Category: Libertarian paternalism

Calculus Of Libertarian Paternalism

Max Ernst

German artist Max Ernst (1891 – 1976) incorporated a lot of sophisticated mathematical ideas into his works. Indeed, many Surrealists and Dadaists of the Anti-Tradition had a sophisticated grasp of mathematics and represented mathematics in a variety of astounding ways.

The 1942 picture, “Young Man Intrigued by the Flight of a Non-Euclidian Fly” shows a Young man observing a fly, through Euclidean triangle eyes. The fly executes a complex flight path leaving a trace behind it. That trace criss-crossing itself creates a large number of Non-Euclidian triangles. Quite literally, the Young Man is looking at a world with eyes that are utterly different to the reality of the World.

In mathematics, there are broadly three kinds of triangles: Hyperbolic, Euclidean, Elliptic. They each have three sides meeting at three corner angles and those features make them into triangles. An elliptic and hyperbolic triangle will not have corner angles adding up to one hundred and eighty degrees. Where anybody supposes that all triangles can only have angles adding up to one hundred and eighty degrees their calculations will be wrong for two types of triangles. Seeing the world through Euclidean Eyes is much the same as seeing the world through an ideological lense. Especially if the World has a different geometry. Looking at the Young Man Intrigued by the Flight of a Non-Euclidian Fly illustrates all three kinds of triangles and that gives resonance to the idea that the Young Man is intrigued. Anybody would be intrigued at the prospect that the World has hidden depths.

The assumption that all triangles are the same is wrong; but, not something that overly worries people. For enough practical situations, the Euclidean Triangle is acceptable. Good enough for Government Work. It seems obvious and has an intuitive appeal. People see triangles as having straight edges and one hundred and eighty degrees of angles. It makes sense. It is a default pattern of thought. It is what nudge theorists call choice architecture. No matter what you choose your choice will be determined by the assumption that the angles will always add up to one hundred and eighty degrees and that lines are always straight. It is the kind of inflexible thinking that Politicians of all Parties excel at: straight talking, clear thinking, up front. Sadly, the truth is the inability to address the variety in the world makes those politicians inflexible, authoritarian, and even counter-productive.

The inability to accept that, even if you do not know exactly how they work, there are Non-Euclidian triangles is something that prevents living in a world of surprises. Which is not to say that every surprise abolishes all that you know. This is a phenomenon that politicians of a certain sort use repeatedly. Mental gymnastics that present them as being flexible, dynamic, innovative where, in fact, they are inflexible, dull authoritarians. Nowhere is this more useful than in Paternalism.

Paternalism, in essence, tells the world that there is on kind of triangle. For enough practical situations, we can assume that Euclidean Triangles are the only Triangles. These situations do not include the sophisticated situation where there is rapid change and the world enters uncharted territory. Paternalism is not good at uncharted territory.

Paternalism is a political idea of limiting liberty or autonomy in a manner intended to promote the good of a person or group. That limitation of behaviour might be against or regardless of the will of a person. The Paternalist expresses an attitude of superiority: this is the correct way to do things. As a political idea, Paternalism has been unfashionable since the end of the Second World War. There is a small step from table manners to total war.

Telling people, especially people who are increasingly educated, that there is only one kind of triangle is nonsense. Paternalists classify themselves as soft or hard, pure or impure, moral or welfare; and, since the advent of nudge theory these have all been wrapped up into the notion of Libertarian Paternalism. Broadly Libertarian Paternalism is Paternalism where the subject of the Paternalism is influenced in their choices in a way that will make them better off, as judged by themselves. Libertarian Paternalism is about getting the whole world to buy into the notion that there is one, and only one, kind of triangle.

Which makes those who do not accept the nudge, metaphorically, into the wrong kind of triangle. Given there are three general kinds of geometry – Euclidean, Hyperbolic, and Elliptical – there is a two in three probability that a randomly selected triangle is the wrong kind of triangle. Which has a curiously powerful historical resonance for some people. Judging that a nudge is wrong for me places those with judgement in conflict with the Paternalist and the inevitable hardening of whatever powers the Paternalist possesses takes place. Libertarian Paternalism cannot help but become Authoritarian. Paternalism trumping Libertarianism for a very simple reason: Paternalists propose rule escalations and either the Libertarian accepts the escalation or the Paternalist escalates the coercion. There is no real free choice.

The modern paternalism has branded itself as nudge as if there was something harmless about it. In reality nudge relies on cognitive biases. There are around one hundred cognitive biases that have been identified by psychologists. These are systematic patterns of deviation from norm or rationality in judgement in other words: ways in which we assume we know what kind of triangle we are looking at. These cognitive biases result in fairly predictable outcomes. Nudge Theorists spend a lot of time designing decisions for Citizens to make around these cognitive biases which result in decisions that are not really free choices and may not even be rational. Indeed there is often a payoff for the Paternalist in having an irrational choice: the Citizen has made a choice and has no insight into why. Which ensures the Paternalist can narrate social reality simply by saying, “this is why you chose that”.

The list of cognitive biases is long and they are effective means to nudging people into taking the right decision. So, for example, the Default Effect is where, given a choice between several options, the tendency to favour the default one. This is frequently seen in computer systems where, for example, the default language is US-EN and needs to be changed. The subtle impact of this, for English Language Speakers, is that not changing the default US-EN to GB-EN, for example, results in software that is understandable but drives language use towards American semantics.

Then there is the Framing Effect: drawing different conclusions from the same information, depending on how that information is presented. So, for example, using US-EN and GB-EN rather than American English and British English helps to drive the conclusion that these are, somehow, dialects of the same language with equal linguistic value, rather than diverging languages in a struggle for existence. The list of cognitive biases is a list of ways to influence people: framing software use in US-EN has the subtle effect of making software be perceived as American, even though America is not the biggest writer of code in the world.

Cognitive biases are about getting things done: decisions made. They are not about rational decision making but about getting things done. In the word of the Philosopher Harry Frankfurt, they are about bullshit. The use of cognitive biases is not about saying something true or false but about getting things done. It is about Action. The principle of action replacing though has been central to the development of Totalitarianism for at least a century.

The danger of Paternalism is that it ceases being benevolent and becomes Total. In the practices of Nudge there is embodied a subtle yet obvious flaw: those doing the Nudging are not immune to the cognitive biases they use. They see the entire world as Euclidean Triangles – which, in a world with Elliptical and Hyperbolic triangles, amounts to confirmation bias. Confirmation Bias is the tendency to search for, interpret, focus on and remember information in a way that confirms one’s preconceptions. Being in positions of power, those who Nudge are using Confirmation Bias to inform their creation of a Framing Effect and a Default Effect. The outcome is that policies are not evidence based, rational and democratic but prejudice based, irrational and paternalistic.

When Sunstein and Thaler proposed that Libertarian Paternalism was a good idea, they were doing so from a peculiar position of having access to legal, contract and finance skills. Libertarian Paternalism would, it seem, work in a community that had replaced society with enforceable contracts.

This kind of notion seeps into the way the Department for Work and Pensions treat Claimants. The Unemployed become Job Seekers thus taking advantage of the cognitive bias of focusing; and, the Job Seeker has a Job Seekers Agreement which, it turns out, is an actual contract for which the Claimant must fulfil all conditions, however arbitrary. This is where we begin to see how Nudge is also nudging the Department for Work and Pensions.

Job Seekers are viewed as being lumps of labour that can be switched in and out of the Economy mechanistically. This amounts to the cognitive bias of functional fixedness. Which separates the Claimant from any access to legal, contractual or finance resources implicit in the Sunstein and Thaler presentation of Nudge Theory. Which reduces the interaction between the Department and the Claimant to a Paternalistic relationship. Indeed, the nature of that relationship is reinforced by the elimination of legal aid: there is no recourse to effective contract drafting for the Claimant and the whole relationship is determined by who has the deepest pockets.

The Department of Work and Pensions is the clearest example of how Nudge becomes Authoritarianism. The elements that make Nudge workable have all been eliminated. There is no possibility of each Claimant negotiating a realistic Job Seekers Agreement and so the agreement will be dictated, to save time if nothing else. This highlights one of the cognitive biases of the Department: illicit transference – the notion that what is true of one claimant is true of all Claimants or what is true of Claimants collectively is also true of Claimants individually.

Because the Department of Work and Pensions has abandoned the evidence based work in favour of Observer-expectancy “Randomised Control Trials” – there is a veneer of scientific respectability. Yet, the Randomised Control Trials do not actually stand up to scrutiny. Which is evidenced by the consequent Departmental use of statistics. The Department of Work and Pensions has a poor reputation for statistics – being disciplined by the National Audit Office on several occasions – which highlights the Department’s predilection for cognitive biases such as Zero risk bias, Unit Bias, Stereotyping, and Status Quo Bias.

The clear outcome is that, once the capacity for all parties to a nudge to act in a libertarian fashion is removed, all that is left is Paternalism. It is a choice. A choice made in a choice architecture: the choice is transferred from the Claimant or the Citizen to the Department or the Government. Nudge is little more than the choice architecture of authoritarianism. This is no more evident than in the choice of Austerity.

The outcome of Austerity has been the rise of social murder – the killing of reasonably well defined groups such as Claimants – often at considerable cost, in order to sustain a cognitive bias. The multiple cognitive biases, of the Tories, used to support the claim that Markets solve everything are little more than the denial that there is more than one kind of triangle. Independent observers – such as UN Special Rapporteur Philip Alston – have pointed out that Austerity is a choice that could be reversed ‘overnight’ for little cost. It is a choice. Made within a choice architecture created by Authoritarians.

The social murder carried out since 2010 is in the process of transforming society. Obedience is being presented as the default choice. In reality, the cognitive bias of System Justification, is driving the political, economic and social destruction of society and social murder is an acceptable outcome because “society will be reformed”.

It is the same notion that instruction to action – of taking back control – of keeping calm and carrying on – all signify. It is about remaking society in the image of some historical bubble: the cognitive biases of False Memory about some golden age, possibly in the 1940s or 1950s, where the world was somehow, magically, better. It was a world in which there was only one kind of triangle. It was also a world in which Max Ernst was fleeing totalitarians who wanted to kill him for painting the wrong kind of triangle.

Picture: “Young Man Intrigued by the Flight of a Non-Euclidean Fly”, Max Ernst, 1942.

Article by Hubert Huzzah

The Choice Architecture Of Poverty

Special Rapporteur Philip Alston has presented a United Nations Report on Poverty in the UK. The UK Mainstream Media have not really excelled in analysis or presentation of the findings. After almost a decade of Nudge by Press Release, the Guardian has missed the vital message while the BBC has simply recycled old Government Press Releases. The Mainstream Media seem to be shy about embracing the most damning finding of the report.  

In December 2017, Professor Alston carried out a visit to the USA – California, Alabama, Georgia, Puerto Rico, West Virginia, and Washington DC – carrying out the same kind of investigation as has just finished in the UK. The most damning finding of the UN-US Report on Poverty was similar to the most damning finding of the UN-UK Report on Poverty. Had the Guardian excelled in Journalism they might have highlighted that the UN was not simply finding something isolated.

The Guardian and the BBC might not have concluded that the “Government is in denial” because following the implications of the most damning finding is that POVERTY IS A CHOICE 

Both in 2017, in the USA, and in 2018 in the UK, the UN has concluded that poverty is a choice and that Government has made the decision that the only choice on offer is compliance or poverty. The Mainstream Media is failing to follow any kind of analysis that follows the implications of the finding that poverty is a choice and there is no adequate explanation as to why? The notion that poverty is a choice is one that has been foisted onto everybody by the Government since 2010. Welfare Changes have been touted as Reforms which will enable people to choose to lift themselves out of poverty. That choice takes place within the Choice Architecture that has been created by policy.   

In the UN-US Report, Alston states that: 

“ …I heard how thousands of poor people get minor infraction notices which seem to be intentionally designed to quickly explode into unpayable debt, incarceration, and the replenishment of municipal coffers…”  

In the UN-UK Report, Alston similarly finds that:  

One of the key features of Universal Credit involves the imposition of draconian sanctions, even for infringements that seem minor. Endless anecdotal evidence was presented to the Special Rapporteur to illustrate the harsh and arbitrary nature of some of the sanctions, as well as the devastating effects that resulted from being completely shut out of the benefits system for weeks or months at a time. As the system grows older, some penalties will soon be measured in years.”  

The Mainstream Media make no connection between the American Experience and the British Experience. As if there was no connection between US Policy and UK Policy. As if all the shuttling back and forth between Republicans and Conservatives has never had any impact. As if the Minor Infraction Notices are, in no way, related to Benefit Sanctions. There is an almost willing blindness: never stray from the press release.  

The UN Rapporteur was never commissioned to analyse Nudge Theory. The outcome of eight years of Libertarian Paternalism has transformed British Society into something that, the UN recognises, punishes the Poverty it also chooses to deliver. The overwhelming Mainstream Media response has been the Punch and Judy caricature and Poverty Porn Prurience instead of analysis.

How did a Government get to the point where Human Rights are optional or contingent upon being an Employee: this is a question central to the current Welfare Policy which is transforming British Society. It also has an answer that the UN Rapporteur gives: POVERTY IS A CHOICE.  

In putting forward an endless series of press releases and promoting the production of daytime television portraying skivers and strivers the Department of Work and Pensions has been nudging the Mainstream Media into only presenting a narrative where strivers can choose to leave poverty and only skivers would want to avoid that choice. The constant nudging – the well written Press Releases that, frequently, substitute for actual Journalism – has worked. The Government has decided to provide the choice of poverty in a range of ways.  

The Government provision of choices of poverty underline that decisions are placed beyond Claimants in a calculated and cruel manner. The Choice Architecture prevents Claimants from making decisions. Decisions would empower Claimants and also permit innovation. Claimants could determine what is the best course of action. Instead the digital by default process has been used to provide a series of choices without any deviation permitted.

A Claimant who fails to fill in any choice – and fill it in correctly, and fill it in digitally – automatically chooses poverty. Similarly, those who fail to know that choices have been proffered are choosing poverty. The complexity of the choice architecture is overwhelming – even for those engaged in administering it. It is a system that has been designed to deliver poverty – and it has.  

The skills to interact with a State that is being made actively oppositional and digital as the UN-UK Report highlights:   

The reality is that digital assistance has been outsourced to public libraries and civil society organizations. Public libraries are on the frontline of helping the digitally excluded and digitally illiterate who wish to claim their right to Universal Credit.” 

Which is not too distant from the UN-US Report:

Much more attention needs to be given to the ways in which new technology impacts the human rights of the poorest Americans. This inquiry is of relevance to a much wider group since experience shows that the poor are often a testing ground for practices and policies that may then be applied to others. These are some relevant concerns.”  

The truth is, the US and the UK have parallel tracks in overarching Policy objectives: eliminate the State and have the Poor fend for themselves. The emphasis on digital systems as a means to distance Policy Makers from Policy Delivery and to “cut costs” is evident across the US and UK Reports. Pretrial detention has been an area calling for systematic reform in the US for decades. The UN-US Report observes:   

Automated risk assessment tools, take “data about the accused, feed it into a computerized algorithm, and generate a prediction of the statistical probability the person will commit some future misconduct, particularly a new crime or missed court appearance.”

The system will generally indicate whether the risk for the particular defendant, compared to observed outcomes among a population of individuals who share certain characteristics, is ‘high’, ‘moderate’, or ‘low’. Judges maintain discretion, in theory, to ignore the risk score.” 

Which reflects the “automated” nature of the Work Capability Assessment for the Disabled in the UK, previously reported by the UN as being either at risk or actually in the process of grave human rights abuse. In the UN-UK Report the Automated Risk Assessment tools are commented upon:   

But it is clear that more public knowledge about the development and operation of automated systems is necessary. The segmentation of claimants into low, medium and high risk in the benefit system is already happening in contexts such as ‘Risk-based verification.’ Those flagged as ‘higher risk’ are the subject of more intense scrutiny and investigation, often without even being aware of this fact. The presumption of innocence is turned on its head when everyone applying for a benefit is screened for potential wrongdoing in a system of total surveillance. And in the absence of transparency about the existence and workings of automated systems, the rights to contest an adverse decision, and to seek a meaningful remedy, are illusory.”   

Which underlines that the Government of the day – regardless of political inclination – are delivering Policy Objectives without transparency, clarity or even sufficient information to determine what the Policy Objectives are. When policy objectives only become clear through outcomes, there is a clear suspicion that Democracy has been subverted. Which is the general direction the UN-US and UN-UK Reports indicate. There are serious Human Rights failings but also a serious democratic deficit arising from the idea that POVERTY IS A CHOICE.   

The use of Computer Systems is not neutral or innocent. The Special Rapporteur notes that:   

it is worrying that the Data Protection Act 2018 creates a quite significant loophole to the GDPR for government data use and sharing in the context of the Framework for Data Processing by Government.”  

Which is not simplistically that UK Government Departments have “rights” to trawl through personal data but that it is increasingly criminalised for Claimants – more than eight million people – to object to that trawl or to object to the sharing of data with Commercial Contractors. Those same Contractors being Employers and the inevitable consequence of data sharing being to put Claimants at a distinct power and negotation disadvantage when contracts of Employment are considered. Because the UK Government Departments have zero obligation to ensure Claimants get the best possible job. Simply that Claimants flow off the Register.   

Which is how POVERTY IS A CHOICE is being delivered from Government to the People. Interaction with the Department of Work and Pensions has become the single most corrosive interaction with Government that People can have. The design of benefits has become an exercise in delivering the ideological convictions of the Government regardless of the practicality of those convictions. For the Conservative Government, that conviction is that people should be in poverty unless they are Employed. Which ensures the disabled, parents, students, pensioners, entrepreneurs in start-up and Carers are locked into a combative process in which the only exit is to choose poverty.  

