Joint meeting of British Psychological Society / Association of British Psychologists “The Power of Belief: tackling psychological and social determinants of illness, disability, and economic inactivity". Professor Mansel Aylward CB Director, UnumProvident Centre for Psychosocial and Disability Research, Cardiff University & Chair, The Wales Centre for Health AylwardM@cardiff.ac.uk www.cf.ac.uk/psych/cpdr/index.html
The Power of Belief: How should we define “belief”? • •
A common-sense, empirical definition: (cave: Cognitive Psychologists!) A “belief is something that someone holds to be true”
A non-psychologist’s working belief about belief: • Associations stored in the mind • Gained largely through experience of some internal or external stimuli which predicts a particular outcome or response over time. • Stored accumulated associations: a basis for all expected contingencies involving specific behaviours which follow from certain stimulating conditions
A Pragmatic Model of Belief: Do beliefs influence and drive our attitudes and behaviours? • • • •
A pragmatic “yes” Confirmation of expected relationship between stimuli and predicted outcome strengthens association. (ie: belief) Association weakened if predicted outcome(s) does not occur This simplistic approach to belief acquisition is nonetheless the premise for – Behaviour modifying techniques and interventions – Moulding by experience, learning and culture – Educational interventions
“Believing is the most mental thing we do”¹ Is it the most SOCIAL thing we do?² • Successful Genes Promote their own means of transmission • Transgenerational beliefs succeed by the same mechanisms (memes)³ • Accuracy of belief promotes transmissional success • In evolutionary terms: the faculty to transmit true beliefs is pivotal to the propagation of abilities to communicate • The accuracy of belief is empowering. ¹ Bertrand Russell, The Analysis of the Mind: 1921 ² Daniel Gilbert, Stumbling on Happiness: 2006 ³ Richard Dawkins, The Selfish Gene, 1976
Belief - Transmission The survival of inaccurate (false) beliefs: • Succeed if they facilitate their “means of transmission”. • False beliefs become super-replicators if they enhance communication • Beliefs tend to be transmitted when they do things that transmit genes. • “Bad” genes and false beliefs are successfully transmitted if, on balance, they promote their own means of transmission
Belief Transmission and Society:
• False beliefs are propagated in societies if they promote stability in society. • Corollary: people who hold such beliefs tend to live in stable societies.
Belief Transmission and Society: • Happiness: a super-replicating false belief? People desire happiness, thus economies flourish only if people are deluded into believing that production of wealth will make them happy¹ • Wealth may not make us happier but serves the needs of the economy → promotes stable society → propagates false belief. • Children bring happiness → cultural wisdom; but true!? ¹ After: Adam Smith. The Theory of Moral Sentiments, 1759
Symptoms and Illness: an illustration of the propagation of false beliefs. • Symptoms and Common Health Problems in Society • Obstacles to Recovery • Belief about Health and Work • Stability of Society threatened – a public health crisis
Health, Illness and Beliefs: A Clarification of terminology: fundamental health-related concepts •
Symptoms: Subjective bodily or mental sensations that reach awareness – – – –
•
“Bothersome” or “of concern to the person” Some represent clinical expression of disease Many are normal and part of life High frequency and prevalence not associated with recognisable disease¹ ²
Illness: – The subjective feeling of being unwell – An internal, personal experience
•
Sickness: – Social status accorded to ill person by society – External, social phenomenon (individual: society interactions)³ 4
¹ Ursin 1997 ³ Parsons, 1951
² Deyo et al, 1998 4 Mechanic 1968
Recipients of key working age benefits
3,500,000 3,000,000 2,500,000 2,000,000 1,500,000 1,000,000 500,000 0 1979
1983
1987
1991 1995
Source: DWP and ONS
1999
2003
IB Recipients - Diagnoses Incapacity-related benefit recipients by diagnosis group, November 2003 Other conditions or condition not specified 14% Musculoskeletal 26%
Diseases of the respiratory system 2% Injury 1% Diseases of the nervous system 3% Cardiovascular 10%
Mental health 44%
UK Incapacity Benefit
• ‘Severe Medical Conditions’
<25%
• ‘Common Health Problems’ - Mental health problems - Musculoskeletal conditions - Cardio-respiratory conditions
44% 25% 10%
Prevalence of subjective health complaints in the last 30 days in Nordic adults (after, Eriksen et al, 1998)
Any complaints
Substantial complaints
Men Women Men Tiredness 46% 56% Worry 38% 39% 13% Depressed 22% 28% Headache 37% 51% Neck pain 27% 41% Arm/shoulder pain 28% Low back pain 32% 37%
Women 17% 26% 15% 5% 4% 9% 9% 17% 38% 12% 13% 16%
>50% reported two or more symptoms
10%
17%
Common Health Problems: Predomonantly Subjective Health Complaints • High prevalence in the general population (Eriksen et al, 1998; Ursin, 2003, Barnes et al, 2006) – Symptoms: self reported • Unexplained symptoms in people accessing healthcare: – On average < 10% symptoms attributed to organic causes (Kroenke & Mangelsdorff, 1989) – Limited objective evidence of disease, damage or impairment (Page and Wessely, 2003) • Regional (Pain) Disorders [Hadler, 2001] – Low back, upper limb, neck, etc • Medically unexplained Symptoms in Outpatient Clinics: – 30-70 percent without identifiable disease (Bass, 1990, Maiden et al, 2003
Illness Behaviour: What ill people say and do that express and communicate their feelings of being unwell: • Not solely dependent on an underlying health condition ( the limited correlation) • People with similar symptoms (illnesses) may or may not be incapacitated • Poorer quality of life than those with comparable symptoms caused by disease • Consumption of health care disproportionate.
