Psychological. What do you think when you see that term? Be honest with yourself, what’s going through your head right now? When you think about the word psychological or the phrase ‘psychological factors’, what comes to mind?

I ask because I have seen misconceptions abound when it comes to the P word.

Misconceptions about the term ‘psychological’

I have seen it used in such a way that you’d think anything psychological was pathological. That psychology is yellow flags and mental illness that requires a referral to a mental health professional. It seems many treating professions think that ‘psychological factors’ are beyond their scope.

I’ve also seen it used in a way that stigmatizes and marginalizes patients by implying their pain is made up or exaggerated. And this stigma is perpetuated by well-meaning healthcare professionals who believe referring to anything ‘psychological’ downplays their patients’ experiences because it implies they are causing or faking their own pain.

So it’s no wonder that people living with pain are hurt, angered or frustrated any time psychological factors come up because they understand it to mean, as society as a whole seems to, that psychological means the pain is all in their head.

It seems that many folks – healthcare pros, patients, society at large – equate ‘psychological’ to mental problems. To exaggeration, faking it, making it up.

That’s not what psychological means

‘Psychological factors’ do not solely pertain to psycho-pathological thinking or mental illness that needs to be referred out. Psychological factors are not about making pain up or exaggerating it, they’re also not about bringing pain on ourselves. And they’re certainly not, or at least shouldn’t be, a way of downplaying or dismissing a person’s experience.

Right now, this very moment, no matter who you are and whether or not you have pain, psychological factors are at play. If you thought about the term ‘psychological’ when I prompted you to in the first sentence of this post, psychology is at play. If you are reading these words and processing them, integrating them with previous words you’ve read, perhaps forming opinions of them, psychological factors are contributing to your experience.

In fact, if you had any thought whatsoever today, any feeling, any emotion, did any planning or any remembering, any worrying or forgetting, if you laughed or cried, felt frustration or joy, if you interacted with humans or animals or AI…if you were at all conscious today, you’ve been all psychological all over the place.

The meaning we make of our lives, a pretty heady subject and one I think most of us can agree is important, is psychological.

What is psychology?

Psychological factors - what are they?the science of mind and behavior; the mental or behavioral characteristics of an individual or group” ~ Merriam Webster dictionary

What is ‘psychological’?

of, affecting, or arising in the mind; related to the mental and emotional state of a person” ~ Google

So why do we make the P word out to be something bad? That needs to be referred out? That makes us uncomfortable? That stigmatizes and marginalizes?

As long as we are conscious, psychological factors are a part of our experience. All of us, all of our experiences. Psychology is not pathology, it is our mind, our behaviors, our emotions. Our values and meaning. Our dreams and goals.

Are any of us existing in this moment without our mind? Without thought? Or behavior? Or without feeling something?

Psychological factors are part of all of our daily lives

So yes, psychological factors do indeed contribute to our pain experiences, but psychological factors contribute to ALL of our experiences. We think, feel, remember, believe, expect, daydream, plan, react, meditate, focus, read, write, respond and interact with people and things all the livelong day. Whether we have pain or not.

Without ‘psychological factors’ there’d arguably be no reality.

We need to start talking about the breadth and depth of our psychological experiences when we talk about pain, not just one end of the spectrum. Hell, we need to talk about the breadth and depth of our psychological experiences when we talk about just being human.

We can’t stress the importance of getting people back to valued activities and meaningful living on one hand and then say that psychology is beyond our scope on the other.

Psychological factors are also inextricable from our biology

We also need to start talking about psychological factors as a part of our human biology, too. Unless you believe our minds are an entity somehow separate from our brain/body, you understand that our thoughts, emotions and behaviors have a biological underpinning.

Each thought involves neuronal impulses. That’s nervous system activity just as much as sensory input or motor output is. And our neurons are surrounded by glial cells, without which synaptic transmissions couldn’t take place and which for part of our neuroimmune system. So our neurons/nervous system are in constant communication with the immune system.

We also have a neuroendocrine system, where our neurons/nervous system are in constant communication with our endocrine system, the system that regulates our hormones.

So there is unarguably neural activity that occurs in conjunction with our thoughts, emotions, behaviors, feelings, memories, planning and the like, and that neural activity is in constant communication with our immune and endocrine systems.

Psychological factors in action

I used to fiercely resist admitting to ‘psychological’ factors being a part of my pain experience, as though they weren’t legit. As though they were something to be ashamed of. Like my mind, emotions, feelings and behaviors weren’t a part of my human experience before pain. Or that the meaning I ascribed to my life before pain wasn’t relevant.

But when we speak in P word terms, we often focus on the negative aspects of mind, emotion, behavior, and not the entirety of our rich, broad and deep psychological experiences.

