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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.

In Soviet Edinburgh…

November 22, 2011

This isn’t a proper update, I just wanted to share this trainwreck of a conspiracy theory, including this gem:

‘Feminism’ is an evil alright but was first created by the Judeo-Bolshevik “revolution” of 1917 with their decree of ‘nationalizing’ all Soviet females.

To which the only possible response is:

Response to my call for a ‘no confidence’ vote in Maria Miller

September 7, 2011

On the 26 May, I, along with many others, emailed my MP calling for a vote of no confidence in the Minister for Disabled People Maria Miller, citing her refusal to engage with disabled people, her support for the flawed ATOS ‘Work Capability Assessments’, and her failure to address the increasing scapegoating of disabled people in the media and abuse on the streets.

Since I am registered in a Tory safe seat, I was not expecting much of a response, and to be fair to Stephen Dorrell MP his response, although late, does address the concerns in my letter in order, suggesting that he had actually read it. However, the responses he gave were nothing more than restatements of government policy, expecting me to take his word that this was the case, and that there was no need for him to actually do anything to represent my concerns.

The letter in full was as follows:

Please accept my apologies for the length of time it has taken to respond to your email of 26 May. [the letter is dated 1 August].

The Government is doing a great deal to help people with disabilities and I believe the Minister, Maria Miller, is competently taking the lead on these matters.

The substantial recommendations made by the independent review of the Work Capability Assessment, by Professor Malcolm Harrington, have all been accepted by the Government. The improvements planned include greater personalisation of the process, additional safeguards to protect the most vulnerable claimants and taking into account how well claimants have adapted to their conditions before determining whether they can be given specialist help to return to work.

The Government is fundamentally reshaping the benefit system but it does not aim to reduce levels of support for the most severely disabled people. It is important that benefits are appropriately targeted, fair to those on low pay and that the right money goes to the right people; those who are genuinely sick, disabled or retired have nothing to fear.

The Government also owes a duty to disabled people to promote their independence and equality but over the least four decades progress on some issues has been stubbornly slow. The Equality Act 2010 provided a new cross-cutting legislative framework to protect the rights of individuals and advance equality of opportunity for all; to update, simplify and strengthen the previous legislation; and to deliver a simple, modern and accessible framework of discrimination law which protects individuals from unfair treatment and promotes a fair and more equal society.

Suffice it to say, I’m totally reassured that the government cares about disabled people and that it’s all going to be ok.

Utopianism and the Reactionary Victory

June 11, 2011

A constant issue at the moment is the increasing tendency towards extreme Right Wing votes among the ‘White Working Class’. Why, we ask ourselves, do those people who are most under threat from the uncertainties of Capitalism continually vote for parties who either represent the very forces which are maintaining this uncertainty, or focus on immigration as the major cause of all society’s ills?

I propose that the answer to this is that these views provide a far safer and more concrete utopian vision than that offered by the left. The real fight is against capitalism, but capitalism has made things so unstable that people are scared of throwing their weight behind revolution (=more change), so in their fight against capitalism, they tend to prefer conservative utopias, because they seem far more solid. This is especially the case when one looks at the increase in support for anti-immigration parties/groups such as the BNP, EDL and UKIP. They thrive on the uncertainty produced by a society based on debt, consumption, and unstable employment, by suggesting that, with less immigration, we, the ‘Native British Population’, could consume enough to become the ideal figure of capitalism – owning all the latest products, not being saddled with debt, having a stable family.

This is a simple solution, and one which conjours up clear images. ‘Soclalism’ is connected in the public mind to images of austere, Soviet-style urban landscapes, Tom Clancy films, and ‘Enemy at the Gates’, and Anarchism brings to mind riot police and violence. Outside those paradigms, there is nothing clear. Engaging someone and getting beyond those stereotypes, what is there to offer? At best, an intellectual utopia of no capitalism.

That kind of instability is frightening when you’re already worried about losing your job and your family and your house. On the other hand conservative utopias (even the less overtly extreme utopias offered by the Conservative Party) in which the White Man is King of His House which is His Castle and criminals are Up and you had a Local Bobby are very solid, because they represent a perfection and consolidation of a recognisable reality.

I don’t offer any solutions to this, but it’s a point that needs raising. The utopian images connected to political ideologies are a large part of their appeal, and at the moment they are sorely lacking on the left, and often negatively rather than positively defined. This is something which must be addressed in order to prevent a reactionary victory.

