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General Biopsychosocial model paper from 2004

Discussion in 'Other Health News and Research' started by Esther12, Jun 3, 2012.

  1. Esther12

    Esther12 Senior Member

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    edit: I've just realised that I forgot to post a link to the paper I started this thread about! Sorry about that. It's often slightly disappointing to read my old posts and realise how garbled that are!
    Here's the link:

    http://www.annfammed.org/content/2/6/576.full



    I've just read this and the replies (it did take me a day to get through it all), and thought it was kind of interesting. In some ways it sounded really sweet, in other ways, terrifyingly naive about the way the BPS model would actually lead to patients being treated.

    It's just hilarious when you compare it to the impact the biopsychosocial reforms to the UK benefits system are having, or even to those training videos Chalder did: http://forums.phoenixrising.me/inde...sh-gps-on-how-to-deal-with-cfs-patients.3079/

    Anyone thinking that it was a good idea to promote a biopsychosocial approach to CFS within the NHS must have not cared much about the impact it would have upon patients, or have been utterly deluded about the psychosocial setting most medical staff are operating within.

    Some of the things the above paper expects from doctors would require them to be super-human... or else will inevitably lead to quackery.

    In the White book on BPS they talk about the model only gaining influence when politicians and civil servants realise it can be used as a way of saving money... and this now seems to be the primary role of BPS: to justify cutbacks in care and assistance for those with health problems. How very proud all those who made their careers out of it must be.
  2. alex3619

    alex3619 Senior Member

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    Hi Esther12, I am not sure its this clear cut. Like the ideological divide between right and left wings of politics, I think there is a divide in medical attitudes. I suspect that many of these people do indeed think they are doing the right thing - but because they are ideologically and not factually driven they are dangerously unaware of the consequences. Some are aware though - I cannot see an alternative to that conclusion - but to them its political. They want their agenda, and if a few have to be sacrificed along the way, too bad. This is bad politics, its bad science, its bad medicine. Whenever ideology over-rides facts there is a problem.

    I think the idea of BPS is fine. I think the implementation of that idea, current practice, is dangerously flawed. The driving force seems to be fear. Medical and political thinking based on fear (and its cousin hatred) underlies many of the worst periods in history.

    How is this about fear? In politics its about fear of the rising social costs. Add rising resource costs that are expected and the economies of these countries are going to be heavily burdoned. In the case of the psychiatrists its fear that those who practice psychosomatic medicine are a dying breed. They are losing relevance. This is their attempt at a comeback. They are failing, and one day this will be seen for what it is.

    Bye, Alex
  3. oceanblue

    oceanblue Senior Member

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    That's very interesting. Do you have any useable quotes from that source?
  4. Esther12

    Esther12 Senior Member

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    From around page 218 for a couple of pages, here: http://books.google.co.uk/books?id=chwtWAt76JoC&pg=PA250&dq=shorter wessely aylward biopsychosocial&hl=en&sa=X&ei=wpvMT8KhA6f80QWHg6moAQ&redir_esc=y#v=onepage&q=money&f=false

    I can't copy and paste! I didn't re-read it all, but it looks like it says pretty much what I remembered. They also mention the importance of systematic reviews, and as we know, they can easily be skewed one way or the other. This could explain why so many seemingly pointless ones get pumped out.

    I didn't mean to say it was clear cut, and agree that many of the proponents of BPS probably thought that they were doing a good thing which would help patients. I just think that lots of people doing bad things are motivated by a desire to do good.

    I see what you're saying, but when the idea itself is so tied up to pragmatism and claims about results, I think that it's hard to say it's a good idea implemented poorly. I also do not see any way that it could be implemented well within our current social structures, or without some dramatic improvement in our ability to train and regulate our medical staff. A BPS approach seems doomed to fail, and doomed to continue to fail for the foreseeable future.

    I know what you mean about some of the things said as part of the BPS approach to disability sounding good in an abstract kind-of way, but one can say that communism is a good idea in principle, or some other benevolent form of authoritarianism... but they're only good ideas if we assume that people in positions of power and authority are less self-interested, prejudiced and stupid than they really are. In reality, they're bad ideas... and that's where ideas should be judged imo.


