Sep 242014
 
by George Berger

 

This is a conceptual history and critique of the methods used in the United Kingdom to assess persons who are ill and in need of financial, moral and social support. I critique their foundations, as they have led to a system that claims to be evidence-based but is scientifically and philosophically so misguided that much harm to ill people has resulted.

Disabled people are at high risk for harm, as the complete assessment regime is perfectly suited to adversely affect them. A good way to see this is to begin with four statements that typify successive stages in the institutionalisation of the methods. I was surprised to find that one physician, Gordon Waddell, started this decline of scientific, philosophical, moral and political integrity.

Waddell could have avoided this by 1998 but he did not. Instead, he and his ideas became parts of the Establishment’s effort to destroy the Welfare State. An American Insurer, UNUM, helped out. I omit some interesting developments, especially the international assault on psychodynamics by behaviourists like Hans Eysenck in the UK and the American philosopher Adolf Grunbaum. Behaviorism prospered politically even after scholars, e.g. Noam Chomsky, successfully destroyed it.

1. “a medical model must also take into account the patient, the social context in which he lives, and the complementary system devised by society to deal with the disruptive effects of illness, that is, the physician’s role and the health care system. This requires a biopsychosocial model.” (George L. Engel, ‘The Need for a new Medical Model: A Challenge for Biomedicine.’ Science, 8 April 1977, Volume 196, Number 4286).

2a “Chronic low back pain disability can only develop with family and financial Support.”

2b “Depending on how you look at it, disability is illness behaviour, and illness behavior is disability).

(Gordon Waddell, The Back Pain Revolution, first edition 1998, pp. 227, 170).

3 “You now have targets – we didn’t. You are audited – we didn’t know what that meant. Somebody looked at our work and we worked well, but we didn’t know what the standard was or whether we were achieving it” (Professor Mansel Aylward, Atos Origin Rapport, Conference Special, July 2004).

These highlight today’s ideology of treating work (labour) as necessary to social and personal well-being, in Northern Europe and America. They display aspects of one policy that is used to enforce and justify cruel work incentives and cuts to individuals’ benefits. The basic principle is to ignore physiological problems as much as possible, by replacing them with simple observable behavioural traits whose presence are claimed to show that one can work, even when in pain, distress and medical danger. I am no social scientist, but enough of a philosopher of science to explain what has happened. The political, economic and historical background has been wonderfully treated elsewhere [1].

George Engel proposed influential ideas of treatment and healing. They derive from the holistic approach of general systems theory that was popular in the USA between, roughly, 1950 and 1980. They explored the relations of internal parts of complex physical systems to each other and to the environment in which such systems exist. Only this totality could explain the functions and dysfunctions of a system. In medicine, this was Engel’s biopsychosocial model, an extension of Claude Bernard’s idea of the ‘internal milieu’ of a living organism. It is well meant, humane, but utopian by today’s standards. A healer (or staff) trained in social, psychological and biomedical studies would be needed to implement it (see 1). It would certainly be expensive. Moreover, societal barriers to proper treatment and a patient’s good life would have to be removed. it combines some counter-cultural, philosophical and strictly scientific ideas that appealed to many, in the ‘golden age’ between 1950 and 1979.

Gordon Waddell is one of the world’s most respected orthopaedic surgeons, a status he used to gain political influence on health policy by perverting Professor Engel’s humanistic model into a tool for depriving ill people of their institutional and financial support. In 1980 he was the head author of the influential paper, ‘Nonorganic Physical Signs in Low-Back Pain’ (Spine, volume 5, number 7, 117-125). It described five bodily ‘signs’ associated with back pain (e.g. reported local skin tenderness) that, it was claimed, are ‘nonorganic, psychological, and social elements that are difficult for the busy clinician to assess,’ and that ‘appeared to have a predominantly nonorganic basis [italics in text].’ These ‘nonorganic physical signs…appear to be completely independent of the conventional symptoms and signs of pathologic conditions of the spine.’ Waddell et al. stated that they were known before they wrote, that they are ‘correlated with failure to return to work,’ and that they might well be ‘more common in “problem patients”.’ The writers used case studies to assert that ‘associated psychological symptoms and social features are usually present to confirm nonorganic physical signs.’ ‘Waddell’s Signs’ are often used to ascribe malingering to benefit claimants. Although Waddell waffles here, his methodology is simply wrong: a bodily state that has no detectable organic causes today can have them tomorrow, if science advances suitably. This obvious point undermines the theory of nonorganic signs.

