http://www.meactionuk.org.uk/More-concerns.htm
More concerns about the current UK Welfare Reform
Margaret Williams 22nd January 2012
Attention is drawn to a letter recently sent to two high-profile members of
The House of Lords by Douglas Fraser, a former professional violinist but
now severely affected by ME/CFS (
http://www.meactionuk.org.uk/FraserToTGTandMM.htm).
In it, Fraser sets out his concerns about a paper circulated by Lord
(David) Freud, Parliamentary Under Secretary of State (Minister for Welfare
Reform) to certain members of the House of Lords (this being =93Models of
Sickness and Disability=94 by Waddell G and Aylward M, whose track record o=
n
the alleged deviance of sick people -- those with ME/CFS being specifically
targeted -- is documented in =93Magical Medicine: how to make a disease
disappear=94 by Professor Malcolm Hooper available at
www.meactionuk.org.uk/magical-medicine.htm).
David Freud=92s history is interesting: he previously worked as a journalis=
t
for the Financial Times and then joined a leading UK investment bank (UBS
investment banking), where he was on record as saying to his deputy: =93If
the rest of the country knew what we were being paid, there would be
tumbrels on the streets and heads carried round on pikes=94. In his city
career he frequently got things seriously wrong. As one reviewer of his
book put it, Freud =93will be remembered in the City as one of the key
players in several of the most embarrassing and badly managed deals in
investment banking=94. His revenue forecasts were, in his own words:
=93completely potty=94; according to the Daily Telegraph, his financial pla=
ns
for Euro Disney =93went so goofy they almost wrecked his career=94 and on t=
he
Channel Tunnel Rail Link he got his sums wrong by =A31.2 billion and had to
be bailed out by the Government (
www.variant.org.uk/events/Doc7Poverty/BankerBankies.pdf ).
Nonetheless, as the =93To Banker from Bankies=94 2009 report (which was
supported and funded by Oxfam) states, in 2007 Freud was appointed as the
key Government advisor on welfare reform by Labour=92s John Hutton, having
been commissioned to produce a report =93Reducing Dependency, Increasing
Opportunity=94 on the =93Welfare to Work=94 programme. This was despite the=
fact
that, in his own words, Freud =93didn=92t know anything about welfare at al=
l=94
(Daily Telegraph, 4th February 2008). Despite the great complexity of the
welfare system, Freud researched and wrote his welfare =93shake-up=94 plan =
in
just three weeks. It recommended that the existing role of private firms
(such as the French company Atos) in the Government=92s =93Welfare to Work=
=94
programme be dramatically increased; he acknowledged that there was no
evidence to suggest that private contractors were any better than the
Department for Work and Pensions, but he still concluded that it would be
=93economically rational=94 to pay them tens of thousands of pounds for eve=
ry
person they removed from benefits.
The Daily Telegraph subsequently reported that Freud himself had severed
all ties with Labour Ministers and was joining the Conservatives=92 Work an=
d
Pensions team =93after being put forward for a peerage=94.
In May 2010 the Coalition Prime Minister (David Cameron) appointed him to
his current post as Minister for Welfare Reform.
On 17th January 2012 Hansard recorded that Lord Freud referred to the
=93Models of Sickness and Disability=94 document that he had handed round t=
o
some members of the House of Lords(
http://www.publications.parliament.uk/pa/ld201212/ldhansrd/text/120117-0001=
.htm),
this being the document which will apparently underpin the transition from
Disabled Living Allowance (DLA) to the Personal Independence Payment (PIP)
and from which document it is clear that the biopsychosocial construct now
permeates medical assessments for state benefits (so it may come as no
surprise that Professor Peter White is acknowledged as an advisor).
Lord Freud explained: =93I am hopeful that PIP will do a better job than
DLA=85.I shall now turn to the more technical aspects of this issue =96 tha=
t
is, looking at what we are doing with the PIP and its assessment. Is it a
medical assessment=85? It absolutely is not.
=93=85Our approach is =96 and this is rather a mouthful =96 akin to the
biopsychosocial model=85
=93I sent round a rather interesting piece of analysis to many noble Lords =
in
the Committee, called Models of Sickness and Disability, which showed the
differences between the models, explaining the medical model, the reaction
of the social model against the pure medical model and the synthesis of the
biopsychosocial model. The summary of the biopsychosocial model in the
analysis is that: =91Sickness and disability are best overcome by an
appropriate combination of healthcare, rehabilitation, personal effort and
social/work adjustments=92. There is a coherent theory behind this
assessment=94.
