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OPINION

people receiving incapacity benefit (or


similar benefits) return to employment
(paid and unpaid)’ (NICE, 2008, p.7).
Indeed, the VR community has been

‘Return to work’ revisited critical of its own role. King and Lloyd
(2007, p.149) noted that ‘there is now
a substantial amount of evidence that
William J. Fear argues that people on incapacity benefit need a psychosocial rehabilitation practitioners do not focus
intervention rooted in self-efficacy clearly on working with clients to achieve
vocational outcomes’.
The current emerging paradigm for
RtW, especially in relation to common
health problems, including mental health
problems, is a psychosocial one. (For an
eing out of work can have harmful new claimants initially expect to return to excellent practical resource see King et

B effects on both physical and mental


health, and nobody wants to hear
that they are too ill to work. Yet the
work in due course (Green et al., 2000).
It is now widely acknowledged that
an improvement in health alone is not
al., 2007.) An argument has been made
for a ‘biopsychosocial’ paradigm.
Unfortunately this biopsychosocial model
number of people on incapacity benefit sufficient to bring about an occupational has remained a largely clinical model that
(IB) has more than trebled since the outcome – a ‘return to work’. However, lacks full and appropriate consideration
1970s to 2.7 million (DWP, 2002), we are becoming increasingly sure that, of psychological, psychosocial, and
without a corresponding decrease in the generally speaking, an occupational organisational factors.
nation’s health. outcome tends to bring about an I’m not suggesting that we should
This wider focus is bringing together improvement in health (e.g. see Ballard, ignore peoples’ health conditions when
(among others) the once disparate and 2006). By an occupational outcome, I assisting them to return to work,
vague constructs, and sectors, of ‘stress’, mean a return to competitive employment: especially in the case of personal injury.
‘health and well-being at work’, ‘the happy working in the labour market for at least Indeed, for someone whose health
and productive worker’, ‘sickness absence the minimum wage for 16 hours or more impacts on their functional ability then,
management’, ‘occupational health’, per week and for a continuous period of in the short term, addressing that element
‘return-to-work (RtW)’, and ‘welfare-to- 13 weeks or more. This is an important of their health in relation to function may
work’. At the same time there is a growing distinction as it is now widely accepted well bring about a resolution of the
recognition that the health-related that other forms of work, such as problem. However, this cannot be taken
elements of these sectors have been voluntary work, do not, overall, bring for granted. Furthermore, this paradigm
largely dominated by a clinical or medical about the same health-related benefits as can arguably do more harm than good
model, and this has not proved effective. competitive employment. This may when iatrogenic effects occur.
This development is particularly especially be the case when mental health An iatrogenic effect is described as an
important in relation to the UK and well-being is taken into account (e.g. unwanted effect that is inadvertently
government’s ‘Pathways to Work’ policy, see King & Lloyd, 2007). introduced by a healthcare professional,
which aims to support people in receipt A recent review of vocational or their treatment (see Gatchel, 2004).
of IB to find and retain competitive rehabilitation (VR) found that while One example is when advised to rest to
employment (see DWP, 2002); that is, health care has a key role, treatment by relieve pain, a person may continue to
people claiming welfare support on itself has little impact on work outcomes. rest for longer than necessary. This can
grounds of long-term ill health, including This was especially the case for mental change the person’s behaviour and/or
and especially psychological distress. health: ‘Sickness absence and long-term beliefs in response to their condition and
There appears to be little or no reason incapacity associated with mental health alter their routine. The consequences of
why most people in receipt of IB could problems are unlikely to be improved this can be extreme debilitation (for
not work (see Waddell & Burton, 2006, simply by providing more healthcare...’ further examples and discussion see
for a review). Waddell and Aylward (Waddell et al., 2008; p.23). And a recent Audy, 1970; Kouyanou et al., 1997;
(2005) found that in the IB population (draft) review by NICE found that ‘there Lucire, 1986; Spillane, 2008).
65–75 per cent of people have only a was a lack of evidence of a sufficient Iatrogenic effects can also be created
limited or inconsistent pathological basis quality to demonstrate the effectiveness when clusters of symptoms that commonly
for incapacity. Furthermore, 90 per cent of of [healthcare] interventions that help occur in the normal population are

Audy, J.R. (1970). Man-made maladies Bandura, A. (1977). Self-efficacy: Toward Booth, D. & James, R. (2008). A literature existing customers (Matched case
references

and medicine. California Medicine, 113, a unifying theory of behavioural review of self-efficacy and effective study). London: Department for Work
48–53. change. Psychological Review, 84, jobsearch. Journal of Occupational and Pensions.
Baily, R., Hales, J., Hayllar, O. & Wood, M. 191–215. Psychology Employment and Disability, Gatchel, R.J. (2004). Psychosocial factors
(2007). Pathways to work: Customer Bandura, A. (1997). Self-efficacy: The 10(1), 27–42. that can influence the self-
experiences and outcomes – 2007 exercise of control. New York: W.H. Department of Work and Pensions (DWP) assessment of function. Journal of
survey. London: Department for Work Freeman. (2002). Pathways to work: Helping Occupational Rehabilitation, 14,
and Pensions. Bartley, M., Sacker, A., Schoon, I. et al. people into employment. London: The 197–206.
Ballard, J. (2006). The health and work (2005). Work, non-work, job satisfaction Stationery Office. Green, H., Smith, A., Lilly, R. et al. (2000).
debate. Occupational Health at Work, and psychological health. London: Dixon, J., Mitchell, M. & Dickens, S. First effects of ONE. Department of
3(3), 10–12. Health Development Agency. (2007). Pathways to work: Extension to Social Security Research Report No.

