‐laden relational forces responsible for interacting with and shaping the subject and how the subject interacts with others—both human and non‐human.

In this article, we contribute to this growing body of work by employing a sociomaterial lens in LBP practice. We engage with Mol and Braidotti’s work to argue for a new ethico‐onto‐epistemological approach to LBP. We will do this by presenting how we entangled with data at two common sites of LBP health care in an urban area in Australia: a private physiotherapy clinic and a public multidisciplinary pain clinic. We (researchers) entangle with clinicians and people with lived experience with LBP to add to the multidimensionality of our exploration of these practices. The article concludes by offering implications for practice, research and pain theory.

RESEARCH ENTANGLEMENTS

Our sociomaterial approach shapes the research practices used in this study. We use post‐qualitative inquiry (St. Pierre, 2018) and the process of ‘thinking with theory’ (Jackson & Mazzei, 2012) to challenge conventional humanist qualitative methodology. Such forms of inquiry propose different ontological orientations for research practices: conceived as an assemblage (Aranda, 2020) and as immanent (St. Pierre, 2018). Research‐assemblages include relations between bodies, places, research tools and contextual elements of research that shape what researchers choose to attend to and report on (Fox & Alldred, 2017). Similarly, an ontology of immanence fosters the recognition that ‘research’ is not separate from the world/us; practices are not pre‐existing but in the process of continual transformation—from conception to writing (St. Pierre, 2018). Sociomaterial theories do not have a particular predetermined set of methods. As such, we draw on empirical work from a larger project conducted from April 2019 to June 2021. This study was approved by the University and hospital ethics committees [#2019002446 and #2019000231]. All participants provided written or verbal consent.

To explore LBP’s multidimensionality, we used ethnographic observations of clinical practices at each site, reflexive dialogues with clinicians and participatory consultations with people with lived experience of LBP. Aligned with Mol’s concept of multiplicity, ethnographic observations attend to daily practices (or doings), allowing exploration of the interconnectedness between people, things and meanings (Hatfield, 2020). Ethnographic fieldwork can, however, emphasise power imbalances between researchers and participants (Griffin & Bengry‐Howell, 2017). To account for this asymmetry, we incorporated participatory consultations with clinicians and people with lived experience of LBP. Considering a posthumanist ethical approach and its commitment to social justice, having patients and clinicians as active and transformative actors in the research process was deemed a more responsible way of engaging with the world, research, and each other (Barad & Alice, 2007; Braidotti, ²⁰¹³; Haraway, ²⁰¹⁶). We describe these multiple research entanglements in more detail below.

We produced a total of ninety 30min‐3h ethnographic observations across the two sites. Five researchers (including primary author KM) with backgrounds in health sciences, education and experiences in both qualitative and quantitative research designs attended the clinics approximately once a week. Some authors already had prior entanglements with the sites—one (JS) had worked in the private clinic previously as a physiotherapist and knew some of the patients and clinicians. Researchers wrote fieldnotes about the physical space, verbal and non‐verbal aspects of clinician‐patient interactions and clinician‐clinician/staff interactions. Fieldnotes also included the researchers’ thoughts and emotions entangled with what was being observed. During COVID‐19 distancing restrictions, the study was paused or clinicians’ video or audio recorded their own sessions (n = 14). The recordings were transcribed, and the researchers analysed the videos to take note of further non‐verbal communication and information related to the room’s physical space. We believe that this adapted approach had minimal impact on the overall dataset/analyses, due to its similarity to the original methods and because it only occurred in a small portion of observations (<20%).

All clinicians from the two sites were invited to participate in the study. We asked clinicians and clinical staff to identify adult patients with a primary complaint of LBP and include a wide range of age groups, gender, ethnicity and years living with the LBP. Of the 35 clinician‐participants observed, 23 identified as female and 12 as male. Clinicians were from different professional backgrounds—physiotherapy, psychology, nursing, occupational therapy, general practice, pain and addiction specialisations and psychiatry—aged between 25 and 60, with an average of 18 years in their occupation. Patient‐participants were aged between 22 and 85, with an average of 16 years of living with pain. Of the 77 patient‐participants, 57 were identified as female and 20 as male.

