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 athttps://www.midmoors.co.uk/Unum/unum_in_uk.pdfhttps://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 https://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, seehttps://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/
George Berger
This article first appeared in Disabled People against the Cuts
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