David J Black

It is doubtless commendable to provide an ill or disabled person with fulfilling work, though hopefully at a better wage than Lord Freud’s suggested £2 per hour (quite something from a multi-millionaire with a country mansion in Kent and a £2 million town house in London’s Highgate!).

The biopsychosocial paradigm, however, has palpably failed to deliver its claimed objective. With the numbers of the working age sick out of control, and the Wessely school remedies of Cognitive Behavioural Therapy and Graded Exercise Therapy now downgraded by both the National Institute for Clinical and Health Excellence and America’s Centers for Disease Control, an awkward question arises: have our politicians been duped by an ostensibly cheap panacea which has turned out to be massively expensive? Indeed given that the PACE trial was described by one MP in a 2018 parliamentary debate as “one of the biggest medical scandals of the 21st century” while its critics damn it as fraudulent, it seems remarkable that the biopsychosocial model’s credibility wasn’t in tatters years ago.

Consider the cult’s origins. Leading protagonist Sir Simon Wessely has drawn parallels with neurasthenia, as identified by US physician Silas Weir Mitchell during the Civil War. Its recent genesis dates from from a 1977 paper The need for a new medical model: a challenge for biomedicine by US physician George Engel. This attempted to codify its key tenets. Prior to that two British psychiatrists, Colin McEvedy and William Beard, had published a flimsy 1970 paper on a 1955 outbreak of ME/CFS at a London hospital, Royal Free epidemic of 1955: a reconsideration. The cause they attributed to mass hysteria among female nurses.  

Context matters. Both psychiatry and neurosurgery were then in trouble. Lobotomies were largely discredited in the late 1960s, though its lesser variants survive – NMD (neurosurgery for mental disorder), stereotactic anterior capsulotomy, cingulotomy, amygdalotomy, rostral leucotomy, ablative neurosurgery, and psychosurgery. Lobotomy’s downfall was Miloš Forman’s 1975 One Flew Over the Cuckoo’s Nest. Meanwhile such ‘anti-psychiatrists’ as Laing and Szasz were questioning psychiatry’s validity.

Psychoanalysis was debunked by one-time supporter Frederick Crews and its practitioners sought new opportunities. One, Aaron Beck, devised Cognitive Behavioural Therapy (CBT), now touted as a putative ‘treatment’ by biopsychosocial model advocates in search of remedies. Though viewed by some as a form of gaslighting, it’s not to say there weren’t those who genuinely believed in it. Yet the focus on “unhelpful cognitions” and “false illness beliefs” carried an accusatory implication that those who couldn’t overcome their ME might be guilty of “pervasive refusal syndrome” and were defying their therapists. Thus there developed a “one true faith” conviction that where CBT wasn’t cutting through, it must be down to the patient’s unwillingness to cooperate.

This purported science had an echo from a distant past. Two centuries earlier another fad had, like the biopsychosocial model, been peddled as ‘evidence-led’. Its proponent was Viennese neuro-anatomist Franz Gall whose disciple, Johann Spurzheim, spread the new gospel of phrenology. It was all about diagnosing head-bumps as a guide to character, and it was utter bunkum.

In post-enlightenment Scotland, with its appetite for scientific and secular certainties, the cause was embraced by Edinburgh lawyer George Combe, who was something of a showman (his wife, Celia, was daughter of the great actress, Elizabeth Siddons) Combe’s 1828 The Constitution of Man became a bestseller, outpacing Darwin’s On the Origin of Species by a factor of seven to one.

Combe’s lectures were celebrated, and he furthered the cause by founding the Edinburgh Phrenological Society. Its museum facade in Chambers Street, with keystone portraits of Gall, Spurzhein, and funder William Ramsay Henderson over the windows, and Combe above the door, survives within the Crown Office building. Today all ranks, from the humblest accused to the most eminent ornaments of His Majesty’s bench, jostle in the street below on their way into the Sheriff Court.  

Phrenology – Britain’s first great wave of psychobabble – would be discredited as a pseudoscience, and relegated to the realms of charlatanism. Its parallels with the biopsychosocial model are approximate, but there is an interesting institutional link which should not escape our attention. By the mid-19th century almost all of Britain’s lunatic asylums were run along ‘phrenological lines’. One of the most outstanding, the Crichton Royal, had as its superintendent an old friend of Charles Darwin and founding member of Edinburgh’s Phrenological Society, William Browne. In 1866 Browne was elected president of the Medico-Psychological Association, which in 1971 rebranded as the Royal College of Psychiatrists. Thus is a link between the advocates of the biopsychosocial model and the founders of the pseudo-science of phrenology established!

Yet we are now in a health funding crisis perfect storm, and the lessons of history can only take us so far. Richard Hughes of the OBR has calculated that the coming expenditure crunch has less to do with waiting lists for the retired but rather a need for “preventative interventions that can save you costs down the road” for those of working age in poor health. “The trajectory of health spending just goes up and up” he informed MPs. “It is growing faster than the economy consistently over time – You have a health service that historically has grown faster than GDP.”

As to how much of this fiscal catastrophe has been the outcome of the hegemony of a politically favoured biopsychosocial school displacing biomedical healthcare alternatives which might have actually healed many of the sick, rather than stigmatise them as shirkers and malingerers, is a matter which politicians like Wes Streeting should consider while we still have a solvent NHS. Treating the pre-retired sick for their illnesses, rather than demonising them as shirkers, might actually save a great deal of public revenue in the long run.

The omens are hardly encouraging. The Prime Minister, in a Peter Lilley and George Osborne redux moment, has vowed to crack down on those who “take advantage of state generosity”. This ‘zero tolerance’ policy for alleged benefit cheats may at first glance seem reasonable but the evidence base is not persuasive.

David Cameron’s work and pensions minister, Iain Duncan Smith, dubbed sick claimants “shirkers and scroungers”, yet his own department’s figures then put the proportion of fraudulent claims at 0.5 per cent (thus 99.5 per cent of claimants were honest). The UK Statistics Authority and a former Cabinet Office chief economist called him out for faking the figures, while a judge condemned him for badgering a visually impaired ME sufferer, among others. Eventually Mr Duncan Smith discarded his own scrounger-bashing myth. He resigned in 2016 after declaring himself unwilling to support yet more government cuts to disability benefits, attacking “the government’s austerity programme for balancing the books on the backs of the poor and vulnerable”.

This is a sentiment his successor, Liz Kendall, declines to emulate, as she berates the unemployed young, including victims of ME, Long Covid, and serious mental health issues (the latter category often ‘self-diagnosed’, she claims.) Her tough-love remedies, dressed up in the language of “help back to work” and “offering opportunities”, will include seizing money from the bank accounts of alleged fraudsters and cancelling benefit payments. She praises the role of “work coaches” in cajoling the sick – including mental hospital in-patients – back into employment, though quite what is meant by “work coach” is not clear. It would appear it isn’t even necessary to have GCSEs for the post, which suggests that the role of this new category of health worker is essentially a low-grade policing one pursuing a doctrine of workfare, rather than healthcare. Not so much support, as sanctions, scare tactics and hostility.

Perhaps the way to tackle this issue is to analyse old mistakes made, and misjudgements exercised. Westminster’s Health Select Committee has been alerted to various aspects of the ME/CFS scandal, yet refuses to investigate. A judge-led statutory public inquiry along the lines of Sir Brian Langstaff’s Infected Blood Inquiry might well be the only recourse with any chance of delivering justice to the victims – dead and alive – of biopsychosocial dogmatism, yet one shouldn’t expect too much from a political class which is always averse to owning up to past blunders and doesn’t do compassion because it costs money.

And that, in essence, is the crux of the problem.