Tuesday, 17 January 2012

Models of Disability

As it has come up in the Welfare Reform Bill debate, and people are asking, here is a quick starter on models of disability.

The Medical Model of Disability

This is the classical view of disability, disabled people are broken and need to be fixed. Most of society and a lot of doctors still stick to this model.

The Social Model of Disability

This is a model created by disabled people themselves, and is very popular with disabled people. It says that the problems we face largely result from the failure of society to adapt to our needs and treat us as equals. We aren’t broken, we don’t need fixing, we’re just people like anyone else. Adapting to our needs can mean everything from replacing steps with a ramp, to acknowledging that mental illness does not make people an axe-murderer and that it is not better to be dead than use a wheelchair, to recognising that someone may need a different pattern of work to accommodate their disability. It really just comes down to treating disabled people as equals,

The Bio-Psycho-Social Model of Disability

The Bio-Psycho-Social Model is a perversion of the Social Model, intended to allow organisations such as large insurers and governments to limit support to people with long term disabilities. It pretends to adopt the Social Model, but then claims that because it acknowledges the need for ramps and so forth, any remaining disability is solely due to the disabled person failing to work hard enough at adapting to their disability, and that therefore they don’t deserve support. So I’ll just wish all my dodgy connective tissue to start working properly, my DNA to magically rewrite itself and ignore the fact that, even through Class 1 opiates, it frequently feels like I have burns across significant parts of my body.

The Bio-Psycho-Social Model of Disability was created by academics at the University of Cardiff sponsored by Unum, an American insurance multi-national that was branded ‘an outlaw company’ and subject to huge class action losses for running ‘disability denial factories’. Guess which American insurance multi-national advises the Department of Work and Pensions on disability benefit policy.


  1. What a terrible model! Depressed at vote lost this pm in House of Lords. Facing losing my v expensive WAV which I only received last week after waiting 10 months! V low about it all....

  2. When the debate says we have ceased to be genetically disabled and are simply lazy, we truly have sunk to the levels of war-time Germany:

    The bourgeois era with its false and lying idea of humanitarianism is over. We are in the middle of a hard century. It will be won not by good nature, but by manliness and strength...

  3. the bio-psycho-social model wasn't invented by Unum. It has been around a long time in the context of severe and enduring mental illness.

    Bio = genetic predisposition.
    Psycho = your psychological make-up, including how you see the world, your personality etc.
    Social = both your current environment and the environment you grew up in, both of which affect your brain development.

    Someone with a genetic combination that predisposes them towards mood swings and psychosis (bio) might be perfectly fine if not exposed to stressful life events (social) and if their thinking patterns were different (psycho).

    In the context of SMI, it isn't presumed that getting rid of one element will magically make the illness go away, but simply that tackling some aspects of it can improve the outcome.

    You can't change a person's genetic make up, and you can't change what's happened to them in the past, but you can affect future development of the brain's physical structure and chemistry with medication, diet and mental and physical activity.

    The bio-psycho-social model of SMI goes hand-in-hand with a concept of recovery that moves away from cure and towards living with things as they are, accepting your SMI and adjusting to it.

    IMO, these are not negatives of themselves. The fact that certain parts of the insurance industry and certain politicians have used the language of it to suit their own purpose does not of itself invalidate the original model and does not mean that we have to let them steal the language from us and leave us without a useful description of the way in which some disabling conditions develop.

    If you simply dismiss a phrase like biopsychosocial because it's been taken by politicians, you risk reinforcing the divide which has for so long stood between mentally ill and other disabled people.

  4. The Bio-Pscyho-Social model was not created at the University of Cardiff. It was introduced by the American psychiatrist George Engel in the 1970s as a holistic and patient-centred alternative to the reductionist medical model. It has its roots in Parsons’ Sick Role theory, which in turn was influenced by the Freudian notion of ‘secondary gains’ of illness.

    Unfortunately the BPS model has provided a handy excuse for medical professionals, academics, private insurance companies and government welfare departments to deny the reality of illness or disability.

    For instance, some psychiatrists have proposed a BPS explanatory model for Chronic Fatigue Syndrome, Fibromyalgia, and other so-called ‘Functional Somatic Syndromes’, which they believe have no physical basis but are perpetuated by irrational illness beliefs.

    The Government’s benefit policy has indeed been shaped by research carried out at the UnumProvident Centre at Cardiff University. The researchers have, among other things, advised the DWP to adopt a BPS model of disability assessment. Apparently, the old system, which was based on the outdated medical model, ignored the psychosocial nature of many chronic conditions, hence encouraged ‘illness behaviour’, trapping people into benefit dependency.