UKUncut, Morris Dancing, and Carnivals

June 3, 2011

This post is mostly inspired by the following description of a morris dance from a 1583 book called Anatomie of Abuses by Philip Stubbs, and its clarification by Claire Sponsler (I’ve modernised the spelling for ease of reading):

Thus all things set in order, then have they their Hobby-horses, Dragons and other Antiques, together with their bawdie Pipers, and thundering Drummers, to strike up the Devil’s Dance withall, then march these Heathen company towards the Church and Churchyard, their Pipers playing, their Drummers thundering, their stumps Dancing, their bells jingling, their handkerchiefs swinging about their heads like madmen, their Hobby-horses and other monsters skirmishing amongst the throng.

Sponsler then summarises the rest of the passage as follows: “Stubbes goes on to complain that the dancers would enter the church, disturb the sermon, and then go into the churchyard, where they would dance away the day and night.”

When the overlap between morris dance and “quasi-criminal acts such as ritual trespass, robbery, and riot” is also considered, we get a picture of a practice far more iconoclastic and threatening to the status quo than the rather eccentric pastime of real ale drinkers outside country pubs that is conjured up by the phrase ‘morris dancing’ today.

Although this subversive image of the dance is impossible to verify, since Stubbes was a conservative, and morris dancing had been around for (possibly) hundreds of years before his complaints were recorded, it does point to a narrative familiar in all iconoclastic practices. Initially, the practice is genuinely threatening, but it rapidly becomes normalised into the structure of the Saturnalia, or the later Feast of Fools, where those in power granted their inferiors impunity to usurp authority for a brief period – a kind of ‘release valve’ for potentially revolutionary sentiment among those who are oppressed.

A more contemporary example of this progression/regression can be seen in Edinburgh’s Beltane festival. In 1988, the first year of Beltane’s revival, it was partially, if not substantially, conceived as protest against the anti-rave legislation found in Thatcher’s Criminal Justice Bill. Today, although still a wonderful spectacle, it exists far more as a tourist draw, with a well-marked delineation between the performers who dance with all the abandon you’d expect, and bored looking tourists who stand totally still, maybe drinking, and snapping away with camera flashes, distanced from any possible subversion by their own disinterest.

How does this connect to UKUncut? Like this: If Beltane and morris dancing are examples of how subversive actions become normalized within dominant power structures, whether as release valves or occasions for associated profit, they can be seen as analogous to the traditional a-b protest march. As controversial as it is among traditional left-wing circles, the ‘Stop the War’ march demonstrated that pure marching and rallying is permitted since it is merely a token gesture: people feel empowered, that they’ve ‘had their say’, that they’ve taken ever recourse available to them. Protest marches are akin to Saturnalia, a moment of empowerment to prevent any serious build up of opposition.

In Edinburgh at least, UKUncut is proving that it does not conform to this narrative, or at least not yet. In entering stores and shopping spaces for the purpose of drawing attention to the negative activities of these brands, rather than the ‘expected’ purpose of consumption, they are doing the modern equivalent of bursting into the church during the sermon. The increasing instances of political policing against them (see the Edinburgh Uncut blog for details) show that this iconoclasm is coming to be seen as more than just ‘letting off steam’, and that there is a serious attempt to suppress it, and thus re-naturalize it within the narrative of ineffectual protesting.

Rather than let this happen, UKUncut can continue to desecrate the hallowed halls of capitalism. In doing so, they have the potential to subvert the expected sequence of protest being a momentary release of public frustration which allows the government to claim it has ‘listened’ without making any quantifiable difference to policy. However, as they do so, they will come up against the resistance of steam building up in a confined space – more political policing, more arrests, more intimidation.

Here again, they can learn from the history of subversive performance. Mikhail Bakhtin is known for his theorizing of the ‘carnivalesque’ – a space in which, like the Saturnalia, opposition to the prevailing order can be displayed, but, unlike it the truths revealed and the ideologies challenged remain challenged. This happens through the employment of humour and ridicule – by the force of laughter.