Dr Waddell used this false theory in 1987, in his ‘A New Clinical Model for the Treatment of Low-Back Pain’ (Spine, volume12 number 7, 632-644), to distinguish acute and chronic pain, physical impairment, personal and social attitudes towards pain and pained persons, and disability. He argued that a sufferer’s ‘perception and interpretation of the significance of the symptoms’ influenced treatment and disability decisions. Indeed, ‘chronic pain and disability become increasingly associated with emotional distress, depression, failed treatment, and adoption of a sick role.’ ‘Chronic pain progressively becomes a self-sustaining condition that is resistant to traditional medical management.’ (My italics.) In ordinary language, Waddell claims that chronic back pain is at least partly a result of a patient’s false beliefs about pain, and a conscious or unconscious adoption of a social role that he/she views as advantageous. He combines these ideas in a perversion of Engel’s model. It reduces the complex unity of biological, psychological and social factors to a person’s ‘illness bahaviour’ in an adopted ‘sick role,’ by citing a 1984 article’s clinical definition of illness behaviour as ‘observable and potentially measurable actions and conduct which express and communicate the individual’s own perception of disturbed health’ (my italics). As Waddell co-authored that article, the definition is merely a restatement of his own idea; its behaviourist-reductionist theme is no feature of Dr Engel’s model and is a travesty of it. I’ll call Waddell’s non-biological, non-social, individualist construct, the BPS model. It is crucial to notice this illicit transformation of a good idea into one whose behaviouristic foundation was rejected for good reasons by philosophers and scientists more than 12 years before this paper was published (see Noam Chomsky’s review of B.F. Skinner’s ‘verbal behavior’ and Ulrich Neisser’s ‘Cognitive Psychology,’ both published before 1970). 2a and 2b show how Waddell distorted Engel’s notions into one barely supported statement and one mere definition. It is quite possible that these ground the non-biological, non-social ‘descriptor’ approach to disability assessments used by UNUM and Atos, developed and applied under contracts with two British governments (Labour and Tory) starting in 1998. If so, then Waddell was either scientifically, methodologically and philosophically ignorant, or was out to set up an assessment programme based on ideas he knew were highly controversial. The transparent falsity of his nonorganic sign system destroys the ‘self-sustaining’ claim, since physiological causes that maintain a condition cannot be excluded. Briefly, his fundamental ideas are scientifically baseless and morally dangerous by normal professional-ethical standards of research and clinical use. Nothing he has written warrants the extreme claims in The Back Pain Revolution, that illness behaviour quite often ‘focuses on money and implies malingering,’ and that it ‘may depend more on… psychologic events than on the underlying physical problem’ (1998: 216, 227). The pseudoscientific BPS model encourages dangerous medical practices and inadequate assessments, since it cannot estimate biological and social contributions to illness [2].

Waddell published a second edition of his book in 2004. In July 2004 Atos Origin (Atos, since 2011) published ‘Looking at the Big Picture,’ a report of a special conference. One of Waddell’s closest associates, Professor Chris Main of Manchester, described the back pain work, stressing psychology. Another, Dr Christopher Bass, applied BPS to ‘Symptoms that defy explanation’ linked to ‘sickness absence.’ He singled out chronic fatigue syndrome, fibromyalgia, chronic low-back pain, repetitive strain injury and non-cardiac chest pain, as conditions having non-organic (read: psychological) maintaining factors, i.e. Waddell’s self-sustaining processes. Professor Mansel Aylward talked about his use of BPS in his work at Cardiff University between 1985 and 2004 (quote 3). In 1989 he became Senior Medical Officer of the British government. The report notes that Aylward ‘worked closely with [Atos Origin’s] Medical Services’ on ‘LIMA, An intelligent evidence-based electronic report writing programme for Incapacity Benefit’. I’ll add that SchlumbergerSema, a firm acquired by Atos Origin in 2004, developed the first version of LIMA in August 2003. It seems that Aylward helped extend it to a second version by October 2004. Version 2’s technical manual was owned by the ‘Medical Director for DWP [Department for Work and Pensions],’ Dr Andrew Cohen. LIMA software embodies Waddell’s BPS in its ‘descriptors,’ categories that describe a person’s behavioural fitness for types of work. All biological and social influences on a person’s health have vanished; a technological corruption of Engel’s ideas whilst using his term ‘biopsychosocial.’ Waddell’s work led to this scientific and medical disgrace.

