Beyond biopsychosocial: a new framework for pain medicine?
David Buchanan1, Milton Cohen2, James Katz3, John Quintner4, Owen Williamson5
1 Department of Health Sciences and Nursing, Notre Dame University, Fremantle WA
2 Department of Rheumatology and Pain Medicine, St Vincent’s Hospital, Sydney NSW
3 Division of Rheumatology, George Washington University, Washington DC, USA
4 Department of Rheumatology, Royal Perth Hospital, Perth WA
5 Department of Epidemiology and Preventive Medicine, Monash University, Melbourne VIC
Purpose of Study
To identify problems in the biopsychosocial model when applied to people in pain and to explore a resolution.
Method
Critical analysis of the literature concerning the theory and application of biopsychosocial models to the practice of pain medicine
Result
The biopsychosocial model for understanding illness has generated the IASP definition of pain, two simpler conceptual frameworks, and three explanatory schemata for pain. However, in the absence of a theory of living systems that seeks to understand how the different domains of these schemata interact with each other, these attempts have been caught in circular argument and have been unable to transcend either biomedical reductionism or the perpetuation of body-mind dualism. In particular, the implication that pain is a “thing” separate and distinct from the body not only bears little relationship to the lived experience of pain but also emphasises the inherent problem that arises when an observer attempts to reduce the experience of the pain of ‘the other’ to predictable parameters.
Conclusion
The self-referentiality of living systems (through their qualities of autopoiesis, non-centrality and negentropy) sees pain ‘emerge’ in unpredictable ways that defy any reduction of the lived experience to any particular ‘thing’. Pain therefore constitutes an aporia, a space and presence that deny us access to its secrets. We suggest a project in which pain may be approached in the clinical encounter through the engagement of two autonomous self-referential beings from which new therapeutic possibilities can arise. We see three challenges to be met in this project: to accept that the pain of another person is irreducible to its neuronal correlates; to acknowledge all the principles which characterise autonomous biological systems; and to allow a rapprochement between the world of the clinician and the world of the person in pain.
