An exploration of victim blaming in ‘medically unexplained symptoms’: Neoliberalism and the need to justify the self, group and the system 2023, Hunt

Sly Saint

Senior Member (Voting Rights)
available in english,german,italian, spanish and greek.

ABSTRACT
Narratives within mainstream psy disciplines around ‘medically unexplained symptoms’ (MUS), as constructed through (bio)psychosocial theorising, have been charged with promoting victim blaming. Psychosocial discourse and practice within this field are also critiqued on grounds of inadequate empirical support and associated with patient harms, yet (bio)psychosocial hegemony persists.

Understanding what drives current practice and attendant victim blaming in the field of MUS is therefore important in challenging dominant discourse and changing psychotherapy practice, thus precluding patient harm. In this article, practitioner psychology is explored through a critical lens, locating this within a context of organisational and biopolitical influences which likely reinforce mainstream theory and practice.

It is argued that victim blaming tendencies within dominant discourse around MUS may serve relational, existential and epistemic needs for practitioners and social actors more broadly, alongside fulfilling a need to assert moral value in the face of social injustices that threaten the neoliberal ‘just world’ view. In other words, (bio)psychosocial constructions of MUS satisfy society’s need to create and ascribe to a shared reality, dominated by a belief in a just, meaningful and relatively predictable world that justifies the status quo. Critical reflexivity is emphasised as a starting point for transforming practice.

https://www.tandfonline.com/doi/abs/10.1080/13642537.2023.2240809?src=&journalCode=rejp20
 
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If Hunt’s arguments about the psychopathology of clinicians have any validity, they should apply to absolutely every professional in every context as well, making them reductive enough to be meaningless.
 
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Isn't the point that when people who need help don't fit into the box marked 'How to help', some professionals will blame the people who need help, rather than blaming the box? By understanding that phenomenon better, professionals can be on guard against that tendency in themselves and others.

It would surely be helpful if 'victim-blaming by professionals' became a widely understood phenomenon among the counsellors and psychologists at whom this journal is aimed.

It would also be good if that audience had some awareness of victim-blaming when they are assessing the evidence for the supposedly widespread phenomena of 'false illness beliefs' and 'secondary gains'.
 
Isn't the point that when people who need help don't fit into the box marked 'How to help', some professionals will blame the people who need help, rather than blaming the box? By understanding that phenomenon better, professionals can be on guard against that tendency in themselves and others.

It would surely be helpful if 'victim-blaming by professionals' became a widely understood phenomenon among the counsellors and psychologists at whom this journal is aimed.

It would also be good if that audience had some awareness of victim-blaming when they are assessing the evidence for the supposedly widespread phenomena of 'false illness beliefs' and 'secondary gains'.

That may be true. What purpose does a supposed aetiology of victim-blaming tendencies serve, though, if awareness of victim-blaming is all that is needed?
 
It is argued that victim blaming tendencies within dominant discourse around MUS may serve relational, existential and epistemic needs for practitioners and social actors more broadly, alongside fulfilling a need to assert moral value in the face of social injustices that threaten the neoliberal ‘just world’ view. In other words, (bio)psychosocial constructions of MUS satisfy society’s need to create and ascribe to a shared reality, dominated by a belief in a just, meaningful and relatively predictable world that justifies the status quo.

Interesting ideas.

One should ask the question why so many people very strongly want unexplained symptoms in others to have a psychological origin. By definition they are unexplained, which would normally mean that we don't know the cause.

The impression is that this satisfies some kind of need. It seems possible this has something to do with the cultural values of our time, but I'm not sure that these are only neoliberal values.

An effective response to ME/CFS would require things that aren't well aligned with neoliberal views, like public health measures to minimize exposure to viruses that trigger ME/CFS, a social safety net for those that never had the chance to work, and public investment in research to find treatments.

CBT and exercise therapy seem very aligned with the individualist and self-improvement culture of today. The illness is depicted as a problem for the individual to solve, and the hardship of rehabilitation becomes a test of strength of character and motivation to get better. Wanting a pharmaceutical treatment is seen as personal failure.

Somehow CFS also became a symbol for various moral failings of society. Patients are accused of medicalizing their personal difficulties, and of being lazy and unwilling to exercise (exercise is a virtue).

But patients can't overcome the illness on their own (this reality is erased), are dependent on others (which is a sin in today's culture), and other people suffer as well (this aspect is mostly ignored because it doesn't fit the idea of the illness being an individual problem).

Psychologization of other people's illness also seems to satisfy the emotional need to avoid feeling the despair that results from witnessing a devastating untreatable illness, because the psychologization always depicts the illness as something that can be relatively easily solved just by thinking differently or overcoming some personal flaw. It also allows the person to take on the role of moral authority that gets to lecture the inferior patient about good behavior. I would argue that this emotional reward of not having to deel despair and feeling superior to others is one of the most important reasons illnesses are psychologized.
 
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That may be true. What purpose does a supposed aetiology of victim-blaming tendencies serve, though, if awareness of victim-blaming is all that is needed?
To persuade psychologists and counsellors who find that kind of reasoning persuasive, including many psychologists giving CBT in the Talking Therapies / Improving Access to Psychological Therapies programmes, the ones performing assessments for insurers, etc. etc.

I don't want to argue for or against another discipline's methodologies, but it seems to me that if psychologists are debating the relative influence of epistemic need fulfillment and of practitioner team building (p. 15) in the aetiology of victim-blaming, it may be possible for the rest of us to get back to talking about the causes of, and treatments for, this debilitating disease.
 
To persuade psychologists and counsellors who find that kind of reasoning persuasive, including many psychologists giving CBT in the Talking Therapies / Improving Access to Psychological Therapies programmes, the ones performing assessments for insurers, etc. etc.