UKUncut have this in spades, and this is what, were Scottish legal precedent not a complete joke, would make it utterly impossible to obtain a prosecution on the charges of ‘Breach of the Peace’ brought against Edinburgh Uncut activists – due to their good nature and humour (including the comedy club inside BHS), members of the public were not ‘alarmed or upset or tempted to make reprisals at their own hand. Laughter is thus a potent weapon, an inclusive force to bring the public onside and keep them there. As Bakhtin argues: “Laughing truth […] degrades power.”

So laugh on, UKUncut – you could even stage a protest dressed as morris dancers!

Abolish Oxbridge? Treat the Causes First

June 1, 2011

On Labourlist today, Owen Jones argues that we should abolish Oxbridge. To be exact, he argues that we should get rid of the ‘Oxbridge system’ – the idea that degrees from Oxford and Cambridge are automatically superior to those gained from other institutions.

I agree that these assumptions are damaging to the ability of employers to judge the abilities of graduates, and that there is a tendency towards an ‘old boy’s club’ approach to recruitment in many City jobs. I also agree that, certainly in the central colleges, there’s a hideously elitist atmosphere, which is made worse by some of the traditions of the university.

However, diagnosing ‘Oxbridge’ as the major problem fundamentally misses the point. As Owen points out, the admissions offices of both universities have put in amazing work trying to rectify these inequalities, but comprehensive students just don’t apply. This is not a problem with Oxbridge, but with the secondary school system itself. Speaking to a student who was the first in ten or fifteen years to attend Oxbridge from a comprehensive school in Leicestershire, I discovered that her head of year, as well as her subject teachers, had told her ‘you won’t get in, people from this school don’t go to Cambridge’ – a prediction she defied. Also, as a friend studying Classics at Oxford points out, you can’t really claim that inequality in her subject is due to institutional bias – classics is 47% independent, but only 38% of state schools teach any classical subjects at all. Again, this is to do with limitations of the state system and which subjects are perceived to be ‘posh’ or ‘useful’, rather than Oxbridge elitism.

When this kind of negativity exists among the staff in schools, how can students receive the best possible education? Will teachers who don’t believe their best students capable of attending Oxbridge be able to inspire them to achieve the best they can?

This raises the question of whether Oxbridge is, in fact, ‘the best’. For many courses, it isn’t. I studied English, and while the course was wide-ranging and engaging, it was also very ‘safe’. Obviously, it takes its reputation for rigour seriously, so that (in the humanities at least, I can’t speak for science departments) it is slow to take up the latest research, in case it is embarrassed by following a dead end. Finally, the ‘traditionalist’ approach it prides itself in means that many subjects (mostly those attacked by the tabloids as ‘mickey mouse’) aren’t even offered – perhaps this is another reason for the low uptake from the comprehensive system?

Within ‘academia’, these idiosyncrasies are well known, so the ‘drive’ towards Oxbridge is again due to a wider cultural perception that it ‘opens doors’ – a self-fulfilling prophesy, and again one which is to do with the cultural position of Oxbridge within national narratives rather than problems with the universities themselves.

As a result, I agree that the idea of two monolithic institutions is one which should be banished from the national consciousness – but I don’t think that Owen’s suggestions will help in doing this. Offering places to the highest achieving students at each school, and the to 10% in the EMA eligibility group might help, but might also continue to perpetuate the myth that Oxbridge and the Russell Group are The Best.

Similarly, I would move in the opposite direction on the subject of interviews. I think that the idea that a private school education automatically gives you an advantage here is overly simplistic, and one which is patronizing towards the many bright, articulate people I know from a comprehensive background.

Even if there was a correlation between educational background and articulacy, at the less traditional college I attended there was a sense that the coached, assured, stereotypical private-school approach to interviews was looked down on. The interviewing tutors had seen it all before, and really wanted someone who was maybe less articulate but had interesting things to say, and could be creative with the material given them.

Rather than remove interviews, which after all are not automatically biased towards private school students, I would like to see them instituted at a short-list stage, if not for all courses, then at least for those which require discursive skills. This would level the playing field without the implicitly paternalistic attitude towards comprehensive school students.

That’s my fundamental problem with Owen’s article – even though the issues he raises are extremely important, his solutions overlook the broader issues. While there is still a wealthy elite with the expectation of getting into positions of power, they will do so, Oxbridge or no Oxbridge – private schools will still allow them to network, and those with ambitions towards City jobs will still congregate at expensive bars and black-tie social events within their universities.

