Mental sickness and the welfare state

It’s interesting the way British public policy is beginning to bring together unemployment policy with mental health policy. The British government today brought out a 10-year strategy for dealing with depression, which includes the key strategy of doing more to get the mentally ill back into work. For example, under the new strategy, job centres will now have mental health advisors.

The same day the government released its report, the Young Foundation – one of the main think-tanks behind the British ‘politics of wellbeing’, released its own report, suggesting that the welfare state needed to transform to be more focused on well-being, including helping the out of work cope with the emotional problems that often go with unemployment.

The head of the think-tank, Geoff Mulgan, says: “The welfare state that was built up after the great economic crisis of the 1930s was designed to address Britain’s material needs – for jobs, homes, health care and pensions. It was assumed that people’s emotional needs would be met by close-knit families and communities. Sixty years later psychological needs have become as pressing as material ones – the risk of loneliness and isolation, the risk of mental illness, the risk of being left behind.”

We already saw the beginning of the merger of unemployment policy with mental health policy in 2005, when Lord Layard, the government advisor, justified the government spending £173 million on training 3,000 new cognitive behavioural therapy (CBT) professionals by arguing it would pay for itself by getting many of the 1 million people claiming incapacity benefits because of mental illness in the UK off the couch and back into work.

You can criticise this shift in policy thinking from the Left or the Right. From a Leftist perspective, this is Thatcherism masquerading as therapy. The reason the government supported the Layard report’s 2005 report on depression, a Leftist sceptic could argue, is that the government hoped by spending a bit more on CBT, it could spend a lot less on incapacity benefits. You get people off the sofa, off Prozac, off the dole, and back into work. It’s Sigmund Freud meets Norman Tebbit.

This fusion of therapy with ‘on your bike’ Thatcherism reduces therapy to a mere band-aid for capitalism, argue Left-leaning therapists like Oliver James: you patch people up, give them a pep talk, and send them off into mindless low-paid jobs. It’s somewhat comparable to the First World War psychologist W.H Rivers complaining that he was treating people for shell-shock only to send them right back to the front line to die, one could argue.

Alternatively, you can criticize the new well-being state from a Rightist perspective as the nanny state gone mad: it’s crazy to think the government can take the place of the family or the church and can whisper therapeutic wisdom into our ear until we feel happier and less inclined to take benefits. At best, it’s a huge waste of money. At worst, it’s Brave New World.

What do I think about it? I think it could potentially be an interesting example of ‘joined up politics’, but it’s quite early days, and we need to see more concrete policies. There’s no doubt that the ability to work and support ourselves gives us a sense of autonomy and self-efficacy, and therefore well-being, while relying on state handouts can decrease that sense. But there’s a danger in using mental health policy to try and decrease welfare spending – not all the unemployed are mentally ill, some just can’t find work. And not all the mentally ill can be cured in a few weeks.

My concern with the Improved Access For Therapies programme (which is what Lord Layard’s CBT initiative is called) is not that it is a good idea – I think it’s a great idea – but that it has promised too much, by saying it will reduce the number of depressed people by 60%, and therefore dramatically reduce the number of people on incapacity benefits by that amount.

It’s not that easy. I know that some studies suggest CBT can cure 60% of depression, and 55% of social anxiety cases – but did the people who take part in these randomised-controlled trials all volunteer? If so, I think the results could be skewed to the positive, because if you volunteer for such a trial, you have already shown an above-average desire to try and recover.

My personal experience overcoming social anxiety, and working with other people trying to overcome it, tells me it is pretty hard to do, and it takes a lot of work. By no means everyone is willing to put in that work – they will find excuses not to, for example, blaming their therapist, or complaining that the therapy is not for them, because to get better you have to confront your fears and change your habits, and that is very difficult. It’s even more difficult if ‘getting better’ means you no longer get welfare payments that allow you to sit at home watching TV, so instead you have to go and get some low-end job.

Have a look at some of the support websites for mentally ill people in the UK, like www.social-anxiety-community.org, and you see that the mentally ill at the moment feel like Native Americans about to be moved off their land in the name of ‘progress’. They sense a new stringency in incapacity benefit assessments, but they complain that the assessments are done very quickly and without any reference to input from GPs or psychiatrists.

One person on the social anxiety forum I link to above, for example, said he filled in a two-page questionnaire, after which the person at the job centre decided he wasn’t mentally ill, and therefore didn’t merit incapacity benefit. Others say they have had similar experiences.

Many worry that if they admit they have a history of mental illness at the job centre or to an employer, they will be treated as second class citizens. It’s like getting ex-convicts back into work – do you set up special programmes to get them jobs? If so, the risk is that the employers treat them worse than ‘normal’ workers, and this only aggravates mentally ill people’s low self-esteem.

At the moment, there’s this great government push to get people better from depression and other emotional disorders, and to get them off incapacity benefits, and the risk is that this feels like a push off a cliff to the mentally ill. ‘All the government cares about is getting us off benefits’, is how one social anxiety sufferer put it.

This is the risk of explicitly linking mental health policies to unemployment policies – the mentally ill (who are typically a rather suspicious and paranoid constituency) start to think CBT is just a way to cut benefits. Which it isn’t, or shouldn’t be.

Comments:

  • Olly says:

    Hi Jules,

    Enjoyed your post.

    Interesting piece from 2007 on how the next version of the DSM will probably use a narrower definition of depression, by adding a number of exclusions that pertain to event-related sadness and grief;
    http://www.npr.org/templates/story/story.php?storyId=9323350

    The actual founder of the DSM, Robert Spitzer, thinks that thanks to their purely symptom-based, non-contextual approach, depression may currently be overdiagnosed by as much as 20-30%! Here's Adam Curtis getting him to admit it…
    http://www.youtube.com/watch?v=rHMs-M3IBHc
    (see 4 minutes in)

    not particularly relevant to your points, but was reminded of it.

    Olly

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