Illness as ‘Deviance’, Work as Glittering Salvation and the ‘Psyching-up’ of the Medical Model: Strategies for Getting The Sick ‘Back To Work’.

by Gill Thorburn

The one thing I am absolutely unreservedly and implacably opposed to in all of this is a real world test.” – Chris Grayling, Minister of State, Department for Work and Pensions, 2011.

An ongoing British government mission of ‘inclusivity’ which has sought to draw into paid employment those previously depicted as ‘excluded’ by conditions of personal circumstance, such as lone mothers, or through lack of ‘skills’ such as NEETS, or to some extent disabled and older claimants, has recently been expanded much further, venturing into territory previously delimited by, and existing under the protection of, certain ‘norms’ – that is the widespread area of sickness and disability. Characteristic of government rhetoric towards an end of ‘including’ the sick and disabled within the work-not-welfare paradigm is the adoption of an ‘abandonment’ discourse when referring to those on long-term health-related benefits (Grayling, quoted in BBC, 2011) – work being posed as their ‘salvation’.

Chris Grayling

It is necessary to concede, first of all, that the right kind of work, with the appropriate support, can contribute to the well-being of those disadvantaged by illness or disability, and afford them at least a share in the positive benefits that accrue to the ‘able-bodied’ from engaging with paid employment. This is particularly in contrast to the poverty level that welfare benefits are set at, it must be added. It is a highly contingent situation, however, and subject to factors beyond their control, such as the concessions employers are willing to make to the irregularities that the physically or mentally impaired worker brings into the workplace, those for whom adaptations or adjustments must be made. Modern employers in a competitive business environment are increasingly disinclined to adapt working conditions to the worker, seeing it as the latter’s responsibility to ‘fit in’ to an established work structure, evidenced in their reported attitude towards young UK adults, perceived as “ill-equipped and poorly prepared to face the working world due to their reluctance to take on menial jobs, especially those involving dirty or monotonous tasks and over-long or anti-social hours”  (Learning and Skills Council, 2006). This is also a tacit admission by employers of the adverse conditions that prevail in the modern workplace.

This wave of inclusivity, then, has now broached an area that, until recent times, had embedded within it certain norms, which could be said to be part of a prevailing ‘humane’ discourse around sickness and disability in our society. For instance the revulsion that is held towards the German Third Reich’s euthanistic program, with its accompanying defamation of the sick and disabled, is illustrative of the sense in which that sector of the populace is acknowledged as vulnerable and deserving of support. Intrinsic to this perception is the notion that the ‘forced independence’ on this group of responsibility for their own wellbeing, through the removal of the social support it relies upon on, would be regarded as a cruelty. Further there is a sense of “there but for the grace of god…” which determines the moral values inherent in these shared norms, and a recognition that infirmity is an inevitable consequence of the aging process which touches all. It is in this sense that until recently the place of work in any ‘illness’ discourse has been marginal and tempered by notions of relevant limitations as to its positive effects.

To contravene these established compassionate norms, then, requires a compelling and strongly persuasive argument, one which is capable of overturning common sense conceptions; that work can cause further difficulties for the sick and disabled, or indeed that work has played a significant part in contributing to illness in the first place. Despite these moral inhibitions, this has now been achieved within the context of welfare policy changes around sickness and disability, and it is an argument which has emerged from a very deliberate theoretical and ideological process. This process has led to the embedding into social policy of the simple, abstract idea that “work is always good for you” (no matter what the circumstances), and has provided the ideological foundation for the implementation of the ‘medicalised bureaucracy’ of the Work Capability Assessment (WCA), administered by the government’s private sub-contractor, Atos Healthcare. The WCA is constructed as a filtering instrument by which those claiming incapacity for work can be ‘streamed’ into categories of; the “work ready”, those “having some barriers to work” and those who are “unlikely to ever be capable of working”. Increasing evidence is accumulating to the effect that this instrument is failing to be fit for purpose (Harrington, 2010; Royston, 2010; Black Triangle, 2011; After Atos; and countless other blogs, campaigns and personal accounts distributed both across the internet, and out on the street1) – unless of course that purpose is to remove welfare from the sick.

If social policies, and the associated bureaucratic procedures through which they are implemented, can be regarded as the visible front-end of government then there is also a corresponding hidden region, where the theories and ideas that lend these policies legitimacy are generated. These theoretical underpinnings are far less likely to be exposed to wider public scrutiny; rather it is accepted on trust that they have substance and arise from authoritative evidence. One set of ideas that has strongly influenced the course of recent reforms has been the deliberate attempt to formulate a ‘New Model Of Illness’ (Waddell and Aylward, 2010), one which the creators assert to be a more appropriate one than the ‘bio-medical’ model, which they claim is an outdated perspective on illness and its relationship to incapacity.

This new approach, a ‘Biopsychosocial’ (BPS) model, originated from the work of George Engel, a trained physician who ‘converted’ from physical to psychosomatic medicine, becoming a leader in the discipline, despite his initial scepticism towards that field. Though there is no definitive text on the theory it is a simple enough concept which reveals its approach in its title. Briefly put, it is a theory that seeks to broaden the perspective on illness, by taking into account not only the biological, but also psychological and social factors which may have an influence on sickness, and consequently on the course that healing takes. The acknowledged value of this approach, when used for the benefit of the patient, is that it allows for the identification of non-biological influences which may interfere with an individual’s capacity to heal. Further indicators of the model’s intended use and objectives can be found in recent re-evaluations taken 25 and 30 years on. With respect to the latter, a Science Daily article (2008) describes it as having posed a ‘challenge’ to the conventional molecular biology perspective, but that it has proven effects through ‘psychotherapeutic strategies’ which facilitate coping and improve quality of life.

Their definition portrays a model which is capable of being tailored to the individual, the assumption being that, once identified, non-biological factors inhibiting healing will be addressed through the accessing of diverse kinds of support that, it is assumed, will be available to the patient. The article also puts significant emphasis on “stressful life events and repeated or chronic environmental challenge in modulating individual vulnerability to illness“, an acknowledgment that these have real effects on a person’s illness, conferring a measure of legitimacy on ‘medically unexplained symptoms’, which it will be seen are afforded a quite different focus within the research which underpins current government policy. The most appropriate use of BPS, it can then be concluded from this, is within healthcare, and amidst a context of widely available services. This quite specific application is confirmed by an earlier re-appraisal, (Borrell-Carrió, 2004) which testifies to its value in clinical assessments, underscoring this context by a defence of its “contribution to the scientific clinical method”. It additionally notes that there is an aspect of BPS which encourages a ‘participatory clinician-patient relationship’, suggestive of an equalising of the power distribution between the two roles “which may not be universally accepted” (presumably by the medical profession). Overall this review, too, emphasises that the value of BPS is as a method which is used according to “the needs of each patient”.

A very different application of this method is found among the material underpinning current government welfare policy that, nevertheless, attempts to substantiate itself through reference to the BPS model. Criticisms exist which argue that theories are open to ‘misreading’ and therefore misapplication, their principles appropriated towards ends which oppose their established purpose. Harvey and Reed (1996), for example, contend that Lewis’ (1969) ‘culture of poverty’ thesis, so widely utilised towards an end of ‘blaming the victim’, was not intended to be a denigration of the poor, but rather proof of their “resilience and resourcefulness … and the cultural defenses they erect against poverty’s everyday uncertainty”.  Similar charges could be laid at the door of those seeking to erect this new model of illness for a purpose that deviates from the strictly clinical ones outlined above. It is the contention of this article that a prime purpose behind recent use of the BPS is to create an artificial distinction between deserving and undeserving sick, through the social construction of a new category of patient/claimant – the illness deviant – in order to facilitate the movement of a high percentage of those claiming illness related benefits off welfare, via the aforementioned WCA.

Due to the shared characteristics of the personnel involved in this project, the public and private sector connections they share (Rutherford, 2007), and the manner in which they have ‘pushed’ the ideas contained within their literature, I propose to refer to them as ‘the BPS lobby’. A leading figure of this movement, Professor Mansel Aylward, formerly Chief Medical Officer with the DWP, is director of the Psychosocial and Disability Centre at Cardiff University, the establishment of which, in 2004, was funded by the global insurance firm, Unum. The body of Aylward’s research and theoretical enquiry, ostensibly via the BPS model, has a peculiarly singular slant considering the diverse nature of that perspective; that is a relentless emphasis on an individual’s ‘beliefs’ and ‘attitudes’ towards their illness (Barnes et al, 2008). In this sense it could more aptly be termed the ‘Psycho’ model of illness, with contributors drawn almost exclusively from within that discipline. Publications exemplifying this bias are too numerous to mention, dominating as it does the lobby’s discourse, but include Aylward’s  co-authored book ‘The Power of Belief’ dedicated to addressing the purported “epidemic of common health problems” that is said to be ‘beleaguering’ British society. A feature of the lobby’s literature in general is the framing of this ‘problem’ in ‘mysterious’ terms, as a ‘paradox’, something unexplainable against a context of the alleged ‘improvement’ in general health of the nation. This assumption it will later be shown, based as it is on a generalisation of data, obscures the uneven distribution of these health benefits across a society stratified by occupation.

