Holistic or harmful? Examining socio-structural factors in biopsychosocial model of chronic illness,‘MUS’& disability, 2022, Hunt

Yea I feel like this must be the case.

 

I see the UK story in fairly simple terms.

The Labour Government came in in 1997. In need of a new structural model for health and social care Engel's model (at that stage void of neoliberal taint) and promoted by Mansel Aylward a doctor and medical academic with philosophical roots that had strong appeal to the then Labour administration, was readily adopted as the basis for a new deal on health and welfare.

Subsequent increased spending on health and welfare saw the biopsychosocial model have a low key but important philosophical impact on the contract between citizen and state. It might be argued that approval of the BPS model within Government gave encouragement to medical academics - Wessely et al- to develop their 'offer' within the NHS, but there's little evidence of them having much notable political or media influence pre 2010.

The stock market crash of 2008 and subsequent change of Government, saw the expansionist spending on health and welfare by the Blaire and Brown Governments replaced by austerity economics, at which point the operative philosophy of health and welfare services (loosely a socialised BPS approached) had to change or be replaced. In fact all that happened was that the already in Government Lord Freud simply changed the existing BPS focus toward one that worked for, rather than against, austerity.

The PACE trial had the right branding for Freud's Dept' of Work and Pensions to get involved by dint of which ME was tied up with austerity BPS. Whether one wants to label that neoliberal is a matter of choice, but to my view it's all a bit happenstance. And Wessely, Sharp et al just the usual academic "choose a horse and run with it".

 

I think things may be even simpler. From my perspective from inside a rheumatology unit that took an interest in chronic pain and fatigue and psychological input the current situation is just an extension of a pattern of practice in place in 1985 at least.

Much as I think that the BPS gurus have tried to take over the intellectual high ground of the trial literature (and now failed) in terms of patient care I think they have simply provided the 'yes-men' to a system that found it convenient to brush tricky problems under a carpet of pseudomultidisciplinarydogooding. There was nothing very new in that either. In 1945 the problem was a mass of de-mobbed and injured men with insoluble problems due to war that was addressed with the original 'rehabilitation centres'. The psychology input increased greatly around 1980, with a huge increase in psychology graduates wanting jobs. But unproven physical jerks therapy had been going for yonks.

 

Thank you Joseafina and welcome.

On the contrary, from my perspective, it has EVERYTHING to do with Politics & politicians- who are all branded with the same brush I would suggest!

At this time I was heavily into the DWP changes & the Harrington Review.

I know Alan Johnson under Labour started the rot...... and the 'fiddling of the figures" about benefits to change.....

I was informed of this by a researcher at York University who was involved.......

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6255230/

Br J Gen Pract. 2018 Dec; 68(677): 579.
doi: 10.3399/bjgp18X700001
PMCID: PMC6255230
PMID: 30498148

Psychological tyranny prescribed by the DWP: preventable harm is government policy
Mo Stewart, Independent Disability Studies Researcher
Author information Copyright and License information Disclaimer
Go to:
GP’S OPINION OF PEOPLE’S SICKNESS NOW RENDERED MEANINGLESS
Influenced by corporate America, the commonly labelled ‘welfare reforms’ began in July 2006 with the introduction of the Welfare Reform Bill by the New Labour government
[...]
Guided by the 2001 Malingering and Illness Deception Conference, there is a strong ideological resistance within the DWP as to the reality of the lives of chronically ill and disabled people who are not in paid employment. Influenced by the American corporate giant Unum (Provident) Insurance since 1992,7 future social welfare policies would create fear within the disabled community, with an NHS report advising that 50% of ESA claimants had attempted suicide at some point.8 The Waddell and Aylward BPS model of assessment disregards diagnosis, prognosis, past medical history and prescribed medicines. So does the WCA.

Thread on this here:
UK: Psychological tyranny prescribed by the DWP: preventable harm is government policy

 

Seems mostly to be the orphan and the siloes. No specialty wants it, and that's how the system is built. There is no plan B for this system, if no one wants it, no one is responsible.

The bigger question is why they wanted it in the first place. Given the history of medicine, it was a given that if any specialty took ownership, the rest of the profession would be happy about it, knowing it's actually being handled.

The issue is obviously over responsibility. People shouldn't be expected to go outside of their expected day-to-day work. Since no one is responsible for it, it simply leaves nothing. There's nothing surprising about disastrous outcomes when no one is responsible, no one has any real obligations, and there is a widespread attitude that it's a waste of time. Nothing can work in those conditions, it's failure by design.

 

I wrote a blog on this many years ago. Nobody takes into account the total impact across all domains. Government should but nearly always does not. Every part of the system that is tracked, such as disability payments by insurers, or health care costs, can be changed to show improvement on their own measures while the total system is getting worse. Optimization to localized criteria needs oversight. There is almost never oversight.