    Edit: I wasn't able to get it all, but this is part of the section from Peter White's BPS book OB asked about:

    from page 218 of Biopsychosocial Medicine: An Integrated Approach to Understanding Illness, edited by Peter White.

    Wessely: Mansel Aylward, you are involved with policy definitions. What have you heard here that might influence your secretary of state?

    Aylward: I have been given a lot of information that reinforces some of the messages that I have passed on to decision makers. I haven't heard anything startlingly new, but I am happy to have my views confirmed. We have made some significant progress. We had some great difficulty last year persuading certain people that the way forward in the more effective assessment of disability and its management in people on state benefits lay more with a BPS approach to rehabilitation, job retention and recovery, than a focus on economic disincentives or wielding the stick approach. There seems to be an antipathy in some part of Government towards anything that is perceived as fuzzy or nebulous, without a hard evidence base. If the BPS approach is perceived in this way and is competing for investment with hard policies focusing on bed occupancy and delivery of acute services, it is very difficult to get the Department of Health, among others in Government, to favour health-focused interventions and rehabilitation adopting the BPS approach. But in recent month I'm beginning to see a change. The Department for Work and Pensions may now have been persuaded to invest in initiating pilot studies in various areas of the country, in particular involving benefit recipients with back pain and fatigue, to see if all the talk about the BPS approach has any basis in improving outcomes.

    Wessely: What made some of the policy makers change their views?

    Aylward: Systematic reviews of the literature garnering evidence to support the BPS concept. Identifications of best practices in using BPS approaches that improve function and rates of return to work, particularly in people with disability caused by back pain. Recent meeting in the form of focus groups of key oppinions makers support with authorative and expert opinion the value of BPS approaches. There are going to be some developments soon.

    Wessely: What kind of evidence caused change?

    Aylward: The evidence which has been there all along. The key aspect has been effectively communicating the evidence in a far more robust and authoritative way. We also ran a series of workshops where we discussed and evaluated various approaches to facilitate return to work and to address the rising numbers of people in receipt of incapacity benefits. Some £25 billion per year is being spent on state benefits resting either directly or indirectly on a medical basis. The prospect of effective interventions that might reduce that expenditure are powerful catalysts for change.

    Waddell: To take this a stage further, I am not sure that evidence is what convinces people. We do need an evidence base, but it is ideas that really influence people. People go to war for ideas, not for evidence. When you look at changing practice, it is really about ideas rather than evidence. My hesitation about what was said earlier is that everything seem to show the the behaviour of health professionals is difficult to change. But there are some suggestions from the Australian education campaign, Kate Lorig's work, and our work in Scotland, that it may actually be easier to change patients and the public and they will then force the professionals to change. The information from Australia has helped tremendously [1,2]. Some decision makers were very jaundiced, but this has played a role in convincing them that there is something in that and that it will save money. It's all about money. The main thing was to persuade the treasury that there was an opportunity for keeping costs down, particularly over the longer term.

    Drossman: One of the efforts in the USA that has had some influence on Congress is the burden of illness study carried out be the American Gastroenterology Assocations. They identified the costs in terms of direct and indirect costs. Direct costs refer to the costs related to the healthcare, such as medication and physician visits and indirect costs are other way in which the illness impacts on the economy, for example, loss of work productivity or wages due to illness. Using irritable bowel syndrome (IBS) as an example the prevalence is 15 million in the USA. When you multiply this by the number of dollars spent in terms of physician visits and prescriptions, it exceeds the cost burden of inflammatory bowel disease (IBD). Thus the higher prevalence (about 100 times great) for IBS offsets the high cost per patient of IBD, yielding greater cost to society. The cost to the economy is about US$2 billion of direct and US$20 billion of indirect costs. This had some inflence on Congress. It is not proving that you can treat it that matters but proving that the economic burden is there and that effort must be placed on finding better treatments.

    Wessely: I once tried to add up the cost burden of a range of conditions and it comes to more than the gross national product of the entire western world!

