By Anna-Marie Schmidt, MM, DC, and Robert Vining, DC, DHSc
The biopsychosocial model is a widely recommended method of clinical evaluation and management.1–5 The model identifies three important areas. “Bio” refers to evaluating/treating biological problems (e.g., pathology), “psych” refers to psychological health, and “social” refers to a person’s relationships with others and the environment.5–7
Biomedically-based training naturally orients practitioners toward evaluating and managing biological/pathological aspects of health. Reimbursement structures also reinforce this approach.2 Important relationships between psychological and physical health are now better understood, compelling practitioners to incorporate mental health screening into regular clinical assessment.1,8,9 However, some evidence suggests that practitioners, as a group, may not be addressing “social” components of health as much as they could.2,5 This potentially overlooked part of clinical evaluation is likely due to one or more factors such as:
- Lack of clarity: Clinical guidelines generally include less emphasis on addressing specific social components of health compared with biological and psychological aspects.2,5,10
- Knowledge gap: Psychological and social factors are often related and sometimes thought of as a single element (“psychosocial”). However, they are distinct.
The table below displays examples of social factors that can influence important aspects of health.3,7,9–12 Several factors can relate to multiple categories. For example, poor access to care can be related to low socioeconomic status, living in an area with few providers, and/or difficulty attending visits during normal business hours.
Table. 1 Examples of negative social factors and their potential implications.3,7,9–12
Negative Social Factor
Potential Negative Implications
Low Socioeconomic status
|Reduced access to health insurance, poor food quality|
Low educational status
|Reduced health literacy, low socioeconomic status|
|Decreased access to health information, low socioeconomic status|
|Reduced access to care, reduces ability to participate in social groups|
Lack of community resources
|Negatively influences food quality and quantity, availability of informal help, access to care, and a social support system|
High occupational demands
|Decreases return to work expectations|
Low expectations for returning to work
|Reduces likelihood of returning to work|
Return to work policies
|Negatively influences clinician decisions regarding treatment plan|
Perception of heavy work
|Negative opinions of ability and reduced expectations for returning to work|
|Impacts return to work timing, decreases return to work expectations|
Poor Social Relationships
|Negatively impacts sense of social connection and support|
Lack of Informal help
|Limited social relationships, social pain of isolation|
|Reduces time for self-care, increased stress|
Lack of clinician empathy
|Negatively influences perceived support from clinician|
Lack of clinician reassurance
|Reduces return to work expectations, negatively influences pain catastrophizing and coping|
Not meeting patient preferences
|Leads to increased patient anxiety, decreased treatment adherence|
Why care about social factors?
Neurophysiological research has demonstrated that both social pain (actual or potential damage to a sense of social connection) and physical pain are processed on shared neural pathways within the cerebral cortex.13–15 Other research evidence suggests several clinically important implications are associated with positive and negative social experiences.
Negative social experiences may result in:
- Increased circulation of proinflammatory cytokines15
- Increased perceived pain intensity13–15
- Reduced ability to cope with pain15
- Increased vulnerability for developing chronic pain15
Positive social experiences such as meaningful social support can:
- Reduce pain intensity1,15,16
- Lead to greater pain tolerance15,16
- Diminish physiological stress reactions1,16
Influencing social factors
In practice settings, clinically evaluating and addressing every possible social factor for every person is likely unrealistic. But, it is sometimes possible to positively influence some social factors. For example, recovery expectations can be directly addressed by helping patients better understand a condition as part of an ongoing educational process.10 Practitioners can also help foster social support for treatment through encouraging patients to invite their spouse, child or close friend to an office visit.12 Other factors, such as job satisfaction, loneliness or socioeconomic status are more difficult to address directly.10 However, these factors can sometimes be addressed indirectly by referring patients to social groups (reading club, senior community group), food banks, shelters, social workers or other healthcare professionals.
Perhaps the greatest opportunity to influence social aspects of health is through fostering a strong therapeutic alliance with patients. Research has shown that strong alliances can support important clinical outcomes.10,15,17 Therapeutic alliance is a concept based on positive rapport between patient and practitioner. It reflects practitioner technical skills, communication capacity and the ability to respond to patient needs in the moment.17 As the ability to recognize and respond to patient needs grows and technical and communication skills improve, the therapeutic alliance is theoretically strengthened.
One way to foster positive rapport is to express both empathy and sympathy. Empathetic interactions show an interest in how a health concern impacts a person’s life.18 Empathy is expressed through statements that acknowledge what a person is going through, such as, “That must be difficult.” In contrast, sympathy expresses the feelings of the doctor, for example “I’m sorry you are going through this.” Both empathy and sympathy can be appropriate mechanisms to show emotional support and encouragement.18 Alternatively, being judgmental of patients’ thoughts, attitudes, and/or beliefs can impede positive rapport and negatively affect clinical outcomes.9
Identifying specific social needs is a key part of a balanced biopsychosocial approach. There are many opportunities to assess and potentially influence social factors in clinical settings. Though addressing all social factors is not likely feasible, enhancing the therapeutic alliance is something on which all providers can focus. In some cases, addressing a social need(s) may be the most important element in moving toward improved health.
