NB. This is not the follow up to which Gill Thorburn referred in her previous response to Professor Aylward, on which she is still working. She says that there is still much more to be said about the way Aylward applies certain ideas according to the objectives he seeks and her follow-up article will be published here in due course.
Gill has written this piece because says felt very strongly that it is important to share her perspective on Aylward’s slide presentation in light of his claim declared to Black Triangle, DPAC and Disability News Service of having changed his views on the Biopsychosocial Model’s fitness-for-purpose and which view he alleged he expressed in his presentation to the IFDM2012 conference.
These claims, it now seems, at best ring hollow.
‘About that presentation, Professor Aylward…’
By Gill Thorburn 1st October 2012
Professor Aylward gave the impression, in his reported comments to Black Triangle and DPAC at the International Forum on Disability Management 2012 conference, that there had been something new in his address to that audience; that he had altered his perspective on the BPS Model, and was recommending changes.
Such changes as might ensure that a neglected ‘social’ aspect of sickness and disability would receive more attention than is currently the case.
Having assessed the slides used by Professor Aylward that day, which he ‘spoke to’ in his address, I can only come to a quite different conclusion. This is that, in full awareness of the significance and value that the Social Model has held historically for the disabled community i.e. that it is ‘their own’ favoured version of how society ‘disables’ people with impairments, he was merely ‘playing to the crowd’.
In effect, it seems likely that he took that turn in order to divert attention from the fact that he was, as is always the case, presenting to the conference audience his usual proposal of the BPS model as a superior one from which to perceive sickness and disability. And I think we’re all now aware of where that has led us – to the fraudulent instrument that is the Work Capability Assessment.
Now, onto those slides:
The ‘distasteful’ Medical Model…it’s ‘history’ man…
Professor Aylward begins his presentation with a perspective on the ‘Medical Model’ which will be familiar to anyone who has studied his literature.
The Medical Model is ‘history’ in the professor’s eyes, too ‘mechanistic’ to be of relevance to disability/incapacity. His professed ‘distaste’ for the medical model is a puzzling one since it is his very own medical background, and professed medical expertise, which bestows upon him the authority that he draws on to exert influence upon government, medical and industry thinking.
I can’t be the only one to see a ‘paradox’ in this, and am surprised that none of his esteemed colleagues, welfare policy-makers or the medical world in general have ever questioned the striking incongruity of this contradictory double stance.
Medicine only wants to ‘cure’ you
Medicine, he suggests, is limited in viewing illness as something to be ‘cured’, from which thinking he asserts there can only be two possible routes – to complete fitness or long term disability. This perspective is presented in terms of “how we thought”.
The professor is determined that we think of this as an outdated model.
It is ‘in the past’, no longer relevant. He extends that idea now into the ‘traditional’ perspective on ‘occupational health’, which connects ill-health to work, and where work is recognised within that medical model as a ‘potential hazard to health’, carrying with it a risk of injury and disease.
From this extraction of authority from the medical model he now moves on to argue the case for the construction of ‘new’ conceptual models.
Think outside the box, or perhaps just inside a new one
New conceptual models, he declares, allow for the introduction of new ways of acting.
Models ‘crystallise’ thinking.
A different interpretation of this idea might be that it serves to close down other ways of thinking, drawing hard boundaries which constrain thinking outside of the ‘new’ conceptual box, once the ideas inside it have been accepted and have replaced their predecessors.
So, in essence, there is no more real value to a ‘new’ concept over an old one, if the ideas which become so crystallised are flawed!
Regardless, one of the professor’s ‘benefits’ of a new conceptual model is stated to be that it:
“Enables the formulation of desired tangible outcomes”
I find this assertion to be somewhat at odds with the spirit of scientific/medical discovery, which derives its authority from the claim to not be working towards pre-determined outcomes.
It is a strangely unobjective approach.
New conceptual models, it seems, can be crafted to engineer whatever outcome we wish, be tailor-made to manufacture the ends we seek.
Surely this encourages and facilitates bias?
