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.
REFERENCES
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.
BIOGRAPHY
Click on image
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.
See also:
9 Responses
On the matter of his ‘distaste’ for the ‘medical model’ – Professor Aylward would not have been able to attain such high status as he has without drawing on the authority that our society bestows upon those considered experts in the field of medical science. Without his medical degree, and actually quite short spells in what most people would consider to be medical roles, (relatively brief stints as a GP and a in a surgical role) he would not have been able to command the kind of influence that he has. As has been described, evidently with his approval, he is as much an entrepreneur and policymaker as he is an academic.
He is not at all reticent about ‘using’ his medical credentials when it suits, to justify certain career decisions he has made. For instance in a 2003 interview he claimed that he sold his pharmaceutical research business because he regretted ending up as a businessman which meant he had “lost touch with [his] medical background”. He sold the business and “returned to medicine.” To most people that would mean something ‘hands on’. But his actual move was into government, and the start of his policy-making career. Not what most would consider a ‘return to medicine’.
Thank you for this, it makes it so much clearer now. People like him need to suffer from one of these illnessess and then ponificate his psycho-social babble when he has had a few months of sleep deprivation and constant pain, I’d bet he’d soon retract from his current position but I doubt he would apologise. Thanks @Gill for his career run-down, it always seems the case that people like this get into positions of power in whatever walk of life they chose to pursue. You see it in Charity work to Nurse training, in schools and parliament. These people are usually intellectually lazy but get feted for their “insights” on the human condition because there is a character flaw within them but they hold persuasive personalities unfortunately.
The man is a quack at best and extremely dangerous at worse. He has obviously never suffered from a disability, the only disability he suffers from is a lack of empathy and a lack of conscience. Doctors take an oath to alleviate suffering and not to take life, this man has forgotten both, money is the motivator for his career shame on him.
The man is a quack at best and extremely dangerous at worse. He has obviously never suffered from a disability, the only disability he suffers from is a lack of empathy and a lack of conscience. Doctors take an oath to alleviate suffering and not to take life, this man has forgotten both, shame on him.
Before the Coalition came to power , Steve Webb, Liberal Democrat work and pensions spokesman, commented in relation to the Labour Government’s Welfare to Work programme :
“The rhetoric sounds great – ‘We’re going to focus on what you can do and not what you can’t do’ – but we all know that what that really means in practice is getting tougher and setting the bar higher.” He added : “What worries me is the idea of a future Tory government going further, faster down this track and already budgeting for millions of savings, saying there’s obviously people who don’t need this money.”
How ironic !
With little protest , Labour’s Welfare to Work programme found seriously ill people, people with debilitating conditions and serious disabilities illegible for Employment and Support Allowance (ESA), the benefit that replaced Incapacity Benefit in October 2008. That is because they had been subjected to the notorious Work Capability Assessment (WCA) which took little account of variable symptoms, generalized pain, exhaustion or the underlying seriousness of a person’s condition.
According to a Citizens Advice Bureau report , those seriously ill and disabled people , found fit for work under the last Government and denied ESA , were subsequently written off, just left to cope with greatly reduced benefits on Job Seekers Allowance and little support. (Source : Not Working . CAB Evidence on the WCA.)
Yet introducing ESA and the WCA in 2007, Peter Hain, Labour, described them as “A new, progressive vision for our welfare system .”
As Debbie Jolly points out, up until then campaigners, protesters, advocates, activists and Centres for Independent Living (CILs) had managed to achieve :
The Independent Living Fund (ILF)
Disability Living Allowance (DLA)
Incapacity Benefit
Access to Work
Direct Payments
The Disability Discrimination Act
All the above achievements, the envy of the world, have now been drastically cut back and replaced.
Labour’s (and now the Coalition’s) extraordinary counterintuitive reasoning , towards disability, has its roots, says Jonathan Rutherford in the American right’s philosophy that the poor are the cause of their own poverty because they fail to take advantage of the opportunities “available” to them..
This all began in 1994 the Conservative Government brought in UNUM, the giant American Medical insurance Company, to advise them on welfare reform, a member of that group was Mansel Aylward, who in 1999, as Chief Medical Officer at the DWP, devised the new Personal Capability Assessment (PCA), contracted out to the American Corporation Atos Origin, where the ” emphasis was no longer on entitlement, but on what a person is capable of doing.”