A double standard is observable within the BPS lobby’s argument against the legitimacy of ‘symptom-defined illnesses'(such as IBS, stress and back conditions). The medical establishment is asserted to have allowed the growth of ‘syndromes’, which they construct as having less validity than ‘diseases’, counterpoised as having a solid pathological basis. It is strongly ironic, then, that they do not hold psychology to the same criticism, since its epistemology is practically founded on the creation of labels around sets of observed behaviours. Aylward and LoCascio treat us to a round-up of some of the terms that have proliferated in psychology around ‘medically unexplained symptoms’: “hypochondriasis”, “hysteria”, “functional overlay”, “somatisation”, “malingering”, “illness behaviour” etc” (Aylward and LoCascio, 1995,p.19) that they state has been to ‘confusing’ effect. Though some might consider this inconsistency to be evidence of a flaw in that general theory, the authors’ motive in recounting this seems to be more in order to establish that there is something there to ‘psychologise’.

Expectation might be that a balance would be attempted between this focus on the psychology of the individual and that most ‘social’ of all activities – work. This aspect of ‘the social’, though, is almost invisible in the lobby’s publications; work is relegated, or more accurately, elevated, to a distant idea which can be summarised in the simple statement: ‘Work is always good for you’. No further justification for this astonishingly sweeping generalisation is offered than a DWP commissioned ‘independent’ literature review co-authored by one of Aylward’s colleagues at Cardiff, Gordon Waddell (Waddell and Burton, 2006). Though the document contains ‘disclaimers’ which qualify that notion in acknowledgement that work can pose hazards to health for some people under certain circumstances, the overriding message is of the positive values inherent in work, and it seeks to make it strongest case in the linking of ill-health and unemployment, concluding that “Work is generally good for health and well-being”. A ‘pamphlet’ on ‘Work and Health’ by the same authors (Waddell and Burton, 2006b) counterpoise this idea against the constructed notion of ‘Common Health Problems’, this latter term, alongside ‘Medically Unexplained Symptoms’ assuming particular prominence in the BPS lobby’s literature.

The pamphlet, aimed at a very broad audience of “those who deal with health issues at work”, including lawyers, but excluding the worker himself, frames its subject in terms of the ‘problem’ of continuing rates of sickness absence which they assert mainly involve these ‘common health problems’ of musculoskeletal, cardio-respiratory and mental health disorders. The explicit message is that people hold ‘illogical’ beliefs about the causes of their illness, which in any case, contain characteristics experienced by the population as a whole (the majority of whom, it is to be assumed, continue to work regardless) and it seeks, as much of the lobby’s literature does, to break existing conceptual links between ill-health and work. This notion is given full sway within Waddell and Aylward’s ‘Models of Sickness and Disability’ (2010). It is a minimising of ill-health which constructs the majority of the sick and disabled community as ‘deficient’ in some way, through having an ‘abnormal’ perception of their health – an ideological construct which pervades the broad literature of this lobby – the ‘paradox’ being “that so many end up with long-term disability”. Perhaps aware of the perceivable bias in their approach the authors contend that though “there is usually no good medical explanation…we must not jump to the conclusion that it’s malingering.”

This is not an inhibition that is demonstrated within a particular collaboration which brings together through contribution, but also in acknowledgements and references, many of the high profile individuals, such as Aylward and Waddell, who have been involved in directing the course of recent work-as-welfare policies for the sick and disabled (Rutherford, 2007), or have generally provided a major influence on official and public perceptions of certain illnesses. It is the ‘big book’ of ‘Malingering and Illness Deception’ (Halligan et al, 2003). This is a volume which can only be described as remorselessly zealous in the pursuit of its topic, so heavily belaboured is the message that deception is rife among humans, and the sick are no exception. It marshals every possible argument, covering a span from history to neuroscience, drawing even upon child development theories and the vague, unproven proposition, via primate studies, that ‘feigning’ sickness may be embedded into our very evolution.

The treatment is so ‘thick’, the overall impression contributing to a sense of paranoia about deception around every corner, that, were it a human, one would expect it to be wearing a tinfoil hat. But, fear not, reassurance is on hand in the form of the closing section, which focuses on the progress made in ‘deception detection’ and the news that neuroscience may be on the verge of developing scanning technology with which to indentify lying activity in the brain. This publication seems to have been welcomed by the ‘psycho’ professions, with one reviewer from that field expressing delight at the way the book “gets off to a cracking start” (Fleminger, 2004), almost as if it was a bestselling thriller, rather than the purported exposition of a serious issue for the medical profession. Somewhat unseemly for a professional to express such glee at the fact that “many of our patients may be deceiving us, and that much of this deception may be conscious“. Fleminger particularly seems to relish Wessely’s “delightful tour of the history of malingering”, concluding that though the book is not likely to be of any help in detecting deceit, readers will have been “entertained and educated“. In this sense, considering the ostensibly serious tone of the book, perhaps there is an aspect of it, with respect to certain of its target readership, which is acting as a ‘dogwhistle’, encouraging and reinforcing scepticism, doubt and cynicism of professionals towards those in their care.

The BPS model is consistently deployed in the framing by this group, across the span of their publications, of an ‘illness deviance’, its principles drawn upon to emphasise the (flawed) ‘subjectivity’ of those suffering ill-health in a way which seeks to undermine their credibility, asserting that there has been a proliferation of ‘medically unexplained symptoms’, juxtaposed against the notion that the majority of health problems are ‘common’, and therefore experienced ‘commonly’ within everyday human experience by most people. This purpose could not be further from the intent of its originator who declared that “[M]any illnesses are largely subjective – at least until we as observers discover the parameters and framework within which we can also make objective observations. Hyperparathyroidism, in many of its manifestations, was a purely subjective experience for many patients until we discovered what to look for and which instruments to use in the search”. (Engel, 1961). Engel further sounds a cautionary note for those involved in the production of new knowledge: qualifying a definition of research as “to see what everyone else has seen and think what nobody else has thought” with a caution not to fall into the trap of thinking that the ‘new’ thought is necessarily any more correct. It is something perhaps that the BPS lobby might well have borne in mind considering the serious effects their ‘theories’ are now having on the lives of the sick and disabled 1.

One initial area of illness which has been exposed to the notion of the ‘medically unexplained’ is that of conditions of the lower back, symptomatically presenting as an individual’s subjective experiencing of pain, and therefore incapacity, in that region, without, it is asserted, any detectable underlying physical pathology. A leading figure from within the BPS lobby in this topic is Gordon Waddell, whose publications, notably his ‘Back Pain Revolution’ (2004), have become key sources in the referencing of ‘medically unexplained symptoms’. Revealingly, his work is referenced over fifty times within the aforementioned ‘Malingering’ book. Of note in this regard is Waddells’ attempt to distance his work, specifically his diagnostic tool, ‘Waddells’ Signs’, which has acquired a reputation for use in discrediting litigants in industrial negligence cases (Gelman and Brazin, 2000; Personal Injury News, 2008) from any notion that it intends to prove malingering. The fact that this disclaimer is reported within the book on malingering itself lends a certain irony to the situation. Much of Waddell’s, and his colleagues’, literature centres, as discussed, around ‘medically unexplained symptoms’, and the assertion of no underlying physical pathology. Implicit within this perspective is a strangely unscientific notion that the existing state of medical knowledge/technology is the final word diagnostically, contrasting with Engel’s insight that medical science often needs to ‘catch up’ with subjective patient experience, through the development of new ‘instruments’. It is just such an occurrence which now casts doubt upon the dismissing of musculoskeletal disorders as lacking detectable pathology. Recent developments in medical technology (University of Aberdeen, 2000) have highlighted the limitations of conventional MRI in detecting the physical causes of musculoskeletal conditions, a category that takes centre stage among the BPS lobby’s ‘medically unexplained’ disorders. Under conventional, non-weight-bearing MRI “the conditions under which symptoms arise are often not reproduced” due to the patient lying down. (Group Health, 2010). New ‘weight-bearing’ i.e. upright MRI technology is proving to have a superior capacity in more accurately identifying the pathologies behind these conditions.

