Welcome back to the Healing Pain Podcast with Peter Stilwell, PhD
We’re talking about a paradigm shift from the biopsychosocial model to what’s being termed an enactive approach for the treatment of pain. Joining us is Dr. Peter Stilwell. He is a Canadian researcher and is on faculty at the School of Physical Medicine and Occupational Therapy at McGill University. In addition to being the Ronald Melzack Fellow in Pain Research, his current research projects involve conceptual and qualitative work on persistent pain and related suffering. In this episode, you’ll learn all about the biopsychosocial model for pain, why the time is ripe to switch to an enactive approach toward pain, and how this new emerging approach can help you reconceptualize pain and provide more effective pain education. Without further ado, let’s begin and meet Peter Stilwell, and learn all about an enactive approach toward the treatment of pain.
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Moving Beyond The Biopsychosocial Model To An Enactive Approach To Pain With Peter Stilwell, PhD
Peter, thanks for joining me. It’s great to have you here.
Thanks for the invite. I appreciate the opportunity.
I’m excited to be talking with you because you’re engaged in a lot of great research and your postdoctoral work in pain science and some of the theories around pain, which are interesting. You’ve written a couple of papers on the philosophy as well as how it relates to a clinical guide for practitioners. You have an interesting story in how you transitioned from your early career to where you are now with postdoctoral research. Tell us about how you started out early on and where you are now?
I got a weird eclectic background and people are like, “What do you do? What’s your background?” I started doing a degree in Kinesiology. That’s human anatomy, biomechanics, and that type of stuff. I went through and did a Doctor of Chiropractic and I always wanted to go that route. Along that path, I got interested in research and in teaching. I was like, “I want to do it all. I’ll teach, be a clinician and do research. I started practicing as a chiropractor while simultaneously doing a Master’s in Rehabilitation Research and Physiotherapy in the School of Physiotherapy at Dalhousie. I got to do teaching, research, and still had a clinical practice on the side as well.
I dove deep into the research and I was like, “This is super interesting. I’m going to do a PhD.” I did a PhD in Health. During the PhD, I transitioned at a clinical practice to focus on research, but I still maintained community connection. I run a free walk-in group with some people that are in medical school who are also physiotherapists. My wife helps out with that as well. She’s a PhD student. I maintain that connection to the community while I’m also doing research. I don’t see patients these days, I just do research.
How long were you in clinical practice as a chiropractor?
Around five years. I did an internship in Toronto as well for a year. I worked in a multidisciplinary hospital setting in downtown Toronto. It is different than what I was doing when I started practicing in Halifax. That was mostly working with people with persistent spinal pain, whereas in Toronto it was a mixture of all types of things.
A lot of people go into pain science, pain research, psychology, physical therapy or potentially some neurobiology or cognitive science. Chiropractic is less. There are chiropractors who go into pain research, but how do you think that your early experience of yours influenced your research?
Chiropractic is such a diverse profession. There are people that are alternative and not evidence-based and it’s problematic, and then there are people that are more reasonable and evidence-based side. They treat MSK conditions, muscle and joint conditions, and follow guidelines. I would be on that evidence-based side of the spectrum. Most chiropractors that do research go into biomechanics. They look at spinal function, epidemiology, and population health type of stuff in relation to MSK care. When I started my interest in pain, I was like, “Pain as I understand it in many people, it’s a subjective experience. How can we best understand that?” Quantitative approaches are wonderful but there’s a neglected area as well. That’s qualitative work, exploring the lived experiences, and getting patient’s perspectives on their care. That’s the route that I went because I saw it as a neglected area.
In chiropractic school, did you learn about the biopsychosocial model? Was that entrenched in education the way it is now in physiotherapy education at least to a certain extent? We can talk about that in a lot of detail. Did you start to touch base that in chiropractic school or was that later on when you started to investigate and begin your PhD thesis and work?
I did my chiropractic education in Toronto. It’s one of the English-speaking schools in Canada. I enjoyed it there. It’s quite structured like evidence-based type of program. It doesn’t reflect what you see in clinical practice where you see a wide range of approach, but the education was good. It was still focused on anatomy and biomechanics. There were neuroscience and touching psychology a bit, yellow flags like psychosocial screening questionnaires. There’s not a strong emphasis on exploring the biopsychosocial model and these nonbiological or social aspects of pain. I went to grad school and right then, I started doing a bit of teaching in the physiotherapy school at the master’s level.
