Holistic or harmful? Examining socio-structural factors in biopsychosocial model of chronic illness,‘MUS’& disability, 2022, Hunt

Holistic or harmful? Examining socio-structural factors in the biopsychosocial model of chronic illness, ‘medically unexplained symptoms’ and disability

Joanne Hunt

Abstract
A particular application of the biopsychosocial model is associated in peer-reviewed literature and patient testimony with harms done to chronically ill and disabled people. These harms derive from an empirically unsubstantiated, neoliberal narrative emphasising the role of personal responsibility and effort in ‘recovery’ from ill-health, ignoring socio-structural contributors to chronic illness and disability. Notably, this biopsychosocial model ignores the health-related impact of welfare and disability insurance reforms which the model has been employed to justify. The model and associated interests can thus be recognised as socio-structural phenomena that should be acknowledged in any truly holistic biopsychosocial approach to chronic illness and disability. A critically informed and reflexive approach to biopsychosocial theorising would allow a more holistic and nuanced understanding of chronic illness and disability, with implications for health and social policy that underline and address what ails society as opposed to what is ‘wrong’ with the individual.

• Points of interest
• The biopsychosocial approach suggests that health and illness should be understood ‘holistically’. This means considering not only a person’s biology, but also their psychology (thoughts and behaviour) and social context (for example, social support levels).
  
  
• A particular variant of biopsychosocial model, dominant in UK health and social policy, has been associated with political agendas, predominantly: welfare reform, healthcare spending cuts, and creation of profits for the disability insurance industry.
  
  
• This variant of the model has also been associated with harms experienced by chronically ill and disabled people.
  
  
• Any truly holistic biopsychosocial framework should acknowledge the broader social (here, political) context that has shaped this model and recognise how the model, and associated practices, may contribute to chronic illness and disability.
  
  
• Such a framework gives rise to recommendations for health and social policy and practice that address what is wrong with society as opposed to what is ‘wrong’ with the person.
  
  
  
  https://www.tandfonline.com/doi/abs/10.1080/09687599.2022.2099250?journalCode=cdso20

 

If one were to measure the harm and costs caused by neglecting sick people at the level of whole society, it might end up costing more than what is saved. But nobody has done this kind of calculation I think.

Neglecting sick people soon results in the sick becoming very sick and needing even more care, from their own family, who don't have access to the therapies and knowledge needed to care for patients effectively.

The neglected patients might disappear from the healthcare system for the most part and from statistics but they're still there and part of society. And they could be contributing more to society if some way to treat the illness was found.

 

One small benefit of the zealous application of the BPS model to chronic illness is that we know for a fact what it does all by itself, that is not in addition to competent medical care, but instead of it. And it's a complete disaster, incapable of producing anything useful or competent. It's not even capable of learning, which is an obvious problem when used in research.

It could have been hard to say otherwise, but we know, have known for years in fact. The BPS model is like Disney's Button soup: by itself? just a button, inedible. In a soup with herbs, spices, vegetables and a big bone? The button is irrelevant, unless it melted or something and made the whole soup toxic, which is an apt metaphor.

So it's either useless or superfluous, at best, massively harmful in real life outcome. And it's not surprising, because of course neither psychological nor social issues are actually taken into account here. Instead imaginary concerns are forced through a false attribution error, they are not our concerns, they are merely cheap excuses to blame us personally for the systemic failures of medicine.

So it will be easy to drop this down a very deep shaft once people are ready. The whole thing could be wiped from existence as if it never happened and not only would the world be a better place, absolutely nothing of value would be lost. It would be equivalent to losing astrology, it changes some things, but so superficially it basically doesn't matter.

 

has anyone accessed the full article?

 

further paper

Mapping out a critical psychology of ‘medically unexplained symptoms’: Neoliberalism, academic-state-corporate agendas, and the need to justify the self and the system

Abstract
‘Medically unexplained symptoms’ (MUS) are positioned in mainstream healthcare discourse as an individualistic psychosocial phenomenon.

This positioning occurs through application of a particular variant of the biopsychosocial model that downplays biological influences, foregrounds individualistic psychosocial factors (‘maladaptive’ patient psychology) with little evidential support, and – of central concern to this article - ignores critically informed social and structural influences in health and illness. A counter-narrative to this, drawing upon critical psychology, is that medically unexplained symptoms as per their current conceptualization serve a number of purposes for mainstream institutions, associated actors and society more broadly.

These purposes include reinforcement of, and justification for, a neoliberal agenda of healthcare and welfare retrenchment, in the UK associated with the interests of an ‘academic-state-corporate nexus’ comprising academics (notably psychiatrists), government officials and actors within the disability insurance industry.