    Lorig: Particularly for morbidity.

    Lewin: One of the other things that Greville Mitchell is helping us do through One Health is an analysis that will look at the lost opportunity costs from not using cognitive behavioural therapy (CBT) approaches. We are doing this in collaboration with Jos Kleijnen. This is a complicated procedure because we haven't even got an agreed definition of CBT. We'd be delighted to have any suggestions for how we might do this.

    Wessely: Can I clarify? Is Jos also doing a review of more direct psychosocial interventions in this area?

    Lewin: Yes. The study is looking at the possible costs savings. What would the Government gain if they were to spend more on these areas?

    Mitchell: People are pretty limited in viewing government future budgets. They will escalate: That is a fact of life. Therefore, if you are going to add to this bill you won't catch the government's attention, even if you
  5. alex3619

    alex3619 Senior Member

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    Hi Esther12, I agree that the BPS approach is being used by some political factions to drive social agendas that would otherwise be considered abhorent. They can point to the medical papers and say, hey, we are doing the right thing. The current fight in the UK against ATOS and the government implementation of austerity measures by removing benefits from disabled people, as easy targets, is a case in point.

    There is failure on so many levels. We, as patients, have failed to see what is happening for far too long - we were dead certain something was wrong, but never clear as to what it was - and to some extent we are still floundering. The general public not only failed to see it but failed (and is still failing) to address the problem. The public is informed by the media who are supposed to be our watchdogs - the media have failed even worse than the public or patients. There is some sign that more and more are aware of this however. The politicians have failed because they are supposed to address issues that are not addressed by other mechanisms. There is too much buck passing and no leadership on these issues.

    In the medical corner the psychosomatic researchers have failed because they have pursued extremely inadequate research methodologies, and set up precedent for pushing science by political and not rational means. The general medical and scientific communities have failed because they have not called them on it. The institutions have failed as they have permitted unethical practices for generations - something can't be unethical if its widely accepted, can it? I mean its traditional, so it can't be bad, right?

    There is plenty of blame to go around. Its systemic. Its less about individual blame than about how badly the whole system is set up. There are no checks and balances in the system that are working.

    Extreme right wing politics tends to drive itself. Right wing politics is an essential part of the democratic process. Taken to an extreme we can wind up with a police state - extreme left wing politics is equally problematic. More often however, historically, there is a sudden and dramatic correction in direction as people become aware. It just requires a sufficient number of people to stand up and say, stop, enough. That requires communication. At least today we have the internet.

    Bye, Alex
  6. Esther12

    Esther12 Senior Member

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    @ alex: I think we're saying pretty similar things, but mybe in slightly different ways.

    re blame: I think that checks and balances require the potential for blame, and I don't think systematic problems absolve indviduals of personal blame. Our systems were set up by individuals, and individual researchers had a responsibility to be aware of the systems which they were operating within.

    I'm possibly less optimistic about our systems potential to self-correct. As you said, I think that those of us who have been badly affected are still groping towards a firm understanding of exactly what has happened and why... and most people are not that interested in doing the work needed to understand these issues. It's really boring! I'm concerned that societies growing ability to pump out complicated and misleading research is going to lead to ever less genuine democratic participation, and much more potential for elites to be able to manipulate and control the social consensus - at least when it comes to matters which affect only a minority, and naturally tend attract little public attention and interest. Or it could be that people will decide that it's important to make a change, and impose more accountability upon those in power and authority. Fingers crossed.



    Some people might be interested in Waddell and Aylaward's Models of Disability pamphlet.

    Sorry for not pulling out quotes and summaries for what I've been reading... I keep forgetting to do that, and some documents don't let me when I try. I've only read the first 20 pages of this, and am feeling wiped out today, so will not be getting any further.

    http://www.craigliebenson.com/wp-content/uploads/2010/08/Models-final-proofs2.pdf
  7. Esther12

    Esther12 Senior Member

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    I was just reading a bit more of the above Aylward doc, and they had a nice little simplification, which is a good illustration of the problems with the new approaches to disability:

    Just yesterday I'd written about the biopsychosocial reforms to disability benefits, and the shift in concern from capacity to performance/productivity:

    This sort of thing is particularly problematic in the case of CFS, where attempts to 'improve' the way patients feel about their condition has included encouraging them to believe that recovery was under personal control, or that the patient's loss of capacity was a result of depression, or deconditioning, or a fear of activity... regardless of the likely accuracy of these claims. The notion that people with poorly understood health problems deserve to be manipulated and managed in this way is repulsive.