The UK Mainstream Media is not really exploring this dimension of the UN Rapporteur’s commentary. It leads to uncomfortable terrain for any Journalist. Not least, the intimate connection between the Republicans in the US and the Conservatives in the UK. The ideological convergence of the Conservatives with the Republicans has delivered a wide range of public policy disasters. The Department of Work and Pensions has been allowed carte blanche to redesign the Welfare State based on the Workfare preferred by the Republicans.

The Nudge Unit has crossed, and recrossed, the Atlantic ensuring that the Conservative’s historic prejudice for “the right to manage” has become inflated. Including all aspects of social existence into contractual relationships between the Government and the People. Dating back to Ronald Reagan’s 1985 “Contract with America” speech where everything was reduced to legislation as contract and society became replaceable with a well ordered business.

The UK Mainstream Media is not really capable of exploring these ideas because, quite simply, to do so is to undermine the interests of their owners. Without any need for coercion, the Government is capable of nudging the Media into endlessly propagating the POVERTY IS A CHOICE agenda.  

Despite the comprehensive nature of the UN Rapporteurs investigations and reporting, there is little about the UN-UK Report that is actually surprising. The connection between the UN-UK and UN-US Reports might well be a surprise to the Media. Realistically, there should be no surprise at all. The Extremists of The Atlantic Bridge, The Heritage Foundation and all the myriad of Far Right Think Tanks since Reagan, have all been promoting the same ideas both sides of the Atlantic. They have all been ensuring that the tools exist for Government to make only once choice possible for the People and that choice is Poverty.  

UN-UK Report  

UN-US Report 

 Picture: Mika Rottenberg, Bowls Balls Souls Holes, Video Installation Rose Art Museum Waltham USA (2104). 

This article was written by Hubert Huzzah.


 

 

The Healthcare Nudge Tax – Hubert Huzzah

Mary Seacole was a British-Jamaican business woman and nurse who set up the British Hotel in the Crimea during the Crimean War. Not as well known as Florence Nightingale, she essentially spent all of her fortune tending to the British Wounded. She was Florence Nightingale’s copay. There are a wide range of reasons why Seacole ended up going from successful Businesswoman to Poverty but the cost of nursing care was a significant contributor.

The National Health Service (Co-funding and Co-Payment) Bill 2017-2019 is seen, on the Left, as introducing something new to the National Health Service: co-funding and co-payment. This is untrue: whenever someone pays for spectacles, dental treatment or a visit to the chiropodist, that falls, broadly into co-funding-co-payment. There is no need to legislate for these things. What the Bill is seeking to create is something a lot more than simple co-payment.

Seacole paid for treatment and facilities for British Soldiers in Crimea. She lacked the social connections in Britain to do anything other than pay the full economic costs for her efforts. The important point is that Seacole was co-funding and co-paying the Healthcare provisions of Florence Nightingale. Lacking the connections of Nightingale, Seacole was obliged to pay in full, up front, the market price of nursing care. Unlike Nightingale, Seacole was not economically supported in delivering nursing care. When the Crimean War ended, Seacole came to Britain and was both well known and sympathetically received but poor. Her fortunes were only really restored by patronage and public subscriptions to her.

Sir Christopher Robert “Chopper” Chope OBE son of a Judge, pioneered the sale of Council Houses – with such aggression he became known as Chopper. As Chairman of Conservative Way Forward he has been vocal in promoting the extremes of Thatcherism even to the detriment of his own Party. As a Private Landlord, in 2014, Chope filibustered a Liberal Democrat bill, with cross party support, seeking to make revenge evictions an offence. Again, in 2015, he filibustered a private member’s bill seeking to restrict car parking charges on Carers at hospitals. His vision is resolutely Thatcherite: he steered the Poll Tax through Parliament; and, his chosen tool is the Private Members Bill. Which helped to ensure the Referendum on European Membership took place. What he does not like he talks into the ground.

Which all begs the question of why a Thatcherite former vice-chairman of the Tory Party would be presenting a bill for co-payment and co-funding since the NHS already operates a co-payment system. Indeed, why would a Member of Parliament waste time on something that already happens when there are so many other issues demanding attention. Across Europe there are a variety of ways in which Healthcare is funded. All involve some degree of co-payment.

1. No co-payments: The Netherlands and Malta.

2. Flat-rate co-payments: Austria, Italy.

3. Implied ceiling flat rate co-payment (prepayment certificate): UK.

4. Percentage rates co-payment: Belgium, France, Greece, Estonia, Latvia, Lithuania, Poland, Portugal, Slovakia, Slovenia and Spain.

5. Percentage rate co-payment with annual ceiling: Finland.

6. Uniform percentage co-payment: Cyprus, Germany, Norway.

7. Co-insurance, with percentage decreasing with accumulated expenditure over a given period and with a ceiling: Denmark and Sweden.

8. Deductible co-payment: Ireland, Sweden.

9. Many countries have explicit exemptions for certain products, as well as for some patient and socio-economic groups.

The only places with zero co-payments are the Netherlands and Malta. Co-payment is the usual European model. Co-payment intrinsically limits the amount paid and allows for exemption. Even in Belgium, France, and so on, the percentage co-payment is open to reduction by negotiation, prepayment or even poverty. Importantly, co-payment takes place at the point of delivery. There is always a way to avoid the refusal of treatment with co-payment. The Economists explanation of co-payment is that it provides an entry cost into the Healthcare Market for the Healthcare recipient which avoids moral hazard. Moral hazard occurs when someone increases their exposure to risk when insured because they are insured. It is the accusation placed against the Banks in 2007. When there were claims Banks were ‘too big to fail’, the claims of moral hazard disappeared. Moral hazard only applies if you are, economically, small, according to policy makers. Fundamentally, co-payments across Europe have been about ensuring equity that is fairness not avoiding moral hazard.

Co-payment as a mechanism for ensuring fairness have always been viewed with suspicion by health economists because co-payment leads to value based pricing of healthcare. Value Based Pricing is distinct from Cost Based Pricing in placing a price onto goods or services based on the value to the purchaser not the cost to the provider. Cost Based Pricing determines how much the time and materials a service or goods cost, a profit margin is applied and the buyer charged.

Buyers of Cost Based Pricing products can always push prices down towards cost. The slogan Think like a patient, act like a taxpayer is being repeated, mantra-like, by close friend of Boris Johnson and former president of United Health Group Inc. – an American commercial health company – as the head of NHS England. It is intended to justify the moving of 36 treatments out of the NHS into a purely co-funded basis. Unlike co-payment, co-funding is never waived. Co-funding ensures that there is a fundamental shift in the relationship between Doctor and Patient.

Since 1948, the NHS has operated on the basis that a Doctor makes a decision about the treatment for a Patient and the Patient receives that treatment from the NHS. The decision involves no third parties. Under a co-funding healthcare model – the decisions about the value of the therapy are made by the Third Party Payee. That Third Party Payee both determines the pricing and the availability based on assessments of value. The Third Party explicitly shapes prescribing decisions through various guidelines and incentives. This is the general system that operates in the US where people think like a patient and act like a premium payer – because the tax paid is a premium paid to an Insurer. The difference between the experience of Florence Nightingale and Mary Seacole is the difference between co-payment and co-funding.

Florence Nightingale could decide on any treatment she wished to give to the Troops. When she did so, she could appeal to sponsors and donors to pay for those treatments. Mary Seacole recommended the treatments that she was experienced with which were particularly around communicable diseases such as cholera. Unless she could find an approving donor, she was obliged to pay out of her own funds. Lack of social connections and her acceptance of the need for Soldiers to have a social existence kept donations at a distance.

Both Nightingale and Seacole were operating on a cost based pricing model and the outcome for both were, economically, different. Both Nightingale and Seacole were accepting payments from those they treated but Seacole would waive fees for those who could not pay or if it served the health of others around that person for them to be treated. She was forced into co-funding of treatments because failing to treat cholera simply because someone cannot pay promotes the spread of cholera. It was that utilitarian compassion that made Seacole a national hero. It was also the success of her approach – that of broadly socialised medicine – that helped to galvanise the Far Right of the Conservative Party into demanding Seacole was removed from the national curriculum and to rabid opposition to her statue being erected as a memorial on NHS Property.

Legitimately, there are those who point out that the Tories are racists who have a problem with Black People from the Caribbean in the Health Service. That point is hugely important but ignores that Seacole was obliged to be a completely commercial healthcare provider which bankrupted her. The fundamental problem was not simplistically racism but that private healthcare simply fails to work. Which illustrates the kind of smokescreen that the Tories adopt: nudging people into an argument about one thing when the real issue is elsewhere: talk about racism and lose the NHS or talk about the NHS and suffer racism.

There is no mistake in saying that the Cosmopolitan nature of British society outside Whitehall and the Establishment is what created the NHS, and that Mary Seacole was an important step along the path to the 1948 Act; but, that distracts from what the National Health Service (Co-funding and Co-Payment) Bill 2017-2019 sets out to achieve.

Mary Seacole illustrated what happens when co-payment and co-funding coexist: someone goes bust. Co-payments are limited and, despite being almost universal in their enforcement, can be waived. Poor people should not die because they are not poor. Introducing co-funding ends the capacity to waive a co-payment. Co-payment is a gateway to full co-funding. Co-payment establishes a threshold price and the result is a shift from Cost Based Pricing to Value Based Pricing. Healthcare co-payment, connected to co-funding, nudges policy from Cost Based Healthcare to Value Based Healthcare by claiming that a Value Based Price should be “largely consistent with the values and preferences of the vast majority of the insured population”.

Value Based Pricing sets a prices according to the value of a product or service to the Payer rather than according to the cost of the product to the Seller. There needs to be no connection to cost based prices or even historical prices. The aim is simply to increase profitability without a need to increase sales volumes. Which is essential in commercial healthcare where successful treatment reduces the need for treatment and failed treatment removes customers from the market.

Value Based Pricing principally works in to the benefit of the Seller. It relies on the perceptions of the Buyer which leads right back to Nudge Theory. For Value Based Pricing the single most valuable emotion is not desire but fear. Realistically, it is Fear Based Pricing that relies on the Buyer being in fear of not obtaining the product. Co-payments create low level fear yet co-funding not only creates low level fear in the short term but reinforces that fear in the longer term. Which creates the environment for perpetual nudge. Value Based Pricing leads to such things as Surge Pricing as operated by Gig Economy Apps such as Uber. Surge Pricing raises price when there is higher demand because there is higher fear of not being able to obtain the service. For the Health Service that kind of Surge Pricing would be apparent around “flu season” or communicable disease outbreaks.

Value Based Pricing is not only about maximising profit but also acknowledge to be associated with high levels of fraud. Co-funding creates a purely Value Based Pricing market place, meaning that co-payments are, at best, a loss leader. With the current Co-payment system in place, it would be possible for a Pharmacist to look at a prescription and tell the Patient that a cheaper over the counter alternative exists. The same would be possible with a General Practitioner: it would be possible for a General Practitioner to recommend a box of generic paracetamol at twenty pence instead of a prescription at three pounds eighty.

Under a system where Co-funding and Co-payment are both present, it is normal for both General Practitioners and Pharmacists to be contractually unable to give any pricing advice whatsoever. Indeed, the American Medical Association, found that 28% of prescriptions for generic drugs included an element of overpayment and 6% of branded drugs included an element of overpayment. The prescription has become, for a good many Americans a nudge into purchasing. The General Practitioners and Pharmacists have terms and conditions dictated by a third party: which is the outcome of marketplace healthcare.

Overpayment at the point of dispensing is counted as healthcare fraud. The FBI estimates that Health Care Fraud costs American tax payers $80Bn/y. Of this amount $2.5Bn was recovered through the False Claims Act in the Financial year 2009-2010 at the cost of paying out $0.3Bn to whistle-blowers. Prescription fraud is not the only source of fraud. Wherever there is a mixture of co-payment and co-funding, there is an elevated level of fraud. This includes Billing for services not rendered, overcharging services and items through computer coding, duplicate charges for items, unbundling treatment packages and charging for individual items, excessive and unnecessary services as well as bribes and falsified medical records.

In fact, where there is fraud in any Healthcare System there is a reduction in life expectancy for Healthcare users. This is particularly evident where medical records are falsified for any reason. The single biggest source of fraudulent activity is around Third Parties being involved in the Patient-Doctor relationship.

The annual cost of Fit To Work assessments, in general, was expected to rise to £579m in 2016-17, it did so. Part of that rise was due to Atos walking away from a contract as Third Party to the Doctor Patient relationship for sick and disabled people. Each employment and support allowance (ESA) test had a price hike from £115 to £190 in order to continue doing them. This was hailed as being contracting out of public services when, in fact, it was the invention of a whole new service, already carried out by General Practitioners, in order to create a Third Party to the relationship between Doctors and Patients. The track record of that relationship has been abysmal – the majority of decisions based on the Third Party are overturned by an appeals process. The important thing is not to be distracted by the large, growing, literature and documentation of rising death rates, suicides and failed decisions but to focus on the entire Work Capability Assessment (WCA) being a government contract with Key Performance Indicators (KPI) that drive organisational behaviours.

By walking away from the contract, Atos demonstrated that the DWP were locked into a Value Based Pricing contract and so the 65% price hike from £115 to £190 is perfectly understandable. The simple reason that the Government paid up was that the assessment price was a co-funding arrangement.

The National Health Service (Co-funding and Co-Payment) Bill 2017-2019 sets out to achieve the institutionalisation of co-payment and co-funding into the NHS. Currently Co-payment exists but there is no lever to be pulled that can nudge Patients into behaving as Consumers. In articles about the frequency and magnitude of co-payments exceeding prescription costs, there is frequently expressed the concern that Consumers are prevented from knowing the full nature of the relationship between themselves and the Third Party. For example, Pharmacists and General Practitioners can be placed into a non disclosure relationship with the Third Party where they cannot be told of a better and cheaper treatment. Because the Third Party manages the relationship between Doctor and Patient. Surveys among US Independent Pharmacies indicate that, despite denials, this is common practice. Which makes perfect sense in an economy that is being pushed into Value Based Pricing even if it is reprehensible behaviour.

The promotion of Value Based Pricing into UK Healthcare is not simply about making a profit. It also seeks to promote behaviour change. To change the behaviour of all NHS Patients into being NHS Customers. Without institutionalised co-funding and co-payment as paired policies, turning Patients into Customers becomes an uphill struggle. Christopher Chope navigated the Poll Tax through the Commons, changing a property based taxation into a person based taxation. It turned out badly, yet neither he nor his opposition dwell upon the fundamental change of relationship between Electorate and Local Authorities that it created. The National Health Service (Co-funding and Co-Payment) Bill 2017-2019 has a far bigger impact.

Martin Shkreli, infamous for hiking the price of Tiopronin (trade name Thiola) from $1.30 to $30, caused outrage demonstrates the power of Value Based Pricing. In 2015, in Shkreli’s company acquired Daraprim: an out of patent drug with no generic version available. The price of a dose of the drug in the U.S. market increased from US$13.50 to US$750 per pill. In interviews, Shkreli explained that co-payments would be lower for patients as the new owner of the drug ensured many patients would get the drug at no cost, through a free drug program, and that it sold half of its drugs for one dollar. Which were all technically correct statements.

What they actually revealed was how dysfunctional co-payment becomes in the presence of co-funding. Co-funding introduces the Third Party to the Doctor Patient relationship. Which is already understood to be dysfunctional from the outcomes at the DWP. Importantly co-funding introduces a Choice Architecture into healthcare which makes future healthcare subject to the Libertarian Paternalism of Nudge.

Value Based Pricing is generally acknowledged to lack intellectual honesty. In reality it is a matter of charging what you can get away with not what the product or service costs. Organisations who deliver a product on a Value Based Pricing basis often push Cost Based Pricing onto their supply chain resulting in inflation of profits. In a commercial environment this is poor treatment but in a Healthcare environment it unsustainable poor treatment that kills the customer base as well as the supplier base.

Combined with co-funding, it locks new market entrants out and so ends the possibility of the NHS reducing costs. In that sense, locking co-payment and co-funding together is little more than an invitation to fraud. While Value Based Pricing is controlled by, for example, the National Institute Of Clinical Excellence (NICE), the advocacy is in favour of the Electorate. NICE might well make unpopular decisions but the are decisions that are rational and internationally respected. Passing Value Based Pricing decisions to a Third Party – as happened at the DWP – changes the advocacy to be for the owners of the treatment.

The National Health Service (Co-funding and Co-Payment) Bill 2017-2019 sets out in a deceptively simple amendment to Section 1 followed by an equally simple looking amendment to section 12E of the National Health Service Act 2006. The overall impact is to change the relationship between the NHS and the Patient:

the making and recovery of charges is expressly provided for by or under any enactment, whenever passed”

Allows the Government to introduce charging by Statutory Instrument. A process that takes a week or so. This would allow for charges to be put in places for any treatment, drug, appliance or activity of the NHS by placing a document with the preamble: “In exercise of the powers conferred on me by The National Health Service (Co-funding and Co-Payment) Bill 2018, I hereby make the following Order:” At which point any charge can be placed into effect. The Statutory Instrument simply needs to remain unchallenged for 40 days and it becomes Law. The last occasion that the House of Commons annulled a Statutory Instrument was in 1979. So, whenever a Statutory Instrument is passed into law, NHS Charges to the Patient could be changed. Which simply means that all that is required is an active Lobbying Group and any NHS Tariff could be amended or even new ones created.