    1. Remove Fibromyalgia from your list.
      It has recognised pathologies.

    2. I believe the original poster's point was that quack psychiatrists are actively ignoring the evidence that all of these illnesses are physical in origin. That the evidence for this exists doesn't change their fingers in ears insistence that it's all in our minds and we would get better if we really wanted to...

      And that's the kind of active denial of reality we're dealing with when we face the Bio-Psycho-Social Model.

  5. I'll accept Anonymous's clarifications on the origin of the pre-Unum-perversion BPS model, however they make no real difference as we aren't discussing that. Instead we're discussion the Unum-perverted form of the BPS model, of which the primary usage in the UK is being pushed by the Unum-sponsored University of Cardiff group and DWP. Equally the Parsonian Sick Role is a tremendously negative interpretation of disability with little time for the actual facts of disability.

    "you can affect future development of the brain's physical structure"

    I have to take issue with this as someone with dyspraxia, there are no treatments that alter brain structure for any of the complex developmental disorders or ASDs. The question of whether it is even potentially possible to turn someone from neurodiverse to neurotypical is unanswered, and deeply ethically problematical (my own belief is that the change could only come at the cost of destroying the existing personality, not a cost most people would willingly pay).

    "The fact that certain parts of the insurance industry and certain politicians have used the language of it to suit their own purpose does not of itself invalidate the original model and does not mean that we have to let them steal the language from us"

    That may be the cost of protecting people. If they insist on using an invalid version of the model then we will have to destroy that in debate, and if the original version is sideswiped by our arguments, then it will still be worth the price.

  6. David G,
    In a sense it makes no difference what the origins of the BSP model are. However, I believe that if we want to be taken seriously, we need to get our facts right, and repeating the myth that the BPS model was invented by Unum is not going to help our cause.

    I’m not a proponent of the BPS model, but I think it is important to realise that it is regarded as a ‘respectable’ mainstream approach to e.g. disability assessment and condition management.

    The point is that the DWP claim that their policies are evidence-based, and in adopting the BPS approach they are simply relying on the latest research. So if you want to criticise their approach (i.e. destroy their version of the model), you need to know precisely what it is you are criticising.

  7. Anonymous, as I've said, I accept your point, but saying that someone is following a model is problematical, we need to know precisely what they believe that model entails. Look at the Social Model, lots of people have lots of different interpretations of precisely what it involves. I've seen, for instance, plenty of supposed followers of the Social Model get irritated when spoonies point out that negative effects and necessarily all due to an unadapted society/environment, and that for some of us our impairments can be disabling all on their own; yet I'm assured by people who know the original Social Model research far better than I do that the Social Model says nothing whatsoever about the negative effects of pain and fatigue based impairments.

    We face a problem of identifying precisely what the bio-psycho-social model, as touted by DWP, entails, we need to pin down the DWP on this, probably look into the 'research' coming out of the University of Cardiff, and we need that done by people able to interpret that research for us and counter it. Which is why I've already said we need to get disability academics on board. I can throw together a quick summary of models for laymen, but I'm not the right person to counter academic research. On the other hand, you might be ;)

  8. There's a current consultation on QOF indicators (which is how GPs get paid). The proposed indicator for depression uses the word "biopsychosocial" - they'll gain points for "The percentage of patients with depression who have had a biopsychosocial assessment by the point of diagnosis".
    Link to consultation document is - http://www.nice.org.uk/aboutnice/qof/ConsultationQOFIndicators.jsp

  9. David G, and All,

    I am an academic who did his Phd on the relationship between chronic illness and disability. I have also had a chronic condition since childhood and have experienced many of these issues first-hand.

    I am in the process of looking at the work of Prof. Mansel Aylward. One of my main concerns so far is the biased evidence base of all research informing changes to welfare.

    As for models of disability the social model is very useful, but unfortunately it has always appealed to ideas of social inclusion through disabled people being able to operate as "normal" if only the "physical" environment was changed.

    This is not surprising given the people involved in developing this model and the point in history when it was created.

    Social "norms" about what people can do were therefore accepted within the social model, rather than challenged. The social model was not about changing society, but about being included in "normal" society.

    However, these aims fail to acknowledge the needs of those who are chronically ill. You can apply the social model to chronic illness, but the aims are not about accepting "normality" but questioning "normality" and changing it, so that the chronic illness can be accommodated.

