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The Tangled Web of the ‘Biopsychosocial Model’ of Disability

January 16, 2012

When it was proposed by George Engel in the late 1970s/early 80s, the so-called ‘biopsychosocial’ model of sickness and disability appeared to be a positive step in unpacking all the issues which surround the treatment of illness. As Engel argued, ‘the biopsychosocial model is a scientific model constructed to take into account the missing dimensions of the biomedical model’ (1980, 535). According to this account, the biomedical approach fails to focus on the patient ‘as a human being’ (536), a complaint shared by RD Laing in his book The Divided Self.

The importance of taking into account the totality of the experience of the patient, rather than merely the specific symptoms, is surely not in doubt. For example, in the case of major depression or generalised anxiety, a purely biomedical account not only fails to take into account the interpersonal experiences which may exacerbate symptoms, but is also of only limited use when designing treatment, as neuroscientific developments have yet to be matched by similar precision in drug treatments.

Engel saw the need for ‘rigour and critical scrutiny’ (543) in assessing the interplay between symptoms and environment, not only in mental health but also in more traditional physical conditions such as myocardial infarction leading to cardiac arrest. This application would work as follows: ‘the physician identifies and evaluate the stabilizing and destabilizing potential of events and relationships in the patient’s social environment, not neglecting how the destabilizing effects of the patient’s illness on others may feed back as a further destabilizing influence on the patient’ (543).

It seems there is nothing to be objected to here, as Engel’s concept seems to merely be a scientific argument, rooted in biological system theory, for treating patients as human beings in social situations, rather than as detached, controlled samples on the laboratory bench. Why, then, does the term ‘biopsychosocial’ cause such anger among disability campaigners?

One reason for this is the concrete connection between this model and the insurance company Unum, who offer employee underwriting and income protection. A Q&A section of their website describes their application of the biopsychosocial model as follows:

The idea is that the impact of an illness on a person isn’t just a result of the purely medical elements. Physical (e.g. disease, joint damage), psychological (e.g. disposition, anxiety) and social factors (e.g. work demands, family support) also play an important role. In simple terms, this means that physical, mental and social factors can all influence the ways in which people respond differently to the same disease. This can mean that two people can have the same medical symptoms, but one recovers and one doesn’t – because of their different circumstances and mindsets.

This is clearly relevant for Unum, where on the one hand we do medical underwriting as part of the insurance application process, and on the other we provide an extensive, market-leading rehabilitation service to help people get back to normality.

In medical underwriting it’s important to help predict which people are likely to become long term sick. It also shapes our approach to rehabilitation for a particular person – identifying the barriers which may prevent them from making a successful return to work following an illness, and helping them overcome those barriers.

There is an assumption in the last section of this explanation which also underpins the current government’s views on welfare reform, and that is the idea that ‘a successful return to work’ is the ultimate measure of an optimum outcome of disease. This assumption is also stated in a 2005 article ‘Concepts of rehabilitation for the management of low back pain’, produced by Gordon Waddell and A. Kim Burton at the Unum-sponsored ‘Centre for Psychosocial and Disability Research’ at the University of Cardiff:

Too often, health professionals see work as the problem rather than the goal or part of the solution, and usually that is wrong. Overall, work is good for physical and mental health and well being, and lack of employment leads to physical and mental deterioration. Return to work is not only the goal and outcome of successful healthcare: work is generally therapeutic and an essential part of rehabilitation (663).

Unum are adamant that, despite sponsoring the research centre from 2003-2009, they ‘were not involved in any of the research carried out’, and that there was also no impropriety in the relationship between the company, chief DWP scientist Professor Sir Mansel Aylward who was appointed Director of the centre, and the DWP itself, which consulted both Sir Mansel and Unum as part of a welfare reform consultation at the same time. This is almost certainly true, but that does not change the fact that there is a strong connection between all three groups, who have a shared interest in reducing the cost of welfare and increasing the number of people insured privately, and the psychosocial research being carried out by the centre.

These shared interests continue when we follow the claims made by Waddell and Burton to their conclusion. Their assertion that ‘lack of employment leads to physical and mental deterioration’, references the Independent Inquiry into Inequalities in Health report, suggesting that this report contains the evidence. However, when the section which deals with the issues created by unemployment is not as clear as it could be. The report itself is well referenced, but the paragraph which dismisses the possibility of the problems caused by unemployment are a result of the conditions causing unemployment rather than the condition itself contains no references at all:

Some of the excess morbidity and mortality associated with unemployment may be a result of people in poorer health being more likely to become unemployed, rather than vice versa. The evidence suggests that selection of unhealthy people into unemployment does indeed occur, but it is not the dominant factor explaining the observed relationship between unemployment and excess risk of ill-health. It does, however, illustrate the double disadvantage that people with chronic sickness or disability may face: their ill-health puts them at greater risk of unemployment, and the experience of unemployment in turn may damage their health still further.

