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Philip Alston, UN special rapporteur on extreme poverty and human rights, travelled across the country to examine the impact of austerity. He came to Newcastle, visiting a West End foodbank, among other places. He concluded that Universal Credit and other ‘reforms’ are “entrenching high levels of poverty and inflicting unnecessary misery.” According to his research, 14 million people – a fifth of the population – live in poverty. Four million of these are more than 50% below the poverty line, and 1.5 million are destitute, unable to afford basics essentials. Alston said: “In the fifth richest country in the world, this is not just a disgrace, but a social calamity and an economic disaster, all rolled into one.”
Universal Credit has been designed to change the relationship between the state and citizens. It is about altering the public’s expectations of the role of government. It is about deepening targeted austerity. It is also about cutting social security and dismantling the welfare state.
The one-off £10 payment, which was designed to be an extra boost to families over the festive period, has been axed under Universal Credit, which demonstrates very well what kind of “mean spirited” intentions went into the design of system. I rang the Department for Work and Pensions press office to confirm this and it was affirmed that the cut has happened. A spokesperson said: “Universal Credit claimants have never received a one-off December payment, but many disabled people on Universal Credit will be better off on average by £100 month than when they received Employment and Support Allowance (ESA).”
Yesterday, someone I know through social media sent me a copy of a notice they got when they logged onto the Universal Credit system. It said:
So, if an employer pays his employees early in December due to the Christmas holiday period or pays a Christmas bonus, people may well receive a reduced Universal Credit payment in December or none at all. This is due the fact that the unadaptable system cannot cope with people being paid twice in one assessment period, even though it isn’t an additional payment, it is simply an early payment.
The controversial Universal Credit programme is to undergo another legal challenge at the High Court in London, as evidence mounts further that the new social security system will leave thousands of people already on low incomes significantly worse off. Four women are taking the government to court because of this reason.
This is the second judicial review of Universal Credit. It follows the High Court’s finding in June that the Universal Credit system was unlawfully discriminating against severely disabled people. Those who had qualified for the support component of income-related Employment and Support Allowance (ESA) are also eligible for a disability premium. However, as a result of the abolition of both the severe disability premium (SDP) and enhanced disability premium (EDP) under Universal Credit rules, according to the disability charity, Scope, the cut to the disability income guarantee will see disabled people lose as much as £395 a month.
The high court judge ruled that the Department for Work and Pensions unlawfully discriminated against two severely disabled men who both saw their benefits dramatically reduced when they moved Local Authority – one of them because of the bedroom tax – and were required to claim Universal Credit. The court found that the implementation of Universal Credit and the absence of any ‘top up’ payments for this vulnerable group as compared to others constitutes discrimination contrary to the European Convention on Human Rights.
Since the court case, Esther McVey, then Secretary of State for Work and Pensions, announced that no severely disabled person in receipt of the SDP will be made to move onto Universal Credit until transitional protection is in place. She also committed to compensating those like the two claimants who have lost out on their disability premium because they had to claim Universal Credit.
Yet despite this, Secretary of State for Work and Pensions has sought permission to appeal, maintaining that there was “nothing unlawful” with the way the claimants were treated.
The second judicial review comes amid mounting concern over Universal Credit, which academics have described as a “complicated, dysfunctional and punitive” system pushing people into debt and rent arrears.
Last week it emerged that more than half of people denied Universal Credit were found to be entitled to it when their cases were investigated, prompting fresh demands for the national rollout of the new system to be halted. It’s something of an irony, given that Universal Credit was introduced in 2013 with the stated intention of bringing “fairness and simplicity” to Britain’s social security system.
Now, four plaintiffs say the flaw, which relates to the way Universal Credit monthly payments are calculated, disproportionately affects working parents with children and leaves claimants with a “dramatically fluctuating income” and unable to budget from month to month.
In one case uncovered by the Child Poverty Action Group (CPAG) reported by The Guardian, a family’s monthly payment swung from £1,185 to zero, making budgeting impossible. One of the women has said that as well as being irrational, the payment system is also discriminatory as it disproportionately affects single parents, who are predominantly female. Last month, MP Frank Field said the system was driving some women in his constituency into sex work in a bid to avoid absolute poverty.
A single mother says she was forced to turn down a promotion and use a food bank after issues with the assessment period for the new benefit system made it “impossible to budget”.
She said: “I invested £40,000 in higher education studies so that I could become an occupational therapist and it’s great that I’ve got my degree but I have had to put my career hopes on hold because of Universal Credit.
