“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 20

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Joint meeting of British Psychological Society / Association of British Psychologists

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

• 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

The survival of inaccurate (false) beliefs:

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

¹ Ursin 1997 ² Deyo et al, 1998 ³ Parsons, 1951 4 Mechanic 1968

4

Recipients of key working age benefits

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

1979 1983 1987 1991 1995 1999 2003

Source: DWP and ONS

IB Recipients - Diagnoses

Cardiovascular10%

Diseases of the nervous system

3%

Injury 1%

Diseases of the respiratory

system2%

Other conditions or condition not

specified14%

Mental health44%

Musculoskeletal26%

Incapacity-related benefit recipients by diagnosis group, November 2003

UK Incapacity Benefit

• ‘Severe Medical Conditions’ <25%

• ‘Common Health Problems’

- Mental health problems 44%

- Musculoskeletal conditions 25%

- Cardio-respiratory conditions 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 Women

Tiredness 46% 56% 17% 26%

Worry 38% 39% 13% 15%

Depressed 22% 28% 5% 10%

Headache 37% 51% 4% 9%

Neck pain 27% 41% 9% 17%

Arm/shoulder pain 28% 38% 12% 17%

Low back pain 32% 37% 13% 16%

>50% reported two or more symptoms

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

PSYCHO-

BIO-

• 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 CultureSocial interactions

The sick role

PSYCHO-Illness behaviour

Beliefs, coping strategiesEmotions, distress

BIO- 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 :

• Benefits:

Symptom managementRecovery and RehabilitationSelf-esteem and ConfidenceSocial identity and rolePromoting activities and participationSocial inclusions and functioningQuality 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

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