Journal of Psychosomatic Obstetrics & Gynecology
ISSN: 0167-482X (Print) 1743-8942 (Online) Journal homepage: http://www.tandfonline.com/loi/ipob20
Biopsychosocial obstetrics and gynaecology – a perspective from Australia Heather Rowe To cite this article: Heather Rowe (2016): Biopsychosocial obstetrics and gynaecology – a perspective from Australia, Journal of Psychosomatic Obstetrics & Gynecology, DOI: 10.3109/0167482X.2015.1124853 To link to this article: http://dx.doi.org/10.3109/0167482X.2015.1124853
Published online: 05 Jan 2016.
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Date: 26 January 2016, At: 01:07
http://informahealthcare.com/pog ISSN: 0167-482X (print), 1743-8942 (electronic) J Psychosom Obstet Gynaecol, Early Online: 1–5 ! 2015 Taylor & Francis DOI: 10.3109/0167482X.2015.1124853
PERSONAL VIEW
Biopsychosocial obstetrics and gynaecology – a perspective from Australia Heather Rowe
Downloaded by [RMIT University] at 01:07 26 January 2016
Monash University, School of Public Health and Preventive Medicine, Jean Hailes Research Unit, Melbourne, Victoria, Australia
Abstract
Keywords
Prior to and throughout the twentieth century, biomedical understandings of health predominated. Australian obstetrician and gynaecologist, Professor Derek Llewellyn-Jones responded to frustrations with the limitations of this narrow approach from both within and beyond the medical profession. His pioneering research, education and writings re-conceptualised the discipline as encompassing the social and psychological contexts and profoundly influenced women’s own understanding of their health and the practice of obstetrics and gynaecology. The biopsychosocial model has replaced biological determinism and is now pervasive in education and clinical practice in many parts of the world. Widespread acceptance of the model has until now been associated with under-recognition of the importance of biology. Recent findings from epigenetics and neuroscience are enabling integration of body, mind and society and enhanced understanding and practice of psychosomatic obstetrics and gynaecology.
Biomedical sciences, body-mind influences, psychosomatic gynaecology History Received 4 November 2015 Revised 18 November 2015 Accepted 23 November 2015
Introduction It has been said that ‘‘obstetrics and gynaecology is the specialty of life, love, sex and death, all the big things that underpin our lives as human beings’’ [1]. Obstetrics and gynaecology (O&G) participates in the joys and the tears, the fear and the wonder, the miracles of life, suffering and joy. O&G is supremely important because the quality of health care that women receive at these times of heightened sensitivity is central to their wellbeing and recalled by them years later with exceptional clarity [2–4]. Reflecting on the quality of clinical practise in O&G has been the substance of ASPOG for more than four decades and this endeavour has been profoundly shaped in Australia and around the world by the man for whom the oration was named.
Derek Llewellyn-Jones 1923–1997 Derek’s legacy was profound and he has remained alive to students of obstetrics and gynaecology through his writings. His Fundamentals of Obstetrics & Gynaecology [5] textbook confirmed his reputation as a great teacher and communicator was written with superb clarity and insight. And, unusually for an O&G textbook at that time, there was a chapter devoted to
Address for correspondence: Dr Heather Rowe, Hons, School of Public Health and Preventive Medicine Jean Hailes Research Unit, Monash University, Level 1, 549 St Kilda Road, Melbourne 3004, Australia. E-mail: [email protected]
breastfeeding, affirming the view that the obstetrician’s role should include attention to the factors that support the establishment of lactation. Llewellyn-Jones was a true pioneer. He was an early proponent of the movement for women to have greater choice in childbirth, and he encouraged partners to stay with each other during labour. He was also a strong supporter of Birth Centers. All of these were revolutionary concepts in the 1960s, when women did as they were told and men were left outside. Yet here was Llewellyn-Jones advocating for men’s right to support their partners during labour and get to know their infant sons and daughters from their earliest moments. The presence of fathers in labour ward has become standard practise in many parts of the world [6], but back then Llewellyn-Jones was absolutely ahead of his time. Not limiting himself to the education of doctors-to-be and challenging the status quo, Llewellyn-Jones went to work to address the appetite for women’s improved understanding of their bodies that was liberated by the rising women’s movement. Reliable knowledge is the foundation of health and wellbeing, and until then, women’s bodies had been largely a mystery to them. Enter Everywoman [7]. A book for a general audience, it seamlessly combined medical and gynaecological knowledge with the social contexts of women’s sexuality and wellbeing, and was to become one of the most successful books ever published on women’s health. And Llewellyn-Jones was no ‘‘Johnny-come-lately’’.
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The ‘‘Doctor’s Group’’, later to become the Boston Women’s Health Book Collective, published Our Bodies Ourselves, on stapled newsprint for hand distribution in 1970 [8], and the first edition of Everywoman appeared in 1971. Everywoman epitomises the joining of body, mind and society, and it paved the way, from inside the medical profession, for a model of clinical practise that involves women as informed partners in their care.