There are about 170 references to =93models=94 scattered throughout the 40 =
page
document and Fraser points out that readers may get the impression when it
comes to the =93biopsychosocial model=94 that a rigorous and scientific
approach has been taken, yet it may be argued that there is no coherent
theory whatsoever behind that =93model=94.
Fraser draws attention to the authors=92 footnotes, which are rife with
selective referencing and contain misquotations from and misrepresentations
of the (not easily available) cited source.
In one instance the authors seem to infer (from their cited source) that it
has been shown to be perfectly legitimate to proceed directly from
biopsychosocial theory (or the =93conceptual model=94) to biopsychosocial
practice and policy, when the cited author in fact concluded that the
biopsychosocial model is =93hardly a theory=94 and =93certainly not a model=
=94.
The central arguments surrounding issues of bias and confounding in
relation to the biopsychosocial model that are exposed within the cited
source are not -- as they should have been -- made known by Waddell and
Aylward.
Notably, the impression from the footnotes is that it was Professor Peter
White who provided =93classic=94 examples on =93how the biopsychosocial mod=
el is
not an aetiological model of disease, and (how) arguments about whether the
cause of a particular disease is biological or psychosocial obscure the
main issue=94, when in reality it was George Davey-Smith, Professor of
Clinical Epidemiology at the University of Bristol who urged caution and
who carried the torch for intellectual integrity: it was he who showed that
bias can generate spurious findings and that when interventional studies to
examine the efficacy of a psychosocial approach have been used, the results
have been disappointing, and he who pointed out that cholera was attributed
to =93moral=94 factors and that peptic ulcer was attributed to stress befor=
e
the appliance of science (Proof Positive? Eileen Marshall & Margaret
Williams, 30th August 2005http://www.meactionuk.org.uk/PROOF_POSITIVE.htm).
According to Waddell and Aylward (and White), both these examples are of
=93specific diseases of doubtful relevance to common health problems=94 and
they are dismissed because they appear to threaten the biopsychosocial
philosophy, which Waddell and Aylward claim applies to =93any illness=94.
However, when one examines Waddell and Aylward=92s claim of supporting
evidence for the biopsychosocial model in the management of low back pain
(=93extensive scientific evidence that the biopsychosocial model provides t=
he
best framework for the modern management of low back pain=94), one finds fr=
om
the latest Cochrane meta-analysis examining the results of behavioural
interventions for low back pain that: =93the risk of bias of the trials
included in this review was generally high=94 and, in relation to the
addition of behavioural therapy to in-patient rehabilitation over the
longer term, that: =93there was only low or very low quality evidence, whic=
h
was based on the results of only two or three small trials=94 (Behavioural
treatment for chronic low-back pain; 7 JUL 2010. The Cochrane Collaboration=
.
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002014.pub3/full ).
Such seeming sleight of hand by Waddell and Aylward in seriously misleading
a Government Minister and members of the House of Lords is to be deplored.
When it comes to ME/CFS, over 20 renowned international experts on ME/CFS
have provided written statements of concern effectively stating that
cognitive behavioural therapy and graded exercise therapy used to support
the alleged existence of the =93biopsychosocial model=94 do not work for pe=
ople
with ME/CFS (Magical Medicine pp 88-92).
Furthermore, numerous trials have shown that not only is the
=93biopsychosocial model=94 unsuccessful in the management of ME/CFS but th=
at
the model itself is not evidence-based and it may be actively harmful:
(i) the evidence that behavioural modification techniques have no role in
the management of ME/CFS is already significant and has been confirmed by a
study in Spain, which found that in ME/CFS patients, the two interventions
used to justify the biopsychosocial model (CBT and GET) did not improve
HRQL (health-related quality of life) scores at 12 months post-intervention
and in fact resulted in worse physical function and bodily pain scores in
the intervention group (Nunez M et al; Health-related quality of life in
patients with chronic fatigue syndrome: group cognitive behavioural therapy
and graded exercise versus usual treatment. A randomised controlled trial
with 1 year follow-up. Clin Rheumatol 2011, Jan 15: Epub ahead of print)
(ii) =93Notwithstanding the medical pathogenesis of ME/CFS, the
(bio)psychosocial model is adopted by many governmental organizations and
medical professionals to legitimize the combination of Cognitive Behavioral
Therapy (CBT) and Graded Exercise Therapy (GET) for ME/CFS=85. Justified by
this model CBT and GET aim at eliminating presumed psychogenic and socially
induced maintaining factors and reversing deconditioning, respectively. In
this review we invalidate the (bio)psychosocial model for ME/CFS and
demonstrate that the success claim for CBT/GET to treat ME/CFS is unjust.