Which is not simply about nudging people to eat less sugar or cease smoking. It is about nudging Legislators to slavishly implement Value Based Pricing decisions of a wide range of goods, products, services, treatments and activities of the NHS. While this seems localised to the UK, the truth is the pricing of Drugs and Treatments in the NHS affects purchasing decisions in 40% of the World’s Health Services. Value Based Pricing in a global market is easier if your product is being sold at a premium in an influential local market. The creation of an institutional nudge has immense, global, commercial value. Lobbying in the UK would avoid scrutiny in, for example, the US but the outcome would be the same: Value Based Prices could rise in America. By nudging Legislator rather than end Customer, the cost of nudging is significantly reduced and the impact is far greater. Not only is the nudge guaranteed to work but it has the force of law to prevent it being dismantled.

The NHS has one of the price drug regimes in the World. Co-payment already exists and needs no legislation to be introduced: it is as simple as asking a General Practitioner to prescribe and asking the price. The National Health Service (Co-funding and Co-Payment) Bill 2017-2019 is not about kite flying or testing the waters or increasing choice for patients but about ensuring that Lobbyists are the Third Party getting between Doctors and Patients not only in the UK but right across the World.

What The National Health Service (Co-funding and Co-Payment) Bill 2017-2019 will promise is more choice and better, cheaper care. The experience in the US where co-payment and co-funding is in place is that Health Tourism increases – people find it cheaper to travel to Canada to get a prescription filled – and fraud rises; but, much more importantly, Healthcare ceases to be about health and becomes a significant way for Third Party Investors to manage social behaviour. The biggest Nudge possible: locking everybody into your marketing plans.

In the same way as Martin Shkreli could claim a price rise was a price fall on the basis of complex Value Based Pricing calculations that are commercial secrets, The National Health Service (Co-funding and Co-Payment) Bill 2017-2019 makes commercial secrets obligatory through Statutory Instruments, which not only ensures the NHS is privatised but that the Privatised NHS promotes healthcare cost rises across the planet.

It has been suggested that The National Health Service (Co-funding and Co-Payment) Bill 2017-2019 should be filibustered into oblivion. That would not end the drive toward Privatisation. It would also not prevent the Bill from being presented again in a similar but different form. This is the experience of the Poll Tax: it was never popular but it was navigated towards legislation by careful use of procedure. Similarly the progress of the European Referendum was navigated by the careful use of Private Members’ Bills. The National Health Service (Co-funding and Co-Payment) Bill 2017-2019 is simply another example of the well tried technique of Thatcherite MPs. This time it embeds nudge into a central Institution of Society: the NHS. The Bill should be utterly repudiated and, along with it, the underlying presumption that the entire population can be nudged and deceived and their health manipulated for profit.

Article by Hubert Huzzah

Picture: Statue of Mary Seacole (Grounds of Saint Thomas’s Hospital London). Martin Jennings 2016.

 

Related

Private bill to introduce further charges to patients for healthcare services is due for second reading today

 


 

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From the abstract to the concrete: urban design as a mechanism of behaviour change and social exclusion

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I rarely venture into large retail areas and shopping centres. They make me feel unwell. I’m rather claustrophobic to begin with. I also have lupus, one of my symptoms is a quite extreme photosensitivity. The lighting in these places quite often triggers an attack of vertigo, nausea, incapacitating disorientation, co-ordination difficulties, muscle rigidity, temporary and severe visual distortions and a very severe headache.

However, I visited one recently with a friend, who was doing some last-minute Christmas shopping. He promised we would visit just two shops, and that our visit would be over quickly.

What struck me straight away is how much retail design is now just about revenue-producing. Shopping malls are unforgiving, soulless and unfriendly places. I was reminded of something I read by David Harvey, about the stark reality of shrinking, privatised and devalued public spaces. Neoliberal marketisation has manifested ongoing conflicts over public access to public space, where profiteering reigns supreme.

My experience of a shopping mall was deeply alienating and physically damaging. It brought with it a recognition of how some groups of people are being coerced and physically situated in the world – how citizens think and act is increasingly being determined by ‘choice architecture’ –  which is all-pervasive: it’s situated at a political, economic, cultural, social and material level. Hostile architecture – in all of its forms – is both a historic and contemporary leitmotif of hegemony. 

Architecture, in both the abstract and the concrete, has become a mechanism of asymmetrically changing citizens’ perceptions, senses, choices and behaviours – ultimately it is being used as a means of defining and targeting politically defined others, enforcing social exclusion and imposing an extremely authoritarian regime of social control. 

Citizens targeted by a range of ‘choice architecture’ as a means of fulfiling a neoliberal ‘behavioural change’ agenda (aimed at fulfiling politically defined neoliberal ‘outcomes’) are those who are already profoundly disempowered and, not by coincidence, among the poorest social groups. The phrase choice architecture implies a range of offered options, with the most ‘optimal’ (defined as being in our ‘best interest’) highlighted or being ‘incentivised’ in some way. However, increasingly, choice architecture is being used to limit the choices of those who already experience heavy socioeconomic and political constraints on their available decision-making options. 

The shopping mall made me ill very quickly. Within minutes the repulsive lighting triggered an attack of vertigo, nausea, co-ordination and visual difficulties. I looked for somewhere to sit, only to find that the seating was not designed for actually sitting on. 

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The public seating that’s just a prop.

This radically limited my choices. In order to sit down to recover sufficiently to escape the building, the only option I had was to buy a drink in a cafe, where the seating is rather more comfortable and fulfils its function. I needed to sit down in order to muster myself to head for the exit, situated at the other end of the building. 

At this point it dawned on me that the hostile seating also fulfils its function. In my short visit, I had been ushered through the frightfully cold, clinical and unfriendly building, compelled to make a purchase I didn’t actually want and then pretty much rudely ejected from the building. It wasn’t a public space designed for me. Or for the heavily pregnant woman who also needed to sit for a while. It didn’t accommodate human diversity. It didn’t extend a welcome or comfort to all of its guests. The functions and comforts of the building are arranged to be steeply stratified, reflecting the conditions of our social reality. The only shred of comfort it offered me was conditional on making a purchase.

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When the purpose of public seating isn’t taking the weight off your feet and providing rest.

Urbanomics and the cutting edge of social exclusion: what is ‘defensive architecture’ defending?

Social exclusion exists on multiple levels. The distribution of wealth and power, access to citizenship rights and freedoms, political influence and consideration are a few expressions of inclusion or exclusion. It also exists and operates in time and space – in places. 

Our towns and cities have also increasingly become spaces that communicate to us who ‘belongs’ and who isn’t welcome. From gated communities and the rise of private policing, surveillance and security to retail spaces designed to fulfil pure profiteering over human need, our urban spaces have become extremely anticommunal; they are now places where an exclusive social-spatial order is being defined and enforced. That order reflects and contains the social-economic order.

Retail spaces are places of increasing psychological and sensual manipulation and control. Hostile architecture is designed and installed to protect the private interests of the wealthy, propertied class in upmarket residential areas and to protect the private profiteering interests of the corporate sector in retail complexes.

The very design of our contemporary cities reflects, directs and amplifies political and social prejudices, discrimination and hostility toward marginalised social groups. Hostile architectural forms prevent people from seeking refuge and comfort in public spaces. Places that once reflected human coexistence are being encroached upon, restrictions are placed on access and limits to its commercial usage, demarcating public and private property and permitting an unrestrained commodification of urban spaces and property.

In 2014, widespread public outrage arose when a luxury London apartment building installed anti-homeless spikes to prevent people from sleeping in an alcove near the front door. The spikes, which were later removed following the public outcry, drew public attention to the broader urban phenomenon of hostile architecture.

Anti-homeless spikes in London

Dehumanising ‘defensive architecture’ – ranging from benches in parks and bus stations that you can’t actually sit on, to railings that look like the inside of iron maidens, to metal spikes that shriek ‘this is our private space, go away’ – is transforming urban landscapes into a brutal battleground for the haves and socioeconomically excluded have-nots. The buildings and spaces are designed to convey often subtle messages about who is welcome and who is not.

Hostile architecture is a form of urban design that aims to prevent people from lingering in public spaces. The anti-homeless spikes here, for example, were installed to deter beggars and those sleeping rough.

Hostile architecture is designed and installed to target, frustrate deter and ultimately exclude citizens who fall within ‘unwanted’ demographics.

Although many hostile architecture designs target homeless people, there are also a number of exclusion strategies aimed at deterring congregating young people, many of these are less physical or obvious than impossibly uncomfortable seating, which is primarily designed and installed to prevent homeless people from finding a space to sleep or rest. However, the seating also excludes others who may need to rest more frequently, from sitting comfortably – from pregnant women, nursing mothers with babies and young children to those who are ill, elderly and disabled citizens.

Some businesses play classical music as a deterrent – based on an assumption that young people don’t like it. Other sound-based strategies include the use of high-frequency sonic buzz generators (the ‘mosquito device’meant to be audible only to young people under the age of 25.

Some housing estates in the UK have also installed pink lighting, aimed at highlighting teenage blemishes, and deterring young males, who, it is assumed, regard pink ‘calming’ light as ‘uncool’. There is little data to show how well these remarkably oppressive strategies actually work. Nor is anyone monitoring the potential harm they may cause to people’s health and wellbeing. Furthermore, no-one seems to care about the psychological impact such oppressive strategies have on the targeted demographics –  the intended and unintended consequences for the sighted populations, and those who aren’t being targeted.

                   Blue lighting in public toilets via Unpleasant Design

Blue lighting has been used in public toilets to deter intravenous drug users; the colour allegedly makes it harder for people to locate their veins. It was claimed that public street crime declined in Glasgow, Scotland following the installation of blue street lights, but it’s difficult to attribute this effect to the new lighting. Blue may have calming effects or may simply (in contrast to yellow) create an unusual atmosphere in which people are uncomfortable – actingout or otherwise. So questions remain about causality versus correlation. Again, no-one is monitoring the potential harm that such coercive strategies may cause. Blue light is particularly dangerous for some migraine sufferers and those with immune-related illnesses, for example, and others who are sensitive to flickering light. 

Hostile architecture isn’t a recent phenomenon

Charles Pierre Baudelaire wrote a lot about the transformation of Paris in the 1850s and 1860s. For example, The Eyes of the Poor captures a whole series of themes and social conflicts that accompanied the radical re-design of Paris under Georges-Eugène Haussmann‘s controversial programme of urban planning interventions.

Baron Haussmann was considered an arrogant, autocratic vandal by many, regarded as a sinister man who ripped the historic heart out of Paris, driving his boulevards through the city’s slums to help the French army crush popular uprisings. Republican opponents criticised the brutality of the work. They saw his avenues as imperialist tools to neuter fermenting civil unrest in working-class areas, allowing troops to be rapidly deployed to quell revolt. Haussmann was also accused of social engineering by destroying the economically mixed areas where rich and poor rubbed shoulders, instead creating distinct wealthy arrondissements.

Baudelaire opens the prose by asking his lover if she understands why it is that he suddenly hates her. Throughout the whole day, he says, they had shared their thoughts and feelings in the utmost intimacy, almost as if they were one. And then:

“That evening, feeling a little tired, you wanted to sit down in front of a new cafe forming the corner of a new boulevard still littered with rubbish but that already displayed proudly its unfinished splendors. The cafe was dazzling. Even the gas burned with all the ardor of a debut, and lighted with all its might the blinding whiteness of the walls, the expanse of mirrors, the gold cornices and moldings…..nymphs and goddesses bearing on their heads piles of fruits, pates and game…..all history and all mythology pandering to gluttony.

On the street directly in front of us, a worthy man of about forty, with tired face and greying beard, was standing holding a small boy by the hand and carrying on his arm another little thing, still too weak to walk. He was playing nurse-maid, taking the children for an evening stroll. They were in rags. The three faces were extraordinarily serious, and those six eyes stared fixedly at the new cafe with admiration, equal in degree but differing in kind according to their ages.

The eyes of the father said: “How beautiful it is! How beautiful it is! All the gold of the poor world must have found its way onto those walls.”

The eyes of the little boy: “How beautiful it is! How beautiful it is! But it is a house where only people who are not like us can go.”

As for the baby, he was much too fascinated to express anything but joy – utterly stupid and profound. 

Song writers say that pleasure ennobles the soul and softens the heart. The song was right that evening as far as I was concerned. Not only was I touched by this family of eyes, but I was even a little ashamed of our glasses and decanters, too big for our thirst. I turned my eyes to look into yours, dear love, to read my thoughts in them; and as I plunged my eyes into your eyes, so beautiful and so curiously soft, into those green eyes, home of Caprice and governed by the Moon, you said:

“Those people are insufferable with their great saucer eyes. Can’t you tell the proprietor
to send them away?”

So you see how difficult it is to understand one another, my dear angel, how incommunicable thought is, even between two people in love.”

I like David Harvey‘s observations on this piece. He says “What is so remarkable about this prose poem is not only the way in which it depicts the contested character of public space and the inherent porosity of the boundary between the public and the private (the latter even including a lover’s thoughts provoking a lover’s quarrel), but how it generates a sense of space where ambiguities of proprietorship, of aesthetics, of social relations (class and gender in particular) and the political economy of everyday life collide.”  

The parallels here are concerning the right to occupy a public space, which is contested by the author’s lover who wants someone to assert proprietorship over it and control its uses.

The cafe is not exactly a private space either; it is a space within which a selective public is allowed for commercial and consumption purposes.

There is no safe space – the unrelenting message of hostile architecture

What message do hostile architectural features send out to those they target? Young people are being intentionally excluded from their own communities, for example, leaving them with significantly fewer safe spaces to meet and socialise. At the same time, youth provision has been radically reduced under the Conservative neoliberal austerity programme – youth services were cut by at least £387m from April 2010 to 2016. I know from my own experience as a youth and community worker that there is a positive correlation between inclusive, co-designed, needs-led youth work interventions and significantly lower levels of antisocial behaviour. The message to young people from society is that they don’t belong in public spaces and communities. Young people nowadays should be neither seen nor heard.

It seems that the creation of hostile environments – operating simultaneously at a physical, behavioural, cognitive, emotional, psychological and subliminal level – is being used to replace public services – traditional support mechanisms and provisions – in order to cut public spending and pander to the neoliberal ideal of austerity and ‘rolling back the state’. 

It also serves to normalise prejudice, discrimination and exclusion that is political- in its origin. Neoliberalism fosters prejudice, discrimination and it seems it is incompatible with basic humanism, human rights, inclusion and democracy.

The government are no longer investing in more appropriate, sustainable and humane responses to the social problems created by ideologically-driven decision-making, anti-public policies and subsequently arising structural inequalities – the direct result of a totalising neoliberal socioeconomic organisation.

For example, homeless people and increasingly disenfranchised and alienated young people would benefit from the traditional provision of shelters, safe spaces, support and public services. Instead both groups are being driven from the formerly safe urban enclaves they inhabited into socioeconomic wastelands and exclaves – places of exile that hide them from public visibility and place further distance between them and wider society. 

Homelessness, poverty, inequality, disempowerment and alienation continue but those affected are being exiled to publicly invisible spaces so that these processes do not disturb the activities and comfort of urban consumers or offend the sensibilities of the corporate sector and property owners. After all, nothing is more important that profit. Least of all human need.

Homelessness as political, economic and public exile

Last year, when interviewed by the national homelessness charity Crisis, rough sleepers reported being brutally hosed with water by security guards to make them move on, and an increase in the use of other ‘deterrent’ measures. More than 450 people were surveyed in homelessness services across England and Wales. 6 in 10 reported an increase over the past year in ‘defensive architecture’ to keep homeless people away, making sitting or lying down impossible – including hostile spikes and railings, curved or segregated, deliberately uncomfortable benches and gated doorways.

Others said they had experienced deliberate ‘noise pollution’, such as loud music or recorded birdsong and traffic sounds, making it hard or impossible to sleep. Almost two-thirds of respondents said there had been an increase in the number of wardens and security guards in public spaces, who were regularly moving people on in the middle of the night, sometimes by washing down spaces where people were attempting to rest or sleep. Others reported noise being played over loudspeakers in tunnels and outside buildings.

Crisis chief executive Jon Sparkes said he had been shocked by the findings. He said: “It’s dehumanising people. If people have chosen the safest, driest spot they can find, your moving them along is making life more dangerous. 

“The rise of hostile measures is a sad indictment of how we treat the most vulnerable in our society. Having to sleep rough is devastating enough, and we need to acknowledge that homelessness is rising and work together to end it. We should be helping people off the streets to rebuild their lives – not just hurting them or throwing water on them.”

‘Defensive architecture’ is a violent gesture and a symbol of a profound social and cultural unkindness. It is considered, calculated, designed, approved, funded and installed with the intention to dehumanise and to communicate exclusion. It reveals how a corporate oligarchy has prioritised a hardened, superficial style and profit motive over human need, diversity, complexity and inclusion. 

Hostile architecture is covert in its capacity to exclude – designed so that those deemed ‘legitimate’ users of urban public space may enjoy a seemingly open, comfortable and inclusive urban environment, uninterrupted by the sight of the casualities of the same socioeconomic system that they derive benefit from. Superficially, dysfunctional benches and spikes appear as an ‘arty’ type of urban design. Visible surveillance technologies make people feel safe.

It’s not a society that everyone experiences in the same way, nor one which everyone feels comfortable and safe in, however.

Hidden from public view, dismissed from political consideration

Earlier this month, Britain’s statistics watchdog said it is considering an investigation into comments made by Theresa May following complaints that they misrepresented the extent of homelessness and misled parliament.