Finally, we engaged and collaborated with clinicians and four people with lived experience of LBP—referred to here as advisors. We met with clinicians and advisors separately to share excerpts from observations and invite discussions about the social and material aspects of clinical practices. With clinicians, we conducted a total of 22 reflexive dialogues to critically explore assumptions and worldviews on health‐care practices (Kumagai & Naidu, 2015; Setchell & Dalziel, ²⁰¹⁹; Setchell et al., ²⁰¹⁸). With people with lived experience of LBP, we had eight advisory meetings (Mescouto & Setchell, 2020). The meeting content was flexible and often participant‐driven, prompting a collective entanglement of experiences, backgrounds, feelings and stories. Advisors were not patients from the study sites. They had extensive experience with health‐care providers, including but not limited to settings similar to our project sites (physiotherapy clinics and multidisciplinary pain clinics). All reflexive dialogues and panel advisory meetings were recorded and professionally transcribed.

Overall, by engaging with a private physiotherapy clinic and a multidisciplinary pain management service, we gained insight into multiple settings (private and public), pathways of referrals, and professionals (physiotherapists and multidisciplinary team) who provide care for people with LBP. As the study progressed, due to its interactive nature, we (authors) became more closely entangled with the sites. For example, KM became familiar with the sites, clinicians and staff when doing the observations at the same time that the sites and staff became familiar with her presence, one clinician started a PhD with JS during the project, and clinicians from the research team and advisors co‐authored papers related to this project. The boundaries between researchers/researched, data/real life, outsiders/insiders—aligned with our theoretical approach—were blurred. These blurred boundaries are illustrated in the way we present our analyses and applied examples below.

Entangled analyses

Our analyses were collaborative and iterative, moving between inductive and theory‐driven approaches. The multiple actors (researchers, clinicians, advisors, observations, experiences, contexts, cultures) were directly—and indirectly—entangled in our analytical processes. Initially, we advanced our analysis across three collaborative spaces: clinician dialogues, advisory meetings (described above) and research team analysis meeting. The two‐hour research meetings were held monthly, fostering predominantly inductive analyses recorded summatively through notetaking. This broader research team comprised people from diverse backgrounds (physiotherapy, sociology, neuroscience, psychology) and nationalities (Brazilian, North American, Australian, Sri Lankan, Irish), including partners from the study sites (two physiotherapists and one psychologist). They had a range of experiences with different health‐care systems and research designs—from quantitative to qualitative and post‐qualitative research expertise. Some researchers had also been clinicians, and some had lived with significant LBP, making the entanglement and separation between researcher/researched and object/subject even more profound. All these entanglements shaped our analysis.

After initial group analyses for this article, we (the three authors, a subgroup of the larger research team) then moved to the process of ‘thinking with theory’. According to Jackson and Mazzei (2012), ‘thinking with theory’ is a process of engaging simultaneously with philosophical and sociological concepts and research data. Instead of looking at patterns or developing codes, researchers connect with theory and data through rounds of simultaneous reading in a process of ‘plugging in’. ‘Plugging in’ is a highly experimental process that involves: (1) Showing how theory and practice constitute one another, (2) Being transparent in what research questions are possible with one’s selected theory, (3) Working repeatedly with data excerpts to create new knowledge and show the interconnectedness between theory and data (Jackson & Mazzei, 2013). Our sociomaterial lens and use of Mol’s concept of multiplicity informed by Braidotti’s nomadic ethics followed an iterative process of ‘reading‐the‐data‐while‐thinking‐the‐theory’ (Jackson & Mazzei, 2013, p. 264) and engaged with elements from the meetings with researchers, clinicians and advisors. Such entanglements provided different insights and explorations in health‐care practices in the care of people with LBP.

In alignment with our sociomaterial approach, we recognise that our multiple analyses were shaped by different human and non‐human actors: the interactions between researchers‐clinicians‐people with LBP; the places where we conducted such analyses (universities, clinic, hospitals, periods of isolation at home); the time availability for each meeting; the discourses and cultural norms presented in each different group; and finally, the theory we chose. Such entanglements make us aware that the way we chose to construct these stories/findings/paper is one possible path among many.