For all the BPS lobby’s assertion that theirs is a more explanatory model of illness their usage of BPS is very unbalanced in favour of its psychological (and therefore, individualised) roots, at the expense of the ‘social’. Yet it is in that sphere where a much more convincing argument for a cause in the rise in musculoskeletal disorders can be found, whether or not the technology yet exists to ‘detect’ them; that is in the changes that have occurred in work practices, conditions and environments, particularly for the low-waged. Within Aylward et al’s conceptual framework the social practice of work is awarded an uncritically positive value (Waddell and Burton, 2006) as opposed to the immense range of activities that constitute it in the ‘real world’ (Dean, 2010), or the diversity of experiences a worker may encounter in the contemporary unequal spread of benefits across the ‘division of labour’. Supporting a competing notion of the effects of work on wellbeing the Cardiff and Oxford Universities based ESRC Centre on Skills, Knowledge and Organisational Performance (SKOPE) has conducted substantial research into ‘bad jobs’ (Payne, 2011). A volume of their findings on working conditions experienced across a range of low paid employment was published in the U.S (Lloyd et al, 2008) as part of a project to assess this sector of the working population across selected European countries and America. A chapter on the food processing industry, which accounts for 13% of manufacturing in the UK, employing over 400,000 workers, offers a far more rational framework for the ‘unexplained’ rise in musculoskeletal disorders, than some perceived psychological defect which causes sufferers to ‘amplify’ or ‘magnify’ their symptoms. The researchers observed that in this sector “working conditions can be both extremely unpleasant (e.g. meat processing plants) as well as harmful to health and safety. Repetitive work routines that are physically demanding … can often result in injuries to the back, neck, hands and shoulders” adding that employees can be under pressure to “work long hours to make up their pay”, and that ‘gruelling’ ten hour shifts” (James and Lloyd, 2008) are common in this intensified work environment.

It is clearly evident within this and other accounts, both in the book and elsewhere (Acquiar and Herod, 2006), of the frequency with which low paid workers must submit to adverse conditions, that modern working practices and conditions are likely to have substantially contributed to the rise in so-called ‘common health problems’, with the high numbers of sufferers from these conditions completely consistent with the fact “there remains a significant number of low paid jobs (about 22% of the UK workforce) and in some instances the numbers are growing, particularly in parts of the service sector” (Lloyd et al, 2008). Consecutive chapters of the book deal with the negative implications for health of various types of low paid work, including that of hotels, retailing, hospitals, food processing and call centres. The strain of call centre work is described as being due to “the combination of high work pressure and limited autonomy”…which results in “high levels of stress…“, while the public hospital is revealed to be a place where “one in five assistant nurses and three in five cleaners are estimated to be paid below the low pay threshold”, a more convincing explanation for the rise in stress-related disorders than the BPS lobby’s ‘individualised’ concept that it arises from the ‘wrong attitude’, dismissing it as the “medicalisation of dissatisfaction”‘ (O’Donnell and Bevan, 2004). This latter term is contestable by the counter claim that there has been a ‘psychologising of work-related illness’, which process it has been the purpose of this article to highlight. The labelling game is not difficult to play, but it reveals little more than the bias of the writer, and their penchant for the ‘overarching phrase’. As journalistic investigations into low paid work, undertaken through participant observation (Ehrenreich, 2002; Toynbee, 2003; Pai, 2008) have revealed, it is more usually the case that low-paid workers are often extremely industrious, of necessity enduring harsh conditions that accompany what is regarded as low-skilled work. It is an image that is more consistent with a worker who ‘works till they drop’ than one who is deterred from working by the ‘subjective’ experience of ‘mild to moderate common health problems’ that other ‘normal’ workers are inclined to overlook.

Selective use of data can provide a misleading impression, and there is a weakness inherent in the BPS lobby’s argument that a ‘paradox’ exists between, on the one hand, “improvements in healthcare and objective measures of health” that they assert proof that ‘everyone is getting healthier’ and on the other the ‘mysterious’ rise in long-term illness (Waddell and Aylward, 2010). Data has long been available to governments, and indeed has often been uncovered by their own commissioned research, on the differing effects of work on health according to occupation (Jones, 2001) and consequently the unequal distribution of health benefits with regard to work. Substantiating the existence of a “class-related health gradient”, evidence from government commissioned reports from 1980 and 1998 (Dept of Health and Social Security, 1980; Acheson, 1998), testifies to continuing, and increasingly marked, disparities in health between socio-economic classes differentiated by occupation. The difference in incidences of disease between those at the top of the occupation hierarchy and those at the bottom were shown to be significant, the likelihood of male professionals contracting a long-term illness between the ages of 44-64 stood at 17% while for those in the lowest group it was 48%. The falling death rate was also shown to favour the higher classes, with a greater number surviving until retirement age. This faster decline in mortality rates among the better off has continued with a widening of disparity between highest and lowest on the occupational scale. In the 1970s mortality was twice as high for men at the lowest end than at the highest, growing to three times higher by the beginning of this century. All the more surprising, then, to find the esteemed professor Aylward declaring in 2006 that though “some jobs are still poorly paid, toxic and unsafe…there are fewer of these jobs now than there were 20 years ago” (Brindley, 2006). This astonishing inversion of fact is all the more alarming considering Aylward’s extended career in government office since 1966; as chief adviser, medical director and chief scientist to the Department for Work and Pensions (Basini, 2004); one which surely must have brought him into frequent contact with these facts.

Within government discourse ‘Work’ features only abstractly, functioning as a ‘glittering generality’ in that it is vaguely, if at all, defined, and afforded only positive value. Abstract concepts, as Orwell stated (1946), can have many irreconcilable meanings, and consequently, he contends, the simplistic statements that contain them, such as ‘Work is always good for you’ are very rarely employed without the intent to deceive.

Despite the government’s reluctance, or, more accurately, refusal, to elaborate on their concept of work (Grayling, 2011), aside from ascribing to it a universally positive value, there is a very specific construction of it within official literature. Analysis of the level of ‘capabilities’ which government perceives as required to sustain a worker in employment reveal an astonishingly narrow conception of the modern workplace or of the conditions that workers are likely to encounter or need to withstand. In light of the foregoing evidence that a large sector of the workforce is compelled to work in conditions of excessive physical and mental strain it is incomprehensible to find such statements as: “Bending and Kneeling: This activity represents an unnecessary requirement for the workplace.” (DWP, 2009, p.19) This will certainly come as startling news to the veritable army of cleaners whose essential maintenance of hospitals, hotels, shops and offices, entails their employment in vast numbers, or indeed others in that ‘unskilled’ quarter of the workforce for whom bending, turning, kneeling, is not merely repetitive but intensively so. Similar examples abound in this literature, some having become notorious among the sick and disabled for their facile allusions towards what work involves, such as the ‘capability’ to “pick up a £1 coin with either hand” (DWP, 2009, p.22) which tiny activity, achievable even for amputees, is then submitted towards evidence that the claimant is ‘fit for work’.

Among Atos’ training materials one specific document compares the roles of GPs/Clinicians against that required of their ‘Disability Analysts’ (Atos Origin, 2004). The GP’s described role is as would be expected, focusing on diagnosis and treatment and the formal use of their skills and knowledge, and stressing the ‘best interests’ of the patient. The literature is at great pains to emphasise the different standpoint which analysts (who are recruited from within the medical professions) must take towards their subject. It is made clear that their role is not to act as the patient’s advocate, but contrariwise, to submit them to surveillance, an activity which, by dictionary definition, carries with it connotations of suspicion. The Analyst is directed to take a very different attitude towards the patient, one which reveals a stark contrast in the way they are to be regarded and treated. The stated objective is assessing ‘functional’ capability/limitations with ‘objectivity’. The method described is one of close detailed scrutiny, attaching great importance to ‘informal observations’, and advising vigilance with respect to exposing ‘inconsistencies’ and “findings which do not indicate disease”. This approach is highly unlikely to produce the ‘objectivity’ to which it lays claim, in its biased focus on revealing ways in which the subject’s behaviour contradicts their assertions about their condition.

Similar evidence of the ‘loaded’ nature of instructions within the literature governing this process can be found on the government side, within the DWP’s ‘Training & Development ESA Handbook (2008). Blatant instructions are given to explicitly search for evidence which contradicts the claimant’s account. The discourse may be couched in the language of ‘objectivity’ but it is clearly evident what form that objectivity is expected to take, which is to minimise or play down the claimant’s incapacity. An illustrative sample can be found in this instruction from the Handbook: “Avoid making a statement such as “Can only walk 50 metres” as this may well be taken as fact by the Decision Maker or the Appeal Tribunal. Better would be; “Says he only walks 50 metres”, then give an example of what the claimant actually does, as far as walking is concerned, on an average day: “Walks to the shops and back (about 200 metres in all) but says he has to stop at least twice due to back pain”. (DWP, 2008, p.41). Here the claimant’s account is contradictorily afforded two opposing values at the same time; their own estimation when directly asked, and a competing one derived from ‘informal’ questioning about daily activities. This method bears more in common with police interrogation of a suspected criminal, when through persistent probing the subject finally displays an inconsistency which incriminates him. Though both pieces of testimony (either one of which may contain errors) are afforded authenticity by originating from the claimant’s ‘own account’ a greater veracity is ascribed to the one which can be used as evidence of ‘fitness for work’. There appears to be no equivalent instruction to garner evidence which might work in the claimant’s favour in any of this literature, neither is it implicit within the texts.