The UK Statistics Authority (UKSA) confirmed that concerns had been raised after the prime minister tried to claim in Parliament that ‘statutory homelessness peaked under the Labour government and is down by over 50 per cent since then.’ Official figures show that the number of households in temporary accommodation stood at 79,190 at the end of September, up 65% on the low of 48,010 in December 2010. Liberal Democrat peer Olly Grender, who made the complaint, also raised concerns last year about the government’s use of the same statistics.

Grender said: “It seems particularly worrying, as we learn today of the increase in homelessness, that this government is still using spin rather than understanding and solving the problem.”

Baroness Grender’s previous complaint prompted UKSA to rebuke the Department for Communities and Local Government. The department claimed homelessness had halved since 2003 but glossed over the fact this referred only to those who met the narrow definition of statutory homelessness, while the overall number of homeless people had not dropped. 

May was accused of callousness when Labour MP Rosena Allin-Khan recently raised questions about homelessness and the rise in food bank use. The prime minister responded, saying that families who qualified as homeless had the right to be found a bed for the night. She said: “Anybody hearing that will assume that what that means is that 2,500 children will be sleeping on our streets. It does not.

“It is important that we are clear about this for all those who hear these questions because, as we all know, families with children who are accepted as homeless will be provided with accommodation.”

Finger wagging authoritarian Theresa May tells us that children in temporary accommodation are not waking up on the streets.

However, Matthew Downie, the director of policy at the Crisis charity for homeless people, said: “The issue we’ve got at the moment is that it’s just taking such a long time for people who are accepted as homeless to get into proper, stable, decent accommodation. And that’s because local councils are struggling so much to access that accommodation in the overheated, broken housing market we’ve got, and with housing benefit rates being nowhere near the market rents that they need to pay.”

He said that while May highlighted a decline in what is categorised as ‘statutory homelessness’, rough sleeping had increased by 130% since 2010.

The category of ‘statutory homelssness’ has also been redefined to include fewer people who qualify for housing support.

Last year, May surprisingly unveiled a £40 million package designed to ‘prevent’ homelessness by intervening to help individuals and families before they end up on the streets. It was claimed that the ‘shift’ in government policy will move the focus away from dealing with the consequences of homelessness and place prevention ‘at the heart’ of the government’s approach. 

Writing in the Big Issue magazine – sold by homeless people – May said: “We know there is no single cause of homelessness and those at risk can often suffer from complex issues such as domestic abuse, addiction, mental health issues or redundancy.”

However, there are a few causes that the prime minister seems to have overlooked, amid the Conservative ritualistic chanting about ‘personal responsibility’ and a ‘culture of entitlement’, which always reflects assumptions and prejudices about the causal factors of social and economic problems. It’s politically expedient to blame the victims and not the perpetrators, these days. It’s also another symptom of failing neoliberal policies.

It’s a curious fact that wealthy people also experience ‘complex issues’ such as addiction, mental health problems and domestic abuse, but they don’t tend to experience homelessness and poverty as a result. The government seems to have completely overlooked the correlation between rising inequality and austerity, and increasing poverty and homelessness – which are direct consequences of political decision-making. Furthermore, a deregulated private sector has meant that rising rents have made tenancies increasingly precarious.

Last year, ludicrously, the Government backed new law to prevent people made homeless through government policy from becoming homeless. The aim is to ‘support’ people by ‘behavioural change’ policies, rather than by supporting people in material hardship – absolute poverty – who are unable to meet their basic survival needs because of the government’s regressive attitude and traditional prejudices about the causes of poverty and the impact of austerity cuts.

Welfare ‘reforms’, such as the increased and extended use of sanctions, the bedroom tax, council tax reduction, benefit caps and the cuts implemented by stealth through Universal Credit have all contributed to a significant rise in repossession actions by social landlords in a trend expected to continue to rise as arrears increase and temporary financial support shrinks.

Housing benefit cuts have played a large part in many cases of homelessness caused by landlords ending a private rental tenancy, and made it harder for those who lost their home to be rehoused.

The most recent National Audit Office (NAO) report on homelessness says, in summary:

  •  88,410 homeless households applied for homelessness assistance
    during 2016-17 
  • 105,240 households were threatened with homelessness and helped to remain in their own home by local authorities during 2016-17 (increase of 63%
    since 2009-10) 
  • 4,134 rough sleepers counted and estimated on a single night in autumn
    2016 (increase of 134% since autumn 2010)
  • Threefold approximate increase in the number of households recorded
    as homeless following the end of an assured shorthold tenancy
    since 2010-11
  • 21,950 households were placed in temporary accommodation outside the local
    authority that recorded them as homeless at March 2017 (increase
    of 248% since March 2011)
  • The end of an assured shorthold tenancy is the defining characteristic of the increase in homelessness that has occurred since 2010

Among the recommendations the NAO report authors make is this one: The government, led by the Department [for Housing] and the Department for Work and Pensions, should develop a much better understanding of the interactions between local housing markets and welfare reform in order to evaluate fully the causes of homelessness.

Record high numbers of families are becoming homeless after being evicted by private landlords and finding themselves unable to afford a suitable alternative place to live, government figures from last year have also shown. Not that empirical evidence seems to matter to the Government, who prefer a purely ideological approach to policy, rather than an evidence-based one. 

The NAO point out that Conservative ministers have not evaluated the effect of their own welfare ‘reforms’  (a euphemism for cuts) on homelessness, nor the effect of own initiatives in this area. Although local councils are required to have a homelessness strategy, it isn’t monitored. There is no published cross-government strategy to deal with homelessness whatsoever. 

Ministers have no basic understanding on the causes or costs of rising homelessness, and have shown no inclination to grasp how the problem has been fuelled in part by housing benefit cuts, the NAO says. It concludes that the government’s attempts to address homelessness since 2011 have failed to deliver value for money.

More than 4,000 people were sleeping rough in 2016, according to the report, an increase of 134% since 2010. There were 77,000 households – including 120,000 children – housed in temporary accommodation in March 2017, up from 49,000 in 2011 and costing £845m a year in housing benefit. 

Homelessness has grown most sharply among households renting privately who struggle to afford to live in expensive areas such as London and the south-east, the NAO found. Private rents in the capital have risen by 24% since the start of the decade, while average earnings have increased by just 3%.

Cuts to local housing allowance (LHA) – a benefit intended to help tenants meet the cost of private rents – have also contributed to the crisis, the report says. LHA support has fallen behind rent levels in many areas, forcing tenants to cover an average rent shortfall of £50 a week in London and £26 a week elsewhere.  This is at the same time that the cost of living has been rising more generally, while both in-work and out-of-work welfare support has been cut. It no longer provides sufficient safety net support to meet people’s basic needs for fuel, food and shelter. 

It was assumed when welfare amounts were originally calculated that people would not be expected to pay rates/council tax and rent. However, this is no longer the case. People are now expected to use money that is allocated for food and fuel to pay a shortfall in housing support, and meet the additional costs of council tax, bedroom tax and so on. 

Local authority attempts to manage the homelessness crisis have been considerably constrained by a shrinking stock of affordable council and housing association homes, coupled with a lack of affordable new properties. London councils have been reduced to offering increasingly reluctant landlords £4,000 to persuade them to offer a tenancy to homeless families on benefits.

Housing shortages in high-rent areas mean that a third of homeless households are placed in temporary housing outside of their home borough, the NAO said. This damages community and family ties, disrupts support networks, isolates families and disrupts children and you people’s education.

London councils are buying up homes in cheaper boroughs outside of the capital to house homeless families, in turn exacerbating the housing crisis in those areas. 

Polly Neate, the chief executive of the housing charity Shelter, said: “The NAO has found what Shelter sees every day, that for many families our housing market is a daily nightmare of rising costs and falling benefits which is leading to nothing less than a national crisis.”

Matt Downie, the director of policy and external affairs at Crisis, said: “The NAO demonstrates that while some parts of government are actively driving the problem, other parts are left to pick up the pieces, causing misery for thousands more people as they slip into homelessness.”

Meg Hillier MP, the chair of the Commons public accounts committee, said the NAO had highlighted a ‘national scandal’. “This reports illustrates the very real human cost of the government’s failure to ensure people have access to affordable housing,” she added. 

More than 9,000 people are sleeping rough on the streets and more than 78,000 households, including 120,000 children, are homeless and living in temporary accommodation, often of a poor standard, according to the Commons public accounts committee.

The Committee say in a report that the attitude of the Department for Communities and Local Government (DCLG) to reducing homelessness has been ‘unacceptably complacent’.

John Healey, the shadow housing secretary, said: “This damning cross-party report shows that the Conservatives have caused the crisis of rapidly rising homelessness but have no plan to fix it.

“This Christmas the increase in homelessness is visible in almost every town and city in the country, but today’s report confirms ministers lack both an understanding of the problem and any urgency in finding solutions.

“After an unprecedented decline in homelessness under Labour, Conservative policy decisions are directly responsible for rising homelessness. You can’t help the homeless without the homes, and ministers have driven new social rented homes to the lowest level on record.”

Surely it’s a reasonable and fundamental expectation of citizens that a government in a democratic, civilised and wealthy society ensures that the population can meet their basic survival needs. 

The fact that absolute poverty and destitution exist in a wealthy, developed and democratic nation is shamefully offensive. However, Conservatives tend to be outraged by poor people themselves, rather than by their own political choices and the design of socioeconomic processes that created inequality and poverty. The government’s response to the adverse consequences of neoliberalism is increasingly despotic and authoritarian.

The comments below from Simon Dudley, the Conservative Leader of the Maidenhead Riverside Council and ironically, a director of a Government agency that supports house building, (Homes and Community Agency (HCA)) reflect a fairly standardised, authoritarian, dehumanising Conservative attitude towards homelessness.

Note the stigmatising language use – likening homelessness and poverty to disease – an epidemic. Dudley’s underpinning prejudice is very evident in the comment that homelessness is a commercial lifestyle choice, and the demand that the police ‘deal’ with it highlights his knee-jerk authoritarian response:

Dudley uses the word ‘vagrancy’, which implies that it is the condition and characteristics of homeless people who causes homelessness, rather than social, political and economic conditions, such as inequality, low wages, austerity and punitive welfare policies. The first major vagrancy law was passed in 1349 to increase the national workforce and impose social control following the Black Death, by making ‘idleness’ (unemployment) and moving to other areas for higher wages an offence. The establishment has a long tradition of punishing those who are, for whatever reason, economically ‘inactive’: who aren’t contributing to the private wealth accumulation of others.

The Vagrancy Act of 1824 is an Act of Parliament that made it an offence to sleep rough or beg. Anyone in England and Wales found to be homeless or begging subsistence money can be arrested. Though amended several times, certain sections of the original 1824 Vagrancy Act remain in force in England and Wales. It’s main aim was removing undesirables from public view. The act assumed that homelessness was due to idleness and therefore deliberate, and made it a criminal offence to engage in behaviours associated with extreme poverty. 

The language that Dudley uses speaks volumes about his prejudiced and regressive view of homelessness and poverty. And his scorn for democracy.

The 1977 Housing (Homeless Persons) Act restricted the homeless housing requirements so that only individuals who were affected by natural disasters could receive housing accommodation from the local authorities. This was partly due to well-organised opposition from district councils and Conservative MPs, who managed to amend
the Bill considerably in its passage through Parliament, resulting in the rejection of many  homeless applications received by the local government because of strict qualifying criteria.

For the first time, the 1977 Act gave local authorities the legal duty to house homeless people in ‘priority’ need, and to provide advice and assistance to those who did not qualify as having a priority need. However, the Act also made it difficult for homeless individuals without children to receive accommodations provided by local authorities, by reducing the categories and definitions of ‘priority need’. 

Use of the law that criminalises homeless people may generally include:

  • Restricting the public areas in which sitting or sleeping are allowed.
  • Removing the homeless from particular areas.
  • Prohibiting begging.
  • Selective enforcement of laws.

Murphy James, manager of the Windsor Homeless Project, branded Cllr Dudley’s comments ‘disgusting’ and described the Southall accommodation offered by the Royal Borough of Windsor & Maidenhead as ‘rat infested’. 

He said: “It shows he hasn’t got a clue. He has quite obviously never walked even an inch in their shoes.

“It is absolutely disgusting he is putting out such an opinion that it is a commercial life choice.”

James added the royal wedding should not be the only reason for helping people on the streets.

“I am a royalist but it should have zero to do with the royal wedding,” he said.

“Nobody in this country should be on the streets.” 

Dudley should pay more attention to national trends instead of attempting to blame homeless people for the consequences of government policies, as many in work are also experiencing destitution.

This short film challenges the stereoytypes that Dudley presents. This is 21st century Britain. But still there are people without homes, still people living rough on the streets, including some who are in work, even some doing vital jobs in the public sector, low paid and increasingly struggling to keep a roof over their heads. Central government doesn’t keep statistics on the ‘working homeless’. But we do know that overall the number of homeless people is once again on the rise.

Meanwhile, figures obtained via a Freedom of Information request by the Liberal Democrats from 234 councils show almost 45,000 people aged 18-24 have come forward in past year for help with homelessness. With more than 100 local authorities not providing information, the real statistic could well be above 70,000.

As Polly Toynbee says: “Food banks and rough sleeping are now the public face of this Tory era, that will end as changing public attitudes show rising concern at so much deliberately induced destitution.”

While the inglorious powers that be spout meaningless, incoherent and reactionary authoritarian bile, citizens are dying as a direct consequence of meaningless, incoherent and reactionary Conservative policies.

 


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The first digital antipsychotic pill with tracking. In an authoritarian state, what could possibly go right?

In the United State, regulators have approved the first “digital pill” with a tracking system. According the Financial Times, this is a pill with an inbuilt sensor, which opens up a new front in pharmaceuticals and the “internet of things”. 

The tablet can be tracked inside the stomach, relaying data on whether, and when, patients have taken “vital medication”. So far, the US Food and Drug Administration has given the green light for it to be used in an antipsychotic medication with the aim that the data can be used “to help doctors and patients better manage treatment.”

Patients who agree to take the digital medication, a version of the antipsychotic drug Abilify, can sign consent forms allowing their doctors and up to four other people, including family members, to receive electronic data showing the date and time pills are ingested.

Dr. Peter Kramer, a psychiatrist and the author of Listening to Prozac, raised concerns about “packaging a medication with a tattletale.”

While ethical for “a fully competent patient who wants to lash him or herself to the mast,” he said, “‘digital drug’ sounds like a potentially coercive tool.”

Other companies are developing digital medication technologies, including another ingestible sensor and visual recognition technology capable of confirming whether a patient has placed a pill on the tongue and has swallowed it. 

The newly approved pill, called Abilify MyCite, is a collaboration between Abilify’s manufacturer, Otsuka, and the Silicon Valley based Proteus Digital Health, the company that created the sensor.

The sensor, which contains copper, magnesium and silicon, generates an electrical signal when splashed by stomach fluid, “like a potato battery,” according to Andrew Thompson, Proteus’s president and chief executive.

After several minutes, the signal is detected by a Band-Aid-like patch that must be worn on the left rib cage and replaced after seven days, said Andrew Wright, Otsuka America’s vice president for digital medicine. The patch then sends the date and time of pill ingestion and the patient’s activity level via Bluetooth to a cellphone app.

Abilify is prescribed to people with schizophrenia, bipolar disorder and, in conjunction with an antidepressant, major depressive disorder. The symptoms of schizophrenia and related disorders can include paranoia and delusions, so you do have to wonder how widely digital Abilify will be accepted, given that it is designed to monitor behaviours and transmit signals from within a person’s body to communicate with their doctor.  

Dr. Jeffrey Lieberman, chairman of psychiatry at Columbia University and New York-Presbyterian Hospital, said many psychiatrists would likely want to try digital Abilify, especially for patients who just experienced their first psychotic episode and are at risk of stopping medication after feeling better.

But he noted it has only been approved to track doses, and has not yet been shown to improve compliance with treatment regimes.

He added, “There’s an irony in it being given to people with mental disorders that can include delusions. It’s like a biomedical Big Brother.”

The FT article goes on to say: “Poor compliance with drug regimes, particularly among sufferers of chronic diseases, is a pervasive problem for pharma companies and health systems, leading to lower consumption of the industry’s products and higher costs for payers when patients’ conditions deteriorate as a result of missing treatment.”

 You can see precisely where the emphasis and priorities lie in that statement. Not a word about the poor dehumanised “patients'” wellbeing and importantly, about their choice. It’s assumed that pharma industry’s products don’t have any adverse effects at all, and that taking the medication is always in the patient’s best interest. It’s assumed that medications will improve someone’s mental health. Apparently the key to good mental health is keeping costs low to tax payers while keeping the pharma industry in business, ensuring that they can keep making profits.

Andrew Thompson, Proteus chief executive, said the technology would allow people with serious mental illness “to engage with their care team about their treatment plan in a new way”. Patients will be able to use a mobile phone to track and “manage” their medication. Worryingly, he is already in talks with other major pharma companies about using the technology in treatments for various chronic conditions.

The tablets contain a sensor, so that when they are swallowed, a signal is sent to a patch worn on the patient’s body, which in turn connects to an app on their phones, showing that they have taken their dose. The doctor who has prescribed the medicine will automatically be sent the data and patients can also choose to nominate family and care team members to receive it.

The wearable patch will also be used to track how much patients are moving around — considered a key indicator of overall health — and allows them to self-report their mood and sleep quality via the app. 

There are some problems with the assumptions behind the development of digital pill, and its proposed use. Firstly, it’s a myth that people with mental health conditions are not very good at taking their medication. Studies have shown that “compliance” with a medication regime is no worse in people with mental health conditions like schizophrenia than it is in long-term physical ailments such as asthma or high blood pressure. In fact demographic factors such as whether a person is single or in a relationship are more likely to play a role in medication compliance.