A FLUX OF MULTIPLE BECOMINGS: TOWARDS AN ETHICAL MULTIPLICITY OF LBP

Here, we explore applied examples from our two clinical sites while ethical considerations are surfaced though attending to LBP’s multidimensionality. By focussing on relations, our approach rejects the idea of unitary fixed moral subjects and recognises subjects as multiple becomings in flux. As Braidotti (2006, p. 163) explains:

Becoming is an intransitive process: it is not about becoming anything in particular (…) It is not deprived of violence, but deeply compassionate. It is an ethical and political sensibility that begins with the recognition of one’s limitations as the necessary counterpart of one’s forces or intensive encounters with multiple others. It has to do with the adequacy of one’s intensity to the modes and time of its enactment. It can only be empirically embodied and embedded, because it is interrelational and collective.

(Braidotti, 2006, p. 163)

In the examples that follow, we expose moments where clinical interactions seemed to embrace interrelationality and collectiveness between patients‐clinicians‐objects‐space‐emotions and embrace an ethical multiplicity of LBP through processes of becoming more‐than‐sterile environments, becoming minoritarian and becoming interdisciplinary within.

Becoming more‐than‐sterile‐environment

Clinical environments matter for clinical interactions. Environments signal who is or is not welcomed and what aspects of care will likely be emphasised. We noticed how the physical spaces we observed enacted LBP as multiple by varying from a clinical environment, where sterileness, technical instruments are prioritised, to one where warmness, relationality and comfort are included. For example, in certain consultation rooms and reception areas, there were pictures of muscles and trigger points depicted on walls, as well as spine skeletal models that were often used to teach patients where the lower back and adjacent anatomical structures were located. When taking field notes of the space at the physiotherapy clinic, the observer wrote:

Sitting in the reception again I noticed that on the wall there were some pictures that focussed on core muscles such as transversus abdominis activation, and one that was written “Treatment of lumbo pelvic pain: learning to control the deep muscular corset”. On the same wall there were also some [posters on] cough etiquette and respiratory hygiene, as well as the clinic’s policies. (…) One of the posters, in consultation room 1, had “Ultrasound imaging of transversus abdominis incorrect activation” and the other “Multifidus in low back pain”.

(Observer)

Other rooms at that site were similarly adorned. These non‐human actors (posters, models) focussed on anatomical structures and enacted LBP as a dysfunctional joint, muscle or fascia. The environment seemed to create dysfunctional bodies and reduce the objects of clinical intervention to bodily structures—detached from bodies’ context, culture, thoughts or relations. Other images on the walls contributed to the enactment of this dysfunctional body, but in a slightly different way. Along with pictures of anatomical structures, there were images aiming to teach people the benefits of exercises and a balanced diet at the pain clinic. The dysfunctional body had rules to follow in a possible attempt to return to its condition of normative functionality. LBP relates to joints, muscles, but also to assumed dysfunctions and actions treating such dysfunctions. The environment contributes to what aspects of LBP are likely to be discussed and emphasised. However, some elements in the environments seemed to prompt an ethical multiplicity of LBP.

Becoming a more‐than‐sterile environment permits reimagination of the dysfunctional body perceived through the physical space. For example, at the multidisciplinary pain clinic’s reception area, photographs authored by patients and featured in a National Injury Insurance Scheme Queensland art exhibition showed ‘a day in the life of an individual living with a traumatic brain injury’ (The Hopkins Centre, 2021). One photograph caught the observer’s attention: a face covered in black and gold paint. Beside it, a plaque explained the artist/patient’s portrayal; Shane Pivac’s self‐portrait was inspired by ‘Kintsugi’, the Japanese art of highlighting imperfections of objects with gold. The artist likened their own scars and imperfections to Kintsugi, showing pride in their struggle and glorifying their new body. Although not specific to LBP, the photographs moved beyond the idea of a dysfunctional body ready to be fixed. The relation between health condition, human, emotion, beauty and art seemed to transform and de‐medicalise the environment. Here, the clinical space was a more‐than‐sterile environment.