New definitions of sickness and illness
Nevertheless, having espoused the value of constructing your own (d.i.y) conceptual models, an intermediate slide signals ahead for the notion of a ‘holistic’ view of health. This references Aristotle, Engel (originator of the BPS model) and contemporary proponents, including the professor’s colleagues from his own Cardiff University Department, Waddell and Burton.
We are then presented with the terms for various aspects of ill-health, redefined by himself and Waddell, and posed as if in clarification, though in reality they can only ever be proposed interpretations of what these terms could mean.
In short these are that:
Disease = objective/has physical pathology
Impairment = demonstrable loss of function/structure
Illness = subjective, feeling unwell
Sickness = a status accorded by society
Disability = limitation on activities/ restricted participation
Incapacity = inability to work because of sickness/disability
These definitions, however, are by no means concrete, as others may offer competing versions, but they are presented here an ‘unravelling’ of any confusion around these ideas, as if these are the most stable authoritative ‘facts’.
It is clear from these definitions just exactly how we are meant to regard concepts such as illness and sickness compared with disease, the first being ‘subjective’, the second drawing on the ‘sick role’ and the third superior since it is ‘objectively’ founded in pathology.
As I have commented previously ‘objectivity’ is not consistently afforded such a reliable or certain value in the professor’s literature.
Dissing the symptoms
Next up is ‘Symptoms’.
As ever BPS literature attempts to downplay this aspect of ill-health, since the term is invariably used to describe the patient’s own account of their negative physical experiences, regardless of the fact that symptoms are the physical manifestations by which doctors undertake an investigation into ill health.
Symptoms, then, are: ‘subjective’, ‘bothersome’, ‘of concern’ to the individual.
An attempt is made here to break the connection with disease, detach them from their connection with ill-health.
Describing them as ‘ubiquitous’ and ‘omnipresent’ is meant to infer that we all suffer from those kind of sensations in everyday life (this is sometimes stated more overtly in BPS literature), they are common, and therefore bear little relevance to ill-health.
Further, there is a denial that symptoms correlate with illness, disability, or (in)capacity for work, citing as evidence for this his own and colleague Waddell’s literature (evidently they are professing to be the authoritative, medical experts in this area).
Raising the essential ‘paradox’
Inevitably, as ever with the BPS propaganda toolkit, the next slide ventures into that mysterious realm, where reside ‘myths’ and the ‘medically unexplained’, or in this case ‘paradoxes’.
A set of paradoxes are constructed thus:
“The typical disabled person (perception vs reality)”
– We are evidently invited to question our perceptions about ‘the typical disabled person’. But is it really true to say that most of us hold an incorrect view of what disability is?
Or does this simply play into the ‘scrounger/malingerer’ stereotype, allowing a false distinction to be made between ‘deserving’ and ‘undeserving’ sick?
No doubt the professor made some astounding revelation at this point, such as ‘You may be astonished to hear that most ‘disabled’ people are suffering from ‘common health problems’. [See next section: ‘Those oh-so-common health conditions’]
“The Health Paradox”
– suggested improved health vs claim’s trends.
As has been pointed out before there really is very little relevance to the idea of a consistent overarching improvement in health when this idea is shaken out, since some enjoy the privilege of robust health and longevity at one end of the scale, while others suffer exceptionally poor health and early death at the other, meaning averages give an artificially overall positive skew to statistics.
That’s not how reality works.
The use of ‘claims’ trends’ betrays the source of this proposed paradox, that of the insurance industry in whose interest it is to portray people as ‘not sick, really’.
Other erected ‘paradoxes’ hint at the notion that people can be ‘fully recovered’ but not be back at work, and an interestingly titled “Disability Rights vs Sick Worker Advocacy”.
This latter we must assume speaks to an idea that ‘Rights’ have got out of hand, have assumed too much importance in the discourse around disability and what is preferable is to get the sick working.
Which is how we arrived at the WCA, an administrative instrument to ensure that this is achieved.
The sick must work.
Or, in actuality, the sick must now languish on the less-costly-to-the-state Jobseeker’s Allowance rather than those expensive health-related and disability benefits.