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Psychosomatics and the birth of ASPOG At around this time, the ASPOG was born and in 1973 held the first national conference in the Barossa Valley in South Australia; Llewellyn-Jones was a founding member [9]. Then the Australian Society for Psychosomatic Obstetrics and Gynaecology, its aims were to study the psychobiological and psychosocial, ethical and cross-cultural problems in the fields of obstetrics and gynaecology, women’s health and reproductive health. The term ‘‘psychosomatic’’ represented a search for a more holistic understanding of the patient, her psychological and social contexts and the meaning she makes of events; and to respond to the question ‘‘Who is this woman?’’. ‘‘Psychosomatic’’ also denoted the joining of the mind and the body, the yoga of soma and psyche. The formation of ASPOG was a response to the growing disenchantment with the dualistic biomedical model of practise that separated body from mind and reduced disease to pathology in individual body parts, and women’s health care to unhelpful and sometimes damaging encounters. The new professional society also responded to the needs of clinicians for whom biomedical explanations were insufficient to inform their practise, in particular for the difficult-to-treat conditions. It attracted the thoughtful who wanted to explore in greater depth the meaning of their profession and to walk the boundaries with the other disciplines of psychology and psychiatry, ethics, philosophy and sociology and, more recently, human rights. And of course, it has always fulfilled a need for individuals to connect, to communicate with the like-minded and to belong.
Is it psychosomatic or psychosocial? The Australian SPOG was ‘‘psychosomatic’’ O&G when it was founded in 1973, but changed its name to ‘‘psychosocial O&G’’ in 1991. It was thought that ‘‘psychosomatic’’ might signify mental health problems and promote the idea that women’s health symptoms are ‘‘all in the head’’ and without a physiological basis; also that the term ‘‘psychosocial’’ might attract a larger range of professional groups (Professor Suzanne Abraham, ASPOG President 2007–2009, personal communication). However, the international society, ISPOG, remains unapologetically ‘‘psychosomatic’’, about which I will say more later. I want to take this opportunity to reflect on the meaning for medical education and clinical practise of the ‘‘bio-psycho-social’’ construct as it has evolved since Llewellyn-Jones’ time.
The biopsychosocial model George Engel, a physician, also writing in the 1970s and 1980s, declared that the way in which a doctor approaches a
J Psychosom Obstet Gynaecol, Early Online: 1–5
patient and her presenting problems is defined by the conceptual models around which the doctor’s knowledge is organised [10]. He declared that ‘‘The crippling flaw of the biomedical model is that it does not include the patient and his attributes as a person, a human being’’ [11]. This is despite the fact that data for the physician appear in psychological and behavioural terms – what the patient thinks and what the patient does and how she reports about herself and her life. The biomedical framework can make use of neither the person as a whole nor of psychological and social data. Engels proposed the biopsychosocial model, a systems approach to diagnosis and treatment, which seeks to understand the presentation and course of illness from multiple perspectives in a hierarchy from the intracellular to the sociocultural levels [11]. ASPOG is dedicated to promoting this understanding and the biopsychosocial model remains influential in medical education and practise today [12].
Biological determinism One of the attractions of the more comprehensive conceptualisation of women’s health offered by the biopsychosocial model is that it addresses the problem of ‘‘biological determinism’’. The ‘‘biology is destiny’’ ideology is used to justify sexual, racial and other inequalities and to argue that initiatives to combat them are futile [13]. In the 1970s and 1980s, feminist [14] and Marxist [15] critiques made the case for the central importance of socio-political structures to the development of human potential and the reproduction of social and health inequalities. In the 1970s, these ideological differences resulted in the unhelpful polarisation of biological and social theories and a discourse that positioned biology and environment in opposition to each other, the (nature versus nurture) dichotomy. Indeed, I was dismayed to discover this when I emerged from my undergraduate degree in the biological sciences. ‘‘Biology’’ was somewhat of a dirty word among feminists with whom I otherwise readily identified. The opposition to biology was a reaction against the damaging discourse as it pertains to women that permeated the twentieth century and long before, which casts women as different, ‘‘the other’’ and as has having inferior strength, talents and potential because of supposed biological limitations inherent in having two X chromosomes [13]. The distinction between ‘‘sex’’ and ‘‘gender’’ enabled the differences between men and women to be understood as acquired at least in part by cultural conditioning rather than caused by biology alone; one is not born but rather becomes a woman [14]. Feminist critiques of biological determinism also disrupted the assumption that women are destined solely for motherhood, an ideology that underpinned the great disservice to women of equating women’s health solely with pregnancy and childbirth: to woman as mothers, rather than women as women [16]. ‘‘Nature versus nurture’’ is of course a false dichotomy. As students, we learn the so-called ‘‘central dogma of genetics’’ – DNA makes RNA makes proteins – that make the characteristics of the organism [17]. But the other central tenet of genetics is that the genotype interacts with the environment to produce the phenotype – in other words – genes provide the
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DOI: 10.3109/0167482X.2015.1124853
blueprint for the body on which experience is written and the person develops [18]. Environmental and social circumstances are fundamental to an individual’s capacity to reach their potential and to their health status. The biopsychosocial discourse offers a way to illuminate the ‘‘black box’’ that exists in the space between biology and health and, importantly, provides a means to study the consequences for women’s health of gender disadvantage in its many forms [19]. Now, many of the contents of the black box are common knowledge. The data assembled by the WHO Commission on the Social Determinants of Health led by Sir Michael Marmot and released in 2008 are compelling [20]. Social stress from poverty, lack of power and agency, violence and discrimination, in the home, the neighbourhood, the workplace and the social and political landscape are the pre-conditions of much poor health. And conversely stable family life, safe workplaces and neighbourhoods, good education, access to health care, social and economic participation, and respectful relationships are keys to a healthy life. Today, clinicians are well aware of the influence of psychological processes and social disadvantage on disease; in fact, sociodemographic disadvantage is regarded as an independent risk factor for adverse pregnancy outcomes [21]. Modern statistical methods also enable epidemiologists to analyse data from multiple levels of Engel’s hierarchy of systems [22,23].