I still saw the same thing where there was a bit of biopsychosocial work. At the time, it was still focused on biological factors, anatomy and biomechanics. Over the last couple of years, I noticed a huge change. Students are coming in knowing a bit about the model and knowing more about psychosocial factors. Not only that, they seem more interested in integrating these things in clinical practice. That has made my teaching a lot easier when there’s already a bit of buy-in. I’ve noticed a change over a little while.
What are your thoughts on the biopsychosocial model now that you’ve done some research on it and have some of your own opinions and philosophies developing? George Engel was a pioneer and did shift pain care as well as a number of different conditions with regard to our healthcare and medical system. Like many theories, they’re not perfect and we build on and we evolve them.
George Engel hit it. That’s my belief too. He’s a pioneer and huge advancement. He challenged the biomedical model. He’s like the current approach, which is impersonal, is mostly focused on biology, and expanding that to include other factors, and pushing more towards the humanistic approach to care. His work is massive. In the one paper we published, if people read the title, Beyond the Biopsychosocial Model, they think that we’re going to be bashing the model or saying that it’s no good. More of the argument in that paper is that it’s been misapplied. We talk about how people applied it in different ways that aren’t congruent with George Engel’s original vision. We made some suggestions, and others have done this too in terms of how we can extend the model a little bit or even clarify aspects. It’s less likely for people to apply it in problematic ways.
I want to make sure we mentioned that paper so that people can access this. It’s in the April 2019 Journal of Phenomenology and the Cognitive Sciences. The title of the paper is called An Enactive Approach to Pain: Beyond the Biopsychosocial Model. In this paper, you talk about moving beyond the biopsychosocial model. Let’s first talk about how the biopsychosocial model has misapplied in both healthcare education as well as the clinical setting.
This is an area I’m still grappling with and trying to understand. We’re working on a paper with two colleagues out of the UK and we’re outlining the key contributions that Engel put forward but also outlining some of these misapplications. In that 2019 paper that you mentioned, we did hit on a variety of ways that we see it being problematic. One is people tend to fragment the model. George Engel originally proposed it as being dynamic. Biological factors interact with psychological and social factors. He didn’t mean for them to be pieced apart, but in clinical practice and even in educational settings, we start to silo it and we start to split it up.
We sometimes see it where we’re still within that biomedical framework where we’re looking for biological causes of pain and a single cause. If we can’t find that, then it must be psychogenic or the pain must be all in the person’s mind. The qualitative literature suggests that can be problematic. It can be stigmatizing. The patient can believe that they’re being told that their pain isn’t real or there aren’t treatment options. That’s one big issue that we see. The other one that we highlight in that paper is Engel wanted to avoid that dualism that I went everybody else wanted to avoid that reductionism.
We didn’t want to just focus on single biological factors. We start to see that with some researchers and research paradigms where they’re advocating for a biopsychosocial approach, but they’re focusing on things like the brain picks primacy. I understand why they go that route, and others have argued this quite extensively that that can potentially minimize the role of the rest of the body besides the brain, culture, and social interactions. It’s almost like they compress everything into the brain and we don’t need to look at these other factors. Raymond Tallis is a philosopher and a retired physician. He calls this neuromania. We get excited about the brain. I’ve been there and I had to put the brakes on where I’m like, “Does this have problematic implications if we go too far down that route?”
What you mentioned there is so key like putting the brakes on certain things that we get excited about as clinicians. When you look back at that biopsychosocial model, there’s a mutual influence of both the mind and the body within that framework. However, if you reflect back and think of that biopsychosocial model in a slide or presentation, it’s always those three circles. There’s a separation of three components. Even within those three circles, if you expand those three circles out into clinical practice, it’s like, “If it’s psychosocial, then that’s something psychologists deal with.” We segmented that over there. If it’s nutrition-related, that’s a nutritionist. If it’s physical structure related, that’s a physical therapist, a chiropractor or someone else. It is interesting how that has still been carried through. What he intended to bring together the mind and the body, to this day in research, education and especially in our siloed practices is still prevalent.
That’s the trap that we get in. We want to use these buckets to make things a bit more simplified. Even though we might explicitly know that these things are dynamic, we ended up siloing it because sometimes that’s easier, “This is a psychological issue, let’s make a referral.” I like the trend where people are saying, “No, always consider all three. Everybody can have a psychologically informed practice and sprinkle these techniques in or look at these other factors.”