It’s ultimately a difference in political outlook, but for me, the idea of using legislation to ‘force’ universities to be more representative represents everything that I find distasteful about the more authoritarian/paternalistic side of socialism. Enforced equality like this elides actual inequality, while patronizing those the policies are intended to help.

Finally, the best academics are ALREADY spread around UK institutions. Oxbridge, while very strong in many departments, does not have a monopoly on academic excellence. This is probably the most important issue to note, as Owen’s article does not differentiate between two functions of universities – the first of which is to provide vocational training for those who wish to continue in academia, and the second of which is to provide a necessary qualification on a CV for entering employment.

This elision is understandable, especially since the Coalition government’s education policy seems to entirely ignore the fact that universities are actually vocational institutions rather than just corporate training centres, but it is one which is vital to unpack within public narratives. Oxbridge DOES have excess influence in the latter category – but that is due to its tradition of having been so, rather than anything inherent to the institution itself.

In the end, the most important element of university education is that it is challenging for students and encourages original, rigourous thought. For this to be the case, there needs to be a transformation in the way that higher education is percieved by the public.

An out and out attack on Oxbridge as proposed by Owen will not achieve this – rather, it leads to the ‘us and them’ attitude being played out in twitter debates at the moment, where the label Oxbridge delegitimizes people in the eyes of those who view the institution as elitist just as much as it legitimizes them to potential employers in certain sectors. If we seek a more egalitarian system, we must achieve it by challenging stereotyping and unearned privilege at the same time. This will not be achieved solely through legislation, but rather through a concerted effort to treat people as people rather than types, and by continually re-stating the fact that universities themselves are already diverse – it is public opinion and convention which claims otherwise.

Thomas Szasz, ‘Care’ in the Community, and Lansley’s NHS ‘Reform’

April 9, 2011

Thomas Szasz, a self-described ‘libertarian psychiatrist’, has written extensively about the ‘myth’ of mental illness. He holds that the idea of ‘mental illness’ is as much a category error as a ‘married bachelor’, and has written passionately against what he sees as the coercive tendency in mental health care.

The points he makes about coercion and the potential for abuse within the mental health system are, I believe, salient and important. Debates over the potential for pathologisation of difference and instances of ‘symptom creep’ have hit the headlines again this week with report of increasing numbers of antidepressant prescriptions, and there is always a balance to be maintained between genuine care for and treatment of those suffering from mental distress, and the use of extrajudicial power to curtail the rights of the individual.

However, his ideas also resonate in a worrying fashion with both the infamous ‘Care in the Community’ policy of Thatcher’s government, and the current Tory administration’s approach to disability, welfare and the NHS. Szasz’s critique of the psychiatry as an institution is founded in a free-market fundamentalism which views state-provided healthcare as coercive since it obscures the financial relationships which underpin the therapeutic relationship between doctor and patient.  In his re-framing of the concept of mental illness, he casts those traditionally considered mentally ill as either victims deprived of liberty, or as merely using the label as an excuse for not taking responsibility for their own actions, and for restricting the liberty of others.

In this context, Care in the Community can be seen as a deliberate attempt to reduce the extent to which people who refuse to take responsibility can impact on others. This is not to argue that the policy was necessarily influenced directly by Szasz’s views (although this is not unlikely), but that the logic is the same – focus the argument on the problematic tension between liberty and clinical intervention, and use this as a way to withdraw care and place blame on the service user.

The worrying thing about this is the similarities between the model suggested for ‘Care in the Community’ in the 1988 Griffiths Report and Lansley’s NHS reform proposals. The Griffiths Report is summarised as follows by Vicki Coppock and John Hopton:

Local authority service departments:
– Should be given the lead role in the provision of community care;
– Should receive cash limited funds;
– should undertake ‘needs-led’ assessments and design individual ‘packages of care’;
– should become ‘enabling agencies’, purchasing and overseeing care, NOT directly providing it. (2000: 42)

This ‘market led’ approach to ‘Care in the Community’ was a demonstrable failure, and its basis can be placed within the development of an explicitly market-libertarian ideology diametrically opposed to NHS-style state healthcare.

It is unsurprising, therefore, that Lansley’s policies should follow a similar pattern (and be expressed in similar language), but also deeply worrying. This is not a path anyone who suffers from mental distress (or indeed anyone who might get ill, ever) wants to take, and one which should be opposed as strongly as possible.