“I had to go to a food bank and I took out an advance that I am still paying back. I took two jobs – as a PA and a waitress – which I could do without the education I invested in but which had paydays which don’t clash with my assessment period. I wanted to become free of welfare through my chosen profession but Universal Credit is holding me back from that.”
Although she had originally wanted a healthcare job, which was relevant to her degree and would move her nearer earnings that would eventually take her out of the social security system altogether, she found that the NHS and other health organisations mostly paid salaries at the end of the working month so she would face the same assessment period trap.
She left the council and initially took two part time jobs, and she now has one part time job.
Her solicitor, Carla Clarke of Child Poverty Action Group (CPAG), said: “Universal Credit is promoted as a benefit that ‘incentivises’ work but in practice its rigid assessment period system undercuts that claim.
“Our clients have been left repeatedly without money for family essentials simply because of the date of their paydays.
“One of them, for example, did her utmost to find a workaround but ultimately had to decline a promotion in a job with good prospects when her then contract came to an end just to escape the trap.
“We say that the DWP’s refusal to alter our clients’ assessment period dates to avoid this problem discriminates against working parents – one of the two groups who are entitled to a work allowance – as well as being irrational and undermining one of the stated purposes of universal credit – to make sure that ‘work always pays’.”
CPAG argues that the DWP refusal to alter Woods’ assessment period dates to avoid the problem discriminated against working parents – one of the two groups who are entitled to a work allowance – as well as being “irrational and undermining.”
Clarke added “This is a fundamental defect in Universal Credit and an injustice to hard-working parents and their children that must be put right for our clients and everyone else affected”.
Another of the women involved in the court case is paid by her employer on the last working day of each month. However, the Universal Credit assessment periods run from the last day of each month, meaning that if she is paid before the last day of the month she is assessed as having been paid twice that month.
Lawyers from the legal firm supporting Johnson at LeighDay, say: “This has resulted in her receiving fluctuating Universal Credit payments throughout the year, making it very hard to budget from one month to the next.”
They add: “It has also caused her to be around £500 worse off annually due to the fact that she is entitled to ‘work allowance’ as a parent.
“The work allowance is a disregard of £198 per month of a parent’s monthly earnings so in months where she is treated as having no earned income, she loses the whole benefit of the work allowance. In months where she is treated as having double income, she does not receive any extra work allowance.”
Legal aid for social security appeals is almost entirely gone. People adversely affected by unfair decisions are effectively being denied support in accessing justice. It’s difficult to see this as anything other than a planned and coordinated attack on people’s most basic human and democratic rights.
Universal Credit increases and extends the risk of domestic abuse
Couples who live together are required to make a single household claim for Universal Credit. Their individual entitlements are calculated—based on household income—and combined into a single payment, paid into one account only. In December 2017, 55,000 couple households, including 40,000 with dependent children, were claiming Universal Credit. Once it is fully rolled out, around 2.9 million couple households will claim it. MPs have warned that Universal Credit increases the risk of allowing domestic abusers to exert financial control over victims.
A critical report by the Work and Pensions committee in August said the way Universal Credit is paid per household means that perpetrators could too easily take control of the entire budget, leaving vulnerable women and their children dependent on an abusive partner to survive. Frank Field, Labour chair of the committee, said: “This is not the 1950s. Men and women work independently, pay taxes as individuals, and should each have an independent income.
“Not only does Universal Credit’s single household payment bear no relation to the world of work, it is out of step with modern life and turns back the clock on decades of hard-won equality for women.”
He added “The government must acknowledge the increased risk of harm to claimants living with domestic abuse it creates by breaching that basic principle, and take the necessary steps to reduce it.”
Ministers were urged by the committee to consider overhauling the system so payments are automatically split between couples, as victims face “great danger” if they request their own payments under current rules.
The report said: “Universal Credit currently only allows claims to be split between partners in ‘exceptional circumstances’.
“The DWP itself recognises the risk that requesting such an arrangement poses to survivors. The perpetrator will realise the survivor has requested the split when their own payments fall, potentially putting them in great danger.
“In light of this risk, many survivors simply will not request a split.”
The committee also suggested the main carer of children should automatically receive the whole payment, while officials explore ways to develop a split payment scheme. JobCentres must set aside private rooms for vulnerable claimants and appoint a domestic violence specialist to deal with specific claims, the report also said.
Katie Ghose, chief executive of Women’s Aid, said: “We have long been warning that Universal Credit risks making the domestic abuse worse for survivors and putting an additional barrier in the way of them escaping the abuse.