Physical spaces can also signal what aspects of care are welcomed or allowed to surface. Displaying anatomical structures may signal that only physical dimensions are expected to be emphasised. However, different elements can allow other enactments and relations to transform LBP. Take, for example, a simple tissue box. In certain rooms at the pain clinic, tissue boxes were strategically located within arm’s reach. When patients got emotional, this tissue box was there to provide some support—tears could be caught, a face covered. In one session, the observer wrote:

RubyPsych asked if Mila ever thought about harming herself. Mila said she did have those thoughts in the past. Mila started crying and took a tissue that was strategically positioned at the table, in front of her. Mila said that was a really hard moment for her. RubyPsych paused and was silent for a moment.

(Observer)

This non‐human object signals that tears, sadness and frustration are expected and welcomed emotions in clinical interactions. The tissue box was accompanied by a moment of silence and pause in clinical note taking. Through tears, tissue boxes and silences, LBP is enacted as an emotional body. In comparing pictures of muscles and trigger points to tissue boxes, LBP is enacted as a different object with different relations. The tissue box seemingly transformed the clinical space into a place of comfort and safety—becoming a more‐than‐sterile environment.

Tears were not the only element of non‐sterileness welcomed in consultations. Laughter, humour and pleasure were also observed in the ethical multiplicity of LBP. In a group Pilates session at the physiotherapy clinic, a patient came directly up to the observer and stated emphatically: ‘Laughter is the best medicine. You write this down!’. Laughter was considered part of clinical encounters. In this session, while exercises were being prescribed and performed, clinicians and patients shared stories, talked about TV shows, laughed and enjoyed themselves. Such moments provided an opportunity to engage with exercise in a‐more‐than‐mechanistic mode, foregrounding relational joy in the performance of movements. LBP is enacted as a joyful body in multiple ways: relating to Pilates’ equipment, other bodies and laughter. However, these elements of laughter/joy/pleasure can only be considered ethical if accompanied by affirmative relations. Considering the vulnerability of living with pain, laughter and humour may not always be possible and need to be used with care.

Clinical physical spaces are active, enacting LBP as multiple. They can bring attention to dysfunctions, or welcome imperfections, tears, laughter, and joy.

Depending on the elements and relations that are built, clinical spaces can engage with an ethical multiplicity of LBP through a process of becoming more‐than‐sterile environments.

Becoming minoritarian

Power relations and differences relate and interact with LBP’s multidimensionality. At times, in observed clinical interactions, power between clinicians and patients seemed shared, allowing space for collaboration and a process of becoming minoritarian. One example at the pain clinic involved strong pain medications, NoahDr (a pain specialist), Tom (a patient) and physical withdrawal amongst other human and non‐human actors. Tom had recently gone through a surgical procedure (nerve ablation) for his neck, which significantly decreased his pain; he then decided to stop taking two medications: an opioid, and a pregabalin. After severe withdraw side effects, Tom and NoahDr discussed safe ways to decrease Tom’s medication. The observer wrote:

“With [medication], it’s even slower” NoahDr said explaining what he had planned. At some point, Tom corrected NoahDr and mentioned he was in a different dosage than what was suggested. “Ok, sorry. All right” NoahDr said looking like he was really sorry for getting the dosage wrong. [I think it was the first time that a doctor had trusted the patient’s words related to medication. In other consultations, the doctor would look at their computer and check if the patient was telling the truth].

“We don’t touch the night‐time dose, and you choose (…) you slow down if you think we are going too fast”. NoahDr said. He did not want to change Tom’s night medication, and he sounded like he wanted to give Tom total control over this process of weaning off his medication.

(Observer)

NoahDr did a couple of things in this small excerpt towards becoming minoritarian. First, he trusted Tom’s word on the medication dosage. As the researcher noted, in other observations, clinicians would confirm in their notes if the information they had on the chart matched what the patient was saying. There were times where patients looked uncomfortable with this lack of trust. Second, NoahDr made it explicit that he would follow Tom’s lead regarding dosage tapering. The interaction had a sense of mutual collaboration. Although NoahDr had implicitly greater power due to his training and position in the interaction, he recognised the patients’ expertise in their own conditions and prioritised their comfort with the medication. Here, LBP is enacted as physical pain, intertwined with pain in other locations: surgical procedures, medication, charts and withdrawal symptoms. LBP also relates to trust, comfort and collaboration. Physicality, medication, trust, charts, comfort and collaboration matter in the process of becoming minoritarian and attending ethically to the multiplicity of LBP.

