*This piece is based on the book Better Outcomes: A Guide to Humanizing Healthcare. I actually had someone ask specific questions about each chapter of the book to develop this series; so it’ll read like a Q&A session with the author.
I’ll never forget my first day at an outpatient orthopedic clinic. I was nervous — genuinely terrified, if I’m being honest. I didn’t feel ready to treat the complex upper extremity cases coming through the door.
An experienced therapist noticed. She put her arm around my shoulder and said, with this wonderfully warm Southern drawl: “Now honey, just remember — a shoulder is a shoulder is a shoulder. You treat ‘em all like shoulders.”
I held onto that advice like a life raft. For about a week.
Then reality hit. Two patients with identical diagnoses, same surgery, same protocol — wildly different results. One recovered quickly. The other barely progressed. I kept asking myself why. That question eventually led me to the biopsychosocial model, and it changed everything about how I practiced.
What does “biopsychosocial” actually mean?
Strip away the jargon and the concept of a biopsychosocial approach is genuinely pretty simple. Every patient’s experience of pain, illness, or injury is shaped by three overlapping layers:
Biology — the tissues, joints, nerves, and physical structures. This is what most of us were trained to focus on, and it matters. But it’s only part of the story.
Psychology — the patient’s beliefs about their pain, their fear of movement, their mood, their trauma history. These aren’t “soft” factors. They have real, measurable effects on how someone experiences and recovers from physical conditions.
Social and environmental factors — family dynamics, work stress, cultural beliefs about illness, what their neighbor told them about their diagnosis. All of it shapes what happens when they walk into your clinic.
These three layers don’t operate in isolation. They interact constantly. When I started seeing that, I couldn’t unsee it.
Can psychological factors really affect physical outcomes? That sounds like a stretch.
I used to think so too. It doesn’t anymore.
Here’s what the neuroscience actually tells us: pain is not simply a signal from damaged tissue. The brain creates pain as a protective mechanism. That’s why two people can have identical imaging findings — same disc herniation, same arthritis — and one of them is debilitated while the other barely notices. And it’s why I’ve had patients in my clinic with significant, life-limiting pain and completely normal X-rays. Their pain was absolutely real.
Pain is always real. I can’t say that strongly enough. And understanding that — and communicating it clearly to patients — is itself a clinical intervention. The research shows that combining neuroscience education with physical rehabilitation produces meaningfully better outcomes in patients with chronic low back pain. The way I explain what’s happening in a patient’s body actually changes what happens in their body.
Okay, practically — how do you actually use the BSP model in the clinic?
I want to give you real answers here, not academic ones. Here’s what changed in my own practice:
I broadened my intake questions. I stopped treating the appointment as purely a physical assessment and started asking: “How is this affecting your day-to-day life?” or “What do you think is causing this?” That last one especially — a patient’s own beliefs about their condition are a direct window into psychological and social factors you’d never find on a standard intake form.
I started choosing outcome measures that showed the whole picture — not just ROM and manual muscle tests, but self-reported pain quality, fear-avoidance measures, functional impact in the patient’s actual life.
And I got very careful about language. If I describe someone’s spine as “degenerating” or their disc as “crumbling,” I’m not just providing clinical information — I’m potentially triggering fear responses that worsen their outcomes. Words that catastrophize lead to avoidance. Words that normalize and empower lead to engagement. I think about this now before every clinical conversation.
What’s the most important takeaway from the Biopsychosocial Model?
This: when a patient tells me they’re in pain, they are in pain. Full stop. Not metaphorically. Not psychosomatically in some dismissive sense. Their pain is real and neurologically genuine.
My first job — before any assessment, before any treatment decision — is to acknowledge that as true. Patients know when a clinician believes them. And they know when they don’t. That moment of genuine acknowledgment is the first brick in every therapeutic relationship that actually goes somewhere.
All content in this series is drawn from Better Outcomes: A Guide to Humanizing Healthcare by Rafael E. Salazar II, MHS, OTR/L (Business Expert Press, 2022).
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Join Rafael E. Salazar II, MHS, OTR/L (Rafi), principal of Rehab U Practice Solutions and host of The Better Outcomes Show as he explores the possibilities of a new healthcare. Guests range from clinicians trying new techniques and treatments to executives and entrepreneurs exploring new technology, innovative service delivery methods, business models, and organizational structures. Grab a copy of the book: Better Outcomes: A Guide to Humanizing Healthcare. Or, hire Rafi to speak at your organization or event.
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