To close, note that 2001 through 2006 were critical years. In this period the American insurance company UnumProvident’s John LoCascio attended a conference near Oxford on ‘Malingering and Illness Deception,’ the UnumProvident Centre for Psychosocial and Disability Research was set up at Cardiff University, Waddell joined it as a surgeon turned academic, and Aylward became its Director. Its publications and related texts officially established Waddell’s BPS, used it to tragically describe disability as at least partly dependent on an individual’s psychological attitudes, beliefs and personal choice in a social context, and proposed linguistic changes and punitive action to enforce behavioural change leading either to work or minimal (if any) social security. LIMA was developed to do this, as described above. In 2006 Gordon Waddell and A. Kim Burton announced (with provisos neglected in practice) that ‘[W]ork is generally good for health and well-being.’ This completed the harmful and scientifically irresponsible application of Waddell’s misappropriation of Engel, via LIMA’s descriptors, to the illnesses mentioned above. Since these supposedly lacked organic symptoms caused by bodily dysfunctions, a new version of Waddell’s nonorganic signs emerged, which aided claim denials by insurers (esp. UNUM) and governments. Current biological research is finding increasingly more evidence of such causes. Waddell’s pseudoscience started cruel political developments that led to Atos’ notorious disability assessments. Given today’s evidence, any BPS assessment regime like the WCA should be stopped at once [3].

[1] See Jonathan Rutherford’s ‘New Labour, the market state, and the end of welfare’ in Soundings, available at http://www.midmoors.co.uk/Unum/unum_in_uk.pdf, Debbie Jolly’s ‘A Tale od two Models: Disabled People vs Unum, Atos, Government and Disability Charities,’ at https://dpac.uk.net/2012/04/a-tale-of-two-models-disabled-people-vs-unum-atos-government-and-disability-charities-debbie-jolly/ , and Gil Thornton’s ‘Illness as “Deviance,” Work as Glittering Salvation and the “Psyching-up” of the Medical Model: Strategies for Getting The Sick “Back To Work”, ’ at http://internationalgreensocialist.wordpress.com/illness-as-deviance-work-as-glittering-salvation-and-the-psyching-up-of-the-medical-model-strategies-for-getting-the-sick-back-to-work/ .

[2] My philosophical remarks derive from the Scientific Realism of the late Wilfrid Sellars and his followers, especially my deceased good friend Jay Rosenberg, Jeff Sicha, Jim O’Shea and Willem A. de Vries. On Sellars, see http://plato.stanford.edu/entries/sellars/ .

[3] I wish to thank Anita Bellows, Gail Ward, Debbie Jolly, Ann Whitehurst, Andy Cropper

and Karen Springer, for ideas, information and support. All of us are members or supporters of the UK’s Disabled People Against Cuts. See https://dpac.uk.net/ .

[suffusion-the-author]

[suffusion-the-author display='description']
 Posted by at 14:46

  14 Responses to “Gordon Waddell’s biopsychosocial attack on disabled people”

  1. This would explain a lot of what I have had to endure, on top of having moderate to severe ME for 25 years. In the early years of my illness, in the early 1990s, I was referred to Mental Health, completely inappropriate for a neurological illness like ME, and worse than useless. That ME has been categorized as a neurological illness by the WHO since 1969 was just ignored. I was assigned a keyworker, who was trained to treat people with depression and who had no experience or understanding of someone with my sort of problem. I was not clinically depressed, I was ill, dammit, and am still! She aggressively tried to ‘gee me up’, trying to get me to do activities that made me worse, and wouldn’t let me lay down when I needed to. I was referred on to a psychiatrist, who was convinced that a sustained high level of fluoxetine (Prozac) would cure me. When it failed to do so, I was referred to an OT nurse who was a hidebound disciple of Simon Wessely and Trudi Chalder. She was convinced that CBT would cure me. When it failed to do so, she declared that I wasn’t really ill, I just thought I was ill, and that I didn’t WANT to get better! In 1996, when the old Invalidity Benefit was changed to Incapacity Benefit with the All-Work Test, the assessor told a pack of lies about what I was tested for and what I was able to do during the All-Work Test, and my benefit was cut off cold. I had to borrow money from friends, to have anything at all. The knock-on effect on my illness made me much worse, and I had to have a friend live with me to look after me for around three weeks as I was too ill to look after myself. I had to go to tribunal to fight to have my benefits reinstated, and was made to feel like a criminal in the dock. I was faced with a panel of assessors from the DWP who included a doctor. I was not allowed to communicate directly with the doctor. In effect, I was treated like a criminal, for the crime of being chronically and incurably ill.

