Summary: Structural dimensions of the biopsychosocial model
Following feedback, I have written a summary of the series of four blogposts looking at structural (essentially, socio-political) dimensions of the biopsychosocial (BPS) model.
The full series of blogposts can be found here:
Peer-reviewed published literature has demonstrated how the BPS model is applied and impacts on patients on the level of healthcare encounters (what we might term ‘micro’ level) and also on the level of healthcare policy (what we might term ‘meso’ levels).
However, very little research has been published looking at the BPS model on a structural level. Structural is this sense refers to macro level (national and global) economic policies, corporate interests, legislation and associated institutions. In particular, the UK government’s welfare reform agenda and the associated interests of the academic-state-corporate nexus (Jonathan Rutherford’s term) are largely absent (at time of writing) from peer-reviewed journals.
Tom Shakespeare et al.’s work present a notable exception in peer-reviewed literature, whilst Mo Stewart has perhaps written more than any other researcher in this area. Disability scholars and activists such as the late Debbie Jolly (co-founder of DPAC) and George Berger have also done much to highlight the socio-political underpinnings of the BPS model. Another great resource is the Centre for Welfare Reform which has published a number of reports in this field.
This particular series of blogposts was an attempt to pull together information from various sources into a relatively succinct and coherent account of the socio-political and structural dimensions of the BPS model and the impact of this model and associated interests on chronically ill and disabled people. It focuses on myalgic encephalomyelitis / chronic fatigue syndrome (ME/CFS) as an example of broader chronic illness and disability matters. With the emergence of long Covid, and a strong possibility of a tidal wave of chronic illness and disability, the political underbelly of the BPS model should be of concern to everybody. This, particularly as it is evident that those complicit in the psychologisation, and thus medical neglect, of ME/CFS have now set their sights on long Covid.
Political underpinnings of the BPS model
Whilst the BPS model is typically associated with the thinking of George Engel, many disability scholars and disabled people have highlighted that the model has much to do with the work of certain academics at Cardiff University within a broader context of government welfare reforms and health insurance industry profiteering. The term ‘academic-state-corporate nexus’ therefore represents the main players in this network of interests.
Professor Sir Mansel Aylward and the late Professor Gordon Waddell, both medics and academics, were key architects of the BPS model as it is applied within health and social policy. Waddell had an interest in back pain which he appeared to believe was a primarily psychosocial phenomenon and had previously promoted graduated exercise for recovery. Aylward had enjoyed a distinguished career at the UK Department of Work and Pensions (DWP) as Chief Medical Advisor, Medical Director and Chief Scientist, and had been involved in developing more stringent benefits assessments. Aylward had also been involved in Atos, a company which was for some time contracted by the DWP to manage disability and fitness to work assessments. Both men became involved in the Centre for Psychosocial Research at Cardiff University, established in 2004, where Aylward served as director and Waddell as honorary professor. The centre was sponsored for some years by Unum Provident, a US health insurance giant, which has a well-established history of being a financially and morally corrupt, disability denying corporation on both sides of the Atlantic. Unum also has a well-established association with the UK government reaching back to at least the 1990s, providing consultancy for welfare reform. The research produced by the Cardiff centre, some of which was commissioned by the DWP, provided an academic framework for the UK government’s welfare reforms and also helped reinforce a reform of health insurance policy towards disabled people.
These ‘reforms' arose from common state and corporate interests. The government and health insurance industry were both concerned over the rising cost of supporting chronically ill and disabled people in the form of social security benefits and health insurance pay-outs respectively. These interests and concerns can be positioned within the broader context of neoliberal policies and austerity management approaches of OECD countries, where disabled and chronically ill people have been targeted.
A healthcare or social policy model that appeared to provide a scientific basis for reducing welfare expenditure and maximising corporate profits was indubitably a politically and economically attractive prospect. Specifically, conditions that could be framed as psychological or psychosocial in nature, and thus amenable to psychosocial interventions, could be exempted from welfare provision and health insurance pay-outs. To do this whilst maintaining a façade of ethics, the interventions would have to be demonstrated as being evidence-based. This façade was achieved through a particular application of the BPS model, as it applies to ME/CFS and to chronic illness and disability more broadly.