CBT/ GET is not only hardly more effective than non-interventions or
standard medical care, but many patients report that the therapy had
affected them adversely, the majority of them even reporting substantial
deterioration=85. We conclude that it is unethical to treat patients with
ME/CFS with ineffective, non-evidence-based and potentially harmful
=91rehabilitation therapies=92 such as CBT/GET=94 (A Review on Cognitive
Behavioural Therapy (CBT) and Graded Exercise Therapy (GET) in Myalgic
Encephalomyelitis (ME) / Chronic Fatigue Syndrome (CFS). Neuroendocrinol
Lett 2009:30(3):284-299)
(iii) The Wessely School=92s much-vaunted FINE (Fatigue Intervention by
Nurses Evaluation) Trial could not by any standards be judged to have been
successful: the results showed that =93pragmatic rehabilitation=94 (PR, bas=
ed
on CBT/GET) was minimally effective in reducing fatigue and improving sleep
only whilst participants were engaged in the programme and that there was
no statistically significant effect at follow-up. Furthermore, pragmatic
rehabilitation had no statistically significant effect on physical
functioning; equally, its effect on depression had diminished at follow-up.
Moreover the other intervention being tested (=93supportive listening=94 or=
SL)
had no effect in reducing fatigue, improving physical functioning, sleep or
depression (AJ Wearden et al; BMC Medicine 2006, 4:9
doi:10.1186/1741-7015-4-9)
(iv) Equally, the widely acclaimed but statistically unsustainable PACE
Trial cannot be said to have been successful since, uniquely, ratings that
would qualify a potential participant as sufficiently impaired to enter the
trial were considered =93within the normal range=94 when recorded on comple=
tion
of the trial and no recovery statistics have been published by the Chief
Principal Investigator, Professor Peter White (Comparison of adaptive
pacing therapy, cognitive behaviour therapy, graded exercise therapy, and
specialist medical care for chronic fatigue syndrome (PACE): a randomised
trial. PD White et al. Lancet 2011 Mar 5;377(9768):823-36).
It has not been possible to determine Lord Freud=92s awareness of the need =
to
distinguish biomedical science from biopsychosocial ideology before he
formulates Government policies that will have a profoundly detrimental
impact on sick and frightened people whose means of survival is threatened
if their state support is withdrawn.
The term =93biopsychosocial model=94 is used almost exclusively by Wessely
School psychiatrists to refer to disorders that they continue to regard as
psychosomatic (especially ME/CFS) and it is not used by other disciplines.
For example, cardiologists do not refer to patients as having a
=93biopsychosocial=94 disorder and oncologists do not refer to cancer as a
=93biopsychosocial=94 disorder, nor do they claim that their patients must =
be
coerced back to work by the withdrawal of their state benefits because it
is patients=92 aberrant belief that they are physically sick which maintain=
s
their disease.
The use of such a term can be seen as a linguistic misdirection by these
psychiatrists, allowing them to conceal their belief that ME/CFS is not a
physical disease but an aberrant state of mind maintained by psychological
and behavioural factors (ie. the psychosocial components of
=93biopsychosocial=94). The only =93bio=94 in their =93biopsychosocial mode=
l=94 is
their reluctant concession that ME/CFS is sometimes preceded by a
self-limiting viral infection (and, despite the overwhelming international
evidence to the contrary, they insist it is maintained by psychosocial
elements that do not result from any organic pathology).
As Fraser states: =93As the tortured arguments continue, one suspects that
the authors (Waddell and Aylward) are keenly trying to ensure something is
kept out of public view=85.Had Lord Freud said =91We have not gone for the
medical model; we have gone for the psychosomatic model=92, I do not think
that members of the House would have been impressed for a moment=94.