The intellectual basis behind the PCA was UNUM’s “The Scientific and Conceptual Basis of Incapacity Benefits “, written by the apparently apologetic Mansel Aylward, which is based upon the biopsychosocial model of illness, designed to “liberate” the disabled from the ” medical model” . According to the biopsychosocial model, under which untold tens of thousands with people ME have suffered horrible abuse and even death : ” Disease is the only objective, medically diagnosable pathology. Sickness is a temporary phenomenon. Illness is a behavior social phenomenon rather than a health problem. The solution is not to cure the sick, but a “fundamental transformation in the way society deals with sickness and disabilities. ”
The transformation is this : ” Sickness is a social and cultural phenomenon rather than a health problem. The solution is not to cure the sick, but to transform the culture of welfare. No one who is ill should have a straightforward right to receive benefit.”, this extreme agenda ” was adopted by the former banker Labour brought in, David Freud , now Lord Freud , Parliamentary Under Secretary of State (Welfare Reform) .
Pushing the neoliberal agenda to triumphant heights, the Coalition maintains says the “only” way to save money is to slash welfare spending.
Effectively as many claimants as possible must be bumped off benefits. The disabled have been thoroughly demonized; the need to reduce ” welfare dependency” is shouted out , as loud as possible, to all who can hear. The consequences have been terrible, with the disabled bearing the brunt of cuts , as Patrick Butler writes :
Savage cuts to social benefits have shredded the welfare “safety net” and left many disabled families in a “struggle for survival”, according to a detailed study of the impact of the government’s austerity programme. It calculates that disabled people and their carers have seen their income collectively cut by £500m in the past two years, leaving many increasingly financially impoverished, socially isolated, and at risk of declining mental health.
Many disabled people’s quality of life will continue to deteriorate over the next three years, warns the study, as a further £9bn of predicted cuts todisability support are rolled out and local authority social care budgets shrink further.
“Although nearly everyone faces tough times in this current economic climate, disabled people are hit particularly hard as a result of lower income, higher costs, fewer support services and unpredictable health conditions,” the report, published by the thinktank Demos and Scope, the disability charity.
Denied even the basic right of proper medical care for decades , under the biopsychosocial regime that has now gone global, people with ME know more than most, how evil this regime is.
Does Mansel Aylward sleep well at night, I wonder ?
The experience of people with ME , who have suffered for decades under the psychosocial domination of the corporate medical insurance industry ,offers a stark insight into the smoke and mirrors that passes for Mansel’s “21st Century ” disability policy :
(By the way, only a terminally ill cancer patient or someone dying of AIDS what the degree of suffering is like in ME, there is no cure, no known treatment. And it can and does kill.)
The process is this :
In ME :
Change the Name : ME to CFS
Change the Criteria : Virus to Fatigue
Simplify the Criteria: So that ME is diluted down and is lost in an irrelevance of Fatigue and mental health jargon.
Change the Focus : Biomedical to Psychiatric
Move the Definition : To incorporate people with a mental health need.
Create a skewed approach : Based solely upon a limited psychosocial view of ME
Create Systems to sustain the flawed Ideology : Created vy the medical insurance industry, who have a massive financial stake in denying the physical reality of ME, either covertly or overtly
Set up psychosocial clinics that focus purely on mental health strategies and deny the physical reality of ME, staffed by workers who believe that ME is not a physical disease.
Ignore genuine need by switching the focus and making the person’s reality irrelevant: Do not look at ME within the context of a physical, untreated disease. In ME switch the focus from the real issue of illness, to rehabilitation and away from the physical needs of the person.
The outcome is a denial of people’s reality, the misapplication of Cognitive Behaviour Therapy and the channelling of resources away from where they are needed. The present reality of ME : ME is treated as if it is a mental health issue. The person with ME is subtly blamed for being ill and not doing enough to get better Their physical health is denied. Their level of disability is denied Their needs go unmet and people with genuine ME are neglected unseen and left without appropriate medical support leading to a never-ending life of illness and disability, unsupported by the social and medical systems that should be in place to help them.
In PIP :
Change the Name : DLA to PIP
Change the Criteria : What you “can’t do” , to what you “can do” Simplify the criteria: So that disability is watered-down and the complexity of disability gets lost in irrelevance. In truth disability is complex and needs detailed understanding
Change the Focus : Disability to Ability.
