Tuesday, January 31, 2012

Looking Under The Lid - The BioPsychoSocial Model - guest blog by @margojmilne

Like many others, I've been anxiously watching what's been going on in the House of Lords with the Welfare Reform Bill. After all, it affects my future, very directly. I couldn't help but notice Lord Freud, the WRB's sponsor in the Lords, referring to a document he'd shown to "certain" of the Lords. He was using it as the justification for the Government's change from the social model of disability to the biopsychosocial model in drawing up the Bill. I wrote a post recently about the differences between those two models.

Anyway, it seemed a bit unfair to me, if they got to see it and we didn't. With the help of Twitter, I managed to get a pdf of the document in question. It's Models of Illness and Disability, by Gordon Waddell and Mansell Aylward - both from the Centre for Psychosocial and Disability Research at Cardiff University. The Centre is funded by Unum Group, whose relationship with the DWP has long been - well let's just say "interesting". A good place to start in learning more about that is here.

Now, there's certainly a lot I disagree with in the report. But it might surprise you to learn that there are things I agree with too. There's only space here for me to point out a few of the things I found, so I'm sure you won't be surprised if I concentrate on the things I disagree with!

The report starts by describing the medical and social models, and some of the limitations of each. Unfortunately, the authors seem not to have understood the social model in the first place! They describe it as applying best to those with permanent physical impairment, learning disabilities, and severe medical conditions. In fact, many people with learning difficulties and medical conditions (as well as those with mental health conditions) have argued that the social model, with its emphasis on societal barriers rather than personal experience of impairment, fails to represent their experience of disability.

The authors also, when talking about the social model, use the term "disability" interchangeably with "impairment". The social model sees impairment as an actual physical, sensory, mental or intellectual variation from the norm, and disability as the as the exclusion that arises through society failing to respond to those variations. They are not synonymous.

Waddell and Aylward then attempt to apply the social model to mental health. They have said earlier, however, that "mild to moderate" conditions often have symptoms without objective findings, which would mean there is no impairment. It's necessary to have an impairment to be disabled.

Aylward and Waddell speak constantly about "health conditions" and "healthcare". There seems to be no recognition that many people on disability benefits have disabilities (that are not also illnesses), and have no more contact with health professionals than able-bodied members of the public

They also talk about free will and personal responsibility, and point out (and this is fair enough, in my opinion) that if sick and disabled people receive benefits, they have to fulfil their side of the bargain by deciding if it is reasonable for them to return to work.The corollary is, however, that benefit decisions must be made with "understanding and compassion".

With recent decisions from Atos including finding a man in a coma fit for work, and requiring a terminally ill man with dementia to attend a "Preparing For Work" interview, it could surely be said that the government has breached this contract.

Fairness demands that rights and responsibilities work both ways, say the authors.The onus is on society to provide the necessary opportunities and support before imposing responsibilities on sick and disabled people. Well, those opportunities and support are certainly not in place as yet.

The biopsychosocial model (which I'll refer to as the BPS model from here on in) was only ever intended to deal with about 2/3 of people on ill-health benefits, with what they refer to as "common health problems" - things like mild to moderate mental health problems, musculoskeletal problems, or cardiorespiratory problems. Waddell and Aylward argue that such problems are very different from the severe medical problems and permanent impairments for which the sickness and disability system was originally designed.

A key underpinning of the BPS model is that work is good for you, and for your health. Now, I do agree (I AGREE WITH THEM ON SOMETHING!) that being out of work is bad for your health, but it's not quite as simplistic a relationship as they suggest. Just about every illness is more common the lower down the socio-economic ladder you slide, and benefit claimants are right at the bottom footing the ladder for everyone else. People working in unskilled jobs have very slightly less risk of getting the majority of conditions than benefit claimants.

The beneficial effects of returning to the job market generally outweigh the risks, say the authors, as long as there is a realistic chance of obtaining a "good" job from the perspective of promoting health and well-being, preferably locally.

In the present economic climate, even able-bodied candidates with "clean" sickness records cannot find work.What chance do we, as sick and disabled people, have? Pretty much zero.

The authors argue that medical treatment for "common health problems" focuses on symptoms rather than treating the cause. I would reject this claim. Depression, for instance, is now treated with medications that correct biochemical imbalances in the brain.

They discuss mental health problems specifically as being BPS disorders. Severe mental illness is the minority: the majority of sickness absence for mental health issues, they say, is for mild to moderate conditions like depression and anxiety. This bit made me rather angry! Having had severe depression and anxiety in the past, I can confirm it's no walk in the park..

So. Conclusions. I'm not over-impressed by the report - it's slack in its use of language, and its understanding of the preceding models it discusses.We can also see how the Government has cherry-picked from it, used the bits that serve its ideology (working is good for your health, etc) while ignoring the bits that don't suit (benefit decisions must be made with understanding and compassion, society must provide opportunities and support before imposing responsibilities on disabled people, etc). And the BPS model was only ever supposed to apply to 2/3 of "health problems" anyway, not all. Overall then, a resounding Fail, I'd say. Must try harder.

Oh - and must stop trying to apply this nonsense to the millions of distressed, vulnerable people up and down the UK who will be affected if this blancmange of a Bill goes through.

Thanks to Margo who's excellent blog can be found here

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