Informed readers of =93Models of Sickness and Disability=94 might wonder wh=
y
something that has been repeatedly shown not to be a successful model is
being promoted by a UK Government.
As Fraser points out, an explanation may be found from a 2005 issue of
=93Decision Makers=92 Exchange=94 (DME), the monthly newsletter for DLA and
Attendance Allowance decision makers: =93Confirmation that Medical Services
(ie. the DWP) have adopted the Biopsychosocial Model for assessing not just
claims based on incapacity for work but also DLA and AA came in the July
edition of Decision Makers=92 Exchange=85An item explained that Medical
Services have recently introduced a change in the way that they assess a
customer=92s disabilities and the effect it has on their lives. The
Biopsychosocial Model aims to address how a person=92s disability has an
effect on that individual=92s life=94. The newsletter features an article b=
y
Mansel Aylward, former Chief Scientist at the DWP, entitled =93Professor
Aylward endorses the Biopsychosocial Model of Disability=85.Conditions for
which there is limited or no recognised pathological basis, such as chronic
fatigue, fibromyalgia=85feature regularly in disability assessments for sta=
te
benefits=85.The Biopsychosocial Model is the answer to the disability
analyst=92s plight=94.
Fraser then quotes from an Atos Origin Medical Services meeting in 2004
which sets out just how the dogma that underpins the =93biopsychosocial
model=94 is being authoritatively promulgated, and he notes =93the convenie=
nt
fictions and lack of logic those responsible would=85refuse to tolerate if
applied to their own family and friends=94.
The Atos Origin 2004 Conference report is explicit: =93Psychosocial
factors=85are at least as important as physical factors in the onset and
maintenance of these conditions. Patients can make a number of =91secondary
gains=92 with these unexplained illnesses, such as=85turning a socially
unacceptable disability into a more acceptable =91organic=92 disability cau=
sed
by injury or disease beyond their control. They can blame their failures on
the illness; elicit care, sympathy and concern from family and friends;
avoid work or even sex; and there are financial rewards associated with
disability.
=93=85if a patient believes their illness was caused by a virus and there=
=92s
nothing they can do about it, their prognosis is not likely to be positive.
But if the patient believes=85that the symptoms won=92t last long and they =
have
control over them, then the prognosis will be better=85. We need patients t=
o
understand their situation, so they are more likely to go back to work=94 (
http://www.meactionuk.org.uk/AtosConference2004.pdf).
Fraser concludes in his letter: =93Given the combined forces of what appear=
s
as an unseen (and) corporate-generated self-serving attitude (tacitly
approved by =93Models of Sickness and Disability=94 authors as perfectly mo=
ral)
in the guise of the=85psychosomatic model=85promoting the prejudice
of=85pop-psychology directed at vulnerable and relatively powerless
others=85and a profit-driven foreign company=85it is unsurprising that so m=
any
of the bad decisions they help facilitate are overturned on closer
examination at costly appeals. It would of course, be much cheaper in the
long run to adopt some of the higher standards of appeal tribunals in the
first place=94.
This non-evidence-based but pervasive biopsychosocial ideology is now being
foisted on the unsuspecting people of Australia and New Zealand, because in
May 2010 Aylward wrote a report for the Australasian Faculty of
Occupational and Environmental Health (Realising the Health Benefits of
Work: A Position Paper. Professor Sir Mansel Aylward CB; Director: Centre
for Psychosocial Research and Disability Research, Cardiff University (the
Centre being funded by the health insurance company UNUM Provident). In it,
Aylward asserts:
=93Fundamental Precepts:
Main determinants of health and illness depend more upon lifestyle,
socio-cultural environment and psychological (personal) factors than they
do on biological status and conventional healthcare
Work: most effective means to improve well-being of individuals, their
families and their communities
Objective: rigorously tackling an individual=92s obstacles to a life in wor=
k.