The B-P-S model in clinical practise In ISPOG, ‘‘psychosomatic’’ is closely aligned to Engels’ ‘‘biopsychosocial’’ systems approach, but it goes further than that. It engages with the subjective experiences of women, their unique life events, biographies and personalities. Johannes Bitzer (ISPOG President 2001–2004) has written about the value of a psychosomatic approach to the difficult clinical questions [24]. For example, when there are different manifestations of the same disease in different individuals or no detectable cause for presenting symptoms like pain, fatigue or nausea; in decision-making, when there is uncertainty about evidence-based solutions or the woman does not accept or adhere to an evidence-based therapy but maintains her risk behaviour, or when patients seek help for personal problems like sexual difficulties, partner and family violence, adverse life events, and when patients are experienced as difficult and demanding and the gynaecologist feels helpless and demoralised. Each clinician will have their own difficult questions. I would add questions about evidence-based practise in the highly anxiety-arousing environment of pregnancy care in high-income countries. How do clinicians manage when there are multiple routine tests with complicated results and sometimes profound consequences for pregnancy management? And, in a multicultural society like Australia, how does the obstetrician or gynaecologist reconcile with the Western biomedical tradition the variety of meanings that patients may attach to the cause, experience and cure of their illness? [25]. According to Bitzer [24], in clinical practise of the psychosomatic model, symptoms represent the woman’s personal suffering and are an expression of multifactorial interactions specific to her. This means that ‘‘the basic unit of observation is the interaction of the disease process and the
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3
individual person in her life situation’’. Diagnostic procedures must therefore seek to understand the patient’s circumstances, how she thinks, feels and behaves, the meaning to her of the illness, and to integrate this knowledge with diagnostic test results. And therapeutic plans must take into account her motivation, hopes and priorities. This might sound simply like good psychologically-informed care, or perhaps it just sounds nebulous and unfocussed. But maybe not. Innovative approaches demonstrate that it is possible, for example, to engage therapeutically with the meaning to a woman of her pain [26,27]. Generating evidence that a biopsychosocial approach actually works in clinical practise is no simple task. It might be easy enough to measure a well-defined outcome, but how do we standardise a ‘‘psychosomatic’’ approach, so that what is being measured is clearly defined? How do we grasp the feelings and emotions that exist in the space between the doctor and patient, or account for variability in contextspecific features of workplace culture and economic constraints. Producing gold-standard evidence of the effects of this kind of clinical practise might even be inimical to the very thing that psychosomatics is intended to achieve. Notwithstanding these difficulties, the evidence is accruing. Qualitative research with women identifies the features of care that women in specific circumstances value, and evidencebased guidelines are appearing. Guideline documents include the level of evidence that supports each recommendation and point out where more research is needed. The guidelines for fertility staff about routine psychosocial care in infertility and medically-assisted reproduction, recently published by ESHRE, are a case in point [28]. Sibil Tschudin (ISPOG President Elect) and her colleagues [29] argue that if psychosomatic aspects are neglected, underlying problems can remain undiagnosed and inadequately treated, which can affect morbidity and medical costs. From the doctor’s perspective, poor psychosocial competence may increase stress and contribute to burnout. Conversely, good communication can improve patients’ satisfaction as well as their adherence to treatments. Identifying relevant psychosocial information and managing accordingly are therefore essential clinical competencies.
Teaching biopsychosocial medicine In medical schools in many parts of the world, the biopsychosocial model is standard curriculum fare [12]. However, conveying the relevance of the social determinants of health, preventive medicine and the patient in social context to medical students keen for anatomy, physiology, biochemistry and clinical skills can be challenging. In my own experience, the biopsychosocial model can be reduced by students to a mantra to be trotted out in exams in the hope that available marks are acquired. This leads to questions about what biopsychosocial clinical practise really looks like. At worst, at least in medical education, it can look disappointingly reductionist. In a recent Lancet commentary, Deborah Cabaniss describes a clinical scenario where patients are metaphorically ‘‘chopped up’’ into neat bio, psycho and social components, and therapies are selected and applied accordingly: drugs for the pathology, counselling for the
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distress, and social interventions for the disadvantage [30]. At best this might look like good multi-disciplinary team care, where the person is managed from multiple perspectives by highly skilled specialists in a comprehensive treatment plan [31]. But does it achieve true integration where each clinician is able to draw on highly developed skills and treat the whole person, not just their parts? And how are these capabilities inculcated in trainee medical and other professionals? This is not an easy task, because they are about things like professional attitude, communication, cooperation, empathy and compassion, which involve disrupting stereotypes and personal prejudices, and other reflective capabilities. Problem-based and casebased learning strategies are useful, and of course proficiency grows over time and with maturity, but many would agree that there is still a long way to go. There is likely to be more activity in the educational sphere during Sibil Tschudin’s forthcoming ISPOG presidency, and after the new ISPOG textbook is launched in the 18th ISPOG Congress being held in 2015 in Spain.