I don't want to argue for or against another discipline's methodologies, but it seems to me that if psychologists are debating the relative influence of epistemic need fulfillment and of practitioner team building (p. 15) in the aetiology of victim-blaming, it may be possible for the rest of us to get back to talking about the causes of, and treatments for, this debilitating disease.


It’s a nice idea, but if the best hope is to distract psychologists, and the only way to do so is by insulting them, I’d prefer another patient group to get the blame!
 
Has anyone been able to read the full paper? I’d like to but can’t at that link and it’s not up on SciHub yet as far as I can tell.
 
I think this is an important area for therapists to learn about. If I understand Jo Hunt's purpose in this abstract, it is to help therapists question the approach they have been taught to take in providing psychological therapy for people with 'MUS' which I take it includes ME.

The PACE CBT therapists' manual tells the therapist that pwME have "fearful thoughts such as “activity will make my problems worse”, which may lead to an avoidance or reduction of activities". The GET manual says "The rationale behind GET stems from both physical and behavioural understanding of CFS/ME. Physical deconditioning, exercise intolerance and avoidance caused by relative inactivity are reversed by gradually and carefully re-introducing regular physical exercise, aiming to return a patient to normal health and ability."
[Burgess and Chalder, 2004, PACE trial CBT for CFS Manual for Therapists
https://www.qmul.ac.uk/wiph/media/t...lth-wiph/documents/3.cbt-therapist-manual.pdf
Bavinton, Darbishire, White, 2004, PACE trial GET for CFS Manual for Therapists
https://www.qmul.ac.uk/wiph/media/t...lth-wiph/documents/5.get-therapist-manual.pdf]

Both manuals were based on preconceived ideas of people like White, Wessely, Chalder etc, not on evidence. They not only suited their view of pwME, and their professional career advancement, they also were part of the government disability benefit and insurance company narrative of ME being a psychosomatic condition fixable with exercise, and work being good for us.

There is a strong political and big business dimension. Disability insurance is much less generous to people with psychosomatic conditions than to people with physical diseases. If governments can classify some diseases as curable and helped by working, then they have the perfect excuse to deny state sickness and disablity benefits, and for the wider society to judge people with these diseases as malingering and unworthy because we don't make the effort to work and thereby be worthy by contributing to the common good, blah blah. The whole re-enablement approach to social care is presented as a social good, for the individual giving them independence, and for society for not being a burden. For pwME it's a disaster. Whether all this is about neoliberalism is beyond the scope of this forum.

If the therapist finds that their patients are telling them the therapy is not helping, and they are clearly just as sick, then the therapist's training and the wider attitudes in society tell them that the reason the patient isn't getting better is that they are not trying, they don't want to get better, and they are therefore malingering, getting secondary gains from being ill etc.

What the therapist with an open mind and not steeped in a society that values exercise, work, self improvement etc. needs to be able to do is to review their training and societal expectations, listen to the patient and be able to say, actually this patient is sick with something I can't treat. They need support and care, not misguided therapy and blame. That should be the norm in clinical care, not the exception.

What actually happens is therapists tend to assume that if the patient isn't getting better, it's the patient's fault. I recall the nurses trained by psychs for the FINE trial on finding their patients weren't recovering with psych therapy were quoted as saying 'the buggers just don't want to get better'. Those nurses were not bad people, but they were part of a society that supports what they had been trained to think.

Or as Jo Hunt says in her abstract:

"In other words, (bio)psychosocial constructions of MUS satisfy society’s need to create and ascribe to a shared reality, dominated by a belief in a just, meaningful and relatively predictable world that justifies the status quo. Critical reflexivity is emphasised as a starting point for transforming practice."

I'm sorry we can't access the whole article. All I'm going on here is the abstract. I may have misunderstood.
 
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I was able to read this paper thanks to a generous s4me user. I don’t want to fall afoul of any forum rules, so I’ll just say I’d be happy to pay their kindness forward and my PM inbox is open :).

I think many of the arguments in this paper will be familiar to members of this forum and are along the lines of things we often talk about:
Collective victim blaming behaviours may unwittingly satisfy practitioners’ psychological needs through easing anxiety associated with epistemic, relational and existential threats, whilst facilitating assertion of moral value and deflection of responsibility in the face of injustices such as societally neglected chronic illness and disability. Such fulfillment of fundamental psychological needs, alongside the political and financial interests implicated in the dominant approach to MUS as referenced here and detailed elsewhere, may help to elucidate the persistence of (bio)psychosocial hegemony and attendant victim blaming in this field. That is, the construction of MUS as per psychosocial theorising satisfies not only practitioners’ but also society’s need to create and ascribe to a shared reality which is dominated by a belief in a just, meaningful and relatively predictable world, thus fulfilling relational, epistemic and existential needs.
I don’t understand the paper to be arguing for neoliberalist ideology as the sole cause of patient blaming but as one factor which lends discriminatory human impulses ethical cover in many contemporary societies:
Neoliberalism positions individual responsibility, motivation and autonomy as central to achieving health, whilst blaming marginalised persons as masters of their own fate. Equally pertinent is that neoliberalism justifies an (inequitable) social status quo: in promulgating a ‘survival of the most hard working, productive and thus deserving’ narrative, neoliberalism is implicitly underpinned with a deserving/undeserving binary and a just world fallacy that encourages victim blaming narratives.
The author forwards arguments about the psychology of patient blaming. I’m not convinced of the truth of their position by what’s offered but the idea that the dehumanization of disabled people comes from a place of mortal fear feels plausible to me:
The clinical splitting as previously outlined may therefore protect the practitioner’s self not only from epistemic and relational threats, but also from existential threats arising from mainstream notions of disability: threats relating to dependency, deterioration and perhaps, ultimately, death.
 
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