The evidence cited by Waddell and Burton for a further assertion, that ‘Too many doctors are also unaware of, and fail to consider, the effects of sick certification and extended periods of sickness absence’ can also be linked back to the government, as the evidence for these effects is found in a 2001 article written by Dr Philip Swaney of the DWP, which discusses the connection between being signed off and adopting the ‘sick role’, as well as containing another uncited assertion which forms the basis of current government policy:

The availability of income replacement benefits may act as an incentive for workers with marginal disabilities to drop out of the work force and seek these benefits instead, particularly where there is relatively loose control of the gateway to such ben- efits. The receipt, or potential receipt, of disability benefits may act as a disincentive to rehabilitation. The level of income replacement benefits may act as a financial barrier, because to be financially better off, a wage plus any ‘in- work’ benefits must exceed the level of income from ‘out of work’ benefits. This may be characterised by the so-called ‘benefit trap’, in which disabled people find themselves unable to get a job, particularly part-time work, which will pay more than their income from being out of work. The bal- ance of incentives may clearly influence the behaviour of a rational person and may help to reinforce the notion of inca- pacity for work. (219)

This web of links between the DWP, academia and private insurance companies provides a body of research justifying a monolithic policy approach to disablity and sickness, which uses the biopsychosocial model as a basis, but does not employ it in the way in which it was originally formulated. Rather than the ‘rigour and critical scrutiny’ suggested by Engel, Unum and the DWP have been involved in the introduction of papers into the academic field which confirm a single orthodox view of the position of the patient, which sees all sick and disabled people as money-motivated, idle individuals who have become ‘trapped’ in a ‘jobless’ state, and this state is exacerbating their symptoms.

Although this analysis uses the biopsychosocial model as a basis it is clear from the evidence presented above, which is only one small area of this web of influences and mutual interest, that the model has been reduced to a simplistic, neoliberal account of the importance of work as part of any ‘rehabilitation’ – it has become a means of attacking the character of sick and disabled people under the guise of psychology.

The ‘biological’ element is almost absent, as the ability of doctors to accurately diagnose conditions is questioned. The ‘psychological’ element is used as a stick to beat sick and disabled people with, using the argument that any condition which produces long-term ‘worklessness’ does so only as a result of the individuals psychological belief that they can’t work. The ‘social’ element is barely present – although the social model of disability is widely cited as part of this framework, the broader societal barriers to the integration of disabled people as people, the rhetoric of the biopsychosocial model increases the impression among the general public that disabled people are workshy scroungers, thus actually reducing their ability to be integrated into society, and limiting their scope for employment.

EDIT: I enjoy the irony of the fact this blog complained about a lack of references, yet I forgot to post the bibliography. Here it is:

Engel, GL (1980) ‘The Clinical Application of the Biopsychosocial Model’, in American Journal of Psychiatry, 131:5
Swaney, P (2002) ‘Current issues in fitness for work certification’, in British Journal of General Practice, 52, 217-222.
Widdel, G and Burton, A Kim (2005) ‘Concepts of rehabilitation for the management of low back pain’, in Best Practice and Research Clinical Rheumatology, 19:4, 655-670

EDIT 2: This is not intended to be a professional attack on the researchers cited, rather a demonstration of the ways in which the ‘biopsychosocial model’ has been, in my view, irredeemably compromised by a creeping orthodoxy which undermines its initial insight. This is partly to do with the interests of those involved in research, and partly due to the nature of academic research, which can unfortunately become short-sighted due to its focus on references.

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6 Comments leave one →
  1. sanabituranima permalink
    January 16, 2012 5:09 pm

    Well said.

  2. January 16, 2012 6:53 pm

    Excellent analysis of the unethical, non-empirical, pseudo-scientific theory used to support the unethical neoliberal agenda of cuts to the welfare of sick and disabled people.

    The “Biopsychosocial Model” is not a model at all.

    It is a narrative employed to justify an unconscionable, ideologically motivated series of cuts and attacks on the human rights of disabled people – all to win brownie points with the tabloid mob and to create and exploit social division in society which are ultimately a distraction from the real scroungers: The City and their minions in Westminster!

  3. msjustice permalink
    January 16, 2012 7:25 pm

    The worst case of this being used unethically is with the made up syndrome, CFS which the psychiatrists in unison with unum managed to pull of to play down the neurological disease, ME. The diagnostic criteria has changed, tests are refused and treatment is brainwashing CBT that denies the serious nature of ME and a gradual exercise therapy which is harmful to those with ME. The DWP funded their first trial into these therapies as part of their back to work agenda.

    • January 21, 2012 12:29 pm

      they put me sufferers in with the mental and take them of their meds,no care is given.
      the new diagnostic manual was/is(?) a farce.

      its the economy thats made up bullshite.

      compassion,always.forgiveness.no.
      forgive them they know not what they do.
      because they are fkn sociopathic
      can we get one of them sectioned?

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