It is also a taken for granted assumption that pharmaceutical solutions are the best guarantee of positive outcomes for people with mental health conditions. Before concentrating on specific medication issues it is important to remember that medication is not the sole focus of a mental health intervention. This is because the causes of mental illness are complex and various, and quite often do not arise solely from “within” individuals, rather, it often arises because of interactions between environmental factors, circumstances, and individual predispositions and vulnerabilities (including both psychological and biological). Some psychiatrists have stated that mental illness – in all its forms – is intrinsically social.

We know, for example, that discrimination plays a part in explaining why certain groups in our society are more likely to experience poor mental health compared to others. Direct experiences of prejudice and harassment impact negatively on mental wellbeing, while indirect factors such as deprivation and social exclusion also contribute to poor mental health. Studies have highlighted the role that prejudice, stigma and discrimination can play in poor mental health.

It is only by fully acknowledging and understanding the external risk factors for poor mental health that we can develop our understanding of protective factors for good mental health at the individual, community and societal level. 

Sometimes causes are confused with effects

Despite controversies in psychiatry regarding the very complex aetiology of mental illness, including the role of sociological practices, political practices and economic conditions, it is widely held that mental illness arises “within” the individual and has a purely neurobiological origin. Yet there is no conclusive evidence to demonstrate that major mental illnesses are “proven biological diseases of the brain” and that emotional distress results from “chemical imbalances.”

One attempt to explain a physical cause of schizophrenia is the dopamine hypothesis. Dopamine is a neurotransmitter. It is one of the chemicals in the brain which causes neurons to fire. The original dopamine hypothesis stated that people with schizophrenia suffered from an excessive amount of dopamine. This causes the neurons that use dopamine to fire too often and transmit too many “messages”. High dopamine activity leads to acute episodes, and positive symptoms which include delusions, hallucinations and “confused thinking.”

Evidence for this hypothesis comes from that fact that amphetamines increase the amounts of dopamine. Large doses of amphetamine given to people with no history of psychological disorders produce behavior which is very similar to paranoid schizophrenia. Small doses given to people already suffering from schizophrenia tend to worsen their symptoms.

However, the problem with this hypothesis is that we don’t know if the raised dopamine levels are the cause of the schizophrenia, or if the raised dopamine level is the result of schizophrenia. It is not clear which comes first. 

One of the biggest criticisms of the dopamine hypothesis came when Farde et al found no difference between levels of dopamine in people with schizophrenia compared with “healthy” individuals in 1990.

Another problem is that schizophrenia is something of an umbrella term that encompasses a wide array of symptoms, and can be reached by multiple routes that may, nevertheless, impact the same biological pathways. However, there is emerging evidence that different routes to experiences currently deemed indicative of schizophrenia may need different treatments.

For example, preliminary evidence suggests that people with a history of childhood trauma who are diagnosed with schizophrenia are less likely to be helped by antipsychotic drugs. However, more research into this is needed. It has also been suggested that some cases of schizophrenia are actually a form of autoimmune encephalitis, which means that the most effective treatment may be immunotherapy and corticosteroids. People with autoimmune illness such as lupus are also at an increased risk of developing autoimmune mediated psychosis.

Some interventions, such as the family-therapy based dialogue approach, show some promise for many people with schizophrenia diagnoses. Both general interventions and specific ones, tailored to someone’s personal route to the experiences associated with schizophrenia, may be needed. It’s therefore crucial that psychiatrists ask people about all the potentially relevant circumstances and routes.

For example, suffering childhood adversityusing cannabis and having childhood viral infections of the central nervous system all increase the odds of someone being diagnosed with a psychotic disorder (such as schizophrenia) by at least two – to threefold. 

Although the exact causes of most mental illnesses are not known, it is becoming clear through extensive research that many conditions are caused by a complex combination of biological, psychological, social, cultural, political, economic and environmental factors. It’s widely recognised that poverty, social isolation, being unemployed or highly stressed in work can all have an effect on an individual’s mental health. 

Adults in the poorest fifth of the population are much more at risk of developing a mental illness as those on average incomes: around 24% compared with 14%. Those who have an existing mental illness are significantly more likely to be living in poverty, also. 

Poverty can therefore be both a causal factor and a consequence of mental ill-health. Mental health is shaped by the wide-ranging characteristics (including inequalities) of the social, economic, political and physical environments in which people live.

Successfully supporting the mental health and wellbeing of people living in poverty, and reducing the number of people with mental health problems experiencing poverty, requires an engagement with this complexity. Simply medicating a person is neither sufficient nor appropriate. Nor is it ethical. Pharmaceutical companies tend to promote the assumption that mental illness is entirely biomedical. The relationship between economics and health is complex and politically fraught. But it is too important to ignore.

Psychiatric diagnosis tends to reify the complexity of people’s problems. However, in the UK, the political (mis)use of behaviourism has also resulted in the reification of social and economic problems. The government here extend the view that unemployment is evidence of both personal failure and psychological deficit. The use of crude behaviourist psychology in the delivery of social security denies the individuals’ experience of the effects of social and economic inequalities, and has been used to authorise the extension of the state and to justify state-contracted surveillance to individuals’ psychological characteristics.  

In a “business friendly” environoment, with a distinctly authoritarian government, I can’t help but wonder how long will it be before we see the increasingy intrusive Conservative state locking up or drugging patients whose diseases are defined not by organic dysfunction but by politically defined “socially unacceptable behaviours”.

I’m a critic of state entanglement with psychiatry AND psychology. For people with mental health problems in the UK, policies are being formulated to act upon them as if they are objects, rather than autonomous human subjects. Such a dehumanising approach has contributed significantly to a wider process of  social outgrouping, increasing stigmatisation and ultimately, to further socioeconomic and mental health inequalities. Most government policies aimed at ill and disabled people more generally are about cutting costs and removing lifeline support. This has been increasingly justified by a narrative that focuses on problematising sick role behaviours, rather than on the real impacts of illness and the additional needs that being chronically ill invariably generates. 

Earlier this year, George Freeman, Conservative MP for Norfolk and chair of the Prime Minister’s Policy Board, defended the government’s decision to subvert the judicial system, by disregarding the rulings of two independent tribunals concerning Personal Independence Payment (PIP) for disabled people. The government ushered in an “emergency” legislation to reverse the legal decisions in order to cut cost. In an interview on Pienaar’s Politics, on BBC 5 Live, Freeman said: 

“These tweaks [new regulations to cut PIP eligibility] are actually about rolling back some bizarre decisions by tribunals that now mean benefits are being given to people who are taking pills at home, who suffer from anxiety”.

He claimed that the “bizarre” upper tribunal rulings meant that“claimants with psychological problems, who are unable to travel without help, should be treated in a similar way to those who are blind.”

He said: “We want to make sure we get the money to the really disabled people who need it.”

He added that both he and the Prime Minister “totally” understood anxiety, and went on to say: “We’ve set out in the mental health strategy how seriously we take it.” 

He said: “Personal Independence Payments reforms were needed to roll back the bizarre decisions of tribunals.” 

Freeman’s controversial comments about people with anxiety “at home taking pills” implies that those with mental health problems are somehow faking their disability. He trivialises the often wide-ranging disabling consequences of mental ill health, and clearly implies that he regards mental illnesses as somehow not “real” disabilities.

His comments contradict the government’s pledge to ensure that mental health and physical health are given a parity of esteem, just months after the Prime Minister pledged to take action to tackle the stigma around mental health problems. 

Yet people with the following mental health conditions are likely to be affected by the reversal of the Independent Tribunal’s ruling on PIP mobility awards – those in particular who suffer “overwhelming psychological distress” when travelling alone:

Mood disorders – Other / type not known, Psychotic disorders – Other / type not known, Schizophrenia, Schizoaffective disorder, Phobia – Social Panic disorder, Learning disability – Other / type not known, Generalized anxiety disorder, Agoraphobia, Alcohol misuse, Anxiety and depressive disorders – mixed Anxiety disorders – Other / type not known, Autism, Bipolar affective disorder (Hypomania / Mania), Cognitive disorder due to stroke, Cognitive disorders – Other / type not known, Dementia, Depressive disorder, Drug misuse, Stress reaction disorders – Other / type not known, Post-traumatic stress disorder (PTSD), Phobia – Specific Personality disorder, Obsessive compulsive disorder (OCD).

Freeman’s comments signposts the Conservative’s “deserving” and “undeserving” narrative, implying that some disabled people are malingering. However, disabled people do not “cheat” the social security system: the system has been redesigned by the government to cheat disabled people.

When people are attacked, oppressed and controlled psychologically by a so-called democratic government that embeds punishment at the heart of public policies to target the poorest citizens, it’s hardly surprising they become increasingly anxious, depressed and mentally unwell.

An era of technocratic solutions for social problems

Some psychiatrists see a strengthening of psychiatry’s identity as essentially “applied neuroscience”. Although not discounting the importance of the neurological sciences and psychopharmacology, they have argued that psychiatry needs to move beyond the dominance of the current dominant technological paradigm. Such critical practitioners say that psychiatry ought to primarily involve engagement with the non-technical dimensions of their work such as relationships, meanings and values. Psychiatry has operated from within a technological paradigm that, although not ignoring these aspects of work, has kept them as secondary concerns.

Psychiatry sits within a predominantly biomedical idiom. This means that problems with feelings, thoughts, behaviours and relationships can be fully grasped with the same sort of scientific tools that we use to investigate physical problems with our kidneys, blood cells, lungs, and so on.

While psychiatry has generally focused a lot of attention on neuroscience, neuroscientists themselves have become more cautious about the value of reductionist and deterministic approaches to understanding the nature of human thought, emotion and behaviour.

The dominance of this paradigm can be seen in the importance attached to classification systems, causal models of understanding mental distress and the framing of psychiatric care as a series of discrete interventions that can be analysed and measured independent of context.

More recently, models of cognitive psychology, based on “information processing”, have been developed that work within the technological idiom. Psychiatry stubbornly operates within a positivist tradition, and subscribes to the following assumptions: mental health problems arise from faulty mechanisms or processes involving abnormal physiological or psychological events occurring within the individual, these processes can be modelled in causal terms.

These processes are regarded as not being context dependent. They reside “within” the individual. Technological interventions are instrumental and can be designed and studied independently of experiences, subjective states, relationships, and values. However, in 2013, psychiatrist Allen Frances said that “psychiatric diagnosis still relies exclusively on fallible subjective judgments rather than objective biological tests”.

Many people within the growing service user movement seek to reframe experiences of mental illness, distress and alienation by framing them as human experiences, rather than biomedical events, simplistic causal relationships and “scientific” challenges. In a study of users’ views of psychiatric services, Rogers et al found that many service users did not really value the “technical” expertise of professionals. Instead, they were much more concerned with the subjective experience and human elements of their encounters such as being listened to, taken seriously, and treated with dignity, kindness and respect.

Cutting the Stone (Bosch).jpg

The Extraction of the Stone of Madness by Hieronymus Boschfrom around 1494.

In his work, History of Madness, Michel Foucault says “Bosch’s famous doctor is far more insane than the patient he is attempting to cure, and his false knowledge does nothing more than reveal the worst excesses of a madness immediately apparent to all but himself.” 

I have to say I have never seen a person by looking at a brain.

It’s not all “in here”, it’s “out there”: the problem with locating mental illness “within” the individual

To paraphrase R.D Laing, “insanity”, mental illness and psychological distress may be seen as a perfectly rational adjustment to an insane world. Laing examined the nature of human experience from a phenomenological perspective, as well as exploring the possibilities for psychotherapy in an existentially distorted world. He challenges the whole idea of “normality” in society. 

It simply isn’t effective or appropriate to treat distress arising because of, say, socioeconomic problems or difficult relationships with psychotropic drugs alone, administered to people experiencing the consequences of political decision-making, the adverse consequences of socioeconomic organisation, exclusion, stigma, abuse or damaging parenting practices. 

Coping with past or current traumatic experiences such as abuse, bereavement or divorce will also strongly influence an individual’s mental and emotional state which can in turn have an influence on their wider mental health. Psychological interventions are therefore a crucial and integral part of effective treatment for mental illnesses.

However, in the UK, the current political-psychological model also locates social problems “within” the individual. The government plan to merge health and employment services. In a move that is both unethical and likely to present significant risk of harm to many patients, health professionals are being tasked to deliver benefit cuts for the Department for Work an Pensions. This involves measures to support the imposition of work cures, including setting employment as a clinical outcome and allowing medically unqualified job coaches to directly update a patient’s medical record.

The Conservatives have proposed more than once the mandatory treatment for people with long term conditions (which was first flagged up in the Conservative Party Manifesto) and this is currently under review, including whether benefit entitlements should be linked to “accepting appropriate treatments or support/taking reasonable steps towards “rehabilitation”.  The work, health and disability green paper and consultation suggests that people with the most severe illnesses in the support group may also be subjected to welfare conditionality and sanctions.

Such a move has extremely serious implications. It would be extremely unethical and makes the issue of consent to medical treatment very problematic if it is linked to the loss of lifeline support or the fear of loss of benefits. However this is clearly the direction that government policy is moving in and represents a serious threat to the human rights of patients and the independence of health professionals.

The digital pill in an age of surveillance has potential implications for civil liberties

For people with severe and enduring mental health problems, it is crucial that their context is also considered, and it’s important that people are provided with support with their living circumstances, and taking into account their wider social conditions, also. 

Furthermore, there is the important issue of drug tolerability to consider. Antipsychotic drugs are also associated with adverse effects that can lead to poor medication adherence, stigma, distress and impaired quality of life. For example, the stiffness, slowness of movement and tremor of antipsychotic-induced parkinsonism (See Dursun et al, 2004) can make it difficult for a patient to write, fasten buttons and tie shoelaces. Some antipsychotic medications can affect facial expressions, which flatten nonverbal communication and may impact on ordinary social interactions, potentially leading to stigma and further isolation.

Side effect or symptom?

The impact of drug side-effects on patients has not been sufficiently studied. Researchers have stressed the importance of the patient’s subjective experience, in which adverse effects have a role, and are considered and included in the assessment of drugs, though this doesn’t always happen. Although adverse effects are an important outcome, with many antipsychotics, they account for less treatment discontinuation than lack of efficacy; this finding has been noted in naturalistic studies and in Randomised Controlled Trials (RCTs). 

Both older and newer antipsychotic drugs can cause:

  • Uncontrollable movements, such as tics, tremors, or muscle spasms, blank facial expression and abnormal gait (risk is higher with first-generation antipsychotics)
  • Weight gain (risk is higher with second-generation antipsychotics)
  • Photosensitivity – increased sensitivity to sunlight
  • Anxiety
  • Drowsiness
  • Dizziness
  • Restlessness
  • Dry mouth
  • Constipation
  • Nausea
  • Vomiting
  • Blurred vision
  • Low blood pressure
  • Seizures
  • Low white blood cell count
  • Sexual dysfunction in both men and women
  • Menstruation problems in women and feminising effects such as abnormal breast growth and lactation in men. These latter problems are caused by the effect that the newer drugs have on a hormone in the blood called prolactin
  • Osteoporosis
  • Some neuroleptic drugs have withdrawal effects which can be very unpleasant

In addition some side effects of the newer antipsychotics may be confused with the symptoms of schizophrenia, such as apathy and withdrawal.

Antipsychotics can also cause bad interactions with other medications.

Bioethic considerations

One of the serious bioethic considerations is whether the digital medicine could be used coercively, on people against their will or as part of probation, healthcare or welfare conditions, for example.

Otsuka has said: “We intend that this system only be used with patient consent.”

However, here in the UK, the government have been kite-flying the idea of social security support being made conditional to imposed “health” regimes for a while. 

The Conservatives have already made proposals to strip obese or those who are ill because of substance misuse of their welfare benefits if they refuse treatment. This  violates medical ethics. The president of the British Psychological Society responded, at the time, Professor Jamie Hacker Hughes, said people should not be coerced into accepting psychological treatment and, if they were, evidence shows that it simply would not work.

He went on to say: “There is a major issue around consent, because as psychologists we offer interventions but everybody has got a right to accept or refuse treatment. So we have got a big concern about coercion.”

Hacker Hughes lent his voice to a chorus of criticism following the announcement of an official review to consider how best to get people suffering from obesity, drug addiction or alcoholism back into work. 

The government consultation paper, launched in 2015, that raised concerns acknowleged that strong ethical issues were at stake, but at the same time also questioned whether people should continue to receive benefits if they refused state provided treatment.

The government regard work as a health outcome, and believe that welfare creates “perverse incentives” that prevent people from finding employment. However, international research and evidence demonstrates that this is untrue, and that generous welfare states tend to be correlated with a stronger work ethic.

Hacker Hughes said claimants with obesity and addiction problems often faced complex mental health issues. But he warned the government against using sanctions to force people to accept interventions.

“It’s a problem firstly because we don’t believe people should be coerced into accepting any treatment, and secondly there is a problem because the evidence shows that if you are trying to change people’s behaviour, coercion doesn’t work,” he said.

There is a well-documented link between being out of work and psychological problems, but Hacker Hughes pointed out that the government’s plan risked “confusing the symptoms with the cause.”

Paul Atkinson, a London-based psychotherapist and member of the Alliance for Counselling and Psychotherapy, called the government’s proposals an outrage. He said: “It’s the same psychology from the government of punishing rather than working with people. Under a regime like welfare and jobcentres at the moment it is going to be felt as abuse, punitive and moralistic.”

Yes, and that’s because it is.