“That’s why we welcome the committee’s report and urge the government to take action to make Universal Credit safe for survivors.
“We know from our work with survivors that abusers will exploit single household payments, yet applying for a split payment can also be dangerous. If the abuser finds out that a survivor has made an application, she may be at further risk.”
Domestic abuse is hugely complex, and the training Work Coaches currently receive leaves them ill-equipped to perform this vital function. Under Universal Credit, claimants living with domestic abuse can face seeing their entire monthly income—including money meant for their children—go into their abusive partner’s account. There is no guarantee that any of the money they need to live or care for their children will reach them. That risks them remaining dependent on their abusive partner and making it much harder for them to leave, should the opportunity present itself.
Yet the Scottish Parliament has passed legislation which requires the Scottish Government to introduce split payments by default.
Universal Credit is perpetuating gender inequality – an issue that the Equality and Human Rights Commission have also raised concerns about. If money is paid into an abuser’s account, that compromises a woman’s financial autonomy. Their recent report recommends:
- offering Universal Credit as single payments to individuals rather than joint payments to avoid exacerbating financial abuse for women experiencing domestic violence
- reconsidering the ‘spare room subsidy’ regulations which discriminate against survivors of domestic abuse who have safe rooms.
But the government justifies the policy by claiming that few couples manage their finances separately. They argue that paying one benefit into a single bank account means families can make decisions about their household finances without government interference. However, this assessment ignores the realities of women trapped in controlling relationships.
Two child policy – regarding children as a commodity, and some say, eugenics by stealth
This policy restricts support through means-tested family benefits to two children only and affects the child tax credit payable for all third or subsequent children born after April 2017 and all new claims for Universal Credit, whenever they were born. In doing so, the two-child policy breaks the fundamental link between need and the provision of minimum support and implies that some children, by virtue of their birth order, are less deserving of support. It is a very large direct cut to the living standards of the poorest families of up to £2780 per child, per year.
In 2015/16 — the latest year for which data is available — 27 per cent of households with children had more than two children, representing more than 1 in 3 children in poverty (after housing costs). The risk of poverty is already 39 per cent for households (after housing costs) with three or more children compared with 26 per cent for one- and 27 per cent for two-child families. The most recent statistics reveal that during the first year of operation, 59% of the 73,500 families who lost financial support for a third child were in work. Nine per cent of UK claimant households with three or more children were affected.
A number of groups in the population are particularly likely to be hard hit by the policy, including Orthodox Jews, Pakistani and Bangladeshi families, and Roman Catholics. It will also hit large families bereaved by the loss of a parent, divorced families, and all large families falling upon hard times and needing to claim means-tested support.
Originally there were no intentions to make exceptions to the two-child policy, but the government was forced to make concessions for, among others, third and subsequent children under kinship care and those conceived as a result of rape — which in itself forces highly sensitive disclosure. A number of women’s rights and rape support organisations have raised serious concerns about the third-party evidence model for the rape/coercion exception and the risk that women claiming this exception will be exposed to further trauma and gross breaches of privacy.
The so-called rape clause has been condemned by campaigners, who say it is outrageous that a woman must account for the circumstances of her rape to qualify for support. The SNP MP Alison Thewliss called it “one of the most inhumane and barbaric policies ever to emanate from Whitehall”.
A government spokesperson said: “The policy to provide support in child tax credit and universal credit for a maximum of two children ensures people on benefits have to make the same financial choices as those supporting themselves solely through work.
The rationale for the two-child limit was to reduce the deficit by £1.36 billion per year by 2020/21. But the government also sought to justify it on the basis that they are hoping to ‘change behaviours’ — hoping to ‘encourage parents to reflect carefully on their readiness to support an additional child’. Yet, the savings to be made from the policy are quite modest in the context of the austerity cuts of £27 billion per year since 2010.
The rollout of Universal Credit will increase the number of families affected. All new claims for the benefit after February 2019 will have the child element restricted to two children in a family, even if they were born before the policy was introduced.
The government estimated 640,000 families will lose support as a direct result of the proposed changes. The Children’s Society estimate that the total loss of a child element plus the family element of child tax credit will mean that a family with three children will lose up to £3,325 per year. A family with four children will lose up to £6100. Troublingly, disabled children will also be affected by this measure on top of the major cuts in children’s disability support through Universal Credit.
Jamie Grier, the development director at the welfare advice charity Turn2us, has spoken out about mothers in low income families faced with the agonising choice of terminating wanted pregnancies already, because of their financial circumstances.
