Healthcare Hubris - blogs on the biopsychosocial model by Joanne Hunt

"If the doctor told you he could find nothing wrong with you, would you believe him?"

I only ask because this seems to be a question on the Illness Behaviour Questionnaire which Waddell seemed to be using in 1989 for his biopsychosocial approach. I think I would tend to reply that, unless I had particular grounds for doubting the veracity of the doctor on this occasion, of course I would. It is quite possible to believe a doctor honest but inadequately informed. This comes four years after the problems with Pilowsky's Abnormal Illness Behavior had been pointed out by Mayou. It seems very strange.

 

I think the phrasing of that question is ambiguous, what are they driving at? I mean, yes, I'd believe that to the best of their ability the doctor was unable to objectively demonstrate any abnormal findings, and to some extent this depends on their own bias and view of the illness, and what resources they're prepared to invest to looking. I wouldn't think I was being intentionally deceived by the doctor. But, if I had ongoing symptoms, would I then believe there was actually nothing much wrong, or potentially verifiably wrong, with me? No...

 

Precisely. Unless they are being much more clever than we can imagine, which seems unlikely, the whole basis of this needs close scrutiny.

 

Presumably this question is aimed at picking up patients with false beliefs. It is based on an implicit assumption that the doctor is always right, and any one that disagrees with ‘him’ (deliberately chose not to be gender neutral, to raise the gender issues, it would be interested to know if there were any differences reflected in male versus female doctors diagnosing psychosomatic conditions) must have mental health issues.

However, it is open to a very different interpretation, just as many items in such inventories (eg ‘do you regularly go out with friends?) fail to distinguish behaviour due to depression and behaviour reflecting disability/ill health, with this question a ‘no’ answer may reflect psychological issues, or it could be a rational response by a chronically ill patient who has had extended experience of medical gaslighting.

 

Yes. Pilowsky's 1969 AIB was defined as "the persistence of an inappropriate or maladaptive mode of perceiving, evaluating and acting in relation to one's own state of health, despite the fact that a doctor has offered a reasonably lucid explanation of the nature of the illness and the appropriate course of treatment to be followed a patient's failure to be reassured by appropriate medical advice".

In 1985 Mayou said "Pilowsky's essential criterion of resistance to reasonable medical explanation is entirely arbitrary, excludes important clinical problems, and ignores the patient's own views of his/her symptoms. What is the clinical value of labelling a proportion of those who suffer somatic symptoms as "abnormal" because they do not agree with their doctors? What is meant by "maladaptive", "reasonably lucid explanation " appropriate treatment"? Does a reasonably lucid explanation and treatment mean reassurance, which is often ineffective, or does it include psychiatric assessment, full discussion with the patient and behavioural or other treatment.."

The use of illness behaviour concepts in psychiatry. Richard Mayou. In Illness Behaviour - a multidisciplinary approach (!986) eds McHugh and Vallis.

In he 1989 paper Waddell appears to be still relying on the 1969 definition. It will be interesting to discover what the basis of Waddell's theory was. Having said that it seems a worthy cause to avooid unnecessary spinal surgery. The problem is with the wider application of the theory.

 

I would assume this question is based on the assumption by the authors of the questionnaire that doctors can never be wrong, and me, a patient, thinking otherwise is a sign of me being mentally ill. I have many examples in my own medical history of doctors wrongly attributing my symptoms to mental illness when there is actually a fixable problem. I decided some time ago that I would never voluntarily and knowingly ever fill in a questionnaire from a doctor. I'm wary about surveys too.

 

Thank you so much, @Art Vandelay. My computer guru is coming on Sunday.

 

Healthcare Hubris has now produced a shorter version of the blog with text that should be easier to read: https://www.healthcarehubris.com/post/summary-structural-dimensions-of-the-biopsychosocial-model

https://twitter.com/user/status/1424352634379571202

 

A very timely piece and worth reading as background to the recent government Green Paper on out of work and disability benefits.