Constructs and propaganda
Waddell and Aylward’s work uses the BPS model to target ‘common health problems’. These are mental health, musculoskeletal and cardio-respiratory conditions that are considered “subjective health complaints” (see here and here). Papers produced by the Cardiff centre clarify that ‘common health problems’ are another term for ‘medically unexplained symptoms’ (MUS) or ‘functional somatic syndromes’, that are considered to lack detectable pathology. (However, in practice, some patients with such conditions are not investigated beyond routine bloods, which means that biological pathology cannot be ruled out). The Cardiff academics cite the work of certain BPS proponents in the field of ME/CFS, notably Sir Prof Simon Wessely who is well known for his belief that ME/CFS is a psychosocial phenomenon. It is noteworthy that ‘chronic fatigue syndrome’ is mentioned in the Cardiff centre’s work within the context of these common health problems, under the rubric of mental health.
Waddell and Aylward argue that workers’ compensation and social security benefits were originally designed for people with “severe medical conditions and permanent impairment”, conditions associated with detectable pathology. In contrast, they frame common health problems as being something similar to what most adults of working age experience at times. Given that ME/CFS has been associated with a lower health-related quality of life and/or greater functional impairment than (for example) various cancers, multiple sclerosis, chronic renal failure and stroke (see here and here), comparing such conditions to something that most people experience at times is both inaccurate and highly minimising. This distinction also serves to create a hierarchy of disability: ‘serious medical conditions’ (worthy of welfare support and biomedical healthcare) and ‘common health problems’ (unworthy of such). Such in-group out-group dynamics facilitate stigma and may add to burden of illness.
Waddell and Aylward’s narrative around common health problems can be observed in BPS proponents’ framing of ME/CFS, hardly surprising given that the models are one and the same. Psychological factors are claimed to perpetuate disability in ME/CFS, notably negative thinking around the illness and reduction of activity. Effort and motivation are expected to lead to recovery, notably through graded exercise and cognitive behavioural therapy. Social factors such as receipt of benefits, sympathetic physicians or family members and support groups (especially support groups which do not agree with the BPS model) are considered to present barriers to recovery. These barriers are often understood as ‘secondary gains’; it is suggested that patients are somehow invested (largely unconsciously) in remaining ill in order to gain attention or financial benefit, avoid work and/or family obligations.
A shocking aspect of the BPS model is the lack of empirical underpinning and theoretical coherency (see here and here for critiques). Conflating correlation with cause (and always interpreting the direction of causality to suit pet theories) is a feature of both the Cardiff centre’s work and that of BPS proponents of ME/CFS. Self-referencing, mis-referencing and selective referencing to aid weak arguments is also not uncommon. Strategic use of language is apparent both in the writings of the Cardiff academics and usual suspects in the psychologisation of ME/CFS. ‘Disability’ takes on a whole new meaning, essentially to refer to something that a disabled person chooses or creates with social and financial reinforcement. However, when key actors in this game want to defend their positions or deflect from criticism, they will profess to believe that patients are genuinely disabled. Similarly, strategic conflation can be evidenced around the use of ME, CFS and ME/CFS. Such use of terminology is intentionally confusing and may raise issues with validity and replicability in research. Creating such ambiguity also helps to deflect from an underpinning lack of evidence-base. Whilst empirically unsubstantiated BPS theorising in the realm of MUS has hijacked healthcare policy, it would appear that social policy fares no better: scholars have argued that levels of benefit fraud have been over-exaggerated to serve the government’s agenda of welfare cuts.
An exceedingly tangled web of connections exists between the Cardiff academics and key proponents of the BPS conceptualisation of ME/CFS, along with their government and health insurance industry associations. This power complex is arguably strengthened through biases within the media, research funding bodies and academic publishing – all areas where certain BPS proponents of ME/CFS have influence.
The oft-named Woodstock conference, held in Oxford in 2001 on the subject of “malingering and illness deception”, is a prime example of the academic-state-corporate nexus, although by no means the only example, and associations existed between many of the attendees long before 2001.