Becoming minoritarian is also about challenging differences between patients and clinicians (or between self and others). In certain moments, clinicians‐became‐patients, showing empathy towards patients’ situations. One example came from a clinician dialogue at the physiotherapy clinic where the researchers and clinicians discussed exercise prescription. A researcher asked how the clinicians would feel if their patients had not done the prescribed exercises. Jade (physiotherapist) mentioned:

I think the biggest thing comes from when you have to go to see someone about yourself or your child or whatever and then suddenly you have to do these exercises regularly and you realise how incredibly hard it is to fit in even three or four exercises even a few times a week. And if we can't do it as physios when we know this is right, then, you can understand it. I guess if you've never had to do that, and you haven't had that experience of ‐ “Jeez it's really hard to actually do these things every day even if I really want to get better (…)”, then there’s no point in taking it personally.

(Jade [physiotherapist])

At this moment, JadePhysio recognised that—even as a physiotherapist‐patient who knows the benefits—it is hard to follow an exercise programme. JadePhysio blurred the boundaries between clinicians and patients by recognising that clinicians can be patients. LBP is enacted as a shared condition—in both clinicians’ and patients’ bodies. Here, JadePhysio became‐patient, and by becoming‐patient, she engaged in becoming minoritarian.

Finally, becoming minoritarian entangles with becoming a more‐than‐sterile environment. Considering further how physical spaces may define power relations, observers noted how images in the clinics were usually of thin, white, heteronormative‐looking people with little diversity depicted. Here, LBP is enacted as a specific body type, and relates to skin colour, sexuality and body size. Certain human characteristics seemed to be more accepted than others—the physical space reinforcing implicit power relations. However, the environment could also engage in becoming minoritarian: Indigenous peoples’ artwork (given by that community to the clinic) on the walls in one of the sites, information depicted in other languages besides English, different‐sized chairs to accommodate different body shapes. These elements have the potential to make more people feel welcomed and represented in the physical space.

LBP is enacted as diverse bodies, and relates with culture, signs, languages and chairs. Accounting for the multiplicity of LBP is also accounting for the multiple physical bodies with LBP.

Becoming minoritarian involves considering power relations in the multiplicity of LBP: acting towards better connectiveness and belonging. According to Braidotti (2006, p. 149), ‘Human nature is the play of similarity and differences under the impact of social forces that are constructed by relations of power among human beings’. Becoming minoritarian is about shifting perspectives, accounting for multiple ways of being human and interacting with the environment. An ethical multiplicity is becoming minoritarian so that differences are seen and accommodated for. But like being careful with laughter and joy, using elements that signal diversity in the space and thinking about physical comfort and expressing a sense of belonging need to be an ethical practice. Such practices need to reflect an affirmative relation with others. The intent is to pursue shared interests and sustain an opportunity for mutual growth (Braidotti, 2006).

Becoming interdisciplinary within

Finally, transposing or blurring traditional boundaries between disciplines matters in clinical interactions. Such action is similar to transposing differences between self/others depicted in the previous becoming. Becoming ‘interdisciplinary within’ is about blurring traditional boundaries of practice to attend to the multiplicity of LBP well. In clinics, there were times where such boundaries were blurred, allowing clinicians to expand their scope of practice in subtle ways. There was a silent acknowledgement that LBP cannot be fragmented into different specialities. One example is in Mila’s sessions with RubyPsych at the pain clinic. Mila was going through a ‘multidisciplinary assessment’, where she would have sessions with a psychologist, a doctor and a physiotherapist. The observer wrote:

RubyPsych started to ask Mila some questions regarding her pain, the location and what type of pain it was. (…) RubyPsych asked Mila about the location of her pain, and this time Mila positioned her hand on her back. RubyPsych leaned forward on her chair so she could see the location. (…) Mila continued to explain her pain, and she would emphasise from time to time that she would ask herself “What did I do to make it flare up”. RubyPsych seemed very understanding and always reassured Mila that she knew what she was talking about, and that this was very common among patients with persistent pain. [I confess that I was surprised that RubyPsych asked so many questions related to Mila’s physical condition – location of pain, what activities would ease or worse the pain. I wouldn’t expect that a psychologist would ask those type of questions].