Reclaiming biology I want to finish by returning to where we started, with questions about the primacy of biology. But first, a short digression to the land of Erewhon. In his novel of the same name published in 1872 [32], Samuel Butler describes Erewhon (‘‘Nowhere’’ almost spelt backwards), a fictional country where criminal offenders are treated as if they are ill, whereas ill people are looked upon as criminals. It was a satire on Victorian society, but Butler demonstrated remarkable prescience whereby in the twenty-first century, ‘‘evil’’ is for many an outdated concept - criminals can usually be described as having suffered childhood abuse and disadvantage, whilst the chronically ill or marginalised - although not necessarily locked up, can be held responsible for their socalled poor ‘‘lifestyle choices’’ [33]. If in the twentieth century people were blamed for their biology, in the twentyfirst century they are blamed for their circumstances! The public discourse still favours simplistic binaries. But, perhaps after all, the biological sciences can redeem us by offering a true integration of body, mind and society. Indeed, it has been claimed that it is no longer scientifically tenable to split the psychosocial from the biological – everything is biological – and the idea that mind and brain are independent is no longer credible. Talking therapies are effective because they cause biochemical modifications in underlying brain structures, and ‘‘interpersonal events have biological sequelae’’ [30]. But, how does this come about? The so-called ‘‘life course health development’’ framework [34] describes how individual and population health develops, how developmental trajectories are determined by interactions among multiple factors during the lifetime. It provides a construct for interpreting how people’s experiences in the early years of life, especially in the first 1000 days, influence later health conditions and functional status. Details of the biological mechanisms that describes how social and psychological experience influence biology, and therefore health and illness, are accumulating rapidly. We know that at the intra-cellular level, epigenetic phenomena
J Psychosom Obstet Gynaecol, Early Online: 1–5
involve modifications to gene expression caused by environmental triggers, including adversity. Some of these may be replicated during cell divisions that produce the gametes and be passed to future generations [35]. For example, a recent study showed that epigenetic modification of the oxytocin receptor gene influences the perception of anger and fear in the human brain [36]. Careful work over decades has demonstrated the adverse impact of maternal anxiety in pregnancy on perinatal and child outcomes and the impact of (preventable) social stress [37]. Finally, we know that social factors contribute to age at puberty in girls [38] and there is an emerging role for social stress in the development and course of perplexing conditions like PCOS [39]. Emphasis on developmental trajectories draws attention to underlying susceptibilities on which current circumstances impinge. It enables a theory of causation that incorporates genes and environment, proposes a treatment plan that addresses causes not just symptoms, and emphasises social factors, most notably gender discrimination and violence against women, which urgently need to be addressed. So, we have come full circle to reclaim biology. With a clearer understanding of the development of illness that includes biopsychosocial causes, the health practitioner is in a better position to answer two fundamental clinical questions ‘‘why this patient? and why now?’’ and to manage appropriately.
Declaration of interest Heather Rowe BSc (Hons) PhD is Secretary General of ISPOG. The author reports no other conflicts of interest.
References 1. Cockburn J, Pauson M. Preface. In: Cockburn J, Pauson M, eds. Psychological challenges in obstetrics and gynecology the clinical management. London: Springer-Verlag London Limited; 2007. 2. Simkin P. Just another day in a woman’s life? Women’s long-term perceptions of their first birth experience. Part 1. Birth 1991;18: 203–10. 3. Simkin P. Just another day in a woman’s life? Part II: nature and consistency of women’s long-term memories of their first birth experiences. Birth 1992;19:64–81. 4. Lundgren I, Karlsdottir S, Bondas T. Long-term memories and experiences of childbirth in a Nordic context – a secondary analysis. Int J Qual Stud Health Well-Being 2009;4:115–28. 5. Llewellyn-Jones D. Fundamentals of obstetrics and gynaecology. Volume 1 obstetrics. 1st ed. London: Faber & Faber Limited; 1969. 6. Vernon D, ed. Men at birth. 2nd ed. Sydney: Finch Publishing; 2011. 7. Llewellyn-Jones D. Every woman. A gynaecological guide for life. Faber and Faber Limited; 1971. 8. Our bodies ourselves information inspires action. History. Available at: http://www.ourbodiesourselves.org/history/ [last accessed 10 Sep 2015]. 9. ASPOG. Australian Society for Psychosocial Obstetrics and Gynaecology. Available at: www.aspog.org [last accessed 10 Sep 2015]. 10. Engel G. The need for a new medical model: a challenge for biomedicine. Science 1977;196:129–36. 11. Engel G. The clinical application of the biopsychosocial model. J Med Philos 1981;6:101–23. 12. University of Rochester Medical Centre. Medical education admissions. Available at: https://www.urmc.rochester.edu/education/md/admissions/md-curriculum.aspx [last accesssed 11 Sep 2015]. 13. Mikkola M. Feminist perspectives on sex and gender. In: Zalta EN, ed. The Stanford encyclopedia of philosophy. Available at: http://
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plato.stanford.edu/archives/fall2012/entries/feminism-gender/ [last accessed 21 Aug 2015]. de Beauvoir S. The second sex. Harmondsworth: Penguin; 1972. Lewontin RC, Kamin LJ, Rose SPR. Not in our genes biology, ideology, and human nature. New York: Pantheon Books. 1984. Gannon L. The impact of medical and sexual politics on women’s health. Femin Psychol 1998;8:285–302. Crick F. Central dogma of molecular biology. Nature 1970;227: 561–3. Cavalli-Sforza L, Bodmer W. The genetics of human populations. San Francisco: WH Freeman and Company; 1971. WGEKN. Unequal, unfair, ineffective and inefficient – gender inequity in health: why it exists and how we can change it. Final report of the women and gender equity knowledge network of the commission on social determinants of health. Geneva: World Health Organization; 2007. CSDH. Closing the gap in a generation: health equity through action on the social determinants of health: final report of the commission on social determinants of health. Geneva: World Health Organization; 2008. Lindquist A, Noor N, Sullivan E, Knight M. The impact of socioeconomic position on severe maternal morbidity outcomes among women in Australia: a national case–control study. BJOG 2014;122:1601–9. Duncan C, Jones K, Moon G. Context, composition and heterogeneity: using multilevel models in health research. Soc Sci Med 1998;46:97–117. Hays RD, Revicki D, Coyne KS. Application of structural equation modeling to health outcomes research. Eval Health Prof 2005;28: 295–309. Bitzer J. Teaching psychosomatic obstetrics and gynecology. In: Cockburn J, Pauson M, eds. Psychological challenges in obstetrics and gynecology the clinical management. London: Springer-Verlag London Limited; 2007:3–14. Rice P, Ly B, Lumley J. Childbirth and soul loss: the case of a Hmong woman. Med J Aust 1994;160:577–8. Moseley G. Painful yarns: metaphors and stories to help understand the biology of pain. Canberra, Australia: Dancing Giraffe Press; 2007.