=93Making the distinction: definitions and usage:
Disease: objective, medically diagnosed pathology
Illness: subjective feeling of being unwell
Sickness: social status accorded to the ill person by society
In that report Aylward claims that largely subjective complaints (such as
ME/CFS) are often associated with psychosocial issues, not with pathology,
and that =93bio-psycho-social factors=94 may aggravate and perpetuate
disability and that they may also act as obstacles to recovery and barriers
to return to work. He refers to the UK Government=92s =93Pathways to Work=
=94
initiative, with its mandatory work-focused interviews for sick people and
the use of CBT to change people=92s alleged misperceptions about their
health; his message is: =93Barriers to recovery and return to (retention in=
)
work are primarily personal, psychological and social rather than
health-related =91medical problems=92 and that =93Perceptions lie at the =
=91heart=92
of the problem=94.
His report provides guidance on =93 Engaging and Exploiting Stakeholders=94=
,
which he says must include
changing the beliefs and attitudes of politicians, civil servants, health
professionals, employers etc and changing the present culture about health
and well-being in order to deliver =93visible hard outcomes=94.
Even more disturbingly, Aylward=92s report asserts that there must be new
roles for health professionals, who must no longer permit their patients to
believe that they are incapable of work if they have a disease but must
instead propel them back into work even if they do have a legitimate
medical disease. In the UK, there are recorded accounts of people with
cancer being forced back to work and of a cancer sufferer dying whilst
awaiting an appeal against a refusal of benefits by Atos.
Unsurprisingly, since he has invested so much into the promulgation of it,
despite the accumulating evidence to the contrary, Aylward claims that the
biopsychosocial principles of management are evidence-based, when the
=93biopsychosocial model=94 can be readily shown to have no empirical
foundation, particularly in relation to ME/CFS.
It has nevertheless been used to justify beliefs and policies, for example,
in his letter to the two members of the House of Lords, Douglas Fraser
quotes the following:
"Benefits and Work has seen one recent medical report in which a DWP doctor
explicitly stated that he had used the Biopsychosocial model. The claimant
has Chronic Fatigue Syndrome and was seeking renewal of an award of the
middle rate of the care component and the higher rate of the mobility
component. His condition had deteriorated since his last award over two and
a half years ago. The doctor who visited him recorded that: =91There are fe=
w
significant findings other than subjective tenderness and stiffness. But
the customer is clearly living the life of a disabled person and I have
applied the Biopsychosocial model=92. The doctor then stated, without
explaining how the conclusion had been reached, that the claimant=92s
condition was just 40% physical and =9160% psychosocial=92=85. This allowed=
the
decision maker to conclude that the claimant=92s award of higher rate
mobility was no longer appropriate as the primary reason for his virtual
inability to walk was psychosocial rather than physical".
The specific numbers given (40/60 split) provided a superficial appearance
of scientific objectivity to cover what was in fact no more than a
highly-prejudiced guess, because such things cannot be measured or
quantified, but they achieved the required outcome (which was to strip this
person of his benefits and for which the company to which the DWP has
delegated its medical assessments would receive a handsome financial
reward).
It is, of course, imperative to seek out and remove from state benefits the
cheats and idle lead-swingers, but it is even more imperative to take
appropriate medical care of the sick, yet what underpins current Government
welfare reform is the un-evidenced conviction that work is always good for
people, no matter how ill they may be.
Commenting on a response to her article =93Illness as Deviance, Work as
Glittering Salvation and the =91Psyching-up=92 of the Medical Model: Strate=
gies
for Getting the Sick =91Back to Work=92 =94 (
http://www.democraticgreensocialist.org/wordpress/?page_id=3D1716), Gill
Thorburn says: =93I was appalled to discover what they have been doing to t=
he
ME community for so many years. Its nothing short of legitimised abuse. The
one discouraging thing I=92ve experienced in all my research so far has bee=
n
discovering for how many years how much authentic evidence has been simply
disregarded by those in power in favour of this spurious psychological
approach. Some of the accounts on the net are simply heartbreaking, and it
beggars belief that these people should have been allowed to continue with
their =91methods=92 and =91theories=92. As someone pointed out recently, th=
ey
=91intervene=92 in peoples=92 lives with impunity, disregarding their negat=
ive
effects, for which they are never held to account=94.
A UK Government is democratically elected to look after the best interests
of the nation and of its citizens, not to abuse and persecute the sick in
favour of foreign corporate profits by imposing the =93biopsychosocial mode=
l=94
that is promoted by UK psychiatrists who have vested financial interests in
such a =93model=94 because they work for the health insurance industry, who=
se
profits benefit from its use.
---------------------------------------------
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