(Observer)

RubyPsych recognised Mila’s pain as a physical experience, located and felt in a particular part of the body. Although RubyPsych dealt with emotional and psychological questionings later in the session, she assessed the pain as physical. Underlying assumptions of professional boundaries are characterised by the researcher’s own words: they were surprised by the psychologist’s many ‘physical’ questions.

LBP is enacted as physical and relates with assumptions, questions, professional boundaries and psychological concerns.

Although uncommon, similar interactions occurred when non‐psychologists attended to patients’ emotions. Becoming interdisciplinary within recognises that LBP is physical‐and‐psychological, emotional‐and‐social, and so on. LBP is multiple, and requires health‐care professionals to attend to this multiplicity.

Becoming interdisciplinary within can bring tensions and requires courage and sensibility to address certain objects that may be considered outside one professional’s field. Objects such as weight (and food), mental health, financial conditions (and money) and social support, were commonly addressed with discomfort or sometimes dismissed in interactions. It is possible that because such objects are thought to be connected to certain professionals’ scopes of practice, it was easier to either provide a referral or move to a more familiar topic (usually related to biomedical and physical aspects of LBP). For example, at the physiotherapy clinic, a patient briefly mentioned to the physiotherapist that she needed to lose some weight in one interaction. According to the observer:

Linda mentions that she “eats low fat” and some other things she was doing. “Have you talked to your GP about your weight? They are good to talk to,” PruePhysio said, explaining that Linda’s GP could refer her to a dietician. PruePhysio was very positive about the idea of a dietician, but Linda seemed dismissive of it. Linda mentioned that the GP had referred her son to a dietician and the dietician was “useless”. “You’ve gotta find a good one.” PruePhysio said she knew a GP and said more about seeing a dietician. Linda’s eyes glazed over. “I reckon I need to watch you move”, said PruePhysio.

(Observer)

PruePhysio’s mention of a GP and a dietician implies that only those professionals are ‘good to talk to’ regarding weight and food. Linda did not look like she wanted a referral and perhaps just wanted to share what actions she was taking for controlling her weight. Linda’s eyes glazing over indicates that she became uninterested in, or perhaps offended by, PruePhysio’s suggestions. Weight and food are objects entangled with stigma, where patients are blamed for being a certain size or eating in a certain way—as pointed out by one of our patient advisors. LBP relates to weight, food, other health‐care professionals, but also to stigma and blame. Instead of assuming what profession is ‘good to talk to’, becoming interdisciplinary within allows further explorations and openness. For example, it can consider if the patient is comfortable discussing weight‐loss strategies with their current clinician, or directly asking if they are interested in a referral or simply opening the door for a future conversation. The relation between LBP, weight, food, stigma and blame is considered and attended to.

Becoming interdisciplinary within allows a disruption of entrenched ideas of fixed and stereotypical professional roles. It challenges and resists the fragmentation of bodies with LBP, where some health‐care professionals are thought to be responsible to the physical, others to the mind and emotions, and others to the social context. Becoming interdisciplinary within is not about ignoring the limits of scope of practice. However, since LBP is multiple and involves multiple physical, material, mental/emotional and social dimensions, it eventually transgresses disciplinary boundaries. Clinical action may require a more fluid consideration of disciplines, since the body is not, and should not be, fragmented into different dimensions.

ETHICAL OPENINGS

In this article, we aimed to explore how LBP is constructed through sociomaterial practices and how attending to these sociomaterialities may be done well. Our analysis suggests that the object of clinical enquiry (LBP) is not a single fixed condition; it multiplies and changes through practices. The multiplicity of LBP goes beyond a biopsychosocial approach and is epistemologically and ontologically distinct. Rather than naming three elements of LBP for attention (biological, psychological, social), multiplicity suggests that the elements entangled in a person’s LBP have limitless human and non‐human possibilities. They could be paintings on walls in clinics, photographs, tissue boxes, depression, social connection, tears, laughter and so on. We suggest that attending to the multiplicity of LBP well is an ethical endeavour requiring a radical shift in clinical practices. Thus, we propose an ethical multiplicity of LBP that can provide other avenues of philosophical and practical enquiries, allowing more creativity and openness in clinical practices to exploring LBP’s multidimensionality.