Let’s go there, though, and just explore those ‘negative’ aspects, which are often made out to be aberrant or abnormal or pathological. Are they really?

A case study of sorts – putting you in their (ok, my…) shoes

Pre-pain firefighting me :)

Let’s say you went through nearly a year of unexplained and worsening pain, how would you feel? Let’s also say your career was on the line – and thus your livelihood, identity, retirement and future. What sorts of thoughts, emotions, feelings and behaviors might you have?

Might you be distressed? Worried? Anxious? Afraid? Would you think that abnormal? Unreasonable? Might you think it a natural and understandable response to unexplained, worsening pain that jeopardized your career and disrupted your identity?

And let’s further say that you had surgery to fix that pain some 13 months after it started, after months of battling within the work comp system, but it didn’t fix it.

That you did lose your job after nearly two more years of struggle within the work comp system. That your pain didn’t get better and you had no explanations as to why and no prognosis for the future. How would you think, feel and behave then?

So, yea. My pain definitely had some psychological factors contributing to it, do you blame me? Do you fault me for that? Could you reasonably think that there would be no distress, no worry, no fear, no anxiety?

There’s more to it, there always is

Psychology and biology are inextricably interconnected and embedded within one another. They are further inextricably interconnected and embedded within our social environments, too. This is the case for all of us all the time. They cannot be separated.

Whether we’re in pain or not. Healthy or not. Every bit of every one of our experiences has inseparable biological, psychological and social factors that influence and are influenced by one another. Every single conscious moment of our lives.

Pain and the P in BPS

When we first feel pain it grabs our attention. That’s it’s job after all. That attention we’re paying it, that’s psychology. The decision we make to seek care or to wait it out, that’s psychology. If we do seek care, the thoughts, concerns and expectations we go into our appointment with, that’s psychology.

And all those thoughts, expectations and concerns are accompanied by neurons firing in our brain. Perhaps some old connections/neurotags are firing and certainly some new connections/neurotags are being formed.

Psychological factors - neurotags

We’ve established thoughts as neuronal impulses. And we know that neuronal impulses are in constant bidirectional communication with our immune and endocrine systems all the while. Our psychology and biology are inseparable.

Continuing with our example. Our health literacy and ability to understand what the healthcare professional tells us, that’s psychology. (And biology, mind you, as mentioned above. And social too, of course. For now I’m focusing on the psychological stuff and hope you see the broader picture, too.)

The ability of the healthcare pro to convey the information to us is their own psychological mechanisms at work, too. And the social interaction between us is going to in turn influence both of ours psychology and biology (I don’t think anyone would argue that the brain is silent during these interactions with no activity going on).

Scenario 1:

Now let’s say we don’t get clear explanation or prognosis for our pain, yet we’re told to limit our activities until the pain goes away. Naturally that leads to a whole lot of thoughts, concerns, worries, planning, behaviors, potentially distressing interactions with others, etc. It may ramp up our anxiety and/or elevate our stress levels.

It may lead to a bit of fear, too. Fear of movement, either out of worry about making the pain worse or worry over causing damage to the tissues.  Or fear of the future and a life of pain. Or just plain and simple fear of the unknown.

It can be a bit dark and scary when you don’t know why you have pain or if it’ll ever change.

Psychological factors - fear, anxiety, hopelessness, isolationAll sorts of neuronal activity is going on all the while, which is constantly communicating with our endocrine and immune systems. We actively try to make sense of it all – searching for meaning, purpose, reasons.

Our lives change.

It’s a complex milieu of B, P and S

Do you see how it’s not just ‘psychology’ at this point? The responses will vary from person to person and even within the same person over time. The nervous, immune and endocrine responses can be numerous (and they’re not the only things going on, either, just the ones I happen to be highlighting).

Our stress levels may rise via our endocrine system, our immune responses may intensify, our pain may go up.

Some people might start to feel fatigued and exhausted, others might have heart palpitations and nausea, others still might have some swelling and redness in the body part that hurts, some might feel their pain ramp up, others may not be able to sleep or eat, yet others may want to sleep all the time or overeat.

And if we do get a ramped up endocrine and/or immune and/or pain response –  some swelling and redness, say, or inexplicable exhaustion or heart palpitations – of course we’re going to notice it, pay attention to it, think about it. Our biological reactions thus influence our thoughts, just as our thoughts influence our biology.

An unintentional cycle

Understandably, we might become more distressed because of the things happening in our body. All those protective mechanisms can then ramp up more. In fact, our immune responses can make our pain responses even more efficient! And if our systems are getting ramped up, that’ll then affect our thoughts, feelings, emotions, behaviors, which then again affect the protective mechanisms that are trying to keep us in homeostasis.

And round and round we go.

Sheesh! This psychology stuff can have a huge influence, eh? It is absolutely inextricable from our biology and the social environment we exist within.