It is not only the patient/claimant who can be constructed as ‘deviant’ within this new BPS and government discourse. The traditionally sacrosanct medical authority of GPs is being undermined through suggestions that they may be prone to ‘collude’ with patients for a variety of reasons (Halligan et al, 2003b, p.19; Wessely, 2007). Advice targeting doctors charged with filling in forms for DLA/AA (Disability Living Allowance/Attendance Allowance) bears an uncanny resemblance to that embedded within the WCA and ESA regulations: “Are regular scripts being ordered?” introduces the idea that the patient can be ‘caught out’ if their medication intake is not consistent with their condition. Examples of suggested wording leave little ambiguity regarding which aspects of patient behaviour the health professional should focus on “eg rose unaided from a chair in the surgery, no bending difficulty.” (DWP, 2008b) The stubborn resistance of GPs who remain committed to a code of ethics (McCartney, 2011) which prioritises advocacy of the patient, provide something of an obstacle to the intended ‘paradigm shift’ envisaged by the lobby. Among materials aimed at removing this include those which caution them against making ‘false attributions’ of illness to work (Waddell, 2006c), or contend that “sick certification is a major therapeutic intervention“, and play on the idea of a benefits “culture” (with accompanying stereotypical cartoon), the latter form of construction as has been described, being frequently deployed to ‘blame the victim’. The shift that they seek to bring about in general practice is a transformation away from the notion that “Work is a risk, and potentially harmful” towards “Work is healthy, and therapeutic” (Waddell, 2006c).

A noteworthy feature of the BPS lobby is the opportunistic aspect of their methods, drawing alternately, and selectively, from the fields of medicine, sociology and psychology those elements which best suit their purpose. The authority historically bestowed upon bio-medicine is drawn upon to underpin the legitimacy of their point of view – they are ‘experts’-

a presumption underscored by their frequent holding of titles such as ‘Chief Medical Officer’, whether in the public or private sector. This is the full extent of bio-medicine’s usefulness to the lobby as, outside of that legitimising function, they are at pains to present it as an inferior ‘model’ of modern illness. Concepts from sociology such as ‘illness behaviour’ and ‘the sick role‘ are deployed to support the idea that there are ‘gains’ or ‘rewards’ associated with being ill. Conscious, no doubt, of the social unacceptability of the suggestion that all sick and disabled people are malingerers, there is then the attempt to construct a ‘softer’ variant of the illness deviant via psychology. This individual is more by way of being an ‘accidental’ malingerer, subject to a form of self-deception, in which they harbour ‘irrational’ beliefs about their condition, and how it affects their ‘functioning’ or ‘capabilities’. This deviant also holds similar mistaken attitudes towards work in that they make ‘false attributions’ towards it as the source of their illness or potential cause of further suffering, and fail to realise it is the only means by which they can heal. Once these have been posed as the ‘problem’ and ‘solution’, a process in which sufferers are invariably found ‘fit for work’ can justify a snatching away of the crutches of benefit support through a doublespeak discourse reframing such support as ‘abandonment’ and redefining this actual form of abandonment as ‘rescue’.

This peculiarly  ‘messianic’ use of the concept of work, and the explicit bias of the WCA, with its excessive numbers of the sick ‘found fit’, has prompted some disabled activists to resort to parody, through an irreverent depiction of the ‘miracle cures’ of Atos (Atos Miracles; Holmey, 2011). It is through a more sombre parallel, though, that the harmful and defamatory nature of the BPS lobby’s material can be exposed. Those activists who have adopted the symbol of the ‘Black Triangle’, with its connotations of a sick and disabled community that were vilified through their depiction as arbeitsscheu (work-shy), also remind us that a means by which that regime concealed their abuses was through an emphasis on the idea of the supposedly ‘liberating’ potential of work. The most deplorable aspect of the dominance of this official discourse has been the way in which it works to conceal the real nature of sickness and disability, and the hard work that sufferers must already do to bridge the gap between their impairments and an involvement in everyday life which the able-bodied take for granted. But it is a discourse, hopefully, whose days are numbered as increasing numbers of that community ‘find their voice’ (Marsh, S; Campbell et al, 2012) and assemble themselves around a counter narrative which promises to shatter the grievously false image which has been imposed upon them.


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Basini, M. (2004) Western Mail, Cardiff, 12 July.

BBC News (2011) Grayling quoted in ‘Benefit applicants – ‘75% fit to work or drop claims’. BBC News [online] Available at: (Accessed: 30 December 2011).

benefitsclaimantsfightback. (2011) ‘Atos Origin Protests Across the UK – full round up’. Available at: (Accessed: 05 January 2012).

Black Triangle (2011) Black Triangle – Anti-Defamation Campaign in Defence of Disabled Claimants. Available at: (Accessed: 23 December 2011).

Borrell-Carrió, F., Suchman. A. L., and Epstein, R. M. (2004) ‘The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific Inquiry’. Annals of Family Medicine, 2 (6).

Brindley, M. (2006) ‘Boring, hard and a chore but work makes us happy’.Western Mail, Cardiff. 15 September.

Campbell, S. J., Anon, ME., Marsh, S., Franklin, K., Gaffney, D., Anon., Dixon, M., James, L., Barnett-Cormack, S., Fon-James, R., Willis, D. and Anon (2012) ‘Responsible Reform: A Report on the proposed changes to Disability Living Allowance'(The Spartacus Report). Available at: (Accessed: 10 January 2012).

Dean, H. (2010) ‘From work to welfare?: reconstructing the liberal political discourse.’ In: Social Policy Association Annual Conference, Social policy in times of change, 5-7 July, University of Lincoln. Available at: (Accessed: 05 January 2012).

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James, S. and Lloyd, C. (2008) ‘Supply chain Pressures and Migrant Workers: Deteriorating Job Quality in the United Kingdom Food-Processing Industry’ in Lloyd, C., Mason, G. And Mayhew, K. (2008) (eds) Low-Wage Work in The United Kingdom. New York: The Russell Sage Foundation.

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Lloyd, C., Mason, G. And Mayhew, K. (2008) (eds) Low-Wage Work in The United Kingdom. New York: The Russell Sage Foundation.

Marsh, S. (2012) ‘Spartacus Report – Day 2’. Diary of a Benefit Scrounger. Available at: (Accessed: 10 January 2012).

McCartney, M. (2011) ‘Well Enough To Work?’. British Medical Journal, 342. Available online at: (Accessed: 20 December 2011).

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Royston, S. (2010) ‘Not Working: CAB Evidence on the ESA Work Capability Assessment’. London: Citizens Advice Bureau.

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Waddell, G. (2004) The Back Pain Revolution. Churchill Livingstone.

Waddell, G. And Burton, K. (2006) ‘Is Work Good For Your Health and Well-Being?’London: The Stationery Office.

Waddell, G. and Burton, K. (2006b) Work and Health: Changing How We Think About Common Health Problems’. London:The Stationery Office. Also available at: (Accessed: 28 December 2011).

Waddell, (2006c) ‘Health, work & well-being’ [Powerpoint presentation], Centre for Psychosocial & Disability Research, Cardiff. Available at: (Accessed: 23 December 2011).

Waddell, G. and Aylward, M. (2010) Models of Sickness and Disability: Applied to Common Health Problems. London: The Royal Society of Medicine Press Ltd.

Wessely, S. (2007) ‘Why and When do Doctors Collude with their Patients?’, in O’Donnell, M. Mind Over Matter: Exploring the issues of Mental Health. Unum Chief Medical Officer’s Report 2007.


1 Accounts of deaths and suicides directly connected to Atos Assessments:

Scotsman (2010) ‘Author’s suicide ‘due to slash in benefits’. The Scotsman, 23 July. Available at:

Black Triangle Campaign ‘Calums List – NOW 17 DWP “Welfare Reform & Unemployment Deaths”. Available at:

Anderson, G. (2011a) ‘Stress of Tory benefits killed our dad, family claims’. Sunday Mirror. Available at:

Gentleman, A. (2011b) ‘Atos case study: Larry Newman. The Guardian, 24 July. Available at:

Gentleman, A. (2011c) ‘The medical was an absolute joke’. The Guardian, 23 February. Available at:

WhyWaitForever (2011) ‘DWP ESA Medical Examinations’. Available at:

(All Accessed: 04 January 2012).