    There's a later section on personal responsibility and self-interest, and I really wonder if the authors thought about how it might apply to themselves, and what responsibility they hold for the suffering which has been inflicted upon others as a result of their work.

    Oops - just found a way to copy text. I using a funny setting before, instead of the PDF.

    I think it's fair to assume that Aylward and UNUM are self-interested, and should be assumed to be aware of what they are doing and their action's likely consequences.

    Aylward criticises the old sick role, and comes up with a new one:



    Luckily for the health professional, there are no new systems of accountability or regulation, so if the are unable to live up to these additional demands, and harm their patients, they won't bear any of the cost of that. Placing patients under the power of people unable to live up to the demands of the model they're instructed to follow is win-win, so long as you're not over-cautious about 'do no harm'.

    One would have thought that this might give pause to thought? We've now had the two largest RCTs of biopsyhcosocial interventions - FINE showing no benefit, and leading medical staff to view patients as "bastards [who] don't want to get better", and PACE which showed some minor improvements in subjective questionnaire scores (following necessarily unblinded treatment), but which White has reported led to no improvement in employment levels (although he's not quite ready to publish that data).

    What a cheering starting point.

    I think this is the only mention of fatigue - don't worry people... it's a personal problem.

    Does anyone think that society lived up to that responsibility prior to instituting these reforms?

    Invest in cutbacks now?!

    Is Aylward furiously campaigning against the reforms which have currently being implemented, and are just leading
    to widespread poverty amongst those with serious and chronic health problems? If not, one might have to conclude that he is just in the pocket of groups like UNUM, and that his talk of societies responsibilities to the disabled is just cover for the cutbacks which he has helped push through.

    I also found this short piece on some of his testimony to MPs: http://www.sayer.abel.co.uk/MES-Nmpsmisled.html

    He does seem to be a wretched little shit. I understand why he's so widely hated by so many different groups of disabled people.
    alex3619 and biophile like this.
  8. Esther12

    Esther12 Senior Member

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    I can't recommend anyone watch this video:

    It's a painfully dull Aylward presentation, which was only entertaining because he reminded me so much of someone from middle-management who got over promoted. He makes me feel grateful for Wessely.
  9. alex3619

    alex3619 Senior Member

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    Hi Esther12, yes, convert PDF to plain HTML and it can be saved. In Google Books there is a button called view, the option is there. Bye, Alex
  10. Esther12

    Esther12 Senior Member

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    Ta Alex.

    Also, I've just realised that I forgot to post a link to the paper I started this thread about! Sorry about that. It's often slightly disappointing to read my old posts and realise how garbled that are!

    Here's the link:

    http://www.annfammed.org/content/2/6/576.full

    And finally... I think that there's a nice progression from the ideal of that paper, to the Aylward examination of the biopsychosocial model of disability, to the application of this model by ATOS. Power corrupts pragmatism, and those who do not realise this are useful tools of the powerful. I expect that the problems of the BPS approach to disability would have been less obvious to me if I had not experienced them myself.
  11. Esther12

    Esther12 Senior Member

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    Just stumbled upon something where Lord Freud is using the Aylward leaflet from above to justify reforms to DLA (excuses to cut spending on helping those with health problems).

    http://www.publications.parliament.uk/pa/ld201212/ldhansrd/text/120117-0001.htm

    There's loads of funny stuff about Lord Freud about. Apparently he's as clueless as he sounds, and admitted to knowing nothing about welfare issues three weeks before he released a report recommending a series of dramatic reforms. It seems that he's just happy to do what those with power want him to, and screw over the sick and disabled.

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