I want to be clear that we are not bringing this cycle onto ourselves consciously. We are not intentionally making this happen, not willing it into existence. Nor are we making pain up or exaggerating it or faking it, even though there is a psychological component to all of it.

This is all happening below our conscious level of awareness. It is not ‘all in our head’, it’s in all of our being. All of our systems are involved ALL OF THE TIME. Pain or no pain. Healthy or not.

Scenario 2:

Say, instead, we felt reassured by the appointment. That we were given a clear explanation as to what was going on, we understand the prognosis and course of action that is going to be undertaken and we are encouraged to keep moving and working. We leave feeling equipped for what’s to come and like we have some control over our situation.

Our thoughts would be much different than in the first scenario, don’t you think? Our concerns and worries assuaged rather than amplified. A different sort of planning would take place, different interactions with the people in our lives would occur. Our behaviors would be markedly different. Rather than fearing movement we might seek it out believing that it will help, for example.

And all of that leads to different neuronal impulses/neurotags firing and different messages being communicated between the nervous, immune and endocrine systems.

Pain might improve, sleep might improve, mood might improve. Blood pressure might go down, stress levels might recede. Swelling and redness might resolve. Palpitations and nausea never come to be in the first place.

Life might be groovy, full of love and light.

Psychological factors - love, hope, gratitude, acceptance, appreciation

Our psychology affects our biology here, too, just as much as it does in the first scenario. And our biology affects our psychology.

Psychology doesn’t = bad, you see?

Psychology is awesome!

This is awesome stuff, folks, don’t you agree? How humans think, feel and behave is pretty friggin’ fascinating.

We are all psychological all the friggin’ time. At least those of us who think, feel and behave at all ;)

Isn’t also awesome and empowering to know that though much of this is taking place below our level of conscious awareness, we can bring a level of awareness to it and have some influence over it?

We are not at fault for our pain. But we can influence it. We can become better informed, more aware and better equipped to take action. We can have some control. That’s friggin’ fantastic!

We can consciously affect our biology and our experience because psychology – thoughts, feelings, emotions, behaviors – is always underpinned by biology. What amazing beings we are! (And not entirely understood ones.)

To wrap it up, and what I’ve hope I’ve made clear: our psychological factors matter to our very existence, not just our pain. We are all B, P and S all the time.

Me with pain, hiking, happy and healthy with all sorts of psychological-ing going on ;)

Disclaimer

I’m biased as hell! My undergraduate degree is in Psychology and first graduate school stint was in Biopsychology/Neuroscience. My last graduate school stint was in Human Movement and my track was Sport and Exercise Psychology. I’m a bit of psychology nerd because I love the brain and I love humans.

But even though I’m biased, it doesn’t mean my points aren’t valid!

As to my points – if I’ve got any of the more sciency bits wrong, please tell me. Always always always please tell me, on any of my posts.

Sorry for another long post, folks. But this has been getting my goat lately.

Additional reading:

For a cool article on pain and neuroimmune and neuroendocrine stuff, check out: “Lifetime Modulation of the Pain System via Neuroimmune and Neuroendocrine Interactions

For more on the immune system and the brain, particularly the glymphatic system, check out this article: “Brain Drain

 

 

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8 Responses to "Psychological: Let’s talk about the P in BioPsychoSocial"

  1. I always think it’s “funny” when someone says, “so it’s all in my/your head.” It’s said dismissively as if the issue were imaginary or almost non existent.

    But “all in your head” is huge! People spend their whole lives trying to resolve stuff that’s in our head! A broken wrist, sprained ankle, or torn ACL all have fairly direct, obvious solutions. But “all in your head…?” That’s a massively complex collection of riddles. Thanks for writing.

    • Thanks for reading the post, Kyle, and for taking the time to leave a message. I agree, I don’t really understand the phrase ‘it’s all in my/your head”, as so much of our lives are all in our head! Nothing happens bereft of thought, emotion, integrating previous experiences, memory, learning, behaviors. I think that’s what we need to make more clear. That when we talk about pain as an output of the brain we are also comparing that to other outputs, too, like love, joy, personality and such. We need to destigmatize the happenings of our minds!

      And even with a broken writs, a sprained ankle, a torn ACL there are psychological factors at play. There will be thoughts and emotions, planning and expectations. An athlete with a broken wrist before the first game of the playoffs is going to have different thoughts and emotions than the same athlete with a broken wrist in the off-season.

      We humans are indeed a complex collection of riddles, aren’t we? Thanks so much for reaching out!

  2. Explaining pain is not easy and requires skills and empathy from the clinicians. That pain and amount of damage tissue isn’t fully related. Also the importance of minimize the fear within the patients in front of you.
    To tell that, all is in your head, won’t make to much difference.
    Thank’s for your sharing of your thoughts and knowledge.
    It will contribute time my job as an Physiotherapist working with people in pain.