I’ll say pain education as an umbrella term. Lots of people have taken those theories and models, and built them out. Even those early models, were one of neurobiology in some way. We dipped into the psychosocial aspects, but we would never go as far as mentioning emotion at all or anything like that in them. I always wonder, was there enough bravery in people’s minds when they start to develop those early concepts of pain education with the hope of honoring George Engel’s work in that biopsychosocial model?
You hit on such an important point. Some of the early pain education paradigms were advocated as being within a biopsychosocial framework, but they were focused on pain biology and neurotransmitters.
Also, receptors, moving, growing and changing.
That goes back to that neuromania, where it’s like, “Let’s focus in on these things.” We talk briefly about psychosocial factors and how they’re important. They don’t seem to get the same attention. At least they didn’t historically as these other factors are a bit more attractive. There have always been parallel running streams of research and people doing this work that has been pushing for social and psychological approaches to practice. In the mainstream medicine, it’s still to this day biomedically focused. These things get neglected.
If we talk about the brain as an organ, which is part of the body but it does run the risk of shifting an entire biomedical model to a psychological model. With that, people may think, “My body has no influence on my mind,” which I presume that’s not what George Engel meant in the biopsychosocial model.
That’s the tricky thing is that people talk about these pendulum swinging or pushing too far towards psychosocial factors. You may see it in some small pockets on social media and stuff where a couple of people maybe minimize the importance of biomedical factors, important things like infections, tumors, fractures and stuff that we need to be vigilant of. In the mainstream, for the most part in everyday clinical practices, that pendulum hasn’t swung far towards the psychosocial. I don’t think we have to worry about that too much but on social media, you do see it swinging a bit aggressively.
Tell us about your work and philosophy with an enactive approach, and how that piggybacks off a biopsychosocial model and potentially improves upon it?
I’ve been interested in enactivism or some people call it enaction. When people write papers about it, they often say like, “It’s an evolving series of ideas and it’s difficult to summarize.” I would agree with that. I’m not good at it. I don’t think at this point that I do a good summary, but I’ll try to hit on a couple of the key ideas. I’ve been trying to apply that body of the enactive literature that’s out there. It’s mostly in the area of philosophy. I’ve been trying to apply that to pain. Enactive approaches suggest that if we’re talking about pain, we can’t find pain by only looking at the firing of nerves or imaging of the brain. If we think about it, its common sense that it’s just nerves firing and wet mash. It’s not the experience or the essence of pain. It still an important research, but most enactivist would say that’s one piece of the puzzle.
Maybe a couple of analogies might help. We used one about a bird in the paper from 2019. We borrowed that from Evan Thompson, but there are some other ones that are also helpful. Alva Noë talks about thinking that we can look into the body or brain would be similar to saying that we can find the value of money intrinsic to the paper it’s printed on. We can look into the paper and the actual material of the paper and know exactly the value of money. We know that it’s more dynamic than that. That one is abstract but maybe another analogy might help. This book, Linguistic Bodies. They’re not talking about pain, but we can apply this to pain. Looking into the body or the brain would be thinking that we can find or understand the speed of a car by looking in the engine. It’s a reductionist approach.
What enactivist argue is that we need to take a bigger picture approach in line with what the biopsychosocial model was advocating for. Enactivist plays a particular emphasis on things being relational. It immediately breaks down to we’re not talking about silos, we’re talking about relations between things. They talk about typically how we need to appreciate the full person, their brain and also the rest of their body, and how they interact in their environment. One key feature of enactivism is they tend to place an emphasis on action or the capacity to act. It is a bit more dynamic and it’s mostly a model for perception. A lot of researchers or philosophers in this area use it as a model or a framework for perception and argue that perception shaped our actions and our context. The brain is important. It’s helping us attune to our environment. It’s more of a relational view.
From my personal experience. I was at a conference and I was having a conversation with a physical therapist who was in a position on a committee to make the decision on who should be speaking at the next conference with regard to topics related to pain. I had sat down at this table at a conference and had lunch with her. I didn’t know her well and we were chatting about things. This is no judgment necessarily against anyone’s views on pain, but she was very passionate about Vania Apkarian’s work with regard to pain signatures in the brain. Vania Apkarian has some interesting research. He’s a pain researcher who has done a lot of functional MRI studies looking at pathways and firing patterns of what happens in the brain when someone is perceiving pain. His work is important.