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27. Moseley G, Butler D. Explain pain. 2nd ed. Adelaide, Australia: Noigroup Publications; 2013. 28. The European Society of Human Reproduction and Embryology. Routine psychosocial care in infertility and medically assisted reproduction – a guide for fertility staff. Available at: http:// www.eshre.eu/Guidelines-and-Legal/Guidelines/Psychosocial-careguideline.aspx [last accessed 22 Sep 2015]. 29. Tschudin S, Kaplan Z, Alder J, et al. Psychosomatics in obstetrics and gynecology – evaluation of a compulsory standardized teaching program. J Psychosom Obstet Gynaecol 2013;34:108–15. 30. Cabaniss D, Moga D, Oquendo M. Rethinking the biopsychosocial formulation. Lancet 2015;2:579–81. 31. Mitchell P, Wynia M, Golden R, et al. Core principles and values of effective team-based health care. Discussion Paper. Washington, DC: Institute of Medicine; 2012. Available at: www.iom.edu/tbc [last accesssed 18 Sep 2015]. 32. Butler S. Erewhon: or, over the range. Available at: https:// www.gutenberg.org/files/1906/1906-h/1906-h.htm [last accessed 22 Sep 2015]. 33. Medhora S. Remote communities are ’lifestyle choices’, says Tony Abbott. Guardian 2015. Available at: http://www.theguardian.com/ australia-news/2015/mar/10/remote-communities-are-lifestylechoices-says-tony-abbott [last accessed 22 Sep 2015]. 34. Halfon N, Hochstein M. Life course health development: an integrated framework for developing health, policy, and research. Milbank Q 2002;80:433–79. 35. Meaney MJ. Epigenetics and the biological definition of gene environment interactions. Child Develop 2010;81:41–79. 36. Puglia MH, Lillard TS, Morris JP, Connelly JJ. Epigenetic modification of the oxytocin receptor gene influences the perception of anger and fear in the human brain. Proc Natl Acad Sci 2015; 112:3308–13. 37. Glover V. Prenatal stress and its effects on the fetus and the child: possible underlying biological mechanisms. In: Antonelli MC, ed. Perinatal programming of neurodevelopment. New York: Springer; 2015:269–83. 38. Patton GC, Viner R. Pubertal transitions in health. Lancet 2007;369:1130–9. 39. Pasquali R, Gambineri A. Cortisol and the polycystic ovary syndrome. Expert Rev Endocrinol Metab 2012;7:555–66.
ISSN: 0167-482X (Print) 1743-8942 (Online) Journal homepage: http://www.tandfonline.com/loi/ipob20
Biopsychosocial obstetrics and gynaecology – a perspective from Australia Heather Rowe To cite this article: Heather Rowe (2016): Biopsychosocial obstetrics and gynaecology – a perspective from Australia, Journal of Psychosomatic Obstetrics & Gynecology, DOI: 10.3109/0167482X.2015.1124853 To link to this article: http://dx.doi.org/10.3109/0167482X.2015.1124853
Published online: 05 Jan 2016.
Submit your article to this journal
Article views: 10
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipob20 Download by: [RMIT University]
Date: 26 January 2016, At: 01:07
http://informahealthcare.com/pog ISSN: 0167-482X (print), 1743-8942 (electronic) J Psychosom Obstet Gynaecol, Early Online: 1–5 ! 2015 Taylor & Francis DOI: 10.3109/0167482X.2015.1124853
PERSONAL VIEW
Biopsychosocial obstetrics and gynaecology – a perspective from Australia Heather Rowe
Downloaded by [RMIT University] at 01:07 26 January 2016
Monash University, School of Public Health and Preventive Medicine, Jean Hailes Research Unit, Melbourne, Victoria, Australia
Abstract
Keywords
Prior to and throughout the twentieth century, biomedical understandings of health predominated. Australian obstetrician and gynaecologist, Professor Derek Llewellyn-Jones responded to frustrations with the limitations of this narrow approach from both within and beyond the medical profession. His pioneering research, education and writings re-conceptualised the discipline as encompassing the social and psychological contexts and profoundly influenced women’s own understanding of their health and the practice of obstetrics and gynaecology. The biopsychosocial model has replaced biological determinism and is now pervasive in education and clinical practice in many parts of the world. Widespread acceptance of the model has until now been associated with under-recognition of the importance of biology. Recent findings from epigenetics and neuroscience are enabling integration of body, mind and society and enhanced understanding and practice of psychosomatic obstetrics and gynaecology.