    • Thank you so much for reading my post and for sharing your thoughts, it’s greatly appreciated.

      Explaining pain is hard, and each individual will need different bits of the science to help them make sense of their pain based on their unique lived experience, current understanding and things they value and find meaningful.

      Learning that pain did not always mean tissue damage, that pain and damage were poorly related, especially in pain that was persistent, was life changing for me. The work of Lorimer Moseley and David Butler opened the door onto my life again and I was able to re-engage with people, places and experiences that I valued once again.

      It’s unfortunate that so often the psychological factors in biopsychosocial approaches to care are misconstrued, by both practitioners and people living with pain. Saying that pain is all in y/our head isn’t helpful and can perpetuate misunderstanding and stigmatization. There are better ways to convey the meaning of psychological!

      This pain stuff is hard, though, no doubt. On both the people living with persisting pain and the practitioners who are trying to help them. I thank you for all you do!

  3. “It is not ‘all in our head’, it’s in all of our being.” This was such a powerful statement for me to read. Though I’ve made it a point to listen to my patients, I feel that I never get to fully embrace their entire experience. Possibly because many of them cannot organize their words to communicate it like you have. I’m sure that statement will resonate through my very existence as I listen with a stronger intention to now understand better what anyone has to tell me. Finally, thank you for making it a point that psychological is normal and not synonymous with pathological. This is something that I couldn’t put into words as eloquently as you have when explaining to colleagues who stigmatize psychology in the BPS model as a yellow flag needing referral to a specialist.

    • What a wonderful message to receive this morning Ken, thank you. I can’t find the words to adequately express how much this means to me. When my pain was at it’s worst, I was at a loss for words, unable to describe the entirety of my experience. To be truthful I wasn’t even aware then of the entirety of my experience, all I knew was pain. That’s why I write about it now, reflecting back on where I’ve been in order to give others a voice who may not have the words themselves. So it means the world to me that you can relate my words to your patients experiences and that you will remember them during your encounters with them. That is invaluable.

      The more we can destigmatize the word psychology in the health professions the better off people living with pain will be, too. It’s a hard ship to turn but I think it is slowly happening. I think the more we can relate our own psychological experiences to our every day lives, the more we an recognize that is so infused throughout our reality it makes no sense to stigmatize it or pathologize it! And to ask ourselves from time to time, if I were experiencing what this person is going through, what would I think and feel? And not just the pain part but the strained relationships, loss of identity, inability to engage in loved activities, fear of losing one’s job or career, uncertainty about the future, believing oneself to be damaged, broken or frail, believing that every painful movement means more damage, brokenness and frailty. These are hard thing to deal with for anyone. Pain is in all of our being. It influences and is influenced by every aspect of our lives.

      Thanks so much for sharing your thoughts, Ken. I appreciate it beyond measure.

  4. I am so relieved to read this article which underlines the inextricable links between our feelings, our sensations and the physical responses which form part of the complex cycle of experience. It seems when we have pain we can interrupt that cycle at any point to good effect. Medicine can interrupt the body’s responses, psychotherapy or other emotional input from friends or literature can interrupt the psychological response, physical exercise or activity can also interrupt the cycle by stimulating new neurological input which lifts the spirits. Interrupting the pain gives the body, the mind and the soul some breathing space to notice and take stock of the rest of our human experience.
    Also important is to pay attention to what you learned about pain as a child – is it good to beat it? Do you get Brownie points for not feeling it? Now as adults we need to be extra kind to ourselves and not beat ourselves up for feeling it. Being brave is not about disconnecting from our feelings.

    • I am so grateful for your comments here and on the Meaning post, thank you kindly. You so eloquently express my own thoughts on the matter, much better (and more succinctly!) than I ever could! I felt most empowered about my own pain issues when I realized what you brought forth here, that I could interrupt the cycle and that there were many ways in which to do so. And I appreciate that you mentioned how relevant what we learned of pain as a child is, I think that is too often overlooked. As is how society in general conceptualizes pain, and our micro-cultures of work and family/friends.

      And not beating ourselves up! That’s a biggie. Self-kindness is something I am working on, that I’m sure I’ll always be working on, and I am finding it easier now than I used to. We are all but human. It took me a long time to be able to be with my feelings, thoughts, emotions…pain. I fought and resisted and ignored for a long time. But the only way through is through, with rather than around. Accepting my present reality, being able to acknowledge it with the recognition that all is impermanent and that it, too, would change, was life-changing. For so long I had thought of it as giving up or giving in but I realized that accepting and being within the present moment does not consign you to a future of that same moment.

      Thanks so much for sharing your insights, they have given me much food for thought and simply state so much of what I’m trying to convey!

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