    I have heard of even worse things happening to other people, of children taken away from parents and put on mental health wards because both parents and children had ME and the parents were assumed to have made their children ill. Parents have been accused of having mental health conditions such as Munchausen’s by Proxy, when they had ME and had passed it on to their children who had had the misfortune to inherit it. I know of one poor woman with ME whose daughters were taken from her and examined for signs of sexual abuse! This was horribly traumatic for parent and child, on top of them both feeling horribly ill with ME.

    The revelations in this frightening article explain at last, the framework of assessment under which I and so many others like me were assessed and the crime against humanity that has been perpetrated against us, and is perpetrated against us still. I would like to think that there will be a time – perhaps even in my lifetime – when those involved are exposed and called to account for what they have done, but I doubt it.

    • Thank you for the comment. I cannot fully comprehend how awful ME is, and how utterly disgusting and inhumane the actions of the Wesley group (and their British, Dutch, and American, colleagues) have been and still are. Hopefully the current effort to expose the school will help end this horror. Maybe this article will help. Only my use of scientific realist philosophy and my quite selective use of the literature are new. I put my intellectual cards on the table and knowingly chose disturbing texts.

  2. Waddell tried somewhat to backpedal in 1998 claiming that his ‘signs’ had been subject to ‘misuse’, claiming that he had never intended for them to be seen as indications of malingering. (“Behavioral responses to examination. A reappraisal of the interpretation of “nonorganic signs”.) Interestingly on the side panel of the abstract for this article at PubMed one of the related articles is entitled: “Is it malingering, or is it real? Eight signs that point to nonorganic back pain.”(1999) Yes, that’s Gordon’s ‘signs’.

    Rather unfortunate, then, for Waddell that his work is so *very* heavily referenced (almost fifty times) in the (Big Book of) “Malingering and Illness Deception”, edited by psychologists Halligan, Bass & Oakley, with contributions by Simon Wessely (‘Malingering: historical perspectives’), Unum executive John LoCascio (‘Malingering, insurance medicine, and the medicalization of fraud’), and the ubiquitous Mansel Aylward (‘Origins, practice, and limitations of Disability Assessment Medicine’). The latter having been at great pains of late to distance himself from the essential part he played in creating the ‘disability assessment’ that is the WCA.

    Some more delightful article titles from that book:

    ‘Wilful deception as illness behaviour’.
    ‘Malingering, shirking, and self-inflicted injuries in the military’.
    ‘Conceptual issues and explanatory models of malingering’.
    ‘Characteristics of the sick role’.
    ‘The contemporary cultural context for deception and malingering in Britain’.
    ‘When the quantity of mercy is strained: US physicians’ deception of insurers for patients’.
    ‘Investigating benefit fraud and illness deception in the United Kingdom’.
    ‘Misrepresentation of pain and facial expression’
    ‘Deceptive responses and detecting deceit’.

    By their works shall ye know them.

  3. George, thank you very much indeed for this article, which I only recently saw. You might be interested in my book ‘Authors of our own Misfortune? The Problems with Psychogenic Explanations for Physical Illnesses’ (it’s on Amazon with a ‘look inside’ facility for further info), in which I address the problems with Waddell’s claims also. I suspect you and I have a lot of common ground of research in this area 🙂

  4. I had a major stroke in ’11 and the dedicated staff at Warrington Hospital’s stroke unit nursed me back to health. The following year I was again hospitalised with heart failure – the stroke had damaged my heart, yet despite that Atos demanded I attended a WCA. Atos subsequently were told to “do one” – I qualified for Pension Credit! How well would Waddell’s and Aylward’s psychobabble have worked in my case? Not of all of us have “lower back pain” – a the majority have other conditions, but in the view of IDS and his minions, everyone on the sick has back pain, and of course malingerers.

  5. The link in [1] to Jonathan Rutherford’s article does not work. Please use this, instead http://www.midmoors.co.uk/Unum/unum_in_uk.pdf .