Significant Woodstock attendees included Waddell and Aylward (Aylward was then medical advisor to the DWP), Prof Peter Halligan (who went on to become associate director at the Unum Psychosocial Research Centre), Prof Derick Wade (of the Oxford centre for Enablement and author of various papers on the BPS model, notably with Halligan). Prof Sir Simon Wessely, Profs Michael Sharpe and Peter White - all with a special interest in ‘chronic fatigue syndrome’ as they like to call it – were also present. Malcolm Wicks (then, Parliamentary Under Secretary of State for Work) attended, along with Dr John LoCascio (then, Unum’s second vice-president and medical director at Unum who had also been drafted into the UK government to provide consultancy on welfare reform). ‘Wessely School’ psychiatrists Profs Christopher Bass and Anthony David were also present. The meeting was funded by the DWP and its purpose has been summed up by Jonathan Rutherford as none other than “the transformation of the welfare system”. Essentially, the nexus needed to work out how to frame chronically ill and disabled people as morally void scroungers and malingerers with no insight into their own health conditions, so that benefits and insurance pay-outs could be denied, all whilst claiming to be working in best interests of these communities and following the science.
The Woodstock conference also spawned a book, also entitled ‘Illness Deception and Malingering’, co-edited by Halligan with chapters authored by, amongst others, Sharpe, Wessely, Aylward and LoCascio. The publication also acknowledges the contributions of other Woodstock attendees including Wade, White and Waddell. The nexus can also be observed in DWP commissioned and Unum sponsored monoliths that originated from the Cardiff centre, notably ‘The Scientific and Conceptual Basis of Incapacity Benefits’ which essentially laid down the protocol for the 2006 welfare reform bill. This monolith draws on the work of a number of the usual suspects, with Halligan, Wade, Wessely and White featuring amongst those given special acknowledgement.
It is fair to suggest that ME/CFS would have been high on the agenda during the Woodstock conference. Prior to Woodstock, a narrative around ME/CFS as a psychosocial entity amenable to CBT and GET was being constructed by psychiatrists with an interest in ME/CFS, in some cases in collaboration with actors within the DWP, including Aylward. Unum had also singled out ME/CFS, which it referred to as a “new banner for neurosis”, as a target for aggressive claims policy management. That is, Unum wanted to target illnesses that could be re-framed as psychosocial entities, which meant exemption from insurance pay-outs and a boost in their profits, and ME/CFS was first in line. Literature from various players within the academic-state-corporate nexus demonstrates that saving money – and making money – was a prime driving force in the denial of disability and attendant reforms within state welfare provision and health insurance policy.
The extent of the tangled web of academic, government and health insurance industry links is such that an entire book could be written on them. Mansel Aylward appears to have been heavily involved in all aspects of the nexus (see here and here), and his move from the DWP to directorship of a research centre sponsored by an ethically corrupt health insurance company is particularly questionable. Whilst Aylward was at the DWP (or DSS as it was then), he had been in communication with Wessely and White who appeared anxious to convince Aylward that ME/CFS should not be considered a permanent disability, but rather something that might be amenable their favoured interventions of CBT and GET. White is known to have provided consultancy for the UK DWP and Department of Health and Social Care along these same lines. Further, certain BPS academics, notably in the field of ME/CFS, are known for providing consultancy across a vast array of health insurance companies on the alleged nature of ME/CFS and how it is purportedly amenable to the psychosocial interventions they have helped to develop. Prime examples include White’s long-standing association with Swiss Re (reinsurance) and Sharpe’s association with Unum and Allied Dunbar.
These consultancy links were spectacularly played down when White led a research team on the PACE trial, part funded by the DWP with Aylward’s assistance, with Wessely and Aylward on the Trial Management Group and Trial Steering Committee respectively. Sharpe was a principal investigator along with Prof Trudie Chalder, who has also done consultancy work for insurance companies. Despite the PACE trial being internationally debunked, and despite NICE assessing the quality of evidence for GET and CBT in managing ME/CFS as low and very low, BPS proponents are acting like nothing ever happened. This is facilitated by comrades in high places within academic publishing (Richard Horton of The Lancet being a case in point) and not infrequently biased peer review processes. BPS hegemony persists, now with a threat of long Covid being annexed.
Impact of biopsychosocial corruption on health and social policy
Academics associated with this nexus have worked at all levels within the healthcare system. Beyond their work for the government and health insurance companies, certain academics have served as clinicians and clinical researchers as well as NHS advisors, contributors to clinical guidelines, clinical handbooks and GP training packages. These influential BPS proponents also helped to develop a case definition of ME/CFS (or CFS as they like to call it) – Oxford Criteria – that is so broad it risks selecting otherwise healthy individuals who present with the symptom of chronic fatigue or people with primary psychological conditions. Many of these academics and associates are prolific publishers in well-respected scientific and professional journals (journals whose editorial boards not infrequently include BPS proponents), including the British Medical Journal (BMJ), which arguably informs as well as represents medical opinion. The BMJ has historically appeared content to publish highly stigmatising pieces about people with ME/CFS (see here and here) and, it would appear, any illness that is poorly understood, poorly delineated and/or poorly treated.