The government introduced “ordeals” into the welfare system to deter people from claiming the social security that most have paid for via national insurance and tax contributions, in order to “deter” what they see as “welfare dependency”. Yet labor market deregulation, anti-union legislation and other political decisions have also driven down wages, leaving many in work in poverty, also. The government’s “solution” to in-work poverty was to introduce further conditionality, in the form of extremely punitive financial sanctions for people who need to claim in-work welfare support, to “ensure they progress in work”. It is assumed that the problem of low pay resides “within the individual” rather than being the consequence of structural and labor market conditions, the profit incentive, “business friendly” political decision-making and board room choices. Ultimately, it’s down to the unequal distribution of power.

A gaslighting state: punitive psychopolicy interventions

No-one seems to be concerned with monitoring the impact of the government’s “behavioural change” agenda. Strict behavioural requirements and punishments in the form of sanctions are an integral part of the Conservative ideological pseudo-moralisation of welfare, and their  “reforms” aimed at making claiming benefits much less attractive than taking a low paid, insecure, exploitative job. 

Welfare has been redefined: it is preoccupied with assumptions about and modification of the behaviour and character of recipients rather than with the alleviation of poverty and ensuring economic and social wellbeing. Furthermore, the political stigmatisation of people needing benefits is designed purposefully to displace public sympathy for the poor, and to generate moral outrage, which is then used to further justify the steady dismantling of the welfare state. (See Stigmatising unemployment: the government has redefined it as a psychological disorder.)

However, the problems of austerity and the economy were not caused by people claiming welfare, or by any other powerless, scapegoated, marginalised group for that matter, such as migrants. The problems have arisen because of social conservatism and neoliberalism. The victims of the government’s policies and decision-making are being portrayed as miscreants – as perpetrators of the social problems caused by the government’s decisions, rather than as the casualities.

Under the government’s plans, therapists from the NHS’s Improving Access to Psychological Therapies (IAPT) programme are to support jobcentre staff to assess and treat claimants, who may be referred to online cognitive behavioural therapy (CBT) courses.

Again, we really must question the ethics of linking receipt of welfare with “state therapy,” which, upon closer scrutiny, is not therapy at all. Linked to such a narrow outcome – getting a job – this is nothing more than a blunt behaviour modification programme. The fact that the Conservatives plan to make receipt of benefits contingent on participation in “treatment” worryingly takes away the fundamental right of consent.

Not only is the government trespassing on an intimate, existential level; it is tampering with our perceptions and experiences, damaging and isolating the poorest, burdening them with the blame for the consequences of their own policies whilst editing out state responsibilities towards citizens. (See the The power of positive thinking is really political gaslighting, and IAPT is value-laden, non-prefigurative, non-dialogic, antidemocratic and reflects a political agenda.)

It’s very important that we don’t overlook the importance of context regarding psychological distress. The idea that mental “illness” arises strictly “within” the individual, therefore, requiring medicine as treatment, as opposed to, say, different socioeconomic policies, is a controversial one. People’s mental health is, after all, at least influenced by the social, political, cultural and economic spaces that they occupy. 

The current government has a 7 year history of decontextualing structural inequality and poverty, using narratives that “relocate” the causes and effects of an unequal distribution of power and wealth. Such narratives are about coercing the responsibility, internalisation and containment of social problems within some targeted individuals in some marginalised social groups. This process always involves projection, stigmatising, outgrouping and scapegoating. 

Earlier this year, the UK Council for Psychotherapy (UKCP) said that government policies – in particular, the Conservatives’ draconian “reforms” of social security payments and austerity regime – were to blame for a steep rise in the rates of severe anxiety and depression among unemployed people, as benefit cuts and sanctions, together with an extremely punitive and coercive welfare conditionality regime, “are having a toxic impact on mental health”.

It’s hardly ethical, appropriate or effective to impose a medical treatment on people who are suffering because of policies that bring about financial and psychological insecurity, hardships and harms.  

We have witnessed an ongoing attempt by the Conservatives to “rewrite the welfare contract” for disabled people, which has become a key site of controversy within UK welfare reform, and fierce debates about the circumstances in which the use of  conditionality may, or may not, be ethically justified. And denial from the government that their welfare policy is causing some of our most vulnerable citizens harm, hardship and distress. 

Wilkinson and Pickett’s key finding in their work, The Spirit Level: Why More Equal Societies Almost Always Do Better is that it is the inequality itself, and not the overall wealth of a society that is the key factor in creating various pathologies. The authors  show that for each of eleven different health and social problems: physical health, mental health, drug abuse, education, imprisonment, obesity, social mobility, trust and community life, violence, teenage pregnancies, and child wellbeing, outcomes are significantly worse in more unequal rich countries. The evidence also shows that poorer places with more equality have better overall social outcomes than wealthy ones marked by gross inequality. (See also The still face paradigm, the just world fallacy, inequality and the decline of empathy, for further discussion about how neoliberaism itself creates profound psychological trauma, and builds social “empathy walls”).

Theresa May has pledged new initiatives to end “stigma” around mental health and encourage schools and employers to provide mental health support. Despite government assurances mental health services would receive equal treatment to physical health, 40% of NHS trusts saw cuts to mental health services across 2015-2016.

But in the absence of genuine funding commitments, the Prime Minister has faced charges of hypocrisy from mental campaigners, for not doing anywhere near enough to address the root causes of problems faced by disabled and mentally ill people. 

At one point in 2014, there were no mental health beds available for adults in the whole of England, while an NSPCC survey published in October 2015 found that more than a fifth of children referred to child and adolescent mental health services (CAMHS) in England were refused access to support. 

There have recently been a number of high-profile cases reported more than once in the media across the UK when the necessary kind of hospital bed could not be found for mental health patients in England. The NHS Confederation’s Mental Health Network – the representative body for NHS-funded mental health service providers – also heard evidence from its members last year that “there are occasions when there are no routine acute mental health assessment beds available across the country.”

Importantly, Psychologists Against Austerity have said: “Addressing mental health is not just about ensuring more ‘treatment’ is available and stigma is reduced, although they are important. It is fundamentally also about the evidence that ideological economic policies, like the continued austerity programme, have hit the most vulnerable citizens the hardest and have been toxic for mental health.”

The government’s “employment and support programme” for sick and disabled people coincided with at least 590 “additional” suicides, 279,000 cases of mental illness and 725,000 more prescriptions for antidepressants – and one mental health charity found that at least 21 per cent of their patients had experienced suicidal thoughts due to the stress of the draconian Work Capability Assessments. 

It’s crucially important that a positive therapeutic alliance based on trust is developed  between doctors and patients. Specific problems with the therapeutic alliance include doctors failing to acknowledge patients’ concerns, an example of which is the failure to respond to patients who talk about their auditory halluci­nations in schizophrenia (McCabe et al, 2002). Furthermore, doctors appear not to appreciate the degree of distress caused by certain antipsychotic side-effects (Day et al, 1998). There is, therefore a fundamental need for doctors to listen more effectively to patients and elicit their particular concerns about their illness and its treatments. In fact Poor doctor-patient relationships have been cited by recent research as a key factor that influences a patient’s attitude towards treatment.

Critics of psychiatry commonly express a concern that the path of diagnosis and treatment is primarily shaped by profit prerogatives, echoing a common criticism of general medical practice, particularly in the United States, and increasingly, in the UK, where many of the largest psychopharmaceutical producers are based.

It’s an inbuilt “cognitive bias”. 

This critique is not meant to imply that physiological factors in mental illnesss can or should be ignored. However, as I’ve pointed out, the biomedical model avoids the personal, social, cultural, political and economic dimensions of mental illness, in the same way that the political behaviourist (behavioural economics, used in public policy) model does.

One concern is that both the behaviourist and biomedical model protects those formulating provision and care from the pain experienced by those needing support. The temptation to retreat into objectification of those identified as mentally ill may also be a factor in a state cost cutting exercise. 

The UK government has already demonstrated a worrying overreliance on individualistic approaches to socioeconomic problems that prioritise citizen responsibility and “self help”. The behavioural turn has been powerfully influenced by libertarian paternalism – itself a political doctirne, despite its claims to “value-neutrality”.

The Conservatives’ neoliberal policies increasingly embed behaviour modification techniques that aim to quantifiably change the perceptions and behaviours of citizens, aligning them with narrow neoliberal outcomes through rewards or “consequences.” Rewards, such as tax cuts, are aimed at the wealthiest, whereas the most vulnerable citizens who are the poorest are simply presented with imposed cuts to their lifeline support as an “incentive” to not be poor. Taking money from the poorest is apparently “for their own good”, according to the government, as it reduces “dependency”. 

“Dependency” and “need” have somehow become conflated, the government have resisted urges to acknowledge that some citizens have more needs than others for a wide array of reasons, including their mental health status.

Defining human agency and rationality in terms of economic outcomes is extremely problematic. And dehumanising. Despite the alleged value-neutrality of behavioural economic theory and CBT, both have become invariably biased towards the status quo rather than progressive change and social justice.

Behavoural economics theory has permited policy-makers to indulge ideological impulses whilst presenting them as “objective science.” From a libertarian paternalist perspective, the problems of neoliberalism don’t lie in the market, or in growing inequality and poverty: neoliberalism isn’t flawed, nor are governments – we are. Governments and behavioural economists don’t make mistakes – only citizens do. No-one is nudging the nudgers.

It’s assumed that their decision-making is infallible and they have no whopping cognitive biases of their own. One assumption that has become embedded in the poliical narrative is that an adequate level of social security to meet people’s basic survival needs is somehow mutually exclusive from encouraging people to find a suitable job.

In the current political context, it’s easy to see how the medicalisation of political, economic, cultural and social problems may be politically misused, especially by an authoritarian government, and in an ideological era that extolls the virtues of a “small state” and austerity, to exempt the state completely from its fundamental responsibility towards the prosperity, health and wellbeing of citizens.

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Neoliberalism


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Choice architecture, neoliberalism and the politics of compliance

 

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The point for neoliberalism is not to make a model that is more adequate to the real world, but to make the real world more adequate to its model” – Simon Clarke (2005). (See also If You Look Behind Neoliberal Economists, You’ll Discover the Rich: How Economic Theories Serve Big Business. The road to serfdom – sponsored by big business).

Nudge: when the luxury of making choices has been commodified and packaged

Choice architecture is a term was coined by libertarian paternalists Richard Thaler and Cass Sunstein (2008). It refers to the practice of influencing choice by changing the manner in which options are presented to people.

For example, this can be done by setting defaults, framing, or adding decoy options. 

Choice architecture influences decision-making by simplifying the presentation of choices, by automatically evoking particular associations, or by making one option more salient or “easier” to choose than the alternatives. It works “beneath” our rational and reflective processes.

Personally, I see choice architecture as starkly lit Orwellian features along the short road and cul-de-sac to choiceless choices. It’s a reductive and determined journey, which ends by the state deciding and determining how citizens ought to be

A government that is acting upon the perceptions and behaviours of citizens in order to align them with politically defined socioeconomic outcomes turns democracy on its head. It detaches public policies from genuine wider public needs and interests. Governments are elected in the expectation that they will behave in ways that meet the needs of a population.

Democracy entails a dialogue between government and citizens. However, nudge closes down that dialogue, and restricts human agency – the capacity of individuals to act independently and to make their own free choices. Policies are increasingly about the government instructing us how to behave. How to be.

Choice architecture redesigns our experiences without our consent. Diversion from the path of those choices chosen for us by choice architects is considered to be pathological. Nudge doesn’t accommodate creative opportunity, critical thinking or any form of genuine learning. It simply claims that we each operate within the confines of bounded rationality. We are cognitively flawed. But nudge doesn’t present the opportunity for citizens to develop awareness of potential limits, to problem-solve or to learn how to become better cognitively equipped.

It’s precisely because we are ALL cognitively flawed that the production of knowledge for governance itself needs be governed.  In this respect, behavioural econmics displays an arrogance and epistemoloical authoritarianism in that it is assumed the theories it’s founded on somehow escape the confines of rational boundaries that everyone else is unable to transcend. It’s like saying “that’s your “human nature”, but not ours”. If we are all cognitively flawed, then no-one is exempt from that rule.

Nudge reduces our experiences to measured, measurable, politically defned quantitative “outcomes”, at the expense of the crucial qualitative accounts and participation of citizens that contribute to a functioning democracy.

Thaler and Sunstein define a “nudge” as:

Any aspect of the choice architecture that alters people’s behaviour in a predictable way without forbidding any options or significantly changing their economic incentives.”

This statement puzzles me. If a behaviour is altered in a predictable way, then how will we know if any of the other potential options were forbidden or not, and surely, it means at the very least that the other possibilities – alternative choices – have been foreclosed intentionally by the choice architect. If it didn’t mean that, then why use nudge at all, how exactly does nudging work, and why are we funding it?

Libertarian paternalism or “nudging” is a mechanism to exploit the ways that individuals deviate from rational choice in order to benefit themselves or society at large – for instance, by using our bias toward the status quo to encourage employees to put more of their paychecks into savings.

This benefits employees because it means they will be able to afford to live when they hit hard times, as state provision such as unemployment support and pensions have been incrementally cut away to almost nothing. The powers that be in the UK regard any kind of welfare provision as a “perverse incentive”. This benefits the government because if everyone pays for their own pension, periods of unemployment, sickness and so on, then the government can spend your national insurance contributions and taxes on other things. Like very wealthy people’s tax cuts. 

The privatisation of choice and consent

Power is defined in the social sciences as the ability to influence (“soft power”) or shape and outright control the behaviour of people (“hard power”). Attempts by a government to shape and control the behaviour of citizens (including the targeting of specific social groups), either via policies or by brute force, isn’t generally considered to be compatible with democracy, social justice or notions of inclusion.

Thaler and Sunstein have claimed that governments always influence citizens’ behaviours. We have laws to deter clearly defined crimes such as murder, theft and so on. However, those laws are clearly stated and citizens are aware of their purpose and that they aim to control socially harmful behaviours. They are transparent. Most people would  agree that they are necessary to protect citizens, and most are aware of the probable consequences of being found breaking those laws.

These are overt attempts to dissuade people from behaving in potentially harmful ways towards others and wider society generally tends to endorse them, regarding them as necessary. Such laws permit us to engage our rational processes precisely because they are visible to us. Nudge is designed to bypass our critical and rational capacities.

Nudge or “behavioural economics” is the attempt to shape people’s socioeconomic behaviours without people being aware of the process or the aim. Nudge ceases to work when people become aware that they are being nudged – it only works “in the dark”. 

The Nudge Unit was part-privatised in 2014, which means it is protected from public scrutiny.  It is no longer subject to the Freedom of Information Act, and it can sue for libel.

Ian Dunt said at the time of the Nudge Unit’s privatisation: “The secrecy and legal might of private firms offering public services is morally indefensible whatever the sector. But in the case of nudge it is particularly dangerous, because this is an organisation specifically tasked with implementing policy on the subconscious of the British public.

However sympathetic we are to the goals nudge is trying to achieve – such as reducing car accidents or increasing tax collection – we should be deeply sceptical of its tactics, which involve influencing the public without them knowing it is happening.

This is what makes nudge so toxic an idea. While it seems more liberal than using legislation to clamp down on unhealthy behaviour, it is actually more pernicious. At least when something is banned, you know you are being prevented from doing it. With nudge, you will never know.”

The application of nudge tends to be asymmetrical – is targeted disproportionately at poor citizens. This is because of the political belief – a weighted bias – that poor people are poor because they make “irrational” and “wrong” choice. Conversly, wealthy people are deemed “rational” precisely because they are wealthy. This is a line of teleological reasoning – rather than being causal explanation of the phenomenon of inequality, the aims, ends, or intentions of the observed phenomenon or behaviour are used to explain the process. Teleology refers to a view that justifies certain phenomena, which are explained by reference to their purposes.  The Conservatives see inequality as functional, because it “encourages competition” and serves as an “incentive”. Social scientific arguments among positivists in particular quite often rest on rational short cuts like this. This short cut is a weighted bias that becomes embedded in the process of how particular areas of research are chosen, how the research is designed, and how interpretation of the results and conclusions are framed. Rather than the “scientific method” in social research serving to ensure value neutrality, quite often it simply distils the ideological premises of it.

Nudge reduces a persons’ choices to one choice – that of the state or “choice architects”. Nudge tends to draw on punishments, threats of punishment and negative reinforcements to change the behaviours of poor people – such as those embedded in welfare conditionality and sanctions, which exploit a cognitive bias we have, apparently, called “loss aversion”

Something that the government and libertarian paternalists choose to ignore is that it is poverty itself that restricts choices, not poor people’s cognitive “abilities” or decision-making. A good example is how the use of credit scoring ultimately leads to the poorest people having to pay the most interest on credit, if they manage to get any at all. Being poor limits our choices for credit, and other ways out of financial hardship. It’s difficult to find work that pays an adequate wage to support an adequate standard of living, especially when you have so few resources that you can’t meet all of your basic needs, let alone pay your broadband bill and meet travel costs.

It’s a very dangerously slippery slope when a group of technocrats claim they have perfected the art of knowing what is best for us, and what our best interests are, especially when it is especially geared towards the political goal of fulfilling “small state” ideology. 

Psychopaths see others as a means to an end, they also like to define other people’s “best interests”. They use justification narratives for their behaviours to manipulate people, which are often plausible, but ultimately, this is simply to get their own way.

Similarly, the Conservatives’ use of nudge reflects their ideological agenda, and their justification narratives reflect an authoritarian turn. 

The rise of nudge refects a miserly neoliberal government with an ideological agenda

If people who are poor are struggling with decision-making, then nudging people – even if “opt out” provision is made (and it generally isn’t) – without their knowledge or informed consent cannot be justified as a “non intrusive” intervention, as behavioural economists try to argue. Nudging reduces our autonomy and imposes a framework of psychological reductionism and determinism.