2 The ‘friending’ system of social networking has facilitated the growth of groups which are accumulating condemning evidence against the WCA. Numerous dedicated blogs and forums testify to the considerable, and increasing, need it has created among the sick and disabled for support and advice. A corresponding amount of ‘real-world’ activity is also occurring as sick and disabled people have ‘taken to the streets’ to try and highlight the adverse effects of the benefit changes (benefitsclaimantsfightback, 2011), though these actions are seldom reported in the mainstream media. All in all a substantial social movement is taking shape, whose participants are, understandably, aggrieved and outraged at the government’s actions.

Reports by charities, and advocacy groups, including the Citizens Advice Bureau (Royston, 2011), those representing specific conditions, and regional organisations testify to widespread suffering of the sick and disabled who have been wrongly assessed as able to work. Some agencies have been overwhelmed by the volume of people seeking aid and requesting representation at tribunals (Independent Resource Centre, 2011), leaving some people with nowhere to turn for help. The WCA also drew strong criticism from the Work and Pensions Select Committee (HOC, 2011), where many of its systemic flaws were highlighted, and from Professor Paul Gregg, one of the architects of the new welfare system, who has called it “badly malfunctioning” and “a complete mess”.

86 Responses to Illness as ‘Deviance’, Work as Glittering Salvation and the ‘Psyching-up’ of the Medical Model: Strategies for Getting The Sick ‘Back To Work’.

  1. Sam says:

    Thank you very much for for this.

    I have been trying to write about it but am too ill to do it so clearly.

    I am happy to find that someone else has written it all down.

    They have been using ME/CFS as a model for definitional creep for sometime.

    The jump is always from ‘medically unexplained physical symptoms’ to ‘pscyhological causation’ and/or then to ‘malingering’.

    Horrifying – I wake up everyday with a pit of fear in my stomach because of this stuff.

  2. Peter Kemp says:

    Being a UK citizen has some disadvantages when it comes to considering the incredible mess that has been made of solving Chronic Fatigue Syndrome (CFS).

    Having the National Health Service (NHS) means that the importance and influence of medical/disability insurance is not always so readily appreciated.

    Though it may seem contradictory, I believe this may make the UK an attractive target for insurance companies should they wish to exert influence over CFS policies. This is because in countries like the USA, although insurance companies may already have established links to healthcare providers, those providers in turn, have knowledge and experience of the kind of pressures that vested interests could exert. Forewarned is forearmed, as they say.

    In the UK, however, doctors may see patients with insurance claims as a small minority of their medical practice. They may encounter pharmaceutical company reps on a daily basis, and be familiar with the strategies they employ. But they may be less prepared to notice, let alone look for, opinions that could be influenced by the vested interests of health insurance companies. This may be especially so when such influences reach them indirectly; i.e. via medical journals or the media.

    Similarly, patients who do not have private health insurance might find it difficult to see how companies that have nothing to do with them, might want to exert influence over their diagnosis and treatment.

    Very often the opinions about CFS that describe it as ‘psychosocial’ or ‘biopsychosocial’ (e.g. the ‘wessely school’); originate from or are repeated by people that have connections to the health insurance industry. Knowing and understanding the implications of these connections might give some people pause for thought.

    As Margaret Williams quoted from the Gibson Parliamentary Group Report of 2006: ‘“There have been numerous cases where advisors (on ME/CFS) have also had consultancy roles in medical insurance companies. Given the vested interest private medical insurance companies have in ensuring CFS/ME remains classified as a psychological illness, there is blatant conflict of interest here. The Group finds this to be an area for serious concern and recommends a full investigation by the appropriate standards body”.

    Click to access FACTS_re_GET.pdf

    It might be interesting if it were possible to answer the questions:

    If the insurance industry had no connection or influence with anyone connected to the DWP, the MRC, the Dept of Health, NICE, the CMO; in fact if there was no health insurance industry at all – would things be better for people with CFS?

    If there were no health insurance industry, would CFS research funding be on a par with MS research; i.e. 67.5 times higher? (assuming prevalence of CFS 2.5 times higher than MS and estimated NIH budget for 2012:

    If there were no health insurance industry, would CFS patients have less occasion to complain about abuse from medical personnel, benefits agencies and the media?

    If there were no health insurance industry, could the causes of CFS and authentic treatments have been discovered by now, saving untold suffering for many people for years on end?

    If there were no health insurance industry would it be ‘M.E.’ and a number of other rational diagnoses, with the derisory name ‘CFS’ never being concocted at all?

    I wish I knew the answers, but must settle for concluding with a quote from Marshall, Williams and Hooper:

    “The incidence of ME / ICD-CFS is known to be rising: in April 1994, the insurance company UNUM (one of the largest disability insurers) reported that in the five years from 1989 – 1993, mens’ disability claims for CFS increased 360%, whilst womens’ claims for CFS increased 557%. No other disease category surpassed these rates of increase. In order of insurance costs, ME/ICD-CFS came second in the list of the five most expensive chronic conditions, being three places above AIDS.”

  3. Tig says:

    A great piece of research. Thank you.

    Last year DWP published a survey that was misrepresented by most of the media and embedded in people’s minds the ‘fact’ that work as good for you.

    The survey? A set of leading questions, biased tick boxes – a travesty of a survey. It reported on the general public’s view of whether or not work was good for disabled people. And, assisted by the appalling questionnaire plus the preliminary spin across the media about benefit scroungers, the answer was an overwhelming yes.

    The chinese whispers converted this, with help from DWP’s wording, into ‘a survey showed that work is good for disabled people.’
    I pointed out to the BBC that this was just a summary of opinions from unqualified people, and I asked DWP why they funded it. No answer.

  4. Gill says:

    I’m learning a lot from these comments. Angela, grateful for your input on BPS. I didn’t feel qualified to critique that approach other than to try and obtain a general impression about its application (which as you saw seemed to indicate a value in a clinical setting, with the proviso that there were accessible resources to address what could be seen as problems which complicate illness recovery). Now, perhaps its worth me looking into whether in itself it has any validity or is just another way of distracting from the physicality of illness (and its sources/causes).

  5. Gill says:

    Henry, yes I know I did present it as something recent :/
    though I tried to indicate that this was a widening out of a process to encompass the whole of the sick/disabled community. About the M.E situation as I said recently on facebook:

    “One reason that I haven’t written anything around M.E is that it would be a Very Big Job because it has a long history, is full of (appalling) personal narratives on the one hand, legitimate (yet ignored) medical research on the other, and of course the disinformation propogated by Wessely and his ilk opposing that. Because there has been so much activity already, even consistent attempts to raise the issue politically by serious academics (like Professor Hooper) I feel less qualified to tackle it. Its hard to know what else can be done when so much has fallen on deaf ears, so to speak.”
    I’m glad you brought up that issue here, Henry 🙂
    I *will* try and find time to read up on Professor Hooper’s work!

  6. Gill says:

    Lots of good points, Fred. When you describe all those rapid changes that have taken place in our environments, and their potentially cumulative effects on our health, it just highlights how ‘crazy’ the ideas of the BPS lobby are. That they are prepared to reach back into the past, resurrecting discredited Freudian ideas of hysteria etc, in order to avoid physical truths such as that, can only be viewed as an act of desperation. There’s a horrible sense of it fitting in with a desire on the part of those in power to reverse social progress and return us to a time characterised by ignorance, injustice and mass deprivation. Bring on the asylums, the workhouses, and the hangman…

  7. Gill says:

    Sincere thanks to *everybody* who has contributed material here. Some of which I was aware, but didn’t have space to go into within the article, some new to me such as Tig’s account of the ‘survey’. On the latter you mention the BBC, and I don’t know if you are aware that there was an FOI to them which refered to a brief exposé they had broadcast in 2007 about Unum and their influence on our government’s welfare reforms.

    The FOI requested the BBC to disclose certain documents refered to in the piece, in which Unum boasted about “driving government policy”. It also asked whether in light of further evidence to the effect that this company’s influence was even more deeply embedded in policy-making they would renew their investigations.

    The BBC refused citing that they were exempt from having to comply with that. As I note in the comments (on the FOI) it took them seven visits to my blog where I had posted the transcript to decide this. They completely ignored the second part of the request about whether they would re-investigate Unum.

  8. Sam says:

    Hysteria is still listed in the Diagnostic and Sattistical Manual of the American Psychiatric Association (DSM). It is now called ‘Functional Neurological Disorder’.

    The new DSM is due out in May this year and there is an attempt to alighn it with the WHO International Classification of Diseases (ICD).

    One of the big impacts of the BPS model is that the psychologisation of illnesses with complex and unclear aetiology will lead to people gaining a diagnosis of one of several indistinct and unprooven categories in the DSM such as Functional Neurological Disorder or, more alarmingly, the very wide category of Complex Somatic Symptom Disorder.

    This will prevent people getting proper tretment and will, I believe, eventually errode biomedical research even further and lead to marginalised illnesses being re-coded in the ICD as purely psychological.

