Beliefs, Attitudes and Behaviours Whiplash: What can be done to make a difference Professor Sir Mansel Aylward CB MD F

1. Beliefs, Attitudes and Behaviours Whiplash: What can be done to make a difference? Professor Sir Mansel Aylward CB MD FRCP Director: Centre for Psychosocial and Disability Research, Cardiff University Chair: Public Health Wales

2. Fundamental Precepts:

3. The Power of Belief: A Common-Sense, Empirical Definition: 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. A basis for all expected specific behaviours which follow from certain stimulating conditions

4. A Practical Model of Belief: Confirmation of expected relationship between stimuli and predicted outcome strengthens association. (ie: belief) Association weakened if predicted outcome(s) do 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

5. 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 disability� � The more subjective, the more central the role of beliefs � Beliefs influence: perceptions & expectations; emotions & coping strategies; motivation; uncertainty � Maid & Spanswick, 2000. � Gatchell & Turk, 2002.� Waddell & Aylward

6. The Consequences Illness, Sickness and Incapacity are largely psycho-social rather than medical problems. More and better healthcare is not the answer

7. Symptoms:

8. Cardiff Health Experiences Survey (CHES): Face-to-Face Interviews [N=1000] GB population: Open Question: Inventory: Musculoskeletal 13.5% 32.5% Mental Health 7.5% 38.5% Cardio-respiratory 3.6% 11.9% Headache 2.9% 24.8% G/I 2.4% 7.8% Without any complaint 72.9% 33.6% ______________________________________________________________________________________________________________________________________________________________________ At least one complaint 20.6% 66.4% 2 or more complaints 8.4% 26.3% Severity of main complaint greater for open question than inventory

9. CHES: Musculoskeletal Breakdown

10. PARADOXES The typical disabled person (perception-vs-reality) The health paradox (improved health-vs-claims� trends) The failure to recover (clinical recovery-vs-poor work outcomes) Disability Rights-vs-Sick Worker Advocacy

11. Common Health Problems:Predominantly Subjective Health Complaints Illness Behaviour: What ill people say and do that express and communicate their feelings of being unwell: Subjective Health Complaints have a high prevalence in the working-age population Not solely dependent on an underlying health condition ( the limited correlation) People with similar symptoms (illnesses) may or may not be incapacitated Consumption of health care disproportionate.

12. 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 in UK Thus: Essentially people with manageable health problems given the right support, opportunities & encouragement Chronicity and long-term incapacity are not inevitable

13. Why do some people not recover as expected? Big area for reform to increase the employment rate of sick and disabled people is incapacity benefits. Though not an end in itself There are now around 2.7 million people claiming an incapacity benefit (bit higher than in the chart due to a wider definition). Now have more than 3 times as many people on IB as JSA � stark contrast with the position in early 1980s where there were significantly more people unemployed. In fact caseload has more than trebled since 1979. Most of the increase (over 90%) took place before 1997. Since that time we have seen a reduction in inflows to the benefit (by around one-third since 1997), reflecting greater economic stability and policy changes. Problem is that outflows have fallen too � so we have seen a stabilising of the caseload. Not the case that there is a hidden unemployment problem � which has been in the press recently - unemployment fallen MUCH faster than rise in IB caseload, employment is up (levels and rates). Big area for reform to increase the employment rate of sick and disabled people is incapacity benefits. Though not an end in itself There are now around 2.7 million people claiming an incapacity benefit (bit higher than in the chart due to a wider definition). Now have more than 3 times as many people on IB as JSA � stark contrast with the position in early 1980s where there were significantly more people unemployed. In fact caseload has more than trebled since 1979. Most of the increase (over 90%) took place before 1997. Since that time we have seen a reduction in inflows to the benefit (by around one-third since 1997), reflecting greater economic stability and policy changes. Problem is that outflows have fallen too � so we have seen a stabilising of the caseload. Not the case that there is a hidden unemployment problem � which has been in the press recently - unemployment fallen MUCH faster than rise in IB caseload, employment is up (levels and rates).

14. Cardiff Research: Findings: Principal negative influences on return to work: Personal / psychological: Catastrophising (even minor degrees) Low Self-Efficacy Belief that �stress� is causal factor Social: Lone parents / unstable relationships �Victim� of modern society Rented or social housing General Affect: Sad or low most of the time Pervasive thoughts about personal illness

15. Cardiff Research: Negative Influences: Occupational: Job dissatisfaction Limited attendance incentives (esp. work colleagues) Attribution of illness to work Cognitive: Minimal health literacy Self-monitoring (symptoms) False beliefs Economic: Availability of alternative sources of income / support

17. Negative Influences on Recovery � Neck Pain: Ranking the Barriers:

18. Cardiff Research: Positive Influences Respect for employer Job satisfaction Strong health literacy Moral obligation Positive attendance incentives (especially: work colleagues) Well managed chronic health condition

19. Barriers to recovery and return to work are primarily personal, psychological and social rather than health-related �medical� problems. Workplace culture and organisational features dominate.