 

You only have to ask why the DWP was a part funder of the PACE trial. BPS is pursued by rhetoric and influence, and not facts and sound argument. In other words is a medical political process.

 

I've been on the verge of posting something along these liens a few times.
When I were a lad, going to tech of an evening, during the "troubles" here (Northern Ireland), we briefly had a teacher who may have been trying to teach philosophy or some such. We were there to learn chemistry (at a very basic level) and a little physics---. So these types of teachers weren't really going to get the audience they needed but the £/hr must have been enough. Anyway, I think I recall this teacher suggesting that unknowns were put down to God/divine --- once they were understood, then God/divine were no longer needed to explain that.
Anyway, since ME/CFS hasn't (to our knowledge) got some autoantibodies disrupting the system, or some such, no one can really help and many just back away. Voilà the psychologists move in, functional disorder ---- whatever. Jonathan pointed out, in his expert testimony to NICE, that since the psychological therapies don't work --- well it's not psychological.

Really these folks should have run PACE etc. in a manner that proved CBT, GET --- worked or didn't. Voilà, when the found out it didn't, they should have---- taken themselves off.
Those in charge of public money should e.g. have looked at snow leopard's suggestion --- just give the money to the patients --- let them figure out how to improve the quality of their lives.

I think GWAS, actimetry studies --- potentially provide a way to understand and treat ME/CFS; as for those who have, on the basis of the available evidence, nothing to offer, and who hoover up the available funding, they should go do something useful/else.

 

I wonder why social insurance agencies around the world don't fund more research frankly. If they did good research, it could be a win-win. People with disabilities don't want to sit around and be a cost to society, they want to be healthy again and work.

 

First of all I want to thank @Josefina for all the work that clearly went into the article, and drawing together a wide range of sources. I've still not read it all but already found interesting points to consider and references I'd like to check out. Just things like pulling together the information in the appendixes is useful for helping other people easily access the original documents and make their own judgements about them.

I sometimes worry that it's easy to slip into just making criticisms, and around ME/CFS where there is so much uncertainty and people will be starting from different perspectives it's always going to be easy to point out the things we disagree with. I know that when I'm reading something I'm most likely to pull out something that I disagree with. It's hard to stop myself.

re "psychopathologies" in the abstract - I can see potential problems with that term. Would replacing it with something like 'distortions of thought', 'unwarranted assumptions', 'psychology and biases' etc be better?

I'm a bit run down to get far with it right now but just started looking at the paper.

The paper does make a few contestable claims quite quickly - this makes the author's position quite clear, but could be off-putting to some. Others will appreciate the brevity.

The first reference to 'neoliberal' did stick out to me, but I don't think I read the earlier Hunt piece it refers to:

"According to this dominant narrative, which is couched in neoliberal assumptions (see Hunt, 2022a), people with MUS
perpetuate their ill-health through unhelpful cognitions and fear-avoidance (Wessely et al., 1989; Knoop et al., 2010)."

I feel like this new piece could be difficult to follow without having read the earlier work?

I liked a lot of the discussion of 'the' biopsychosocial model, and there were definitely references there I'd like to follow up on, but I wasn't sure if I was missing out on understanding some of the language, eg: "critically informed socio-structural factors". Google did not provide a clear definition either. For me, terms like that can be a bit confusing, and make the paper difficult to read.

Maybe this paper is more written for those who think of themselves as 'critical psychologists'? This is a group that I don't know a lot about, though I've thought should be more sympathetic to our concerns than they often are. At the same time, even if their claimed values can sound good, in practice they seem a fairly mixed bag - some of them seem ideologically driven in a way that sometimes goes against the evidence imo.

If @Josefina could let us know more about the intended audience it might help us understand more about how the paper is best read? Also, how useful do you think it would it be if people here try to offer feedback on the pre-print? If you know you're writing for a certain academic audience, that uses language in a particular way, comments from us might be less useful than if you're keener to try to get something to be read by as wide a range of people as possible. It seems like you've drawn together ideas from some a wide range of sources that I suspect it will be difficult for anyone to have done the background reading needed to engage with a lot of your points in the way that we could do if, for example, you were just focusing on PACE. It could be because of my lack of familiarity with much of the the work you're citing, but I found the range of points being made could sometimes get in the way of the flow of argument. Thanks again for all your work.

I can see why people are struggling with some of the language as it was a bit academic-ish. I thought that the abstract was more like this than the bits of the paper I read.

I just went through the abstract and thought I'd try to put the language in a less academic-y style to see if that seemed clearer to people here? Hopefully it will give a better sense to people of whether they want to try to read the paper itself.

