The value of social relationships in the biopsychosocial model of pain

Pain is a complex and multidimensional experience. The biopsychosocial model allows for a comprehensive explanation of the aetiology of pain because it provides the premise for a dynamic bidirectional interplay between biological, psychological and social factors. ¹ This model underpins many therapeutic approaches to supporting people with long-term pain where unhelpful cycles of beliefs and emotional/behavioural responses become established. It is well understood that our experience of pain is amplified or reduced by how it is perceived. ² Moreover, how we respond to those perceptions leads to behavioural strategies which can increase or reduce pain sensitivity. In particular, when painful stimuli are interpreted as ‘alarming’ (i.e. indicating danger), this can lead to moving into a protective mode to prevent and protect from the threat. This model accounts for fear/avoidance behavioural responses to the perceived danger, which can lead to a vicious cycle of increased emotional distress and reinforce beliefs around fear. Psychoeducational interventions are ways of applying the biopsychosocial model to help patients understand their pain, its contributors and integration of treatment of peripheral and central nociceptive drivers.^2,3 One such example is the Protectometer educational tool, developed by Moseley and Butler ⁴ . People in pain are encouraged to identify the personal factors that increase or decrease their protective system and, in turn, their pain experiences, labelling them as either ‘DIMs’ (described in the tool as ‘danger in me’) or ‘SIMs’ (safety in me). The intention then is to support people to reduce their attention on DIMs (e.g. staying at home and only taking pills) with a refocus on SIMs (e.g. gentle exercise). By providing this dichotomy, this can tailor pain education for the individual’s perceived pain experience.

Kennedy et al. ⁵ paper on Do threats and reassurances reside in the biological, psychological, or social domain? A Qualitative study in adults and young people chronic pain examines the DIMs and SIMs voiced during group pain management programmes with adults (mean age 56) and young people (mean age 14), and investigates the content of these, and how they are distributed across the biopsychological model. Danger and reassurances stem from the environment (e.g. people and places that were threatening/comforting), sensory features (including those arising from medication and healthcare), activities and behaviours, and emotional experiences with worries and catastrophising thoughts contrasting with positive self-talk and recovery expectations. These beliefs were spread across biological, psychological and social domains, with younger children compared with adults being less concerned with biological aspects of threats. Interestingly, factors that were perceived as safe/reassuring were largely social and psychological in origin, and social support (including practical, emotional and information), social comparison and social connectedness have all been found to impact behaviour and wellbeing (e.g. as shown in social prescribing interventions ⁶ ). Research has typically focused on social network from family, friendships and work. Kennedy et al. ⁵ study reveal that healthcare professionals and their interactions may be playing a social role and, in this capacity, can be viewed as either threatening (DIM) or reassuring (SIM). This important work suggests that social context is an avenue that is underexplored in chronic pain and requires more attention and should be extended to relationships with healthcare professionals.

In the different elements of interaction between clinician and patient about pain (e.g. information exchange and treatment decision-making), ⁷ there lies the importance of social responses to pain. Solicitous and punishing responses to pain, which have been examined by McCracken ⁸ in the family and friends support, also extend to the clinical-patient communication. Social responses provided by healthcare professionals can play an important role in how healthcare and treatment are being perceived as either DIM or SIM. Patients with chronic conditions, that may be poorly understood or where there are areas of uncertainty, can feel dismissed and illegitimate healthcare users, which exacerbates their distress. ⁹ Healthcare professionals describe how they find these interactions complex and difficult to navigate, which in part may arise from their own beliefs about pain.^10,11 There is potential here that healthcare interactions may, inadvertently, increase perceptions of threat. In contrast, where patients feel understood and can build alliances with healthcare professionals evidence suggests this can be therapeutic, potentially through increasing beliefs around safety. Consequently, psychoeducational interventions should focus on two key aspects: identifying and challenging pain misconceptions held by patients and their social networks, and enhancing healthcare professionals’ skills in fostering reassurance and building alliances within clinical encounters. ¹² These interventions should enable professionals to develop beliefs and skills that support these goals.

ORCID iD

Daniela Ghio https://orcid.org/0000-0002-0580-0205