20. Unbundling illness, sickness, disability and (in)capacity for work Disease: objective, medically diagnosed, pathology Illness: subjective feeling of being unwell Sickness: social status accorded to the ill person by society Disability: limitation of activities/ restriction of participation Impairment: demonstrable deviation / loss of structure of function Incapacity: inability to work associated with sickness or disability

21. The objective: Early Intervention to Assist Recovery: Multi � disciplinary integrated approach at the outset Health professionals and employers confident about health and work links Health professionals, employers and multi- disciplinary services work together to achieve sustained return to work Line managers, in particular, need to be better trained to: Detect and respond to early signs of ill-health Protect the physical and mental health of workers

23. Condition Management: Principal Findings Rather than aiming for control of health condition, successful outcomes dependent on learning process towards self management, confidence building and independence Significant improvements in confidence and coping, independent of changes in health condition, engender successful work outcomes Work outcome highly dependent on critical elements of the support and management package and the context in which it is delivered

24. The Bio-Psycho-Social Model: Clarity and Understanding: A person-centred model that considers the person, the health problem and the social context: Biological: the physical and/or mental health condition Psychological: recognition that personal/psychological factors influence responses to health, illness, disease and function Social: importance of the social context on health and well-being; pressures and constraints on illness behaviour and functioning Culture: collective attitudes, beliefs and behaviours characterizing a social group over time.

25. 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

26. Health: A New Definition? WHO (1948): ...�a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.�1 Proposed definition2:... �as the ability to adapt and self manage in the face of social, physical and emotional challenges.�

27. Culture Change: � Much sickness and disability should be preventable. Better management is an immense challenge, but one that is crucially important to everyone of working age, their families and society. It can be achieved, but only be fundamental change in our approach and by all stakeholders working together towards common goals. The biopsychosocial model provides the framework and the tools for that endeavour� *

28. Pursuing Excellence and Achieving Success:

29. Three Main Questions � Whiplash: Can we improve classification/diagnosis of cases? Answer: Yes: Avoid the medical model of injury. Avoid precise diagnosis in absence of objective impairment/major pathology. Avoid medicalisation and purposeless pursuits (eg: imaging, laboratory tests) Categorise by symptomatic approach/barriers to recovery.

30. Three Main Questions � Whiplash: 2. Can we manage claims better, and understand how symptoms are attributed? Answer: Yes: Identify negative influences (barriers) to recovery Avoid being judgemental Tackle the beliefs and attitudes Avoid medicalisation Adopt the new definition of health Focus on self management, confidence building, self-esteem. Return to/remaining at work, independence Multidisciplinary (non medical) approach The bio-psychosocial paradigm predominant

31. Three Main Questions � Whiplash: 3. Can we improve how whiplash problems are managed and treated? Answer: Yes: Main determinants of illness and chronicity depend more on lifestyle, personal (psychological) factors, socio-cultural environment and cognitive functioning Tackle these robustly and vigorously Strongly avoid medicalisation Engender autonomy, build trust and confidence The Bio-psycho-social model provides the framework and tools for this endeavour

33. Professor Sir Mansel Aylward CB Big area for reform to increase the employment rate of sick and disabled people is incapacity benefits. Though not an end in itself There are now around 2.7 million people claiming an incapacity benefit (bit higher than in the chart due to a wider definition). Now have more than 3 times as many people on IB as JSA � stark contrast with the position in early 1980s where there were significantly more people unemployed. In fact caseload has more than trebled since 1979. Most of the increase (over 90%) took place before 1997. Since that time we have seen a reduction in inflows to the benefit (by around one-third since 1997), reflecting greater economic stability and policy changes. Problem is that outflows have fallen too � so we have seen a stabilising of the caseload. Not the case that there is a hidden unemployment problem � which has been in the press recently - unemployment fallen MUCH faster than rise in IB caseload, employment is up (levels and rates). Big area for reform to increase the employment rate of sick and disabled people is incapacity benefits. Though not an end in itself There are now around 2.7 million people claiming an incapacity benefit (bit higher than in the chart due to a wider definition). Now have more than 3 times as many people on IB as JSA � stark contrast with the position in early 1980s where there were significantly more people unemployed. In fact caseload has more than trebled since 1979. Most of the increase (over 90%) took place before 1997. Since that time we have seen a reduction in inflows to the benefit (by around one-third since 1997), reflecting greater economic stability and policy changes. Problem is that outflows have fallen too � so we have seen a stabilising of the caseload. Not the case that there is a hidden unemployment problem � which has been in the press recently - unemployment fallen MUCH faster than rise in IB caseload, employment is up (levels and rates).