LBP has long been considered a fixed object of clinical investigation located in the body or mind. Such dualism is inadvertently perpetuated and implied in the biopsychosocial model of health (Duncan, 2000; Quintner et al., ²⁰⁰⁸). We suggest that LBP is not fixed, and the object of clinical investigation multiplies in practice; LBP can be located both inside and outside the body and relate to different‐sized chairs, Indigenous peoples’ artwork, elements of money and food. The multiplicity of a condition (or the multiplicity of reality) is a matter of ontological enquiry, which is not usually debated in the area of LBP nor within the biopsychosocial model (Aftab & Nielsen, 2021; O’Leary, ²⁰²¹). The biopsychosocial model brings the biological, psychological and social dimensions into separate and distinct ontological spaces. There is no discussion about the ‘permeability’ of bodies, and how inside and outside forces, as well as human and non‐human actors, are inseparably connected to bodies (Cohen & Weiss, 2003; Rice et al., ²⁰²¹; Shildrick, ²⁰¹⁵). Thus, the fixed ontological position of the biopsychosocial model inadvertently restricts what is possible to explore and what matters in clinical practice. For example, although the new International Association for the Study of Pain’s definition of pain brings other elements to pain, such as emotional, personal and social aspects (Raja et al., 2020), Bueno‐Gómez (2017) argues that pain definitions should give space for broader conceptualisations of pain beyond naturalistic and scientific terms and debates about the goals of health care and its role in society. This ethical and political consideration is what the becomings in our empirical analyses add to conceptualisations of LBP—they situate LBP within and beyond the body and mind and urge practices to respond to such a shift.

An ethical multiplicity of LBP foregrounds the need to consider a new ethico‐onto‐epistemological approach to LBP care. Although the biopsychosocial model has advanced the need for a phenomenological consideration of a condition, where lived experience is taken into consideration (Stilwell & Harman, 2019), the ontological assumptions still rely on narrow conceptualisations of biological, psychological and social dimensions (Mescouto, Olson, Hodges, & Setchell, 2022). In contrast, ethical multiplicity is in line with a relational onto‐epistemological approach to health care (Fox & Alldred, 2017; Nortvedt et al., ²⁰¹¹; Slife, ²⁰⁰⁴). That is, the point of reference for medical attention is not the ‘object’ (e.g., LBP), but the multiple relations between the body and other human and non‐human actors: the environment, health‐care professionals, power relations, culture, emotions, trust, comfort and ad infinitum. As mentioned in our analyses of clinical practices above, LBP is produced (or enacted) uniquely through multiple relations between objects in the clinical space, such as tissue boxes and signs in different languages, shared power between clinicians and patients and relations between different professional roles. There is no universal moral or ethical stance in such an approach, but each action should be made considering a relational responsibility with multiple others. An ethical multiplicity is therefore similar to an ‘ethics of care’ (Romanello, 2000) or an ‘ethics of openness’ (Gibson et al., 2018), where clinical goals and needs are brought into being through relationships and where care and justice intertwine (Reeder, 2001). Compared to assumptions underpinning the traditional biopsychosocial model, ethical multiplicity is against fragmentation, embracing multiplicity, flexibility and situatedness in health‐care encounters.