    This is the list of proposed categories and definitions for the forthcoming DSM:

  9. Paul says:

    This indeed is an an excellent article and a very good and mature debate in the tread – though I take issue with the poster who challenged ‘eveidence based medicine’.

    I know freinds who have sufferd at the hands of ATOS precisely because ATOS do not use a serious medically professional evidence based aproach. Instead its a humiliating tick box exercise designed to see if you can stack shelves.

  10. Alex Young aka alex3619 says:

    Hi Paul, the thing that is not clear is that evidence based medicine is also a tick box approach. They do not use the evidence, just the evidence that is on their approved checklist. Any and all contrary evidence that is not on the checklist is ignored and they recommend typically that none of it is tested for. This is cookbook medicine. As a counter-argument they claim its only a guide. However the number of doctors who have been in big trouble because they didn’t follow this “guide” is growing.

    Very large numbers of doctors and scientists are starting to say the same thing. How large? I don’t know, it could still be a small minority because my sample could be biased by what I am looking for.

    I will be writing several blogs on the evidence and published literature against EBM, BPS and CBT/GET at some point in the coming year or two.

    Evidence based medicine has been called Zombie Science for a reason. Its not me who invented that. Its leading medical academics.

    Bye, Alex

  11. Stephen Lee Mowat says:

    This is an excellent article, I’d have to read it a few times more. Wish someone could make such a good study on how to close the tax loopholes for the multi millionaires working here and stashing their tax free British earnings in offshore accounts so there would be no attacks on welfare in the first place. Really good piece. Well done Gill.

  12. wisden says:

    A new survey shows that Britons are ‘more dishonest than 10 years ago’ – but less tolerant of benefit fraud…

    People were asked whether they could justify avoiding paying for public transport, keeping money found in the street, throwing litter and lying, etc. ‘The proportion who said picking up money found in the street was never justified dropped from almost 40% a decade ago to less than 20% – while just one in three were prepared to condemn lying in their own interests’ … ‘while 78% of people condemned benefit fraud in 2000, this had risen to 85% in 2011.’

    Good luck with your campaign.

  13. Suzy Chapman says:

    Sam, I hope you won’t mind my clarifying and expanding a little on your comments.

    The original publication date had been May 2012 but DSM-5 is currently scheduled for publication in May 2013 – so over a year to go before the final version is released.

    There have been two public review and comment exercises on draft proposals for changes to DSM-IV categories and criteria. A third draft had been timelined for release for January-February, this year, but this has been delayed because some of the DSM-5 field trials are running behind schedule and won’t complete until March.

    This third release of draft proposals is now expected to be posted on the APA’s DSM-5 Development website for public review and comment, “no later than May 2012,” according to DSM-5 Task Force Vice-chair, Darrel Regier, MD. So there will be another opportunity to submit comment this Spring (though this is seen by some as little more than a public relations exercise, given the late stage in the criteria and text drafting process).

    You’ve said that the DSM-IV category “Hysteria” is now called “Functional Neurological Disorder”.

    This is indeed a proposed category that needs scrutiny [1] [2].

    The proposed new name, “Functional Neurological Disorder” (which is still under discussion) for what is currently known as “Conversion disorder” [#300.11] in DSM-IV-TR, is under discussion for potential placement under “Dissociative Disorders” (under which class it is located within Chapter V of ICD-10), as opposed to retention under the proposed section “Somatic Symptom Disorders” [2] [3].

    You’ve said “…there is an attempt to align it with the WHO International Classification of Diseases (ICD)”.

    It needs to be understood that the APA participates with the WHO in the “International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders” and a “DSM-ICD Harmonization Coordination Group.”

    There is already a degree of correspondence between some existing DSM-IV categories and Chapter V categories in ICD-10. For the next editions, the APA and the WHO have committed as far as possible:

    “To facilitate the achievement of the highest possible extent of uniformity and harmonization between ICD-11 mental and behavioural disorders and DSM-V disorders and their diagnostic criteria.” with the objective that, “The WHO and APA should make all attempts to ensure that in their core versions, the category names, glossary descriptions and criteria are identical for ICD and DSM.”

    WHO acknowledges that there may be areas where congruency may not be achievable between the two systems. So this is a joint commitment.

    This (simplified) Table “Current DSM-IV Codes and Categories for Somatoform Disorders and ICD-10 Equivalents” sets out how the two classification systems (DSM-IV and ICD-10) currently correspond for their respective “Somatoform Disorders” sections.

    (Note: The US specific “clinical modification” of ICD-10, ICD-10-CM, is scheduled for implementation in October 2013. Proposals for ICD-10-CM “Somatoform Disorders” categories are little changed from those in ICD-10, from which ICD-10-CM has been developed.)

    The framework the DSM-5 “Somatic Symptom Disorders” Work Group is currently proposing, if approved, would effect a major restructuring of the “Somatoform Disorders” section.

    WHO has strict taxonomic rules for ICD codings and classifications. It is difficult to see how congruency between the corresponding sections of the two classification systems might be achieved under current proposals for this section of DSM-5 and how ICD Revision might accommodate these radical proposals to combine a number of existing categories under a new rubric by creating a new category, “CSSD”, within ICD’s more rigid taxonomic framework.

    It isn’t known whether ICD Revision Steering Group and the ICD-11 Topic Advisory Group for Mental and behavioural disorders consider these proposed categories and criteria to be valid constructs but there is no evidence of current intention by ICD-11 Revision to mirror the radical reorganization of the “Somatoform Disorders” that is being proposed and field tested by the DSM-5 SSD Work Group, within the ICD-11’s own Alpha Draft Revision Platform.

    The “Somatic Symptom Disorders” Work Group’s “Rationale/Validation” document fails to address the issue of whether harmonization between these sections of the two classification systems might be viable under current SSD Work Group proposals. Nor does it consider the implications for incongruency for the mapping across of codes between DSM-5 and ICD-10-CM* equivalents on the operational usefulness of this section of the forthcoming DSM-5.

    Since October 1, 2011, ICD-10-CM has been subject to a partial code freeze in preparation for implementation on October 1, 2013. Between October 1, 2011 and October 1, 2014 revisions to ICD-10-CM/PCS will be for new diseases/new technology procedures, and any minor revisions to correct reported errors in these classifications – so little opportunity for “harmonization” there.

    You are right to be concerned about the implications for several patient groups for the highly subjective criteria being proposed for “Complex Somatic Symptom Disorder (CSSD)” [5].

    While the media has focused on the implications for introducing new disorder categories into the DSM and lowering diagnostic thresholds for existing criteria, there has been little scrutiny of the proposals of the “Somatic Symptom Disorders” Work Group.

    This Work Group has been quietly redefining DSM’s Somatoform Disorders categories with proposals that will have the potential for a “bolt-on” diagnosis of a “somatic symptom disorder” for all medical diseases, whether “established general medical conditions or disorders”, like diabetes or angina, or conditions presenting with “somatic symptoms of unclear etiology.”

    These proposals have the potential for bringing many more patients under a mental health banner – expanding markets for psychiatric services, antidepressants and behavioural therapies like CBT, for the “modification of dysfunctional and maladaptive beliefs about symptoms and disease, and behavioral techniques to alter illness and sick role behaviors” for all patients with somatic symptoms, if the clinician decides that the patient’s response (or in the case of a child, a parent’s response) to bodily symptoms and concerns about their health are “excessive”, or the perception of their level of disability “disproportionate”, or their coping styles “maladaptive.”

    Under the guise of “eliminating stigma” and eradicating “terminology [that] enforces a dualism between psychiatric and medical conditions” by “de-emphasizing the concept of ‘medically unexplained'”, the American Psychiatric Association appears hell bent on colonising the entire medical field by licensing the potential application of a “bolt-on” mental health diagnosis to all medical diseases and disorders.

    Extracts from: “Psychiatric creep – Erasing the interface between psychiatry and medicine,” Dx Revision Watch, January 03, 2012:

    [1] “Somatic Symptom Disorders” Disorder Descriptions document

    Click to access Somatic%20Symptom%20Disorders%20description%20April%2018,%202011.pdf

    [2] “Somatic Symptom Disorders” Rationale/Validity document

    Click to access DSM%20Validity%20Propositions%204-18-11.pdf

    [3] Conversion Disorder: Current problems and potential solutions for DSM-5: Jon Stone, W. Curt LaFrance, Richard Brown, David Spiegel, James L. Levenson, Michael Sharpe. Journal of Psychosomatic Research, Volume 71, Issue 6 , Pages 369-376, December 2011

    [4] ICD-10 Online Version: 2010

    [5] Complex Somatic Symptom Disorder (CSSD) Criteria

    Suzy Chapman
    Dx Revision Watch (Formerly “DSM-5 and ICD-11 Revision Watch”)

  14. joe kane says:

    To whom it may concern, re-posted on the excellent Dr Speedy’s blog –

    Douglas Fraser’s letter to two high-profile members of The House of Lords
    The Niceguidelines Blog
    25 Jan 2012
    There is much I find worrying in “Models of Sickness and Disability” (‘MoSaD’ hereafter) by Waddell G and Aylward M, referred to by Lord Freud as “a rather interesting piece of analysis”, which will underpin the PIP assessment in the form of the so-called biopsychosocial assessment, behind which Lord Freud, mistakenly in my view, claimed “there is a coherent theory”.