I cut out some of the points that could not be explained in the abstract alone, and could distract from the main points.

 

Government systems are never optimized, but subject to the vagaries of current political trends. Those trends rarely move around to dealing with the chronically ill.

Even Australia's NDIS, our national disability scheme, has a bias toward those other than the chronically ill. Up to recently, and possibly still now, you need recent investigations and have completed CBT/GET to be likely to get it with ME. Mind you it depends on severity too, I know of one severe patient who had no trouble getting it. In any case, so far as I am aware, our NDIS does not fund research. That is not their role. Government never set it up that way.

 

There is another significant factor that is easy to overlook. I have a medical book from the late thirties and it has large sections on convalescence and good nursing as infections are seen as the most important part of disease.

Once there were antibiotics and vaccines it looked as if infections had been conquered and they were downgraded until it was always someone's fault if serious ones appeared like AIDS behaviour and Legionnaire's faulty water systems. Lifestyle choices became the cause of ill health. Nicely reassuring too because even just a few weeks ago those Norwegian TV people were confident they could never get ME. Much better than the thought every mild cold could leave you bed bound and tube fed.

So we moved to the point where illness could be viewed as a personal choice and psychology filled the vacuum. This chimed well with US ideas of personal responsibilities and the rights of individuals where there should be no state involvement.

So we had infections being conquered by modern science until there came generations who forgot what microbes could do. The idea that a viral infection could leave behind devastating consequences was not wanted while everyone found it easy to believe the mind has an amazing power over the body.

 

Why would health and benefits be anything other than politics ? Isn't saying it's politics just the same labelling exercise as using "neoliberal" a form of 'othering', distancing the thing we don't like from us, from our group, belief system, country etc ?

It's easy (I'd say facile) to characterise Prime Minister Blair as an agent of neoloberalism, less so Brown, but is it really a sound argument to say that "left school at 16, blue collar worker, lifetime Trade Unionist Alan Johnson was signed up to the same shadowy political project as privately educated, great grandson of Sigmund, Investment Banker David Freud ?

So rather than just shoving it all off onto the 'evil other', I think there are challenging questions to face such as why in the early 2000s the UK Labour Party was comfortable to entertain a perspective ultimately provided by Waddel and Aylward in Models of Sickness & Disability ? I don't think it's necessary to invoke neoliberal capture of the UK Labour Party to get some meaningful answers to that question.

Labour, certainly prior to losing power in 2010 had a poorly developed model of who and what a citizen was - essentially the Government provided services and opportunities, Health was provided to all, Education was provided to the 'workers to be', the opportunity for work was provided to 'workers' and pensions were provided to the 'workers who had been'. In that context ill health and disability were problems to be fitted into the three established patterns of workerhood.

Rehabilitation was a vital concept in resolving where the sick and disabled fit in the conception of citizen as worker - work could be made to fit the needs of sick and disabled people (adaptations etc) and sick and disabled people would be reprocessed as 'workers to be' via training and education. Those not able to be rehabilitated would by default become part of the 'workers who had been', notably the earliest comprehensive disability benefit was call a 'Sickness Pension'. Clearly this is all rather reductive for those whose citizenship is defined by being 'not a worker' but there was considerable post war consensus around this approach until the breakdown of the UK's industrial model in the 1970s.

Government (Conservative) economic policies of the 1980s saw major job losses and it became a deliberate policy to use sickness benefits as a way to massage unemployment figures, ultimately leading to a loss of public confidence in the system of sickness benefits and vocal demands for change; albeit demands which perversely denigrated sick and disabled people, not the system or its misuse by Government. The demands for change, and the practicalities of funding the system were still there on the election of a new Government in 1997 and one doesn't need to look outside the UK electorate or the political movement that supported that Government to see what was being demanded or the type of direction that was favoured.

The one notable departure from 1997 perhaps was the making explicit the notion of 'work' as a moral good.

 

Maybe of relevance to some of the discussion here: a subreddit for neo-liberals had a brief discussion on the new NYmag piece on Long Covid and ME/CFS -

One thing with a lot of ideologies is that the people who wield power in its name are often the worst of the lot. Which I guess is one of the observations that can encourage people to follow a form of neo-liberalism.

 

It's very mixed, a little over half of commenters leaning towards biological and the rest towards psychological. Insightful excerpts from the biomedical comments:
A reply to a comment discussing how pwME are angry at BPS ideology:

The most insightful one recognizes both the biological nature of ME/LC and the lack of biomedical leads:

And people who little but are open-minded:

 

So the neoliberal sub is actually more rational and less conspiratorial about this than the medicine sub? lmao