By Angela Kennedy, Social Sciences Lecturer and Researcher and Author
I was somewhat surprised to see Mansel Aylward’s changing view on the ‘biopsychosocial’ model, claimed by him as he was confronted by those representing disabled people victimised by this model for many years. But I am not confident Aylward has actually understood what the problems of this model are.
The so-called ‘biopsychosocial model’ was first proposed by George Engel in his 1977 paper.
It is often claimed that ‘biopsychosocial’ approaches are merely ‘holistic‘ approaches to people’s health, a much-needed move away from the medical model for which Aylward claims so much distaste. And in this context, objections by patients might seem rather odd. Why on earth would patients seek to move away from being seen as ‘whole persons’, in all their social and psychological complexity, from being cared for ‘holistically‘?
To answer this, one needs to look at Engels’ paper. In fact, he does not address the issue of psycho-social impact of illness at all, but merely argues that ‘psycho-social’ factors cause illnesses as diverse as diabetes and schizophrenia. Engel uses the fact that, in diabetes, keto-acidosis and hypoglycaemia (physiological conditions in diabetes) may sometimes cause psychological symptoms, to argue, irrationally, that it therefore follows that signs and symptoms associated with diabetes are symptoms of ‘psychological distress’.
He also (wrongly) assumes that, because physical illness is experienced in psychological, behavioural and social ways by humans, signs and symptoms of diabetes are therefore caused by ‘psychological distress’.
So we do not see a ‘holistic approach’ in Engel’s paper at all, but merely psychogenic
explanations for organic illnesses – even uncontested ones like diabetes! How have such incoherent arguments become equated with ‘holistic’ approaches to health?
Lack of concern about impact of medical impairment is also evident in the responses to the draft NICE guidelines for ’CFS/ME’, made by the ‘CFS/ME’ department at Bart‘s Hospital. They objected to providing blue badges and wheelchairs, and, responding to the issue of management of physical and emotional impact of patients’ symptoms, commented:
“The emphasis here would be appropriate for someone suffering from an incurable chronic disease, which CFS/ME is most often not.”
These responses are remarkable when compared to research demonstrating that ME/CFS sufferers have more impairment than those with multiple sclerosis, end-stage renal disease and heart disease. It is fair to say that sickness impact (physical, psychological, and social) is a key problem in ME/CFS.
Contributors to the book ‘Biopsychosocial Medicine‘ (edited by Peter White) also focus on psychogenic explanations of aetiology, while completely neglecting to address the impact, of physical illness. White also claims the biopsychosocial approach as “better established” for “medically unexplained symptoms” indicating it is most often used as a default psychogenic explanation for difficult to diagnose illnesses. As Mary Horton-Solway comments elsewhere:
“the use of bio-psycho-social reasoning appears somewhat different from the theoretical vision of a holistic disease-process model…”
Patients facing a ‘biopsychosocial approach’ therefore find themselves facing an over-
emphasis on the ‘psycho‘ (and only then with regard to alleged causation, rather than impact, of their illness), at the expense of the ‘bio’ and ‘social’ aspects of their
illness, leading to psychogenic dismissal of their illness and malign constructions of their characters (hypochondriacs, malingerers, wimps etc.) Whatever the ostensible “patient as a whole person” philosophy claimed by proponent of ‘biopsychosocial’ approaches, it is used most often to assume a physical illness is caused by psychopathology and deviance, and to advocate treatment/management approaches based on this belief.
Aylward’s distaste for the ‘medical model’ bears commenting upon as well. Many patients have come to actively seek to reduce medical inquiry to their physical bodies. This is most likely to be a rational attempt to prevent iatrogenic risks to their physical, psychological and social health, caused by an approach that is not holistic at all, but, in real-life practice, an irrational psychogenic dismissal, by doctors, of physical illness, the last thing patients need.
Aylward’s denial of his part in promoting ME/CFS as a psychogenic condition is also
interesting. Papers recently released by the government demonstrate that, in 1993, Aylward, then in a key position at the Department of Social Security, was actually very supportive of Simon Wessely’s psychogenic explanations for ME/CFS, and even hostile to those objecting to how these were forming the government policy on ME/CFS, in which Aylward had key involvement.
Engel, G.L. “The need for a new medical model: a challenge for biomedicine” Science (1977) Apr 8;196(4286):129-36.
Horton-Solway, M. (2002) “Bio-Psycho-Social Reasoning in GP’s Case Narratives: The
Discursive Construction of ME Patients’ Identities” Health: 6: pp 401-421).
White, P. D. (ed.) Biopsychosocial Medicine: An Integrated Approach to Understanding Illness (2005) Oxford University Press, Oxford.
Angela Kennedy is a social sciences lecturer and researcher, and mother and carer of a young disabled woman who became ill as a child.
Her academic research interests include: the social stratification, scapegoating and social exclusion of disadvantaged groups, and the effects of these; constructions of moral panics; and the sociology of science and medicine, including manifestations of the ‘science wars’.
Her book ‘Authors of our Own Misfortune? The Problems with Psychogenic Explanations for Physical Illnesses’ is published by the Village Digital Press.