    Margaret William in her usual devastating form, destroying the pseudo-medical science behind the government’s welfare reforms and shredding Lord Freud’s credibility on the way –
    Margaret Williams: The biopsychosocial model has no empirical foundation in relation to ME/CFS
    The Niceguidelines Blog
    25 Jan 2012

  15. Vicki says:


    Sorry this is long, but like you I wanted to make this argument clear. I must make “illness” my excuse for lack of editing!


    Thank you for a good think piece. One quibble, you say,

    Conscious, no doubt, of the social unacceptability of the suggestion that all sick and disabled people are malingerers, there is then the attempt to construct a ‘softer’ variant of the illness deviant via psychology.

    A few years ago I would have agreed with you, now I don’t. I separate this into two slightly different processes, or perhaps stages in one process.

    Start with a quotation from J K Galbraith

    “The modern conservative is engaged in one of man’s oldest exercises in moral philosophy; that is, the search for a superior moral justification for selfishness.”

    Substitute (or add) “scientific” (not that this is real science, as you point out) and you have a starting point. Observe that a growing cost to health care was threatening the budgeting of both state-run and for-profit healthcare and you have a good reason for those holding the purse strings to want a way of reducing the numbers of the “sick”.

    Stage one is to create a Galbraithian rationale – an intellectual construct which will allow those who can see through crude assertions, even when they would rather not do so, to say that [a] many people claiming to be sick are probably (at best) kidding themselves and then [b] it would be better for them as well as everyone else if they went back to work. You define “sick” very tightly and “work” very loosely as meaning “anything which earns money” and you have a good rationale for saying that (almost) everyone should work. (As an aside, would work as a prostitute count?) Now you can sell this to the politically active – MPs, journalists and party activists.

    In the UK this was very successfully “trialled” on the ME/CFS community, who were natural targets. Wessely was made “gatekeeper” for all “serious” investigation, and he established through the authority of his academic position and the influence of his friends and his money that the BPS model could be used to “rubbish” all those who thought they had something called “ME”. I believe that the Wessely approach here, with its considerable opportunities for saving money, gave encouragement to a wider application of this method of belittlement.

    Now for stage two. With a background the “general agreement” (established via stage one) of “Science”, a much more general social agreement can be created. Fortunately along came the financial crises of 2008 and onwards and someone remembered the old saying, “Never let a crisis go to waste.” Now you have a public mood of pessimism and great financial insecurity, and a wish both for scapegoats and wastage.

    So you start a mood in the press saying that “recent statistics show”, and “scientists have found” … followed by anything you want which people will want to believe. The DWP have been feeding misleading, and even downright false, statistics to everyone, but especially the popular press. Then headlines such as “Only 1 in 17 claimants are genuine!” keep cropping up, with no more backing than “figures show” and “it has been found,” to back them up.

    This is where my quibble with you comes. You talk, “the social unacceptability of the suggestion that all sick and disabled people are malingerers.” I have not seen that suggestion being unacceptable – people on Internet forums who say, “Work or Starve – it’s that simple!” do not get “shouted down”. A phrase which now raises few eyebrows, and fewer complaints is, “Most people getting disability benefits are faking it.” You will usually find that there’s a nod in the direction of conscience when they add, “of course the few genuine ones need to be supported, but ..” The sentences nearly always carry that “but.”

    In hard times people are perfectly willing to throw the weak against the wall, if it might make their own future a little less insecure, especially if someone will provide them with a glib phrase to cover their callousness. When they can be given the bonus of righteous indignation, then the package will sell itself. I think it was the first Lord Northcliffe who explained the success of his newspaper as, “I give them a Daily Hate.”

    I rest my case.

  16. Gill says:

    You’re right, Vicki, on those points. In some cases the government haven’t even tried to hide the fact that saving money is at the bottom of all this, with Aylward having frequently (depending on who the audience is) used the ‘need’ to save money as part of the foundation of his argument that the system must be changed. I find that rather undermines the idea that there is evidence that some people should be taken off support. Which one is it, money or people’s capabilities? Whenever someone cites more than one reason to underpin their argument it suggests they are trying too hard to convince.

    I agree, too, that they’ve exploited a situation of ‘crisis’ in the way you describe. When the masses of people face uncertainty in their own personal circumstances they are less likely to extend any sympathy towards who are in a worse predicament. And they are easier to manipulate through ideas which demonise others (scapegoating). The ground was fertile, as you say. I do think, that the BPS lobby, though, have been careful to stand behind the line where they could be accused of fostering negative attitudes towards the sick and disabled. Rather than be explicit, and risk stirring up outrage, and thus opposition, the suggestions are couched in the language of care and helping, the logic of which it is difficult to contradict. So, its far worse really, than the wholesale public abandonment of ideas of social acceptability. Its the manipulation of public fears towards an end that need not have been. Because I do believe that, left to their own moral devices most people do have sympathy for those who are ill and disabled, as they are likely to be not far from one at any given time, whether in family or neighbourhood.

  17. doug says:

    Excellent piece of (hard) work, and thank you.

    In 2005 the Chief Medical Officer of UnumProvident Michael O’Donnell was clear about the situation. The UnumProvident Insurance Company were then driving the UK Government to adopt their version of the so-called biopsychosocial model, which apparently just then, was moving: “to a new phase in our thinking. This will build on the knowledge we have gained to date, and will be accelerated by our links with the UnumProvident Centre for Psychosocial and Disability Research at Cardiff University. We know that our views and understanding are not yet in the mainstream of doctors’ thinking, but Government Policy is moving in the same direction, to a large extent being driven by our thinking and that of our close associates, both in the UK and overseas. It will not be many years before the rest of medicine follows our lead”

    O’Donnell asks, quite seriously : “What determines why one person with a painful back is completely incapacitated and why another with apparently more severe problems functions reasonably? Why has Stephen Hawking, who has the most severe disability, chosen and managed to continue working when others with much less serious problems give up work? Douglas Bader, a World War II flying ace lost both his legs in an accident and managed to become a fighter pilot again. Even after he was shot down and captured by the Germans, with both artificial legs badly damaged, he made several attempts to escape. How was he able to overcome his difficulties, when most of us would have given up? Stephen Redgrave, the Olympic rower suffers from insulin dependent diabetes, but still managed to win several Gold Medals. What drove him?”

    He suggests, quite seriously : “The nature of these questions implies where some of the answers may lie”.

    Here is one of the the advantages to the so-called BPS model: “In particular, it will mean that we shall have psychiatric expertise much more readily available to all CMS’s. This will enable us to identify much more readily those cases where depression or other psychiatric illness lies behind or complicates the medical presentation of incapacity”.

    And here is another advantage: “What keeps people off sick often has little or no relation to what they went off with in the first place … One of the benefits of our new income protection underwriting philosophy is the reduction in the amount of medical evidence we require. In most cases, we have found the evidence adds little to our knowledge of the risk. It is far more useful to gather the information we need from the life to be insured who is, after all, most knowledgeable about those biopsychosocial risk factors that interest us… We believe our move away from diagnosis-based underwriting to a decision-making process linked far more closely to applicant behaviour and attitude is a significant first step towards being able to predict the resilience of our insured population..”(Group Income Protection EVOLVING the way we look at claims 2005).

    And a little detail from: “Enhancing our claims management services 2007 … we must also consider the powerful role that the psychological and social factors can play in both a person’s initial and then potentially prolonged incapacity”.

    It must be quite fun being well-paid to pen just-so stories about about why someone got ill, or doesn’t recover, especially in the knowledge that your story can downplay and be weighted against legitimate medical evidence from dedicated medical practitioners, but it must equally be a disaster if you’re on the receiving end, when you can so easily be blamed for failing to fully co-operate, getting ill in the first place, failing then to think the right BPS recovery thoughts and carry out other BPS associated twaddell, and possibly be severely penalised if you dare object to having your intelligence thusly insulted in the first place.

    “Although the social-model approach is superficially attractive-and I emphasise that we support it in many ways-we have decided that it is not the right way to go with this assessment. We have not gone for the medical model; we have gone for the biopsychosocial model” quoth Lord Freud after lauding the Aylward and Waddell Model on 17 Jan 2012 (in Hansard at Column 498).