‘The BPS Model allows us to perceive that people are not only sick, but that they are sick and deluded.’
Those oh so ‘common’ conditions
As expected, statistics are included to bolster the presentation, and to lend an aura of legitimacy to the basic argument, and involve one survey administered from within the professor’s Cardiff university department.
Here we find the usual health ‘suspects’ named – the professed ‘medically unexplained’ or ‘symptom defined’ conditions such as musculo-skeletal, mental health, cardio-respiratory and gastro-intestinal disorders. And also ‘headaches’!, perhaps thrown in to convince us just how ‘common’ these other category of illnesses are. “As common as a headache” may be a slogan we are treated to in future to drive home this attitude towards these illness groups.
The BPS lobby seek to minimise the profound impacts that these conditions may have on people’s health, suggesting that sufferers’ health is more threatened by what they ‘believe’ about having these conditions than their physical effects.
That must, surely, be cold comfort indeed to the growing numbers of families of heart disease victims, and others, who have died following being declared ‘fit for work’ by Atos, one at least ‘believing’ that because he was declared fit that meant he was.
It seems his ‘belief’ was not strong enough to counter his evident bad health.
Perhaps the professor could have given him some ‘positive thinking’ pointers in that respect and saved him from an early death.
Enter the Psychosocial…
A slide which extrapolates on the ‘Psychosocial Dimension’ gives insight into the professor’s ambitions in propagating the BPS model.
In it he asserts that when we tell someone something we “attempt to change the way their brain works”, and that how people think/feel about their health problems determines how they deal with their impact [See previous paragraph for how that tends to turn out for the chronically sick].
Aylward cites ‘evidence’ that ‘beliefs’ aggravate and perpetuate illness and disability, and that the more ‘subjective’ the illness the more central the role beliefs play in it. And so on… ‘perceptions’, ‘expectations’, ‘emotions’, ‘uncertainty’… all words wielded here to diminish patients’ claims to be experiencing disabling health.
Why not redefine Health itself?
From this on to a call for a new definition of Health, a modification of the one currently in use within the World Health Organisation, which as it stands speaks to a desirable “state of complete physical, mental and social wellbeing”.
Professor Aylward proposes that, (very much in line with individualistic perspectives on health tied to the notion that there should be ‘no rights without responsibilities’), that there should be a requirement on the part of the individual to be willing to “adapt and self manage in the face of social, physical and emotional challenges”.
The professor wishes to change even the very definition of health itself, globally.
“Why do some people not recover as expected? is the next question posed alongside a BPS graphic. This begs the question in return, “Expected by whom, and by what measure? Surely not the ‘outdated’ medical model, which has previously been disparaged as no longer relevant?”
Evaluating the Models
We are then treated to a review of ‘models’ which could be used to view sickness and disability.
First up, the ‘Social Model’.
He claims that this is only relevant for those with ‘severe’ or ‘permanent’ disability.
There is so much to say about this it’s hard to know where to start.
Most important would have to be the way in which the WCA and ESA (Employment Support Allowance) regulations have moved the goalposts on that particular category, to far, far beyond what any reasonable person would find acceptable.
The medical model is summarily dismissed as inadequate for evaluating ‘capacities’.
This leaves us in a kind of limbo, where it is no longer possible to predict what will be assumed to be a ‘severe’ or ‘permanent’ state of illness, since it is not amputees, not people with chronic heart disease, not cancer patients (at least not those with more than six months to live), not people with progressive or terminal illnesses generally.
Whose ‘face value’ is best?
A further disparaging of the Social Model claims that it takes symptoms and disability at ‘face value’.
This is a difficult one to understand.
Are we not to be ‘taken in’ by the fact that people appear disabled?
Is not the very form of disability assessment that he promotes (WCA) a process which adopts this superficial perspective, one in which the HCP’s ‘observations’ takes precedence over any other evidence?
Is that not itself a kind of ‘face value’?
It must be if, in the professor’s own words, the search for ‘objectivity’ in assessing work capacity is ‘futile’.
It must then be someone’s subjective opinion, no?