It is further argued that 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, the (bio)psychosocial construction of MUS satisfies society’s need to shape and ascribe to a shared reality, dominated by a collective belief in a just, meaningful and relatively predictable world that justifies the societal status quo and bolsters the privilege of subjects who benefit from unjust social structures.

The construct of MUS may therefore reveal more about the psychopathologies of an exclusionary, ableist society than it does about the psychology of people labelled with MUS. Points raised here are highly pertinent to long Covid, notably cases that can be positioned as ‘medically unexplained’.

preprint
pdf

 

Thanks for the summary @Sly Saint , I can't read the whole article at the moment but it seems like a good thing that someone is making these arguments.

 

Skimmed through to see if Hunt at any point defines what she means by “neoliberal”. She doesn’t. Although she says it an awful lot.

Critiques of BPS which adduce loaded terms, and have a pop at 21st century political structures alongside everything else that quite rightly irk them about medicine, are fundamentally unhelpful. They enable the BPS mob to write off their opposition as at best idealists and dogmatists.

And accusing the BPS psychologists of being not just misguided, but pathologically so, also misfires. There’s always a good chance of persuading people that their professional colleagues are barking up the wrong tree, but much less of getting them to accept that those colleagues are plain barking. Even if society is all to blame.

 

I've not read the piece yet, but lots of papers use terms that they don't themselves define, and 'neoliberal' is a pretty widely used term.

I increasingly feel as if it's difficult to address the problems around ME/CFS without addressing the problems with the structures that led to them. At the same time, I also think there's a danger that trying to address those important problems can seem absurd or conspiratorial to many of those we need to try to persuade of our concerns.

It's a difficult one.

edit: Still not read, but Hunt including an appendix with copies of the letters she was referencing is pretty great.

 

Sure, but it’s used by political scientists to describe a particular strand of free market ideology. No one ever calls themselves a neo-liberal. So a definition would have been helpful.

Just as anyone writing about “fatigue”, in this space, should be very precise indeed if they don’t want brickbats.

 

Responding to a deleted post about the term 'holistic'.

Sorry for not seeing the request in August.

In simple terms:

Biopsychosocial = vague bullshit

I see no point, if it is the point, in replacing that with

Holistic = vague bullshit

I don't see either of these terms as having anything useful to contribute to helping sick people. Medicine is about having clear ideas of what you think is wrong and testing ways to make things better using reliable methods before you apply them in practice.

I can see that there are social issues one can discuss but I don't see jargon as getting us much further than admitting that there are a lot of dumb interfering busybodies about who, maybe because they find real medicine too challenging, like to say things like 'psychiatry is for grown-ups' and make a living out of being paternalistic and manipulative and taking backhanders from whoever finds their interfering useful. That probably includes GPs who get rid of difficult patients and insurers who save money.

I doubt it has anything much to do with politics.

 

@Josefina welcome to S4

Its great to have researchers here discussing their work you are very welcome.

Sorry i missed this back in August, i tend to give the psychosocial research threads a wide berth as they tend to say the same crap about sufferers - namely that its our fault & that we are doing whatever it is - thoughts/feelings/behaviour/being alive etc, wrong.

Your paper looks interesting, i hope i'll be well enough to read in soon.

again good to have you here, wishing you well

 

Are you referring to the preprint (mapping out a critical psychology...)? I dedicate over a paragraph to defining neoliberalism.
(Jo Hunt)

 

Neoliberalism is an economics concept and is: shrinking government, including its responsibility for taking care of people in need.

Espouses privatization of everything.


Associated with the Libertarian Party and conservatism in general.

https://en.wikipedia.org/wiki/Neoliberalism

 

Hello.

Yes, the preprint that was posted yesterday. Apologies for missing the definition, if you indicate a page number then I’ll review and reconsider, although I suspect I’ll still end up disagreeing with you on all the main points of your thesis, so fair enough if you don’t bother.

I’m sure there are lots of people here who will have much more time for your approach, though.

 

Not able to read this at the moment but...

This was also briefly discussed on a members only thread, starting here:

https://www.s4me.info/threads/the-d...ft-discussion-thread.16349/page-2#post-281705

 

Was only able to read the abstract of the second paper.

Some of the points seem reasonable ones to me, if they are explained in detail and with reliable references in the paper, but...

On that one I agree with...

 

They do this anyone. I haven't read the paper so not sure of the status of the definition of "neo-liberal." But well-reasoned critiques of social structures that impose disproportionate burdens on the unwell and disadvantaged are important, no matter how others react to them. What does NOT enable the "BPS mob" to write off their opposition?

 

There was a study in Victoria, Australia, a decade or two back. They took homeless people, many of whom have health issues, got them accommodation, health care, guidance, etc. Then they compared that to the typical economic costs. They saved money by helping the homeless. Somebody pays for these issues, not just the people who are homeless, and they save if homeless people are appropriately assisted. I suspect it might be similar for disabled and sick people.