    The two Unum documents quoted above and others concerning this tangled web can be downloaded from this link:

  18. Andrew says:

    I wonder why those who claim to promote a biopsychosocial model heavily emphasise the psychological aspect and neglect both the biological and social aspects?

    There are lots of great studies written on the social aspects and problems with the ‘work at all costs’ model.

    Such as this one:
    “Suffering in a productive world: Chronic illness, visibility, and the space beyond agency”
    (unfortunately, it is not open access)

    Remember what disability actually is. Disability is not merely handicap, it is the inability to regularly do a particular task. There is a reason why those who are short sighted aren’t considered ‘disabled’ – they have access to affordable aids that mean their handicap isn’t a disability. Why is Hawking able to work? Because his mind is not disabled and the large amount of money invested in aids (including full time assistants). His case is clearly the very rare exception and not the norm of those with his disease. I think the general public only sees what they want to see – they don’t wish to embrace disability because it means that there are those out there who are truly being neglected by society.

  19. Sorry to come into this discussion rather late, but on reading Patrick’s comments, I simply must respond.

    The focus on the idea that there may be some people who malinger – a concept that’s most often in the eye of the beholder – completely misses a far more important balancing fact. The amount of money spent on people who can’t (or even won’t) work is a trifle compared to the single gift of allowing Vodaphone off the hook for £6 billion in taxes owed!

    That’s true malingering.

    The idea that it’s necessary to come up with an excuse to encourage or pressure people to work says it all. If work truly is beneficial, then people will want to do it for its own sake. But the reality is that most work is slave labor, completely unfulfilling, and hard on the body and mind. The suggestion that it’s good for us is absurd on the surface.

  20. Gill says:

    Thanks, doug. I’ve retrieved those docs from your link. The parts you quote at the beginning of your comment must be what the BBC were referring to in 2007 when they said they had documents which showed Unum claimed to be ‘driving government policy’. Pity the beeb chose to play the ‘exemption’ card when asked to disclose these recently. But sadly, that’s not the only evidence of their bias they’ve shown of late, the examples keep mounting up.

    I think you’ve just given me my reading list for the next couple of months there! There’s only one or two pieces that I’d already seen, most is new to me. All the usual suspects though 😦
    I hope other people visiting here will download them too.

  21. Pingback: Ex-Atos HCP exposes WCA’s bias against the sick « downwithallthat

  22. Pingback: Physiotherapists banned from touching patients

  23. Debbie Jolly says:

    Fantastic piece well written exposing the contridictions in the whole gov process. disabled people against cuts have developed a survey to capture peoples’ experiences of the WCA to try and get the facts out of all that is happening with this, please see below:

    New survey to collect your experiences of Atos/work capability assessment
    by Disabled People against Cuts (DPAC), Black Triangle and Social Welfare Union (SWU)

    In an answer to a parliamentary question on Atos from Frank Field (lab) Chris Grayling said:

    “Based on the results of a trial during 2011, we have not implemented universal recording for claimants going through the work capability assessment (WCA).
    We have asked Atos Healthcare to accommodate requests for audio recording, where a claimant makes a request in advance of their assessment.
    This approach began in late 2011 and we will monitor take up during 2012 before making a decision on the requirement for recording assessments, taking into account factors such as value for money and the value it adds to the WCA process.
    As part of this process we are also reviewing Atos capacity to provide recordings for those claimants who currently request one”.

    We at Disabled People against Cuts (DPAC), Black Triangle and Social Welfare Union (SWU) want to make sure that we gather the REAL facts on what people are experiencing. We suspect that the government will try to pull the option for recordings of WCA completely due to what they will say is a lack of demand, so we have put together a short survey to gather information on the demand for recordings and on other issues on the WCA.

    Please pass this survey on to as many people as possible. If you know someone who would like a printed paper copy of this survey please send their details to

    Go to survey

  24. My worry is that the way the government and media organisations have been pushing the idea that disabled people are to blame in some way for their life circumstances is going to discourage employers from giving disabled people jobs.

  25. Ullas Soman says:

    Have you ever considered publishing an ebook or guest authoring on other
    sites? I have a blog based upon on the same ideas you discuss and would love to have you share some stories/information.
    I know my audience would appreciate your work.
    If you’re even remotely interested, feel free to shoot me an e-mail.

  26. A most excellent well-reasoned article, Gill.
    Although with all respect a lot to handle in one reading for a layman like myself, relatively new to the subject, so I would echo the call for breaking it up with some sub-headings.
    It deserves to have far wider coverage; have you considered making it into a PDF for downloading and distributing?
    I have put a link to it on our own little community website, but it deserves far far wider attention.

    Many thanks,

  27. Gill says:

    I just popped back because I noticed that there had been the occasional ‘clicking’ over here from the link on my blog. I’m the type of person who feels obliged to acknowledge *every* comment that people make, though I know that’s unrealistic of me :), since everything moves so fast on the internet it’s quite impossible to keep up.

    That said: Thanks again to everyone who has commented and added material pertinent to this situation. As we are witnessing, the situation is becoming increasingly desperate for so many people, the most vulnerable in our society. It’s been heartening to see it gain wider public exposure in recent months, with even the mainstream media, particularly TV, having to take notice. It’s to their shame that they also feel the need to ‘balance’ it not with any reasoned impartial arguments to the contrary, but stigmatising, ‘scrounger’ rhetoric. Perhaps that’s because there *are* no reasoned arguments!

    Ullas: It’s funny you should mention epublishing, as I had been thinking about that myself, wondering if it would be possible (with the respective permissions) to collate related articles and such from across the net into one useful reference volume on the matter. I can’t access your email address on here btw, but if you’d like to do an email ‘follow’ on my blog I’ll be able to see it. (NOT touting for followers, I promise!) Also the link from your name on here seems to be broken?

    [General note: Clicking on my name on here links to my blog, where I write, not always so calmly as I have here, about these ‘reforms’, the DWP, Atos and associated matters.]

    Keith: Thank-you! I do realise it is a long and quite dense piece. It might be time to have a go at making it a bit more easily ‘digestible’. I have actually made it into a pdf, in Times font format, because a few people expressed difficulty in reading the sans serif font. It’s available here:

    Click to access WorkArticle.Times.pdf

    And finally:
    I’ve just received a copy of what promises to become a very important book, particularly for the ME community, but also for anyone who has suffered as a result of the promotion of this ‘biopsychosocial’ approach among not only the medical community, but in its infiltration also of the administration of health-related benefits (as I describe in this piece).

    It’s: “Authors of Our Own Misfortune?” by academic Angela Kennedy. More info about it here:

  28. Pingback: My Response to Professor Aylward’s statements to BT and DPAC « downwithallthat

  29. Mo Stewart says:

    Thanks Gill.

    Very good article and I can tell by the tone of your piece tha tyopu were as amazed at Aylward’s comments to BT as I was.

    I see we are both on the same wavelength :

    Please see: Atos Healthcare or Disability Denial Factories and Welfare Reform – Redress for the Disabled – both published on BT and a few other websites.

    George Potter will be distributing one of my other articles at the Lib Dem conference this afternoon (Sun), so let’s hope some of those ill informed politicians become better informed.

    I would very much value the opportunity to have contact but unable to access Facebook or Twitter so please email.

  30. Pingback: Professor Wessely: Knocking the Docs & Overstepping the Mark « downwithallthat

  31. DavidG says:

    Just found a link to this, and I have to say it’s an excellent dissection of the perversion of the BPS by government, insurers and their funded scientific hacks. I’ve been looking for something similar to use in arguing against the BPS, and thankfully you’ve saved me from the fear that I might have to write it myself (not that I could have done remotely as good a job).

    One of the earlier comments mentions a piece of DWP ‘research’ into attitudes to work being good for you – I actually wrote an article dissecting that paper for Where’s the Benefit, which can be found here: , and it’s difficult to express just how bad it is, it would have embarrassed a 1st year sociology student….

  32. argotina1 says:

    I tried to read this, the subject is of great interest to me. Looks well worth reading. BUT your first sentence contains over 50 words and 4 subjunctive clauses. I struggled past ‘norms’ and ‘paradigm’ and ‘discourse’, all in the second sentence, and their cumulative effect halted me in my tracks. Is your aim to restrict the possible readership of this to people with sociology degrees?

  33. Pingback: Two Apparent Irregularities Involving UNUM, ATOS, And DWP – Black Triangle Campaign

  34. Pingback: Two Apparent Irregularities Involving UNUM, ATOS, And DWP – DPAC

  35. Hiya, I am really glad I have found this info. Nowadays bloggers publish just about gossips and internet and this is actually irritating. A good site with interesting content, this is what I need. Thank you for keeping this web site, I’ll be visiting it. Do you do newsletters? Can not find it.

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