Our proposed ethical approach cannot be measured through the usual objective tools or questionnaires. Due to its philosophical and theoretical underpinnings, an ethical multiplicity also prompts the need for what Braidotti (2006) calls a qualitative shift of perspective, but in the context of health‐care practices. For example, as part of a hospital, the pain clinic’s environment seemed more clinical overall, and their work could be more focussed on becoming more‐than‐sterile. In contrast, as a single discipline site, the physiotherapy clinic could focus more on becoming interdisciplinary‐within. Such a qualitative shift challenges an over‐reliance on objectivity and neutrality in health‐care practice, or a positivist account. The biopsychosocial model, for example, is argued to be conceptualised through a positivist lens (Benning, 2015; Hatala, ²⁰¹²), or the assumption that there is one truth that will be discovered through valid and scientific evidence. On the other hand, an ethical multiplicity may be supported by a nomadic ethical consideration of research, education, policy and medical funding in LBP, since these are usually dominated by positivist or (more rarely) humanist assumptions. For example, this nomadic ethical consideration would challenge research and educational practices that overemphasise the search for a universal truth about a condition (e.g., a singular cause), and instead would prioritise the multiple relations that are brought about within the research and educational practices (e.g., how people relate to each other, or how objects and places impact such relation). Further, a nomadic ethical approach in policy and medical funding would recognise projects that foster and embrace complexity, while attending to a politically engaged and ethically accountable practice within the relation of multiple human and non‐human others. It is important to emphasise that it is not guaranteed that by adopting an ethical multiplicity patients’ outcome will improve. But as this article argues, the goal is not to prove that an intervention will work or not on a particular parameter, but that a more ethically and socially just approach is engaged.

Similar to the biopsychosocial model, our examples and posthuman considerations of the body take place in a Western context. Posthuman and sociomaterial theories have been criticised for being dominated by white, western scholars (Rosiek et al., 2019; Tiffany Lethabo, ²⁰¹⁷), which may exclude multiple other possibilities of human and non‐human entanglements. For example, the ‘Fonofale model’ constructed collaboratively with pacific peoples, brings the dimensions of family, culture and spirituality to the centre of health (Ioane & Tudor, 2017). Here, health is entangled with other actors that we little explored in our ‘becomings’. Krenak (2019, p. 32), an indigenous Brazilian philosopher, warns that ‘Maybe we are conditioned to one unique idea of being human and one type of existence’ and emphasises how the idea of humans being considered detached from the earth is absurd. Health is found on environments beyond the clinic and encompasses nature. Krenak (2019) challenges the idea of what it means to be ‘human’—being human is multiple. For Guattari (1995, p. 29), the choice of multiplicity is an ethical choice ‘in favour of the richness of the possible’. By considering an ethical multiplicity of health care for people with LBP, other models of health are possible and encouraged to respond to context, relationality and interconnectedness in practice.

In summary, processes of ‘becoming’, possible when engaging with an ethical multiplicity of LBP, resist universal and fixed moral approaches to clinical practice and reject dualistic thinking. Ethical multiplicity extends the dominant biopsychosocial model, acknowledging that the object of treatment is multiple, dynamic and shaped by what happens in each moment of practice. The priority is both the interconnectedness of humans with each other and non‐human actors. The object of clinical attention (LBP) is multiple, and this dynamic multiplicity requires clinical practices to engage continually in processes of ‘becoming’ to respond to this ontological fluidity. The different suggested ‘becomings’ are ways that human and non‐human elements entangled in clinical practices can be re/arranged to attend to LBP’s multiplicity through reimagining the clinical environment (‘becoming more than a sterile environment’), reimagining differences (‘becoming minoritarian’), and reimagining disciplinary boundaries (‘becoming interdisciplinary “within”’). An ethical multiplicity is not a framework but can be considered a theoretical resource for a radical qualitative shift towards ethical health‐care education, policy and clinical practices.

AUTHOR CONTRIBUTIONS

Karime Mescouto: conceptualization (lead); data curation (lead); formal analysis (lead); investigation (lead); writing – original draft preparation (lead); writing – review and edit (lead); project administration (supporting). Rebecca Eileen Olson: conceptualization (supporting); writing – original draft preparation (supporting); writing – review and edit (supporting); supervision (supporting). Jenny Setchell: conceptualization (supporting); funding acquisition (lead); investigation (supporting); methodology (lead); project administration (lead); supervision (lead); writing – original draft preparation (supporting); writing – review and editing (supporting).

CONFLICT OF INTEREST

The authors have declared no conflict of interest.

Mescouto, K. , Olson, R. E. , & Setchell, J. (2023). Towards an ethical multiplicity in low back pain care: Practising beyond the biopsychosocial model. Sociology of Health & Illness, 45(3), 522–541. 10.1111/1467-9566.13598

DATA AVAILABILITY STATEMENT

Research data are not shared due to privacy or ethical restrictions.