Nudge reflects a basic “stimulus-response” view of human shaping behaviour, except the word “incentive” has replaced “stimulus” in the old behaviourist terminology. Many behavioural economists talk about cognitive processes, and how flawed most people’s are. But nudge methodology reflects a behaviourist approach – there’s no opportunity for learning, and no consideration of human subjectivity – our inner states, meanings, understandings and so on – all that matters is getting people to comply and behave the way the “choice architects” think we should. Cause and effect.

Nudge was introduced as a policy strategy as a way of cutting costs. Libertarian paternalism is a political doctrine, and is therefore not value-neutral. However, libertarian paternalists argue that their methodology – Randomised Controlled Trials (RTCs) – validates their claim to value neutrality.  Behavioural economists argue that the evidence gathered from RTCs is a better, more reliable and valid form of knowledge than the knowledge of “experts”. But such knowledge is insufficient if it is abstracted from the political side of policymaking in which problems are framed and knowledge given meaning. Furthermore, the RTCs are used to add credibility to the theoretical knowledge of “experts”. But often, those presenting a case for evidence-based policies often ignore the multiplicity of evidence relevant to the policy in question. In this respect, RTCs may be used to filter out alternative accounts of the issue being addressed, and so justifying interventions that are inappropriate or may have unintended (or undeclared and ideologically determined, intended) consequences. 

RTCs are an effective way of determining whether or not a particular intervention has been successful at achieving a specific outcome. One significant concern is that RCTs  are being promoted as the ‘gold standard’ in a hierarchy of evidence that marginalises qualitative research, and the accounts of citizens’ experiences – crucial to a functioning democracy. The government has frequently dismissed citizens accounts of policy impacts as “anecdotal”, claiming that “no causal link” between policy and impact can be demonstrated. Given that some of these accounts have been first hand, and about serious harm caused by policy,  it’s easy to see how the use of  a”scientific methodology” so easily becomes a tool for stifling criticism, debate and a mechanism for political expediency. 

RTCs have been the standard of medical research, and are useful for establishing whether cause-effect relationships exist between treatments and outcomes and for assessing the cost effectiveness of a treatment. However, their use in influencing and quantifying an array of complex human behaviours marks a return of the determinism and reductionism that was central to behaviourist perspectives. 

We must also question the appropriateness of the use of a medical model to frame social problems. Poverty, inequality and the unequal distribution of power doesn’t happen because of some disease process: it is because of government policy and decision-making. No amount of blaming individual citizens’ decision-making and applying “behavioural medicine” to the victims of free neoliberal socioeconomics will remedy that. 

Behaviourism is basically the theory that human and animal behaviour can be explained in terms of conditioning, without appeal to “internal” states -thoughts or feelings – and that psychological disorders are best treated “externally” by altering “faulty” behaviour patterns. Because nudge is used asymmetrically, and targets poor people disproportionately, it is founded on assumptions that reflect traditional prejudices and assumptions about the causes of poverty, and also serves to endorse and extend existing inequalities in wealth, resources and power. Nudge assummes that poor people’s decision-making is the cause of poverty, rather than institutionalised prejudices and the political decision-making that shapes our socioeconomic environment.

One of our fundamental freedoms as human beings is that of decision-making regarding our own lives and experiences. To be responsible for our own thoughts, reflections, intentions and actions is generally felt to be an essential part of what it means to be human.

Of course there are social and legal constraints on some intentions and actions, especially those that may result in harming others, and quite rightly so.

There are other constraints which limit choices, too, insofar that choices are context-bound. We don’t act in an infinite space of opportunities, alternatives, time, information, nor do we have limitless cognitive abilities, for example.

In other words, there are always some limitations on what we can choose to do, and we are further limited because our rationality is bounded. Most people accept this with few problems, because we are still left ultimately with the liberty to operate within those outlined parameters, some of which may be extended to a degree – our capacity for rationality and critical thinking, for example, can be learned and improved upon. But our thoughts, reflections, decisions and actions are our own, held within the realm of our own individual, unique experiences.

However, the government, and the group of behavioural economists and “decision-making psychologists” (employed at the “Nudge” Unit) claim to have found a “practical” and (somehow) “objective way” from the (impossible) perspective of an “outside observer” – in this case, the government – to define our best interests and to prompt us to act in ways that conform to their views. Without our informed consent. “Compliance” is the defintely the governments’ buzzword. Compliance frameworks are embedded in our welfare system and most of our public services. 

Sunstein and Thaler argue that policymakers can preserve an individual’s liberty while still nudging a person towards choices that are supposedly in their best interests. However, since no-one can escape their bounds of their own subjectivity to find some mind-independent vantage point, and since all humans operate within a framework of bounded rationality, the behavioural economists’ claim to value-neutrality, and technocratic appeal to the validity of a “scientific” methodology doesn’t stand up to scrutiny.

The claim to an “objective” scientific methodology does nothing to compensate for the ideological perspectives of the researcher that invariably influence the choice of an area of study, or the nature of generated hypotheses that are tested in artificial environments – “laboratory” conditions. Isolated, tested, short-range hypotheses cannot tell us much about the vast array of complex processes involved in human decision-making, and take any meaningful account of the influence and depth of a cultural, political, social, economic and historical context. As such, they cannot provide a reliable basis for making inferences to real world circumstances.

The results depend on the interpretation and nature of the data used and the reason for the analysis in the first place. Simple causal explanations of behaviour embody reductionism and determinism – and therefore deny human autonomy. Bounded rationality is a theory that proposes we have limited choices, but behaviourist perspectives inform us that basically, we have none. 

Nudge doesn’t take into account that political decision-making also succumbs to the limits of bounded rationality, and that socioeconomic policies impact upon citizens, rather than citizens making choices – “right” or “wrong” ones – about our socioeconomic organisation.  

Medical RCTs are done within the confine a strict ethical framework, with informed consent being central to that framework. The government is conducting experiments on the population without their informed consent. There are no ethical safeguards in place to monitor and acknowledge any potential harm that arises as a consequence of nudging. This is precisely why there is a  need to incorporate qualitative insights into RTCs used to test pubic policy interventions. 

Nudge ignores the negative impact of the attitudes and behaviours of the wealthy and powerful on society

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“People who are poorer should be prepared to take the biggest risks; they’ve got least to lose.” Lord Freud, 2012

The risk-taking and greedy behaviours of wealthy people caused a global financial crash, which has ultimately led to countries like the UK imposing austerity on the poorest citizens. Excess in risk taking by and excessive leverage of banks meant that the finance class ignored externalities and relied on bail-outs by the government following the crisis.

The incentive structure of banks encouraged strategies that increased aggregate risk in the economy, and regulators allowed banks to use their own models to calculate and report riskiness. Deregulation is at the core of the 2008 Financial Crisis. The attempt to decrease government involvement in the financial system backfired. Ultimately, deregulation put depositors, consumers, and banks at risk. Those paying the price for the decision-making behaviours of those in positions of power are the poorest citizens. Austerity has been used as a diversion from where the responsibility for the banking crisis lies, and has become a mechanism of administering disipline and ensuring the conformity of the poorest citizens.

Yet their remains a widespread lack of concern for the financial system’s risk to the economy. No lessons appear to have been learned, and no-one is concerned with “changing the behaviours” of the perpetrators of the global recession.

“If we must talk about “poor choices” then we have to address all poor choices. Not just those “poor choices made by the Poor.” Hubert Huzzah

Austerity measures have caused an unacceptable level of harmhardship and absolute poverty – lacking the means to meet basic survival needs, such as food, fuel and shelter – that we haven’t witnessed as a society since before the establishment of the post-war welfare state. We have also witnessed the violation of the human rights of some socially marginalised groups. This point indicates to me that it isn’t poor people who need “behaviour change” programmes: it’s the rich and powerful who create adverse or “pathological” socioeconomic circumstances and events

“Nudge” bears the hallmark of oppression and is symptom of an authoritarian state. It permits those whose decisions have truly devastating impacts on others and our society to simply carry on doing as they choose, whilst punishing those who are blameless, powerless and don’t participate in decisions regarding how our society is organised. 

As such, nudge has become a prop for neoliberal hegemony and New Right Conservative ideology. It’s a technocratic fix to a socioeconomic system that is not only failing, it’s causing distress and harming many citizens.

Nudge addresses the needs of policy-makers. Not the wider public. The behaviourist educational function, made patronisingly explicit by the Nudge Unit, is now operating on many levels, including through policy programmes, institutionalised attitudes and behaviours, in schools, in forms of “expertise”, and even through the state’s influence on the mass media, other cultural systems and at a subliminal level: it’s embedded in the very language that is being used in political narrative.

Thaler acknowledges that regardless of the original intentions, nudge may be skewed by governments, organisations or individuals looking to capitalise on the cognitive biases of people. Whenever he is asked to sign a copy of his book , he writes “nudge for good” which is a plea, he says, to improve the lives of people and avoid “insidious behaviour.”

In the UK, choice architects work to simply maintain the status quo. Therefore nudge doesn’t and cannot offer us any scope for improving people’s lives.

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Grenfell is a stark monument to the systematic disempowerment of citizens because of the decisions made by the architects of neoliberal policies and the utter disregard and negligence of those in positions of power.

Residents of Grenfell Tower had previously raised serious concerns that a catastrophic event could happen. It did. An action group of Grenfell residents said their warnings fell on “deaf ears” after highlighting major safety concerns about the block. The neoliberalisation of the housing market entailed councils part-privatising public housing – putting them into housing associations or ALMOs (arms length management organisations). This management arrangement was distant and remote – a bureaucratic mechanism rather than a democratic community organisation. 

Austerity was (re)introduced in 2010. Public and social housing budgets were slashed and housing associations encouraged to become more commercial and borrow from banks instead of receiving public funding. At the same time, social security and funding for local government were dramatically cut back. In London alone, 10 fire stations, 27 fire engines and more than 600 firefighters have been lost to cuts since 2010. These undermined emergency responses and efforts to prevent fires by inspecting buildings and taking enforcement action under fire safety regulations.

Government hostility to regulation played a significant role in the unfolding of this terrible tragedy. Following a smaller fatal 2009 fire in South London, a series of recommendations including installing sprinkler systems and reviewing the “stay put” advice given to residents living in higher floors in the event of a fire. These recommendations were sat on, ignored, and delayed despite efforts from parliamentarians and campaigners, and even the magazine representing housing professionals. The requirement to carry out a Fire Risk Safety Assessment by the Fire Brigade was changed to make it the responsibility of landlords – Kensington and Chelsea Council opted to use the cheapest company available to them. 

These assessments are not transparent or public and are now the subject of huge public scrutiny along with the series of decisions that led to Grenfell Tower being “re-clad” in the cheap material that facilitated the rapid spread of the fire.

What is clear is that government decision-making, the ideology of deregulation, of privatising, of austerity, combined to kill people in their homes. Their safety and their lives were not valued by the government nor the system they put in place, nor were their voices heard until it was far too late. 

If we must talk about “poor choices” then we must address all poor choices. Not just those “poor choices” made by the poorest and most disempowered citizens.arnstein-ladder-citizenship-participation

 

 

 

 

 

 

 

 

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Sherry Arnstein’s Ladder of Citizen Participation and Power

Related

The importance of citizen’s qualitative accounts in democratic inclusion and political participation

The connection between Universal Credit, ordeals and experiments in electrocuting laboratory rats

 

I’m currently writing a longer and more in-depth critique of behavioural economics, which will be published very soon.

 


 

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The Nudge Unit’s u-turn on benefit sanctions indicates the need for even more lucrative nudge interventions, say nudge theorists

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Some context: the new neuroliberalism and “behavioural insights”

The behaviourist turn in government administration – the use of targeted citizen behavioural conditionality in neoliberal policy making –  has expanded globally and is linked to the growth of behavioural economics theory (“nudge”) and a New Right brand of “libertarian paternalism.”  

Reconstructing citizenship as highly conditional stands in sharp contrast to democratic principles, rights-based policies and to those policies based on prior financial contribution, as underpinned in the social insurance and social security frameworks that arose from the post-war settlement.

The fact that the poorest citizens are being targeted with behavioural theory-based interventions also indicates discriminatory policy, which reflects traditional Conservative class-based prejudices. It’s an authoritarian approach to poverty which simply strengthens existing power hierarchies, rather than addressing the unequal distribution of power and wealth in the UK.

Some of us have dubbed this trend neuroliberalism because it serves as a justification for enforcing politically defined neoliberal outcomes. A hierarchical socioeconomic organisation is being shaped by increasingly authoritarian policies, placing the responsibility for growing inequality and poverty on individuals, side-stepping the traditional (and very real) political/structural explanations of social and economic problems.

Such a behavioural approach to poverty also adds a dimension of cognitive prejudice which serves to reinforce and established power relations and inequality. It is assumed that those with power and wealth have cognitive competence and know which specific behaviours and decisions are best for poor citizens, who are assumed to lack cognitive competence (because they are poor and therefore make “the wrong decisions”). Apparently the theories and insights of cognitive bias don’t apply to the theorists applying them to increasingly marginalised social groups. Policy has increasingly extended a neoliberal cognitive competence and decision-making hierarchy. 

It’s very interesting that the Behavioural Insights Team now claim that the state using the threat of benefit sanctions may be “counterproductive”. The idea of increasing welfare conditionality and enlarging the scope and increasing the frequency of benefit sanctions originated from the behavioural economics theories of the Nudge Unit in the first place. 

The increased use and rising severity of benefit sanctions became an integrated part of welfare conditionality in the Conservative’s Welfare “reform” Act, 2012. The current sanction regime is based on a principle borrowed from behavioural economics theory – an alleged cognitive bias we have called loss aversion.

It refers to the idea that people’s tendency is to strongly prefer avoiding losses to acquiring gains. The idea is embedded in the use of sanctions to “nudge” people towards compliance with welfare rules of conditionality, by using a threat of punitive financial loss, since the longstanding, underpinning Conservative assumption is that people are unemployed because of alleged behavioural deficits and poor decision-making. Hence the need for policies that “rectify” behaviour.

I’ve argued elsewhere, however, that benefit sanctions are more closely aligned with operant conditioning (behaviourism) than libertarian paternalism, since sanctions are a severe punishment intended to modify behaviour and restrict choices to that of compliance and conformity or destitution. At the very least this approach indicates a slippery slope from “arranging choice architecture” in order to support the “right” decisions that are felt to benefit people, to downright punitive and coercive policies that entail psycho-compulsion, such as sanctioning and mandatory workfare. 

Psychology is being misused by the government to explain unemployment (it’s claimed to happen because people have the “wrong attitude” for work) and as a means to achieve the “right” attitude for job readiness. Psycho-compulsion is the imposition of often pseudo-psychological explanations of unemployment and justifications of mandatory activities which are aimed at changing presumed beliefs, attitudes and dispositions. The Behavioural Insights Team have previously propped up this approach.

Welfare conditionality and its experimental approach to behavioural change doesn’t operate within an ethical framework, citizens cannot withdraw from behavioural experiments, nor is this framework based on informed consent. The impact of state directed psycho-compulsion and potential harm that it may cause citizens is not being monitored. 

The Behavioural Insights Team (BIT) is composed of mostly behavioural economists, who also claim the title of libertarian paternalists (and who have a clear and distinct ideological premise for their behavioural theories, while attempting to claim “objectivity”.)

They claim that while it is legitimate for government, private and public institutions to affect behaviour the aims should be to ensure that “people should be free to opt out of specified arrangements if they choose to do so.” Apparently, that proviso doesn’t apply to poor citizens.

The nudges favoured by libertarian paternalists are also supposed to be “unobtrusive.” That clearly is not the case with the application of extremely coercive and punitive Conservative welfare sanctions.

When it comes to technocratic fads like nudge, it’s worth bearing in mind that truth and ethics quite often have an inversely proportional relationship with the profit motive. It’s a cognitive bias, if you will.

And when one nudge theory fails, there are always lucrative and political opportunities to generate more.

Of course Dr Kizzy Gandy, a leading researcher at the policy unit says: “We are optimistic that behavioural science can help government departments to better design policies to help those who are ‘just managing’ in order to prevent and overcome poverty.”

In a new report released today from the Behavioural Insights Team, the authors say: “There is evidence that welfare conditionality in the UK – mandatory behavior requirements such as attending meetings with work coaches or providing repeated evidence of disability in order to receive benefits – is associated with anxiety and feelings of disempowerment.” 

“However, as far as we know no one has examined whether welfare conditionality has cognitive depleting effects.”

It’s particularly worrying that there is a proposal in the report for further experimental pseudo-psychological approaches to policies aimed at the poorest citizens. The researchers call on the Department for Work and Pensions to conduct experiments into whether welfare conditionality actually had any positive effects and suggested that “self-set” and “enforced goals” might be a better way of “helping people into work.” Although this allows for a little tokenist self-determination and permits a little autonomy, it is still an approach ultimately based on coercion and enforcement.

There is a clear distinction to be made between “behavioural science” – which is almost entirely about economic outcomes; what is politically deemed “best” for citizens and social conformity, and mainstream psychology – which embraces a much broader and deeper perspective of the complexities of human potential and wellbeing.

For anyone curious as to how such tyrannical behaviour modification techniques like benefit sanctions arose from the bland language, inane, managementspeak acronyms and pseudo-scientific framework of “paternal libertarianism” – nudge – here is an interesting read: Employing BELIEF: Applying behavioural economics to welfare to work, which is focused almost exclusively on New Right small state obsessions.

(Update 27/10/17 – the link to the original document no longer works. But I found a copy with the same page layout here, luckily: – https://www2.learningandwork.org.uk/sites/default/files/publications/CESI_employing_BELIEF.pdf).