It’s worth everyone taking a look at. However, there has been some criticism about that type of work. We’re taking this wet brain that it’s a snapshot in time. A millisecond in time based on a current technology, which may not provide us with everything we need. That technology of a functional MRI is still developing and does that. The question with regards to what we’re talking about is, do functional MRIs have a place in the theory you’re talking about? What do you think about this fingerprint of chronic pain in the brain with regard to your model of enactivism? I’ve invited Vania Apkarian multiple times to come onto this show so he’s had an opportunity to come to talk about this. He has yet to accept but I will invite him again.
Looking through your list of speakers, you’ve got some heavy hitters there. I’m just a lowly early career researcher, so I appreciate the opportunity to be on here. Dr. Apkarian’s work is important and valuable along with the methods and the techniques he used. In our 2019 paper, we do make a comment and we target one of his papers that it may be doing what I argued is problematic, trying to compress a subjective experience into that wet brain, maybe a snapshot or a small snapshot. I think that can be problematic.
I like the work of Dr. Sanneke de Haan. She’s an enactive thinker. She talks about how we can zoom in and zoom out at different levels. We need to re-appreciate that experience. For example, experience of pain is not reduceable. We can’t reduce it down to the anatomy, the brain or these functional networks, but we can zoom in within an enactive framework. We can zoom in on the disc and the joints pathology. We can zoom in using fMRI studies, and that can inform what we’re looking at. It’s one piece of the puzzle. A qualitative work focusing on patients’ experiences can inform the quantitative work, and the quantitative work can inform the qualitative work. There’s this mutually beneficial relationship.
One part that is good with enactivism is that it has that deep roots in phenomenology. Within that, most enactivist or a lot of them embrace subjectivity. They would argue that we can’t directly access another person’s experience by using some third-person methods, looking into the brain with imaging techniques or these types of things. That’s attractive to me. It doesn’t say that work is not good. It says, “If we’re trying to understand an experience, maybe we need to take a step back and look at the bigger picture and how these things start to connect.” I tried to do that a bit in that one paper, but people like Dr. de Haan do such a better job than I do at putting some of these ideas together.
Can you define the term phenomenology for us, so people have an idea of where you’re coming from?
It’s used in different ways. It’s the study of experience and consciousness. There’s a whole philosophical movement related to phenomenology, but there’s also phenomenology as a research practice in terms of qualitative research. That’s aimed at using interviews and that type of approach to explore experience. There are different ways of defining it.
It sounds like this enactive approach that you’re developing has a bit of a contextual flavor to it. That perception, which is the environment that someone is in and how they’re perceiving that environment has an influence on pain and then on their recovery.
It has a huge emphasis on environmental context and how perception is malleable. It changes over time. It’s not something that’s static. It changes based on our actions in an environment, our body orientation, intrinsic bodily factors, and how that relates to our environment. People often talk about affordances when they’re talking about enactivism. Affordances are possibilities for action based on the types of bodies we have and our relationship to our environment. What’s attractive to me, that concept of affordances, is it completely breaks down that dichotomy. You can’t talk about affordances without talking about both the environment and the individual at the same time. It helps stop us from fragmenting the biopsychosocial model.
One of the things that I try to talk to practitioners about is maintaining a sense of this flexible out-of-the-box thinking. If you box yourself into any one theory or treatment approach especially, it’s most problematic. Maintaining this flexibility to think about the patient, what they’re experiencing, and how that’s going to influence your evaluation, your treatment, your plan of care, and your interaction with the patient. How does this model help with that flexible out-of-the-box thinking that people have maybe fallen into with regard to that biopsychosocial silos?
At least Sanneke de Haan’s work emphasizes that flexibility. She uses examples of these network models. She shows all the intertwined factors, how they change over time, and how that shapes the individual’s experience. That’s important because that changes over time based on the person. Their body might change and the environment might change. Treatments may be that worked in the past might not work in the future. We have to be constantly attuned to that individual, their current perspectives, and how things might be changing. I’m working with a philosopher now out of Germany to try to explore some of these ideas in relation to pain. I’m slowly learning and struggling. I have a crisis at least once a week where I’m like, “Where am I going with this?” I get excited about all this different literature. At least some people might find it valuable. That might be worthwhile.