He then claims that the Social Model ignores the personal/psychological.
And here of course we come to the nub of the argument.
That prized element – the Psychological – which counter-intuitively trumps all other considerations of physical disability.
Well there’s the Economic Model (sick role) and there’s the Cultural Model (sick role) and then…
Just a brief mention is made to a so-called Economic Model of Illness.
This is basically a nod to the ‘sick role’ idea that some of the ‘secondary gains’ which accrue to those who take onto themselves the mantle of sickness are financial.
Next we have a Cultural Model:
“Sickness and disability are … social phenomena”.
Yes, it’s the ‘sick role’ again, but with added ‘culture’.
A reference to ‘Welfare Culture’ appears to be a veiled hint towards ‘Benefits Culture’, which alleges that there is a ‘mindset’ that people fall into, of becoming ‘dependent’ on a life on benefits as an easier option than working.
It is usually used to ‘collectivise’ people into a group with a shared ‘culture’ which is alleged to hold distorted, morally deficient beliefs compared to the mainstream.
A method of scapegoating the poor turned towards a new target, the sick.
‘One Model to Rule Them All’
Now we’ve arrived at the main event.
The BPS Model is introduced with the tagline of “Clarity and Understanding”.
The claim is that it encompasses all previously mentioned models.
At last we find a model that does it all!
A category graphic (by Waddell and Burton, professor Aylward’s colleagues) is included to demonstrate “The comparison of medical, social and economic models of disability”.
The Medical Model is criticised as bearing ‘little or no responsibility’ on the ‘passive victim’ for their incapacity or rehabilitation.
This ‘passive victim’ also makes an appearance in the Social Model category – depicting disabled people as wanting everything adapted to them, without them making any effort.
And let’s not forget the sick role…
The Economic Model, which makes a surprising appearance here, considering it was barely worth a mention earlier, is suddenly deemed worthy of a far more detailed exposition.
Its relevance is greatly emphasized due to it demonstrating what a ‘disincentive’ Social Security benefits create, and the high cost to the taxpayer.
It is implied that this model holds merit in showing that Social Security trends can be overcome by ‘adjusting incentives’ and ‘controlling access’.
A last point injects ‘individual choice’ into this model suggesting that Social Security Benefits encourage “exaggeration and illness deception”.
Hang on, how did we get back to the ‘sick role’ again?
It must be concluded that that the so-called ‘Economic Model’ is just a part of the ‘sick-role’ thesis, and not an actual model in itself. Cheeky move, that, professor!
Over these two slides, these ‘comparisons’, the BPS Model is positioned as superior.
The BPS Model allows us to perceive that people are not only sick, but that they are sick and deluded.
The chart does acknowledge the need for employers’ involvement and gives a nod to ‘the (disabled community’s version of the) social’ that “provision [is] needed to alleviate and accommodate”.
But, surely, these other aspects of support should be in place before financial support is withdrawn from sick people, which is what is actually happening.
Favouring the removal of the asserted ‘barrier’ of people’s negative beliefs in isolation from the other ‘social’ barriers simply leaves them stranded, as if kicking away a disabled person’s stick (or removing funding for the wheelchair by which they can be hypothetically said to‘mobilise’) will automatically eliminate their physical difficulties.
The presentation ends on the averred strength of the BPS Model, trumpeting its superiority in supposedly covering all bases.
But does it really?
Is it not the case that all that it does, all that it is designed to do, is to provide a model which places unfair responsibility onto the shoulders of sick individuals for their predicament?
And when I say responsibility – I actually mean blame.
The responsibility part comes in when the proposed solution amounts to ‘heal thyself, take up thy bed and work’.
And no, I do not see any variance from any previous material produced by Professor Aylward and the BPS school/lobby.
It is all too depressingly familiar, even to a certain ‘note’ which once again appears within the presentation which states that:
‘A big area of reform with which to increase the employment rate of sick and disabled people is incapacity benefits’
The slides finish with a plug for Aylward and Waddell’s book “Models of Sickness and Disability” (which is presumably available from all good bookstores…)