Common Health Problems: disability and incapacity • High prevalence in general population • Most acute episodes settle quickly: most people remain at work or return to work. • There is no permanent impairment • Only about 1% go on to long-term incapacity Thus: • Essentially people with manageable health problems given the right support, opportunities & encouragement • Chronicity and long-term incapacity are not inevitable
Why do some people not recover as expected?
SOCIAL PSYCHOBIO-
• Bio-psycho-social factors may aggravate and perpetuate disability • They may also act as obstacles to recovery & barriers to return to work
Biopsychosocial Model SOCIAL
PSYCHO-
BIO-
Culture Social interactions The sick role
Illness behaviour Beliefs, coping strategies Emotions, distress Neurophysiology Physiological dysfunction (Tissue damage?)
Strengths of BPS Model • Provides a framework for disability and rehabilitation • Places health condition/disability in personal/social context • Allows for interactions between person and environment • Addresses personal/psychological issues. • Applicable to wide range of health problems
Management of common health problems must address obstacles to recovery. False beliefs play a pivotal role in propagating and perpetuating these illnesses
Focusing on Recovery: the Psychosocial dimension • Almost anytime you tell anyone anything, we are attempting to change the way their brain works • How people think and feel about their health problems determine how they deal with them and their impact • Extensive clinical evidence that beliefs aggravate and perpetuate illness and disability¹ ² • The more subjective, the more central the role of beliefs ³ • Beliefs influence: perceptions & expectations; emotions & coping strategies; motivation; uncertainty •
¹ Maid & Spanswick, 2000. ² Gatchell & Turk, 2002.³ Waddell & Aylward
Illness, Sickness and Incapacity are Psychosocial rather than medical problems. More and better healthcare is not the answer
Shifting attitudes to health & work Current:
Shift to:
Work is a ‘risk’ and (potentially) harmful to physical and mental health.
Work is generally good for physical and mental health
therefore
and
Sickness absence/certification ‘protects’ the worker/patient from work
Recognise the risks and harm of long term worklessness
Work : â&#x20AC;˘ Benefits: Symptom management Recovery and Rehabilitation Self-esteem and Confidence Social identity and role Promoting activities and participation Social inclusions and functioning Quality of Life
Health at Work: • The key idea is that work is healthy • The workplace = environment for promoting health; controlling ill health • A public health issue
Successful Interventions: Practical Elements of Condition Management • Address the main health conditions • Clear work focus, vocational goals, outcome measures • Address biological and psychosocial components • Address individual’s obstacles to RTW • Increase activity and restore function • Shift beliefs and behaviour using CBT (talking therapies)
Condition Management – Successful Strategies: • • • • • •
Make sense of your condition Overcome stress and anxiety Learn to be assertive Promote emotional / physical wellbeing Living with fatigue Living with pain
49% patients have primary and further 39% secondary mental illness diagnosis
PATHWAYS TO WORK PILOTS • 6-800 new job entries each month in existing Pathways areas • Doubling of claimants entering work • Take-up around 5 times that expected from previous RTW interventions • Exceeds threshold for cost-effectiveness • Welfare Bill :extending provision across country by 2008 :Reducing by 1 million the number on Incapacity Benefits :employment rate = 80% working population
False Beliefs → Illness Behaviours (Common Health Problems) • Work – Risky – Harmful – Avoid • Sick Role – Disease basis – Medical model/rehabilitation – Rights • Welfare State – Unlimited resources – Rights without responsibility – dependency
• Health Care Systems → – – – – – –
Overloaded Unmet expectation Reduced public trust Non-compliance Context of health care Success of C&A medicine
Social Security System – – – –
Proliferating expenditure Dependency & chronicity Ageing population “writing people off”
Destabilized Society – – – –
Threatened economy Medical advances outstrip resources Unmet expectations Social exclusion
The Doomsday Scenario:
False Beliefs → Common Health Problems → Overburdened and ill-focused health/SS Systems → Destabilized Society
Meeting the Challenge: • Major Cultural Shift – Perception & management of common health problems – Work is generally good for physical and mental health – Social integration (full participation in society) • Tackling Social inequalities in health & regional deprivation – Multiple disadvantages / failure to compete in job markets – Addressing the social gradient • Getting all Stakeholders onside
At the heart of culture lies belief – Beliefs drive behaviour – Modified by experience – Dispelling the myths – Public policy initiatives Transforming the culture depends on shifting core beliefs about health, illness, sickness and work
The Scientific and Conceptual Basis of Incapacity Benefits
Gordon Waddell and Mansel Aylward
The Power of Belief
Peter Halligan and Mansel Aylward
Professor Mansel Aylward CB
Website: http://www.c http://www.