Biomedical sciences, body-mind influences, psychosomatic gynaecology History Received 4 November 2015 Revised 18 November 2015 Accepted 23 November 2015
Introduction It has been said that ‘‘obstetrics and gynaecology is the specialty of life, love, sex and death, all the big things that underpin our lives as human beings’’ [1]. Obstetrics and gynaecology (O&G) participates in the joys and the tears, the fear and the wonder, the miracles of life, suffering and joy. O&G is supremely important because the quality of health care that women receive at these times of heightened sensitivity is central to their wellbeing and recalled by them years later with exceptional clarity [2–4]. Reflecting on the quality of clinical practise in O&G has been the substance of ASPOG for more than four decades and this endeavour has been profoundly shaped in Australia and around the world by the man for whom the oration was named.
Derek Llewellyn-Jones 1923–1997 Derek’s legacy was profound and he has remained alive to students of obstetrics and gynaecology through his writings. His Fundamentals of Obstetrics & Gynaecology [5] textbook confirmed his reputation as a great teacher and communicator was written with superb clarity and insight. And, unusually for an O&G textbook at that time, there was a chapter devoted to
Address for correspondence: Dr Heather Rowe, Hons, School of Public Health and Preventive Medicine Jean Hailes Research Unit, Monash University, Level 1, 549 St Kilda Road, Melbourne 3004, Australia. E-mail: [email protected]
breastfeeding, affirming the view that the obstetrician’s role should include attention to the factors that support the establishment of lactation. Llewellyn-Jones was a true pioneer. He was an early proponent of the movement for women to have greater choice in childbirth, and he encouraged partners to stay with each other during labour. He was also a strong supporter of Birth Centers. All of these were revolutionary concepts in the 1960s, when women did as they were told and men were left outside. Yet here was Llewellyn-Jones advocating for men’s right to support their partners during labour and get to know their infant sons and daughters from their earliest moments. The presence of fathers in labour ward has become standard practise in many parts of the world [6], but back then Llewellyn-Jones was absolutely ahead of his time. Not limiting himself to the education of doctors-to-be and challenging the status quo, Llewellyn-Jones went to work to address the appetite for women’s improved understanding of their bodies that was liberated by the rising women’s movement. Reliable knowledge is the foundation of health and wellbeing, and until then, women’s bodies had been largely a mystery to them. Enter Everywoman [7]. A book for a general audience, it seamlessly combined medical and gynaecological knowledge with the social contexts of women’s sexuality and wellbeing, and was to become one of the most successful books ever published on women’s health. And Llewellyn-Jones was no ‘‘Johnny-come-lately’’.
2
H. Rowe
The ‘‘Doctor’s Group’’, later to become the Boston Women’s Health Book Collective, published Our Bodies Ourselves, on stapled newsprint for hand distribution in 1970 [8], and the first edition of Everywoman appeared in 1971. Everywoman epitomises the joining of body, mind and society, and it paved the way, from inside the medical profession, for a model of clinical practise that involves women as informed partners in their care.
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Psychosomatics and the birth of ASPOG At around this time, the ASPOG was born and in 1973 held the first national conference in the Barossa Valley in South Australia; Llewellyn-Jones was a founding member [9]. Then the Australian Society for Psychosomatic Obstetrics and Gynaecology, its aims were to study the psychobiological and psychosocial, ethical and cross-cultural problems in the fields of obstetrics and gynaecology, women’s health and reproductive health. The term ‘‘psychosomatic’’ represented a search for a more holistic understanding of the patient, her psychological and social contexts and the meaning she makes of events; and to respond to the question ‘‘Who is this woman?’’. ‘‘Psychosomatic’’ also denoted the joining of the mind and the body, the yoga of soma and psyche. The formation of ASPOG was a response to the growing disenchantment with the dualistic biomedical model of practise that separated body from mind and reduced disease to pathology in individual body parts, and women’s health care to unhelpful and sometimes damaging encounters. The new professional society also responded to the needs of clinicians for whom biomedical explanations were insufficient to inform their practise, in particular for the difficult-to-treat conditions. It attracted the thoughtful who wanted to explore in greater depth the meaning of their profession and to walk the boundaries with the other disciplines of psychology and psychiatry, ethics, philosophy and sociology and, more recently, human rights. And of course, it has always fulfilled a need for individuals to connect, to communicate with the like-minded and to belong.
Is it psychosomatic or psychosocial? The Australian SPOG was ‘‘psychosomatic’’ O&G when it was founded in 1973, but changed its name to ‘‘psychosocial O&G’’ in 1991. It was thought that ‘‘psychosomatic’’ might signify mental health problems and promote the idea that women’s health symptoms are ‘‘all in the head’’ and without a physiological basis; also that the term ‘‘psychosocial’’ might attract a larger range of professional groups (Professor Suzanne Abraham, ASPOG President 2007–2009, personal communication). However, the international society, ISPOG, remains unapologetically ‘‘psychosomatic’’, about which I will say more later. I want to take this opportunity to reflect on the meaning for medical education and clinical practise of the ‘‘bio-psycho-social’’ construct as it has evolved since Llewellyn-Jones’ time.
The biopsychosocial model George Engel, a physician, also writing in the 1970s and 1980s, declared that the way in which a doctor approaches a
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patient and her presenting problems is defined by the conceptual models around which the doctor’s knowledge is organised [10]. He declared that ‘‘The crippling flaw of the biomedical model is that it does not include the patient and his attributes as a person, a human being’’ [11]. This is despite the fact that data for the physician appear in psychological and behavioural terms – what the patient thinks and what the patient does and how she reports about herself and her life. The biomedical framework can make use of neither the person as a whole nor of psychological and social data. Engels proposed the biopsychosocial model, a systems approach to diagnosis and treatment, which seeks to understand the presentation and course of illness from multiple perspectives in a hierarchy from the intracellular to the sociocultural levels [11]. ASPOG is dedicated to promoting this understanding and the biopsychosocial model remains influential in medical education and practise today [12].