I liked what you said there that’s something you use in the past may not work in the present moment. If we take that back and apply it to some of that functional MRI and if you reduce it down to the brain for a minute, your brain changes over time. The structure and function of your brain changes. To think that a certain treatment that works for you when you’re 26 with chronic low back pain may not work well when you’re 60 years old, and you have a flare-up of the same amount of chronic back pain.
What enactive emphasized is the temporal extended nature of these things. It referred to cognition as sense-making. It unfolds over time and things change. That’s a limitation of the scientific methods is we need to structure and sanitize things in a way to isolate certain features. At the same time, minimizing that context sometimes takes away the true nature of it or the clinical applicability. That’s the nature of things. The challenge is like, “What does an enactive approach look like in research? It’s still got some of those same limitations. How can you simultaneously study the brain, subjective experience, and look at these things over time?” It’s resource-intensive and tricky stuff to do. I understand why people take more refined approaches.
I like that temporal relationship over time to think about that, how things change over time. That time change could be within the one-hour treatment session, or it could be over the seven visits you’re seeing someone over the years, that maybe someone comes in and out of your clinic, which is important. Tell us about the projects you’re working on?
I’m still trying to publish some of the work out of my PhD and some of that stuffs in peer-review. A paper come out in Medical Humanities. It’s on some of these enactive ideas in the context of metaphor and clinical practice. People can check that out if they’re interested.
What’s the name of the paper?
It’s called Painful Metaphors. That should be available online.
What’s the central theme or aim of that paper?
We did a qualitative study as a part of my PhD looking at how clinicians explained pain to their patients. We audio-recorded those actual interactions. We did individual interviews with the clinician and also the patient. We explored that process of sense-making. I always knew people use metaphor in clinical practice, but I didn’t realize the extent, how much I use it, and how everybody uses it. A big focus of that paper in Medical Humanities is the different types of metaphors we use and how that can shape a patient’s perceptions for better or for worse. It can potentially increase pain and disability or it can potentially empower a person and help them self-manage.
Peter, this has been fascinating talking to you. The model you have of enactive approach to pain is interesting. It’s one that everyone should read and explore. It’s in the 2019 Journal of Phenomenology and the Cognitive Sciences. It’s called An Enactive Approach to Pain: Beyond the Biopsychosocial Model. As your work develops and your PhD work continues, please come back on the show and share some of the updates you have with us. Let everyone know how they can learn more information about you.
Thanks. I appreciate the invite and I enjoyed talking with you about these ideas. I’ve got a website and a lot of my stuff is up there. It’s Dr.PeterStilwell.com. Moving along with my research, I appreciate the support that I’ve received. I give a shout-out to the people that fund this work. Qualitative research is historically underfunded and people don’t sometimes see it as being important. Lately, people have been seeing some value in that, so I’m hyped. Through the Ronald Melzack Fellowship that I hold, I’m doing some work on pain-related suffering with an awesome team. I appreciate the support through that, and also funding through the Canadian MSK Rehab Research Network. That’s been central to the current postdoc work that I’m doing. Also, the Canadian Chiropractic Research Foundation. They’ve been central to moving my work along and so I appreciate that. People can follow me on Twitter if they want. I try to share my research there. It’s @Peter_Stilwell.
We appreciate and enjoy your work. Make sure you come back on and share with us. You can follow Peter on his website at Dr.PeterStilwell.com. Make sure to share this episode with anyone interested in moving Beyond the Biopsychosocial Model of Pain. Thanks for being here and we’ll see you next episode.
Important Links:
- www.DrPeterStilwell.com
- @Peter_Stilwell – Twitter
- https://Link.springer.com/article/10.1007/s11097-019-09624-7
- Linguistic Bodies
- Painful Metaphors – article
About Peter Stilwell, PhD
Dr. Peter Stilwell is a Canadian pain researcher. He completed a PhD in Health at Dalhousie University in May 2020 and is now a full-time postdoctoral researcher at McGill University in the Faculty of Medicine – School of Physical and Occupational Therapy. He is currently the Ronald Melzack Fellow in Pain Research at the Alan Edwards Centre for Research on Pain (AECRP) at McGill. His current research projects involve conceptual and qualitative work on persistent pain and related suffering.
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