502 vol 22 no 6 june 2009


opinion

labelled as ‘conditions’ that require that while there was an objective set of circumstances will greatly impact on
treatment. This can result in ‘iatrogenic of long-standing variables that predict their perceived (by self and others) ability
epidemics’ of medical/clinical conditions whether and when an IB claimant will to function.
that previously would not have been return to work, the two strongest With regard to RtW in its own right,
debilitating. predictors were the person’s perception of Roger James and David Booth have
As a simple way of thinking about their own health and their ‘distance from demonstrated that self-efficacy is one of
this, many people, probably around 30 work’ or time out of competitive the most important facilitators/barriers to
per cent of the normal population, employment. In addition, perception of successful job outcomes. There are strong
experience ‘common health problems’ – health, not actual health, was found to be indications that self-efficacy is important
combinations of stiffness, soreness, one of the biggest barriers to sustained in terms of maintaining good mental
widespread and enduring pain, lower employment (see Baily et al., 2007, and health at work (see Bartley et al., 2005;
back pain, fatigue, headaches, an inability Dixon et al., 2007). Booth & James, 2008; James, 2007).
to concentrate, stomach upsets, mobility There is a bigger argument here
difficulties, sleeplessness, the triad of about the persons’ beliefs in relation to

JESS HURD (REPORTDIGITAL.CO.UK)


‘depression-anxiety-stress’, and so on. their symptoms, their ability to manage
While most people continue their them in their everyday life, and
normal lives regardless, a small especially their ability to manage their
percentage of people are debilitated by symptoms in relation to return to work
these clusters of symptoms and may and to stay in work. Both the
cease work as a consequence (or take individual and the ‘system’ within
extended time off work with worsening which they work need to be addressed.
symptoms). If only one side is addressed then we
The importance of psychosocial have a ‘clean fish, dirty pond’ scenario
factors is paramount in relation to where the individual is supported to
‘Pathways to Work’ as in the majority of manage their health and well-being,
cases of IB claims (perhaps as many as but then enters a work environment
75 per cent by government statistics: that is harmful to their health and well-
DWP, 2002) there is no debilitating being, and is ‘powerless’ to address the
condition that does not occur in the rest situation. Note that a harmful
of the working population. This is not to environment is not necessarily a
say that people in receipt of IB are not physically harmful environment: it is one
experiencing distress and lack of Arguably the most extensive theoretical where there is a perceived uncontrollable
functional ability, and in some cases this framework we have to address this threat. The only way to address that,
is severe. What it does mean is that for combination of psychosocial factors, and other than changing the environment,
many people the level of distress is in part for developing practical interventions for is to improve self-efficacy.
a function, and in part a consequence, of behavioural change, is social cognitive The massive social experiment that
the person’s behaviour rather than their theory (SCT) and in particular the work was incapacity benefit cannot be
health per se: cognitive, emotional and of Albert Bandura on self-efficacy (see, addressed by ‘fixing broken individuals’
social behaviour, including perception for example, Bandura, 1977, 1997). The and in particular cannot be addressed by
and expectation, are considered importance of perceived self-efficacy in interventions based on the ‘cult of the
behavioural mechanisms for this article. relation to IB claimants, and especially in individual’. It needs to be addressed now,
(For an example of the relevance of relation to iatrogenic effects and as worklessness is becoming one of the
illness perception, see Pietrie & iatrogenic epidemics, is clear when we biggest causes of inequality and social
Weinman, 2006). In many cases, there consider that skills or abilities alone do morbidity not only in the UK but
is a set of entrenched beliefs about the not predict performance but that ‘what worldwide. Psychology as a discipline,
severity and impact of the symptoms. you believe you can do with what you and especially as a discipline with an
These beliefs are held not only by the have under a variety of circumstances’ expert understanding of both
individual but also by members of their has the greatest impact on performance psychosocial factors and the world of
communities, including line managers, (Bandura, 1997, p.37). It follows that work, has much to contribute.
GPs, family, friends, and others. what a person believes they cannot do
We see the importance of this in the due to the perceived (by self and others) I William J. Fear is with A4e (Wales) Ltd
work of Baily et al. (2007). They showed severity of their symptoms under a variety williamjames@live.co.uk

126. London: The Stationery Office. King, R., Lloyd, C. & Meehan, T. (Eds.) absence and incapacity for work: Draft incapacity benefits. London: The
James, R. (2007). Job–capability match, (2007). Handbook of psychosocial guidance. London: NICE. Stationery Office.
adviser skills and the five self-efficacy rehabilitation. Oxford: Blackwell. Pietrie, K., & Weinman, J. (2006). Why Waddell G. & Burton K. (2006). Is work
barriers to employment. Journal of Kouyanou, K., Pither, C. & Wessely, S. illness perceptions matter. Clinical good for your health and well-being?
Occupational Psychology, Employment (1997). Iatrogenic factors and Medicine, 6, 536–539. London: The Stationery Office.
and Disability, 9(1), 3–12. chronic pain. Psychosomatics, 59, Spillane, R. (2008). Medicalising work Waddell, G., Burton, K. & Kendall, N.
King, R. & Lloyd, C. (2007). Vocational 597–604. behaviour: The case of repetition (2008). Vocational rehabilitation:
rehabilitation. In R. King, C. Lloyd & T. Lucire Y. (1986): Neurosis in the strain injury. Asia Pacific Journal of What works, for whom, and when?
Meehan (Eds.) Handbook of workplace. Medical Journal of Human Resources, 46, 1, 85–98. Vocational Rehabilitation Task Group,
psychosocial rehabilitation. Oxford: Australia, 145, 323–326. Waddell G., & Aylward M., (2005). The Industrial Injuries Advisory Council.
Blackwell. NICE (2008). Managing long-term sickness scientific and conceptual basis of London: The Stationery Office.

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