Similarly, the health insurance industry’s influence (notably that of Unum) can be understood as pervading all levels of the healthcare and social security system. Unum stated that it promotes a “non-medical, enabling model of rehabilitation”: non-medical here means psychosocial, and rehabilitation refers to interventions such as GET and CBT. Accordingly, the Cardiff research centre was involved in GP education and revision of sick certification (move from sick note to fit note), encouraging GPs to push chronically ill and disabled patients back into work whether they were able to or not. Conditionality was also promoted - that receipt of benefits should only be a possibility once the patient underwent ‘rehabilitative’ interventions – raising issues around informed consent and coercion. In fact, patient survey data shows that some ME/CFS patients have felt coerced into undertaking CBT and GET, in some cases resulting in harm, and apparently in some cases associated with such conditionality. Nevertheless, Unum documentation shows that the company hoped to produce a significant shift in healthcare practice. This hope appeared to be partly realised in the 2007 NICE guidelines on ME/CFS, which recommended CBT and GET as primary 'treatments' and which cite some of the Cardiff centre’s work amongst its sources.
The interests of the academic-state-corporate nexus have been furthered by much of the UK press, who have historically (with a few exceptions) treated people with chronic illness and disability, in particular people with ME/CFS, very poorly. The dominant media narrative of ME/CFS appears to be one of a psychosocial entity with not infrequent suggestion of malingering, with ME/CFS advocacy framed as anti-psychiatry and extremist. Unsurprisingly, some of the academics in the academic-state-corporate nexus have associations with the Science Media Centre (SMC), which exists to provide the UK media with science and health-related news briefings and interviews. It has been suggested that editors of UK broadsheets are permitted only to publish items about ME/CFS that originate from the SMC. It is also notable that discussion of the academic-state-corporate nexus within the broader context of disability and welfare reform is absent from mainstream media discussion. (The Disability News Service is to my knowledge the only exception here).
The impact of an unaccommodating, if not downright hostile, health and social system on chronically ill and disabled people can be observed in patient survey data and qualitative research. In the case of ME/CFS, patients have suggested that fights with the benefits system adds to the burden of living with ME/CFS. Broader disability research indicates that disabled and chronically ill people feel dehumanised through the benefit system and that stresses of navigating this system impacts negatively across all life domains. Healthcare experiences of people with ME/CFS (both from the perspective of patients and clinicians) have been well-documented: clear cases of negative stereotyping and stigma on the part of clinicians have been demonstrated, with concordant felt stigma and associated distress on the side of patients. Families of children with ME/CFS who object to inappropriate and even harmful 'healthcare' have in some cases been accused of child abuse and neglect, with risk of having their children forcibly removed and taken into psychiatric care. There are also cases of adults with ME/CFS who are forcibly admitted to psychiatric care under the Mental Health Act, resulting in coercive ‘treatment’.
Most disturbing are apparent increasing deaths amongst chronically ill and disabled people which may well be related to the inadequacy and hostility of the health and social security system. UK welfare reform has coincided with reports of concerningly high death, attempted and actual suicide rates amongst disabled people, alongside reports of increased psychological distress (see here, here and here). Various studies have suggested an increased suicide rate amongst people with ME/CFS compared to the general population and recent research suggests that suicidality amongst people with ME/CFS might be at least in part related to systemic failures within healthcare. It is as yet unclear how the medical profession and broader scientific and political structures will frame long Covid; however, some sub-groups which lack specific and detectable organ impairment are clearly susceptible to psychologization and politicization, and there are signs that this is already happening (see here, here, here, and here).
The neglect of patients with such high clinical need, and the ostracization of people who require substantial social accommodations, may seem literally incredible to those who do not have first-hand experience of the abuses occurring within our health and social systems. These abuses amount to human rights violations, and I think that many of them can be explained through understanding the structural dimensions of the BPS model, and the incredibly powerful complex of interests that can be defined as the academic-state-corporate nexus.