  6. I am so shocked at what I have just read and left me feeling angry.
    It does however make perfect sense to me as to y we r I. The mess we r in thanks to ATOS and this governments beliefs.
    In the eyes of ATOS and their twisted version on a theory that was cobblers to begin with, I would b seen as one of the ‘deviant’ one!
    How scary it is when someone has a theory that others adopt and because it suits their predjuces’s they too adopt it!
    To think this is how it’s within our social security system and medical working assessments is absolutly horrifying.
    Thank u so much for sharing this. It has really opened my eyes and allows me to understand the harshness and cruelty that has been inflicted upon the sick and disabled people in this once compassionate country.
    Many thanks again x

  7. My comment seems to have got lost in DPAC moderation so I’ll try again.

    The problem with the biopscyhosocial model isn’t that it has been “perverted” but that it was always a load of unworkable cobblers to begin with. It is completely unworkable in practice, whether as a theory or as a treatment prescription for illness and disability, and therefore it can’t be claimed the BPS model has been perverted never mind that it is actually caring and humane in reality.

    Just for instance, there are no trained BPS experts and there never will be as as it is impossible to imagine anyone training in biology/psychology/sociology and then putting such a discipline into practice on sick and disabled patients.

    Engel’s BPS model is not a real model or theory as such. It just trivially describes that biology, psychology and society is involved in disability and illness. Which is true but trivial and so what?

    Engels model of disability and illness also actually leaves the door open to ascribe disability and illness to causes that are non-medical, even that patients are making stuff up for one reason or another and that they are even imagining they are ill and disabled. Engel’s BPS model, therefore, is hardly the anti-Atos model George Berger seems to be claiming for it.

    Anyone actually interested in real expert, informed criticism of Engels and his vacuous BPS model should read this –
    The Biopsychosocial Model in Psychiatry: A Critique
    http://www.bu.edu/paideia/existenz/volumes/Vol.6-1Ghaemi.html

    • That’s a really interesting point. I just wanted to know whether you’re open to the possibility that there might be psychosocial causes for disabilities as well as purely biomedical ones? I know some disabled people reject this idea on the grounds that medical causesare seen as more ‘real’, and saying a condition is ‘psychological’ can seem like short-hand for saying that it’s ‘made up’ or ‘imaginary’, which seems to be Atos and the DWP’s attitude. There’s another argument though; I know that advocates of social models of disability and critics of mainsteam psychiatry/psychology argue that a purely medical model is actually a very oppressive one; that an individual’s disability is caused by an interaction of social and medical factors and that understanding this is important for self-organization and activism. I know in regards to my own life, I’ve always found this social constructionist idea to be much more empowering than a purely medical one. What are your feelings on this?

  8. One of the most concise reports I have seen on this bastardisation of Engel’s biopsychosocial model. As for Professor Mansel Aylward, The only time I ever heard My former aunt by Marriage Professor Yue Sun (One of the Leading Neuro Psychologists in the world) swear was in respect of Professor Mansel Aylward’s behaviour when he tried to take credit for her several papers published as King College, in respect of MS research.

    If you really want to know the word rhymes with ‘funt’.

    The guy is a complete phoney, with any original research to back up his Professorship, everything he did/does is just a reworking of other peeps work.

    To reiterate what I have mentioned many times elsewhere, along with other Political issues, when I spoke out about Schlumberger(Sema) in 2000 to 2002, and the proposed tick box assessment system that later became known as LIMA, this was what I received in return. http://news.bbc.co.uk/1/hi/northern_ireland/2387909.stm an attempted assassination by Paramilitaries, who where using M.O.D issue firearms.

    If you really want to see how deep this runs, you need only look at the average park in the UK now, most have been fitted with Chinese Style Exercise equipment, just to add that extra Social Engineering nudge to matters.

    • “with any original research” should say without any original research

    • f you really want to see how deep this runs, you need only look at the average park in the UK now, most have been fitted with Chinese Style Exercise equipment, just to add that extra Social Engineering nudge to matters.

      What is Chinese Style Exercise equipment????

  9. Well, according to Waddell, Unum, etc., my wife is a malingerer because she suffers from intense lower back pain.
    The MRI scan she had a few weeks ago showed several displaced and bulging discs, arthritis, bone[s] pressing on her sciatic and other nerves [I forget the medical names], causing pain and numbness in her right leg as well as her back, shoulder and right arm.
    I suppose she chose to develop the symptoms to get drugs from the GP before expertly decieving the high-tech scanner and the doctors who read the results…
    There’s so many people like Sue out there… malingerers the lot of them!
    How I hope Cameron gets a proper, proper bad back.

 Leave a Reply

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <s> <strike> <strong>

(required)

(required)

Facebook