Biological determinism One of the attractions of the more comprehensive conceptualisation of women’s health offered by the biopsychosocial model is that it addresses the problem of ‘‘biological determinism’’. The ‘‘biology is destiny’’ ideology is used to justify sexual, racial and other inequalities and to argue that initiatives to combat them are futile [13]. In the 1970s and 1980s, feminist [14] and Marxist [15] critiques made the case for the central importance of socio-political structures to the development of human potential and the reproduction of social and health inequalities. In the 1970s, these ideological differences resulted in the unhelpful polarisation of biological and social theories and a discourse that positioned biology and environment in opposition to each other, the (nature versus nurture) dichotomy. Indeed, I was dismayed to discover this when I emerged from my undergraduate degree in the biological sciences. ‘‘Biology’’ was somewhat of a dirty word among feminists with whom I otherwise readily identified. The opposition to biology was a reaction against the damaging discourse as it pertains to women that permeated the twentieth century and long before, which casts women as different, ‘‘the other’’ and as has having inferior strength, talents and potential because of supposed biological limitations inherent in having two X chromosomes [13]. The distinction between ‘‘sex’’ and ‘‘gender’’ enabled the differences between men and women to be understood as acquired at least in part by cultural conditioning rather than caused by biology alone; one is not born but rather becomes a woman [14]. Feminist critiques of biological determinism also disrupted the assumption that women are destined solely for motherhood, an ideology that underpinned the great disservice to women of equating women’s health solely with pregnancy and childbirth: to woman as mothers, rather than women as women [16]. ‘‘Nature versus nurture’’ is of course a false dichotomy. As students, we learn the so-called ‘‘central dogma of genetics’’ – DNA makes RNA makes proteins – that make the characteristics of the organism [17]. But the other central tenet of genetics is that the genotype interacts with the environment to produce the phenotype – in other words – genes provide the
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blueprint for the body on which experience is written and the person develops [18]. Environmental and social circumstances are fundamental to an individual’s capacity to reach their potential and to their health status. The biopsychosocial discourse offers a way to illuminate the ‘‘black box’’ that exists in the space between biology and health and, importantly, provides a means to study the consequences for women’s health of gender disadvantage in its many forms [19]. Now, many of the contents of the black box are common knowledge. The data assembled by the WHO Commission on the Social Determinants of Health led by Sir Michael Marmot and released in 2008 are compelling [20]. Social stress from poverty, lack of power and agency, violence and discrimination, in the home, the neighbourhood, the workplace and the social and political landscape are the pre-conditions of much poor health. And conversely stable family life, safe workplaces and neighbourhoods, good education, access to health care, social and economic participation, and respectful relationships are keys to a healthy life. Today, clinicians are well aware of the influence of psychological processes and social disadvantage on disease; in fact, sociodemographic disadvantage is regarded as an independent risk factor for adverse pregnancy outcomes [21]. Modern statistical methods also enable epidemiologists to analyse data from multiple levels of Engel’s hierarchy of systems [22,23].
The B-P-S model in clinical practise In ISPOG, ‘‘psychosomatic’’ is closely aligned to Engels’ ‘‘biopsychosocial’’ systems approach, but it goes further than that. It engages with the subjective experiences of women, their unique life events, biographies and personalities. Johannes Bitzer (ISPOG President 2001–2004) has written about the value of a psychosomatic approach to the difficult clinical questions [24]. For example, when there are different manifestations of the same disease in different individuals or no detectable cause for presenting symptoms like pain, fatigue or nausea; in decision-making, when there is uncertainty about evidence-based solutions or the woman does not accept or adhere to an evidence-based therapy but maintains her risk behaviour, or when patients seek help for personal problems like sexual difficulties, partner and family violence, adverse life events, and when patients are experienced as difficult and demanding and the gynaecologist feels helpless and demoralised. Each clinician will have their own difficult questions. I would add questions about evidence-based practise in the highly anxiety-arousing environment of pregnancy care in high-income countries. How do clinicians manage when there are multiple routine tests with complicated results and sometimes profound consequences for pregnancy management? And, in a multicultural society like Australia, how does the obstetrician or gynaecologist reconcile with the Western biomedical tradition the variety of meanings that patients may attach to the cause, experience and cure of their illness? [25]. According to Bitzer [24], in clinical practise of the psychosomatic model, symptoms represent the woman’s personal suffering and are an expression of multifactorial interactions specific to her. This means that ‘‘the basic unit of observation is the interaction of the disease process and the
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individual person in her life situation’’. Diagnostic procedures must therefore seek to understand the patient’s circumstances, how she thinks, feels and behaves, the meaning to her of the illness, and to integrate this knowledge with diagnostic test results. And therapeutic plans must take into account her motivation, hopes and priorities. This might sound simply like good psychologically-informed care, or perhaps it just sounds nebulous and unfocussed. But maybe not. Innovative approaches demonstrate that it is possible, for example, to engage therapeutically with the meaning to a woman of her pain [26,27]. Generating evidence that a biopsychosocial approach actually works in clinical practise is no simple task. It might be easy enough to measure a well-defined outcome, but how do we standardise a ‘‘psychosomatic’’ approach, so that what is being measured is clearly defined? How do we grasp the feelings and emotions that exist in the space between the doctor and patient, or account for variability in contextspecific features of workplace culture and economic constraints. Producing gold-standard evidence of the effects of this kind of clinical practise might even be inimical to the very thing that psychosomatics is intended to achieve. Notwithstanding these difficulties, the evidence is accruing. Qualitative research with women identifies the features of care that women in specific circumstances value, and evidencebased guidelines are appearing. Guideline documents include the level of evidence that supports each recommendation and point out where more research is needed. The guidelines for fertility staff about routine psychosocial care in infertility and medically-assisted reproduction, recently published by ESHRE, are a case in point [28]. Sibil Tschudin (ISPOG President Elect) and her colleagues [29] argue that if psychosomatic aspects are neglected, underlying problems can remain undiagnosed and inadequately treated, which can affect morbidity and medical costs. From the doctor’s perspective, poor psychosocial competence may increase stress and contribute to burnout. Conversely, good communication can improve patients’ satisfaction as well as their adherence to treatments. Identifying relevant psychosocial information and managing accordingly are therefore essential clinical competencies.