Move the Definition : To exclude the least disabled and possibly the most disabled,who cannot achieve independence, or those in residential care, from getting Benefit.
Create a skewed approach : Based solely upon a limited social view of disability, ignoring the medical and environmental aspects.
Create Systems to sustain the flawed Ideology : There are vested interests behind DLA policy development , who have a massive financial stake in denying the physical reality of disability, either covertly or overtly.
Set up a flawed Consultation Process, after already drafting the Bill to change DLA. Set up ATOS with a financial incentive to remove people from benefits .
Ignore genuine need by switching the focus and making the person’s reality irrelevant: Do not look at the impact of disability upon ability.
In PIP switch the focus from the real issue of disability to an out of context ability. The outcome is a denial of people’s reality, the potential misapplication of Cognitive Behaviour Therapy and the channelling of resources away from where they are needed.
The great error of PIP is looking at ability and denying physical disability . The inevitable result is that disabled people will be viewed , like people with ME :
• as not trying hard enough
• as being more capable than they are
• as having a false “perception” of disability
• of wanting to be disabled
• of not needing the help they actually do need
There is a place beyond anger. While my wife sits, hunched in pain, while there is nothing I can even make her to eat, while she sits tormented by noise, by movement, in silence, it is to read that Mansel Aylward has offered some kind of door step apology – while inside UNUM are as busy as ever handing out branded flash pens and goody bags.
Greg Crowhurst (c) Stonebird 2012
wisted Witch : New Statesman May 2008 http://www.newstatesman.com/politics/2008/05/work-benefit-claimants-reform
Greg Crowhurst Joe Public Blog , The Guardian, June 30 2010 http://www.guardian.co.uk/society/joepublic/2010/jun/30/incapacity-benefits-reform-scared
Melissa Viney, Bending the Rules, Guardian , October 28 2010 http://www.guardian.co.uk/society/2009/oct/28/work-capability-assessment-incapacity-benefits
Citizens Advice , Not Working , 2010 http://www.citizensadvice.org.uk/not_working
Peter Hain, Labour and the Sick Note, New Statesman, 27 Nov 2007 http://www.newstatesman.com/politics/2007/11/work-benefit-welfare-tories
Jonathan Rutherford, E pluribus Unum, The Guardian 17 March 2008 http://www.guardian.co.uk/commentisfree/2008/mar/17/epluribusunum
Jonathan Rutherford, The welfare reform bill’s hour of need, The Guardian 22 June 2009 http://www.guardian.co.uk/commentisfree/2009/jun/22/welfare-reform-bill-mental-health
its with these people they kill us and he nows no bounds that his way is right as with all quacks his way is best while we all fall down but who are they most have worked for unum atos and should be never given voice to this subject as they will be not giving a straight answer as they are now deemed unfit by law as to respound to the questions and answers for unum atos in fact they all in it together ops jeff3
Aylwardism, an illness that results in the belief in any old crap for the Psychological benefit of research funding and lucrative consulting contracts…..
It is interesting how the “social” part of Biopsychosocial Medicine is always minimised, would this not include things such as accessibility, less work or economic pressure etc? It is in fact a misnomer it should actually be called the ‘psychological’ approach because in practice it is pursued on the basis that all disease is in the mind…
I was in Spain recently and incredibly disappointed to read in a regional newspaper that the new conservative government there seems to be adopting this approach. The doctor interviewed again, only seemed to emphasise steps that he thought should be taken by the patient…
There’s nothing wrong with paying attention to social aspects or psychological aspects (will power, moral) of ANY illness be it cancer or depression, however!
The current paradigm disingenuously focuses on and overstates the unproven psychological aspects of the illness. It ignores the biological, including training GP’s to avoid testing (I have first hand experience of this as a patient), it CAUSES massive social harm to the patient because it convinces everyone that the patient can’t be trusted to interpret the severity and permanence of his or her symptoms. This can destroy a patients support network, as well as their self esteem.
This is the true argument against psychological classification of these illnesses, no CFS/ME or Fibromyalgia patient has set out to stigmatize those with mental health issues. We just don’t think the current model used by the NHS is accurate. Remember the burden of proof is on those making the claim regarding the etiology of the illness. Sadly those who push psychological viewpoints are given a free pass when it comes to proof of their claims.