Pay particular attention to the part about the alleged cognitive bias called loss aversion, on page 7.

And this on page 18: The most obvious policy implication arising from loss aversion is that if policy-makers can clearly convey the losses that certain behaviour will incur, it may encourage people not to do it,” and page 46: “Given that, for most people, losses are more important than comparable gains, it is important that potential losses are defined and made explicit to jobseekers (e.g.the sanctions regime).”

The recommendation on that page: We believe the regime is currently too complex and, despite people’s tendency towards loss aversion, the lack of clarity around the sanctions regime can make it ineffective. Complexity prevents claimants from fully appreciating the financial losses they face if they do not comply with the conditions of their benefit.”

The Conservatives duly “simplified” sanctions by extending them in terms of severity and increasing the frequency of use. Sanctions have also been extended to include previously protected social groups, such as lone parents, sick and disabled people. 

The paper was written in November 2010, prior to the Coalition policy of increased “conditionality” and the extended sanctions element of the Tory-led welfare “reforms” in 2012. I wrote about this at length earlier this year, here: Nudging conformity and benefit sanctions: a state experiment in behaviour modification.

The Behavioural Insights Team, (otherwise known as the Nudge Unit) was set up by David Cameron in 2010. In their most recent report called Poverty and decision-making: How behavioural science can improve opportunity in the UK, the nudge researchers now say that burdening unemployed people with responsibilities, using the threat of sanctions might actually be making it harder for them to get jobs.

According to the behavioural economist theorists authoring this highly jargonised report, government policies designed to help people are reducing and impairing people’s so-called cognitive scope and abilities.

However, it’s difficult to imagine how punitive sanctioning, which entails the removal of people’s lifeline income, originally calculated to meet the costs of only basic survival needs, such as for food, fuel and shelter, could ever be seen as “helping people.”

I don’t believe that Orwellian semantic shifts can ever provide a genuine and effective solution to poverty and inequality. 

Some major inconsistencies and incoherences in the report

In the latest BIT report, loss aversion is mentioned again:  “People dislike losses more than they like equivalent gains. Babcock, Congdon, Katz, and Mullainathan (2012) hypothesise that people may experience loss aversion if they consider taking a job paying below past earnings. Therefore, they may stay on unemployment benefits longer than they should. Unrealistic wage expectations may be reinforced when the social status and personal identities of workers are strongly tied to their previous job.” [My emphasis]

Note the phrase “unrealistic wage expectations” and later incoherent comments in the report about in-work poverty, which I will highlight.

The summary report states in the introduction: A third of the UK population spent at least one year in relative income poverty between 2011 and 2014.

Traditionally policymakers and anti-poverty organisations such as the Joseph Rowntree Foundation (JRF) have focused on boosting people’s economic capital (e.g., income) and human capital (e.g., educational attainment) to reduce poverty. While investments in these areas have led to important gains in opportunity for many Britons, emerging research from behavioural science shows that other less tangible resources, which derive from psychological, social and cultural processes, significantly influence people’s ability to overcome disadvantage.

BIT was commissioned by JRF to examine the role of individual decisions in shaping people’s experiences of poverty in the UK and to identify the drivers of these decisions. This reflects JRF’s interest in looking beyond traditional, structural drivers of poverty. Our findings, based on a review of the published literature, are presented in a new report, launched today.”

 

Let’s cut to the chase. The entire document is framed by the use of a distinct and established narrative; it’s composed of a pre-loaded ideological language, references and signposts, using comments and phrases like “[…] we explain some of the ways that cognitive, character and social capital influence social mobility, via decision-making.”  

And a sub-heading:Character capital: Self-efficacy and responsive parenting.” Apparently, “home visits by health workers have had positive effects in preventing intergenerational poverty.” That’s quite a remarkable claim, given that the document acknowledges poverty is actually increasing in the UK.

The whole concept of character capital is itself founded on the notion that people with an “internal locus of control” tend to perform tasks better than those with an “external locus of control.” This is about where people place the responsibility for what they achieve – either “inside” individuals, based solely on notions of merit, specific skills and talents, or external to individuals – “outside” of them, based on environmental conditions such as competition, chance, opportunities, socioeconomic, employment market context and so on. However, the cited evidence to support this theory was later contradicted in the report.

It’s also worrying that it is implied those who believe that achievement is linked with structural conditions are “under-performers.” It reads a little like a Samuel Smiles Victorian treatise on “thrift, character and self-help.”

It’s also an almost subliminal method of dismissing the impact of structural constraints on the opportunities available to individuals. It serves to make invisible what was once a key consideration in public discussions about poverty: the unequal distribution of power, wealth, resources and opportunity.

Also of note: “low levels of financial literacy” was conflated with notions of “human capital”, which “potentially exacerbate the effects of depleted cognitive capital among low income groups when choosing between credit options.”  Nothing to see here, then, regarding the behaviour of lenders. I mean whoever heard of a bank offering an overdraft to people who actually need one. Still, thank goodness there are generous companies like Wonga, always ready to step up to the mark, with eye-watering interest rates to offer those on low incomes.

The research authors seem to think that the only human potential worth recognising is that of our economic decision-making. Yet when people are materially poor, budgeting and decision-making are invariably constrained – that’s intrinsic to the very nature of poverty.

Limited decision-making and reduced available choices don’t cause poverty: they are the subsequent exclusion effects of poverty.

It’s telling that none of the recommendations made in this document actually address the structural and political causes of material poverty and growing inequality in the UK.

There is a substantial incoherence in some of the claims made, too. For example: “The world of work is possibly the single most important policy area for maximising individual and household resources to prevent and overcome poverty.”

Yet: “Just under half of those in poverty in the UK live in a workless household (Joseph Rowntree Foundation, 2014)”. So work clearly doesn’t pay for over half of those people in poverty. 

In fairness, it is later acknowledged that: “However, simply being in work is not sufficient to prevent or overcome poverty. Nearly two-thirds of children in poverty live in working families.” 

This heavily jargonised rhetoric is, on the whole, about looking for cheap individualist “solutions” to poverty that disregard the need for improving people’s material and financial situations, by extending on an existing neoliberal narrative of alleged individual fault, character deficits, cognitive bias and decision-making flaws.

None of this will raise the profile of crucial issues such as the conditions imposed by austerity and neoliberal policies, socioeconomic organisation and political decision-making, that are having a profound impact on growing inequality and increasing poverty in the UK. The persistent use of the word “workless” rather than “unemployed” is another linguistic signpost for neoliberal competitive individualism, too. 

Geographer David Harveydescribes neoliberalism as a process of accumulation by dispossession: predatory policies are used to centralise wealth and power in the hands of a few by dispossessing the public of their wealth and assets. The report does not refer to the mode of political-economic organisation of which growing inequality and poverty are an intrinsic and inevitable feature.

Proposed solutions: more of the same

Summary of recommendations:

MINIMISING COSTS

Consumer credit

1 Make it easier to access low cost credit through extending access to interest-free Budgeting Advances; assisting credit unions to expand online services; and providing tax relief to individuals taking out payroll loans.

2 Further restrict practices by high cost credit providers that play on consumer biases, and test remedies that will improve consumer credit decision-making.

3 Continue to evaluate financial capability programmes through initiatives like the Money Advice Service What Works Fund.

(Access to credit does not alleviate poverty in the long-term.)

Savings

1 Test ways of automating rainy day savings through employer enrolment, default savings accounts with banks, and Universal Credit payments.

2 Evaluate the effectiveness of financial apps for helping people save.

3 Optimise the Help to Save matching scheme, through testing auto-enrolment and prizes for regular saving, to encourage low-income groups to save.

(Poor citizens do not have sufficient funds to make savings. And research shows that absolute poverty is growing in the UK, which means that many people often don’t have sufficient funds for meeting even fundamental survival needs, such as for food and fuel.) 

MAXIMISING RESOURCES

Work

1 Use identity-building activities in Jobcentres to cultivate intrinsic motivation for work in order to improve the quality and sustainability of jobs that people find.

2 Collect longer-term and more holistic outcome measures of labour market interventions to understand their full impact on poverty.

3 Develop a simple tool for Jobcentres to identify capital deficits in order to match interventions to individual job seeker needs.

Entitlements

1 Develop a common “cognitive load stress test” that measures how easy it is for eligible groups to access government entitlements.

2 Use annual entitlement summaries to prompt existing welfare recipients to apply for other assistance they may be eligible for, and to help them budget.

3 Experiment with the design of welfare conditionality to boost cognitive capacity and self-efficacy, such as having claimants set their own payment conditions.

PREVENTING INTERGENERATIONAL POVERTY

Parenting

1 Provide families in or near poverty with free access to evidence-based online parenting programmes.

2 Develop community to strengthen social ties between parents from different backgrounds.

3 Conduct research into whether small and inexpensive adjustments to housing conditions can reduce cognitive load and improve parental decision-making.

Post secondary education

1 Make the application process for post-secondary education as simple as possible, for example, by pre-populating application forms.

2 Use personalised assistance and prompts to encourage students and parents to apply to post-secondary education.

3 Link formal information about returns to post-secondary education with informal information (from peers) about what post-secondary education will be like.

Every single intervention recommendation fails to address the structural causes of poverty, which lie outside of the control of people experiencing poverty. Yet most of these recommendations are aimed at prompting the state to act upon individuals.  

Proposals such as providing access to parenting programmes, “identity-building activities in Jobcentres to cultivate intrinsic motivation for work”, “rainy day savings”, and to “develop a simple tool for Jobcentres to identify capital deficits in order to match interventions to individual job seeker needs” all sound like a New Right blame-storming exercise. Again, the problem of poverty is regarded as being intrinsic to the individual, rather than one that is about material deprivation which arises in a wider political, economic, cultural and social context.

Post secondary education costs money and isn’t supported by the state. The Education Maintenance Award (EMA) was withdrawn by the Conservatives, and the cost of a university education is now far too much for many young people from poorer backgrounds because of the tripling of fees and reduction in maintenance support. It’s the government that need a nudge, here. This is a good example of how opportunities and choices are being limited for poorer citizens by cuts and constraints imposed by the neoliberal ideologues in office.  

The government never question the decision-making of the powerful and wealthy, yet it certainly wasn’t the poorest citizens that caused the global recession in 2007, nor was it the poorest citizens that imposed damaging austerity policies. The poorest people are burdened with a disproportionate weight of austerity cuts to their income and support. The wealthiest citizens have meanwhile been gifted with substantial tax cuts. 

Nudge is a state prop for neoliberalism, inequality and social control

Neoliberals argue that public services present moral hazards and perverse incentives. Providing lifeline support to meet basic survival requirements is seen as a barrier to the effort people put into searching for jobs. From this perspective, the social security system, which supports the inevitable casualties of neoliberal free markets, has somehow created those casualties. But we know that external, market competition-driven policies create a few “haves” and many “have-nots.” This is why the  welfare state came into being, after all – because when we allow such competitive economic dogmas to manifest without restraint, we must also concede that there are always ”winners and losers.”

Neoliberalism organises societies into hierarchies. Inequality is therefore an inevitable feature of the UK’s current mode of socioeconomic organisation. 

The UK currently ranks highly among the most unequal countries in the world.

Inequality and poverty are central features of neoliberalism and the causes therefore cannot be located within individuals.  

Neoliberals see the state as a means to reshape social institutions and social relationships based on the model of a competitive market place. This requires a highly invasive power and mechanisms of persuasion, manifested in an authoritarian turn. Public interests are conflated with narrow economic outcomes. Public behaviours are politically micromanaged. Social groups that don’t conform to ideologically defined outcomes are stigmatised, and outgrouped.

Shamefully, in a so-called first world, wealthy liberal democracy, othering and outgrouping have become common political practices.  

Replacing spent micro-managementspeak with more micro-managementspeak

The Nudge Unit, which was part-privatised in 2014, have now warned that some Government policies were reducing so-called “cognitive bandwidth” or “headspace” of the people they were designed to help. So more theoretical psychobabble to overwrite the previous psychobabble which didn’t work when applied via policy.

This is bland neoliberal managementspeak at its very worst. The policies are causing profound damage, harm and distress to those they were never actually designed to “help”. Let’s not permit an evading of accountability and techniques of neutralisation: the use of rhetoric to obscure the real intention behind policies, as well as the consequences of them. It’s nothing less than political gaslighting. 

Of course the report attempts to apply “the latest findings from behavioural science to improve government services.” In a neoliberal framework, there are many lucrative opportunities for private companies to experiment in the psychological management of populations who have become the casualties of political decision-making, for political ends. The ethical relativity, moral entrepreneurship and sheer financial opportunism on display here certainly reflect some fundamental neoliberal values and principles. The main one being profit over human need.

Dr Kizzy Gandy proposes that cost-effective “simple tweaks” to services could help improve the way services worked. “Government policies should help people to have less on their mind, not more,” she added. 

However, I propose that government policies in democratic societies should also be designed to meet the public’s needs, including alleviating poverty, rather than being about impoverishing targeted social groups and then undemocratically acting upon individuals, without their consent, directing them how to behave in order to accommodate government ideology and meet politically defined neoliberal outcomes.

Material poverty steals aspiration and motivation from any and every person that is reduced to struggling for basic survival. Abraham Maslow (a real social psychologist) explained that when people struggle to meet their basic physical needs, they cannot be “incentivised” to fulfil higher level psychosocial needs – that includes job seeking.

Further criticism 

Labour Shadow Work and Pensions Secretary, Debbie Abrahams, said: “Even the government’s own Behavioural Insights Team now recognise the mountains of evidence that the widespread use of sanctions is not leading to better outcomes for people seeking work. Indeed, this government team’s report suggests that sanctions may be operating as a barrier to finding a job.

“This government should be ashamed of their persistent failure to act on this issue over many years, after I, and other campaigners, have provided evidence of the devastating impacts of their sanctions policy.  I have committed to putting an end to Tories’ cruel and unnecessary sanctions regime, as part of our work to transform the social security system.” 

In fairness to the BIT, the report does say on page nine, among the listed areas of proposed future research: “A significant portion of behavioural science research focuses on improving the decisions of end-users – in this case people in poverty. But what about the decisions of service providers and policymakers? How can we improve the quality of their decisions to support people [to] escape poverty? And how can we build their empathy with those whose opportunities are at stake?”  

But who is nudging the nudgers?  I would think nudgers are “incentivised” by those providing the contracts that pay their salaries, on the whole. The government part-own the nudge unit.

Researchers from a variety of universities across the UK, using qualitative longitudinal interviews with nine groups of welfare service users from across England and Scotland, aim at determining longer-term effects of sanctions. The first wave findings from this collaborative ongoing study regarding the effects and ethics of welfare conditionality were released last year 

It was found that linking continued receipt of benefit and services to mandatory behavioural requirements has created widespread anxiety and feelings of disempowerment. The impacts of benefit sanctions are universally reported by service users as profoundly negative, having severely detrimental financial, material, emotional, psychological and health impacts. Some individuals disengaged from services, some were even pushed toward “survival crime”.  

The most surprising thing about these findings was the general lack of surprise they raised.

A recurring theme is that sanctions are grossly out of proportion to “offences”, such as being a few minutes late for an appointment. Many reported being sanctioned following administrative mistakes. The Claimant Commitment was criticised for not taking sufficient account of individuals’ capabilities, wider responsibilities and vulnerabilities. Many saw job centres as being primarily concerned with monitoring compliance, imposing discipline and enforcement, rather than providing any meaningful support. 

Power relations, class and economic organisation have now completely disappeared from public conversations about poverty. Neoliberal anti-welfarism, amplified by a corporate media, has aimed at reconstruction of society’s “common sense” assumptions, values and beliefs. Class, disability and race narratives in particular, associated with traditional prejudices and categories from the right wing, have been used to nudge the UK to re-imagine citizenship, human rights and democratic inclusion as highly conditional.  

This is not just about shifting public rational and moral boundaries to de-empathise the electorate to the circumstances of politically defined others. It also obscures the consequences more generally of increasingly non-inclusive, anti-democratic, prejudiced and extremely punitive policies.  

The bottom line is that government policies are expressed political intentions regarding how our society is organised and governed. They have calculated social and economic aims and consequences. In democratic societies, citizens’ accounts of the impacts of policies ought to matter. 
 
However, in the UK, the way that policies are justified is being increasingly detached from their aims and consequences, partly because democratic processes and basic human rights are being disassembled or side-stepped, and partly because the government employs the widespread use of linguistic strategies: euphemisms, superficial glittering generalities and techniques of persuasion to intentionally divert us from aims and consequences of ideologically (rather than rationally) driven policies. Furthermore, policies have become increasingly detached from public interests and needs. 

For example, the state has depoliticised disadvantage, making it the private responsibility of citizens, whilst at the same time, justifying a psychopolitical approach that encodes a punitive Conservative moral framework. 

According to the behavioural economist theorists, in their highly jargonised and fairly meaningless report, government policies are reducing so-called “cognitive bandwidth” or “headspace” of the people they were designed to help.

That the government imposes additional “cognitive costs”, as well as material and financial ones, on low-income groups, is hardly a groundbreaking revelation. 

I can put it much more plainly, and strip it of neoliberal psychobabbling: imposing sanctions on people who already have very limited resources is not only irrational, it is absurdly unjust, damaging, distressing and spectacularly cruel. 

See also:

Benefit Sanctions Can’t Possibly ‘Incentivise’ People To Work – And Here’s Why

Two key studies show that punitive benefit sanctions don’t ‘incentivise’ people to work, as claimed by the government

Welfare, Conditional Citizenship and the Neuroliberal State – Conference Presentation