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Friendly or Hostile Universe? The Biopsychosocial Model in Hand Therapy

Updated: Feb 13

Written by: Mirella Deisher, OTD, MS, OTR/L, CHT

Virtual Hand to Shoulder Fellowship, LLC

Founder & Faculty


“The most important decision we make is whether we believe we live in a friendly or hostile universe.”

Albert Einstein



This past weekend the VHSF January cohort learned about the biopsychosocial model. While this may have been more of a foreign concept 15 years ago, today it’s better understood that one’s experiences are a combination of what’s happening in the physical world with how one interprets those experiences. We’ve all been conditioned early in life on how we interpret the world. Is it a friendly or hostile universe? If we interpret the universe to be hostile, we look for and perceive more threats in world, putting us in a “fight or flight” state. If we live in a friendly universe, we revel in our “rose-colored glasses” and the parasympathetics are dominant.


With the acknowledgement that there are many shades of grey in between, recognizing that our patient’s experience is influenced by more than what’s happening on a tangible level, and that their perceived experience will influence their overall recovery, should be an important treatment consideration. Additionally, awareness of our own thoughts, beliefs, and interpretations should be considered as well.


Metacognition is the awareness of our thought processes. Our minds have habitual ways of thinking we may not be aware of. For anyone that drives the same route home, you may have had the experience of realizing you don’t recall the actual drive home. You were on autopilot.

Our mind has habits in the way it processes information that are formed early in life. We’re often unaware of our “thinking habits” but, if you tend to get the same results, for better or worse, you will likely find that the way you habitually, and therefore unconsciously think, is the driving force.


As hand therapists, patients are referred to us for upper limb and hand rehabilitation. They have impairments that are limiting their function, or they need to be protected during the tissue healing phases and then mobilized appropriately to prevent complications, such as stiffness or adhesions. Being able to provide appropriate and effective care requires a certain type of scientific knowledge. Understanding anatomy, biomechanics, physiological processes, along with how injury or disease impacts these processes is critical to being able to effectively protect healing and optimize outcomes.


However, our effectiveness as clinicians depends on the active participation of our patients. We cannot “rehabilitate” anyone without their participation. We can only present them with the strategies, the tools, and the support to rehabilitate themselves. In the end, the patient needs to do the work that the natural healing process alone cannot do. This is where the biopsychosocial model takes center stage.


If you’ve been a clinician long enough, you’ve encountered the patient that despite the severity of their impairments, reports very little disability. And, on the other end of the spectrum, the patient with relatively minor impairments that reports a disproportionate and significant level of disability. With the exception of pain as the limiting factor, I think there’s enough evidence to state that impairments do not have a direct relationship to disability. If they did, I would not have read about the young man who completed a marathon last week despite having a body dominated by spasticity due to cerebral palsy; and we wouldn’t hear the countless other stories of people with varying degrees of illness or disability do what is seemingly impossible.


There’s something else at play and a biopsychosocial approach creates a framework to help identify potential barriers to recovery, and a framework to guide remediation of those barriers within the context of physical or occupational therapy. It makes sense then, to help patients examine their own behaviors and thinking patterns that may be creating barriers to recovery.


Cognitive-behavioral therapy has been described as a means to manage psychosocial barriers of recovery by both physical and occupational therapy professions. Occupational therapy, in particular, is strongly grounded in taking a holistic approach. In fact, the concept of addressing the whole person has been present since the inception of the profession, and clinicians are educated in using related frameworks, such as a cognitive-behavioral frame of reference in combination with other treatment models. The challenge, however, particularly for the profession of occupational therapy is in not undervaluing the importance of the scientific knowledge that best supports remediation and recovery. Being holistic means that there is equal skill and attention to all areas, the physical, psychological, and social.


Ultimately, what should always take precedence is providing optimal care to our patients. Regardless of whether we are PTs or OTs, achieving this necessitates equal consideration of the biological, the psychological, and the social, and an ability to address these areas with equal skill and competency. Thus, our curriculums should prepare us equally to do so. Continuity of skills amongst occupational and physical therapists in the practice area of physical RE-habilitation is necessary to ensure that patients are enabled to achieve their best possible outcome.


Combining the strengths of our professions, specifically in the practice area of physical rehabilitation is what will ultimately provide patients with the best opportunity for recovery. Thus, we should

think about whether we, as physical and occupational therapists, see the universe as hostile or friendly. Do we need to fight for the preservation of our professions? Do we need to be territorial? Is this best serving our patients?


Collaboratively looking at the strengths and weaknesses each profession offers is how we’ll ultimately deliver the highest quality of care to our patients. The strengths of a physical therapist should be acknowledged and the strengths of an occupational therapist equally so. However, not sharing strengths with each other so we can equally provide an opportunity for the best outcomes of our patients, only hurts the patient.


A friendly universe then, would invite a dialogue between those that define and establish curriculum standards, as well as educators within physical and occupational therapy curriculums, so that strengths can be shared in educating future providers to optimize patient recovery in the shared practice area of physical rehabilitation.




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