Teaching biopsychosocial medicine In medical schools in many parts of the world, the biopsychosocial model is standard curriculum fare [12]. However, conveying the relevance of the social determinants of health, preventive medicine and the patient in social context to medical students keen for anatomy, physiology, biochemistry and clinical skills can be challenging. In my own experience, the biopsychosocial model can be reduced by students to a mantra to be trotted out in exams in the hope that available marks are acquired. This leads to questions about what biopsychosocial clinical practise really looks like. At worst, at least in medical education, it can look disappointingly reductionist. In a recent Lancet commentary, Deborah Cabaniss describes a clinical scenario where patients are metaphorically ‘‘chopped up’’ into neat bio, psycho and social components, and therapies are selected and applied accordingly: drugs for the pathology, counselling for the
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H. Rowe
distress, and social interventions for the disadvantage [30]. At best this might look like good multi-disciplinary team care, where the person is managed from multiple perspectives by highly skilled specialists in a comprehensive treatment plan [31]. But does it achieve true integration where each clinician is able to draw on highly developed skills and treat the whole person, not just their parts? And how are these capabilities inculcated in trainee medical and other professionals? This is not an easy task, because they are about things like professional attitude, communication, cooperation, empathy and compassion, which involve disrupting stereotypes and personal prejudices, and other reflective capabilities. Problem-based and casebased learning strategies are useful, and of course proficiency grows over time and with maturity, but many would agree that there is still a long way to go. There is likely to be more activity in the educational sphere during Sibil Tschudin’s forthcoming ISPOG presidency, and after the new ISPOG textbook is launched in the 18th ISPOG Congress being held in 2015 in Spain.
Reclaiming biology I want to finish by returning to where we started, with questions about the primacy of biology. But first, a short digression to the land of Erewhon. In his novel of the same name published in 1872 [32], Samuel Butler describes Erewhon (‘‘Nowhere’’ almost spelt backwards), a fictional country where criminal offenders are treated as if they are ill, whereas ill people are looked upon as criminals. It was a satire on Victorian society, but Butler demonstrated remarkable prescience whereby in the twenty-first century, ‘‘evil’’ is for many an outdated concept - criminals can usually be described as having suffered childhood abuse and disadvantage, whilst the chronically ill or marginalised - although not necessarily locked up, can be held responsible for their socalled poor ‘‘lifestyle choices’’ [33]. If in the twentieth century people were blamed for their biology, in the twentyfirst century they are blamed for their circumstances! The public discourse still favours simplistic binaries. But, perhaps after all, the biological sciences can redeem us by offering a true integration of body, mind and society. Indeed, it has been claimed that it is no longer scientifically tenable to split the psychosocial from the biological – everything is biological – and the idea that mind and brain are independent is no longer credible. Talking therapies are effective because they cause biochemical modifications in underlying brain structures, and ‘‘interpersonal events have biological sequelae’’ [30]. But, how does this come about? The so-called ‘‘life course health development’’ framework [34] describes how individual and population health develops, how developmental trajectories are determined by interactions among multiple factors during the lifetime. It provides a construct for interpreting how people’s experiences in the early years of life, especially in the first 1000 days, influence later health conditions and functional status. Details of the biological mechanisms that describes how social and psychological experience influence biology, and therefore health and illness, are accumulating rapidly. We know that at the intra-cellular level, epigenetic phenomena
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involve modifications to gene expression caused by environmental triggers, including adversity. Some of these may be replicated during cell divisions that produce the gametes and be passed to future generations [35]. For example, a recent study showed that epigenetic modification of the oxytocin receptor gene influences the perception of anger and fear in the human brain [36]. Careful work over decades has demonstrated the adverse impact of maternal anxiety in pregnancy on perinatal and child outcomes and the impact of (preventable) social stress [37]. Finally, we know that social factors contribute to age at puberty in girls [38] and there is an emerging role for social stress in the development and course of perplexing conditions like PCOS [39]. Emphasis on developmental trajectories draws attention to underlying susceptibilities on which current circumstances impinge. It enables a theory of causation that incorporates genes and environment, proposes a treatment plan that addresses causes not just symptoms, and emphasises social factors, most notably gender discrimination and violence against women, which urgently need to be addressed. So, we have come full circle to reclaim biology. With a clearer understanding of the development of illness that includes biopsychosocial causes, the health practitioner is in a better position to answer two fundamental clinical questions ‘‘why this patient? and why now?’’ and to manage appropriately.
Declaration of interest Heather Rowe BSc (Hons) PhD is Secretary General of ISPOG. The author reports no other conflicts of interest.
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