The below piece of DWP commissioned 'research' is particularly disturbing for PWME:

https://assets.publishing.service.g...le/208968/hwwb-concepts-of-rehabilitation.pdf

For those who haven't been able to read the Green Paper, there is a lot of focus on the Limited Capacity for Work Related Activity (LCWRA) group of ESA (the UK's out of work because of ill health benefit), and I suspect this is setting the ground work to try to dramatically reduce the number of claimants in this group. People who have medical conditions which do not show a clear clinical pathology are the likely target for being found fit to do work related activity. I do think PWME in the UK should be quite concerned about this.

 

I am finding Aylward a puzzling character. His biographies make little of his time before 1986 and his move into government employ. It seems that he was by training a rheumatologist and involved with, possibly founded, Simbec Research Limited - a company conducting trials of pharmaceuticals. This is the list of his published research for the company Mansel Aylward's research works | SIMBEC RESEARCH Ltd, Merthyr Tydfil and other places (researchgate.net) As a highly experienced research scientist it might have been expected that he would have shown a close interest in the methodology of the PACE trial before committing public money. There always seem to be new surprises.

As a rheumatologist one can see how he might have become aligned with Waddell, and the interest in lower back pain, but there is an enormous lacuna in need of explanation.

I am increasingly perplexed by the apparent failure of Aylward and Waddell to acknowledge the existing Canadian papers on the BPS model and the treatment of "Illness Behaviour". In this presentation, which is neither new nor interesting, Aylward specifically refers to the term "illness behaviour". M Aylward Presentation (gla.ac.uk) Aylward and Cott were in similar lines of work. Both Waddell and Aylward should have been familiar with the literature. One seems forced to accept one of two options. Either Aylward and Waddell were aware of the papers on illness behaviour and failed to cite them, or they were ignorant of them. The latter option might lesad one to make inferences about their research skills. You are free to draw your own conclusions about the former.

Something seems amiss.

 

@chrisb - have you heard of James B. Talmage in this area?

He authored a chapter on CFS in an AMA guide for the Evaluation of Work Ability and Return to Work that framed a patient not working as the patient's choice and inability to tolerate normal symptoms. Has published other articles on similar topics

 

I had never heard of him, but shall note him for the "to do" list. I was disappointed to see that he was an Ohio man. I thought he would be from Harvard, but cheered up considerably upon seeing that he did his orthopaedic training in the US Army, and is on the advisory board for "The spine journal". I'm not yet sure whether that is the same as the journal "Spine" in which Waddell published his 1987 paper.
The similarity of the backgrounds is interesting.Jim Talmage's Biography (tn.gov)

 

I was pleased to discover this series of posts, I've only read the first so far. I've been down rabbit holes looking at the origins of the BPSModel and how things got to be the way they are now.

I found some useful history in a chapter by Kugelman, in The Body and Psychology (Stam 1998). It explains how the BPSModel evolved or inspired a new theory of pain, and although not the same as fatigue, the narrative is relevant (I think). I can lend the chapter if interested (virtually). This is what I found interesting;

The pain gate control model (first described in 1965) suggests that psychological factors influence pain perception by acting on the gate control system. The model symbolizes a new theory of pain by redefining it as a process, legitamizing new treatments, making all of a patient's existence 'fair game' for medical professionals to 'manage'.

• the author speaks of how health was being equated with morality, as an achievement, and how the BPSM insists on personal responsibility...and again, morality, which the author says is exploitative. It mandates the patient to be 'responsible' and 'open'.
• This invented the patient as a person, and drew the 'medical gaze' towards personality. Medical knowledge and power constructed 'personhood' in the patient, who was formerly more of a passive recipient. All this facilitating a move towards the control of the patient.
• Levinas called both this claim to understand, and this increasing professional authority over all aspects of a person/patient's existence, 'totalization'.
• Before BPSM, inline with the cartesian dualistic model (not sure the authors' reference/linking is correct, having recently read Liang's Divided Self) an individual could control pain via specific interventions. Pre-BPSM did recognise that there is an interpersonal dimension to pain, but respected [domain] as beyond the limits of a professional (who was treating pain). Those boundaries have since been erased.
• The Gate Control Theory provided a scientific justification for behaviorist manipulation. by manipulating the responses of others to expressions of pain, behavioural therapy attempts to silence those expressions (socially inacceptable - chronic pain doesn't 'make sense' - see Kleinman on stigma) and replace with 'well behaviors', attempts to alter the meaning of pain so it does not interfere with a productive life.
• Responsibility for pain shifted from the practicioner, to co-management, whilst professional authority moved towards being all encompassing (totalization), all the while the patient being increasingly responsible (responsibility...morality...).
• BPSM doesn't recognize limits to intervention into the patient's life. Limits are eliminated theoretically, symbolically, and practically, by the mandate for the patient to be a 'responsible' and open team-member.
• they go on to say that "pain is epidemic - a fault with the social matrix that produces suffering. To tempt people in pain to be co-managers in such a social world only deepens our true helplessness" - I haven't decided how to interpret that just yet, I understand the sentiment, but it doesn't sit well.