    The bio-psycho-social model is a very crude way of trying to apply the social model to chronic illnesses without changing society and making it more accommodating.

    Rather, it's trying to marry the social model with a medical model with a resulting ideological monster, a social mess and a re-emerging culture of patronising disabled people.

    In my mind, its a very cynical and disingenuous attempt to acknowledge the social model while twisting it to a political agenda of disability benefit cuts. This model also fits into the ideas of Lawrence Mead and his "new paternalism."

    The end result is that the DWP can look as if they are doing what disabled people want including recognising their wish to work and be seen to be equal, but then saying, if that is the case, then you are fit to work and be treated "normally" like all other unemployed people.

    Moreover, the use of the bio-psycho-social model is able to then go on to blame the individual if they reject this notion of being fit to work. If the disabled person rejects this recognition of being equal and wanting to work, then they therefore they must be workshy - and they are viewing themselves as incapable. They therefore need help with their way of thinking...

    This model goes back to making disability a psychological and individual issue, while acknowledging ideas of disability rights. Its clever, but can only be argued if you ignore swathes of academic evidence and argument, and ignore the person's condition.

    Changes to the working environment are completely ignored, and prejudice and a failure of employers to accommodate people's needs untackled.

    Hope this helps, and I will continue to refine my arguments and criticisms in the coming weeks.

  10. Anonymous, apologies for not getting too this sooner, only just realised it was here and pretty much agree with everything you say.

    "One of my main concerns so far is the biased evidence base of all research informing changes to welfare."

    I looked at this when I analysed a piece of DWP research last year, see http://wheresthebenefit.blogspot.com/2011/08/conclude-then-survey-dwp-at-their.html Either the DWP know no more about survey construction than a first year undergrad, or they had a definite outcome in mind, never mind all that says about their professional ethics. The other concern with Professor Aylward's work is the independence of the work: UNUM propose a change in benefits policy thats to their very considerable financial advantage to him when he's government advisor, he pushes that policy through into practice, and then has a research institute created for him, by UNUM, that then produces a line of research that backs everything that has gone before. Lets just say there are questions that need to be asked.

    "The social model was not about changing society"

    I think that initially, and academically, it was more a way of redefining how disabled people interacted with society (or vice versa), so that we could identify that we were disadvantaged by the status quo, but a lot of people, me included, have then extended its assumptions outside of the academic environment, to use the shortfalls it exposes as targets for reworking society. Effectively there are two levels of applying the Social Model and we need to define which one we're using if we're being completely rigorous.

    "You can apply the social model to chronic illness, but the aims are not about accepting "normality" but questioning "normality" and changing it, so that the chronic illness can be accommodated."

    My interpretation has always been that as long as I'm regarded as different, then I'm disadvantaged, so we don't really need to change the Social Model, we just need to have people apply it with sufficient flexibility and understanding to accommodate things like me not having the energy to get out and do things, even if the physical accessibility of the environment isn't an issue. To my mind it tends to point up a shortcoming in people's, even disabled people's, acceptance of chronic debilitating disabilities, rather than in the applicability of the Social Model to those disabilities.

    I agree fully with what you say about the bio-psycho-social model as spun by UNUM and ESA, though I'd like to know whether the initial pre-UNUM version had a better understanding of disability.

    "Moreover, the use of the bio-psycho-social model is able to then go on to blame the individual if they reject this notion of being fit to work. If the disabled person rejects this recognition of being equal and wanting to work, then they therefore they must be workshy - and they are viewing themselves as incapable. They therefore need help with their way of thinking..."

    This is the classical Talcott Parsons Sick Role, which has been around for so long that I presume there must have been some comprehensive demolitions of it in the literature (I only really know Parsons through his wiki entry, but it's interesting that so much of his work would seem to place him as an extreme neo-con in today's political spectrum, which really makes the blame the patient Sick Role no surprise whatsoever). What might be interesting to look at is when the Parsonian Sick Role got rolled up into the Bio-Psycho-Social model, and who by....

  11. You're forgetting the Bio-Social model of disability... that there's a social issue in terms of society creating and failing to alleviate obstacles to disabled people, but there are also physical or mental health issues creating restrictions for which the social model alone does not account.

    I happen to like the bio-social model... though to add to the mix that people with MS are at fault for failing to adapt, or that people who've lost limbs are at fault for failing to deal with the fact and move on, is the sickening twist that leads to the perverse bio-psycho-social model.