Anna-Marie Schmidt, MM, DC, is a post-doctoral research scholar at the Palmer Center for Chiropractic Research, Palmer College of Chiropractic.
Robert Vining, DC, DHSc, is associate dean of clinical research at the Palmer Center for Chiropractic Research, Palmer College of Chiropractic.
- Meints SM, Edwards RR. Evaluating psychosocial contributions to chronic pain outcomes. Progress in Neuro-Psychopharmacology and Biological Psychiatry. 2018;87:168-182. doi:10.1016/j.pnpbp.2018.01.017
- Kusnanto H, Agustian D, Hilmanto D. Biopsychosocial model of illnesses in primary care: A hermeneutic literature review. J Family Med Prim Care. 2018;7(3):497-500. doi:10.4103/jfmpc.jfmpc_145_17
- Blyth FM, Macfarlane GJ, Nicholas MK. The contribution of psychosocial factors to the development of chronic pain: The key to better outcomes for patients? Pain. 2007;129(1):8-11. doi:10.1016/j.pain.2007.03.009
- Froud R, Patterson S, Eldridge S, et al. A systematic review and meta-synthesis of the impact of low back pain on people’s lives. BMC Musculoskeletal Disorders. 2014;15(1):50. doi:10.1186/1471-2474-15-50
- Erp R, Huijnen I, Jakobs M, Kleijnen J, Smeets R. Effectiveness of Primary Care Interventions Using a Biopsychosocial Approach in Chronic Low Back Pain: A Systematic Review. Pain Practice. 2019;19(2):224-241. doi:10.1111/papr.12735
- Wade DT, Halligan PW. The biopsychosocial model of illness: a model whose time has come. Clin Rehabil. 2017;31(8):995-1004. doi:10.1177/0269215517709890
- Shaw WS, Campbell P, Nelson CC, Main CJ, Linton SJ. Effects of workplace, family and cultural influences on low back pain: What opportunities exist to address social factors in general consultations? Best Practice & Research Clinical Rheumatology. 2013;27(5):637-648. doi:10.1016/j.berh.2013.09.012
- Murphy DR, Hurwitz EL. The Usefulness of Clinical Measures of Psychologic Factors in Patients with Spinal Pain. Journal of Manipulative and Physiological Therapeutics. 2011;34(9):609-613. doi:10.1016/j.jmpt.2011.09.009
- Murphy D, Jacob G, Seaman D, Steven H. Clinical Reasoning in Spine Pain. Volume 1 Primary Management of Low Back Disorders Using the CRISP Protocols. Vol 1. Pawtucket, RI: CRISP Education and Research, LLC; 2013.
- Tousignant-Laflamme Y, Martel MO, Joshi A, Cook C. Rehabilitation management of low back pain – it’s time to pull it all together! Journal of Pain Research. 2017;Volume 10:2373-2385. doi:10.2147/JPR.S146485
- Claréus B, Renström EA. Patients’ return-to-work expectancy relates to their beliefs about their physician’s opinion regarding return to work volition and ability. J Pain Res. 2019;12:353-362. doi:10.2147/JPR.S179061
- Wijma AJ, van Wilgen CP, Meeus M, Nijs J. Clinical biopsychosocial physiotherapy assessment of patients with chronic pain: The first step in pain neuroscience education. Physiotherapy Theory and Practice. 2016;32(5):368-384. doi:10.1080/09593985.2016.1194651
- Eisenberger NI. The pain of social disconnection: examining the shared neural underpinnings of physical and social pain. Nature Reviews Neuroscience. 2012;13(6):421-434. doi:10.1038/nrn3231
- Eisenberger NI. The Neural Bases of Social Pain: Evidence for Shared Representations With Physical Pain. Psychosomatic Medicine. 2012;74(2):126-135. doi:10.1097/PSY.0b013e3182464dd1
- Sturgeon JA, Zautra AJ. Social pain and physical pain: shared paths to resilience. Pain Manag. 2016;6(1):63-74. doi:10.2217/pmt.15.56
- Che X, Cash R, Ng SK, Fitzgerald P, Fitzgibbon BM. A Systematic Review of the Processes Underlying the Main and the Buffering Effect of Social Support on the Experience of Pain: The Clinical Journal of Pain. 2018;34(11):1061-1076. doi:10.1097/AJP.0000000000000624
- Fuentes J, Armijo-Olivo S, Funabashi M, et al. Enhanced Therapeutic Alliance Modulates Pain Intensity and Muscle Pain Sensitivity in Patients With Chronic Low Back Pain: An Experimental Controlled Study. Phys Ther. 2014;94(4):477-489. doi:10.2522/ptj.20130118
- Egnew TR. The Art of Medicine: Seven Skills That Promote Mastery. FPM. 2014;21(4):25-30.