Bit long - hope it's the appropriate place to share.

 

Moved posts

A recent blog by Joanne Hunt on the site Healthcare Hubris

Media silence on the politics driving 'one of the biggest medical scandals of the 21st century'
See https://www.healthcarehubris.com/po...QVd45WQ11l3aW6f8LuvljtSiM2b0T3dCK8YSuUfmMgXJQ

addresses the failure of the media, and the British press in particular, to objectively cover the issues relating chronic illness and ME/CFS in particular.

Though some general readers may dismiss this article as sensationalist I do feel that Joanne Hunt is getting better in her writings on these issues and less prone to let inaccuracies slip through by overgeneralisations.

 

Before seeing the post I link to above, I was not familiar with Joanne Hunt’s Blog Healthcare Hubris which is worth having a look at, see https://www.healthcarehubris.com/blog

 

Thank you Joanne.

I also appreciate the language, in particular "(bio)psychosocial" - the bio seems to be the invisible part of invisible illness in this context. I also liked "hijacked". The bio-psycho-social model is of course trivially true. People's physical health will be partly determined by their physical and social environment, level of education and way they think about risks, prevention etc. Absolutely it was hijacked to be a psychosocial explanation for much of illness - at least the part medicine couldn't explain yet. As @rvallee says: good job everyone.

I can't recall whether I've mentioned this previously, but in hindsight one of my proudest moments in medical school was to fail the third year behavioural science component - which included, and in particular examined on, the revolutionary "new and shiny" BPS model. I had a pretty decent critical faculty according to my high school English teacher and I thought I turned in a similarly pretty decent quality essay on the subject in the final exam. Probably full of social deprivation, inequality, sexism, poor nutrition and educational opportunities - no doubt right on. Nope - fail. Had to sit an oral exam a few weeks later. This was notable as the two lecturers from the Dept of Psychological Medicine sat at one end of the room at a (literally) high table, while I, the (again literally) lowly candidate, sat on an unfeasibly low chair at the other. I'm amazed I was allowed a chair. Anyway I regurgitated the nonsense that they clearly wanted to hear and they seemed truly surprised that my now sufficient knowledge of their course content had not been better reflected in my exam script. "I was ill that day". "Ah" they said, beaming, "of course. We understand."

As far as I could tell most of the class didn't especially embrace their ideas, as most of us seemed to be there to learn about biology and how to fix the broken bits. And for those interested in psychiatry, this wasn't exactly it. As I've noted previously I also think our class was the last to be taught the following year that ME was biological. It really was a horrible shock to see that (B)PS had risen to such dominance 30 years later.

 

What the BPS enthusiasts seem to miss or choose to overlook is that all illness and behaviours are biological. The question is not whether ME/CFS is biological (only a Cartesian dualist could argue otherwise) but wether there is ongoing pathophysiology which prevents recovery with psychological and behavioural therapies – the answer to which should be assumed to be yes given the overwhelming evidence that rehabilitative interventions don’t work.

The irony is that one of the biggest causes of psychological stress for people with ME/CFS is the BPS model itself – not because we are Cartesian dualists, or prejudiced against mental illness, or any of the other falsehoods that are used against us, but because the model is not true and it has resulted in patients being systematically mistreated, neglected and abused by medical professionals and society in general.