Alison Garnham, the chief executive of Child PovertyAction Group, said: “An estimated one in six UK children will be living in a family affected by the two-child limit once the policy has had its full impact. It’s a pernicious, poverty-producing policy.”
The Institute for Fiscal Studies has projected that 600,000 more children will live in absolute child poverty by 2020/21 compared with 2015/16 — all of them in families with three or more children. The absolute child poverty rate is to increase over that period from 15.1 per cent to 18.3 per cent. The two-child limit accounts for around a third of this impact. Absolute poverty is when people can’t meet one or more of their basic survival needs.
The policy is extremely likely to contravene human rights treaties to which the UK is a signatory, including those relating to women’s reproductive rights and protection from religious and gender-based discrimination contrary to Article 16 of the Convention on the Elimination of all Forms of Discrimination Against Women.
It would also discriminate against groups with a conscientious objection to contraception and abortion, or for whom large families are a central tenet of faith, in breach of Article 14 of the European Convention on Human Rights. Furthermore, it fails to give primary consideration to the best interest of the child in contravention of Article 3(1) of the UN Convention on the Rights of the Child.
The UN Committee on Economic, Social and Cultural Rights raised a specific concern about the effect of cuts to social security on the standard of living enjoyed by families with two or more children in the Concluding Observations of its recent review of the UK’s compliance with the International Covenant on Economic, Social and Cultural Rights. The policy is going to be challenged in the courts on discrimination grounds and may well reach the Supreme Court and European Court of Justice.
Context and policy intent
Universal credit is the controversal reform of the social security system, rolling together six so-called “legacy” benefits (including unemployment benefit, employment and tax credits and housing benefit) into one benefit paid monthly to claimants, to “make work pay.”
However, at a time of stagnant wages and ever-increasing living costs, the government slogan ‘making work pay’ is certainly not about a national wage increase. It’s rather more about neoliberal supply-side ideology. Supply-side policies include the promotion of greater competition in labour markets, through the removal of what are deemed ‘restrictive practices’, and labour market rigidities, such as the protection of employment and workers’ rights. For example, as part of neoliberal supply-side reforms in the 1980s, trade union powers were greatly reduced by a series of measures including limiting workers’ ability to call a strike, and by enforcing secret ballots of union members prior to strike action. More recently the Conservatives have again made substantial legislative changes that undermine the role of trade unions.
Deregulation and privatisation of state industry and services are also components of supply-side economics. Supply-side measures have a negative effect on the distribution of income. For example, lower taxes rates for the wealthiest, lower wages for workers, reduced union power, and privatisation have all contributed to a widening of the gap between rich and poor citizens. Universal Credit facilitates a supply-side labour market, it coerces people into accepting low paid, insecure work. Any work.
People claiming Universal Credit do not get a say in the kind of work they take on. If people don’t comply with Universal Credit conditionality they are generally sanctioned. This entails a loss of welfare support for between four weeks and up to a maximum of three years for refusing to take a job or prescribed community work.
Some economists argue that a lack of bargaining power because union membership has been in long term decline – is leading to fewer widespread agreements on earnings increases, which has served to keep wages stagnant. A lack of employee confidence and certainty following the recession and fears, then, over job losses has also led to fewer demands for rises.
Given that collective bargaining has been politically undermined, it is particularly outrageous that the government has introduced sanctions for those on low pay and in work, for a failure to single handedly negotiate better pay or an increase in working hours with their employer.
Perhaps we should ask “making work pay” for whom?
It’s interesting that the government have outlined what Universal Credit means for employers, indicating the intent behind the policy is not about mitigating poverty. It’s about employers “having access to a more flexible and responsive workforce, which can help your business with the challenges of filling vacancies.
“Universal Credit payments automatically adjust each month based on the real time PAYE information you report to HMRC, so it’s important that you report this information accurately and on time.”
The ‘business friendly’ government says “Universal Credit increases the financial incentive of work and provides employers like you with a more flexible workforce.”
So while employers are promised a workforce that will accept more, in terms of conditions, rates of pay and job security, the same workforce is being set up to fail when trying to negotiate more pay and longer hours by the government’s ‘business friendly’ deregulation. And failure can mean facing having their Universal Credit cut via sanctions.
It does go on to say on the site that “Jobcentre Plus work coaches will encourage claimants to discuss with their employers how they can increase their chances of earning more. This could be by improving their skills which may help them to take on more responsibilities. You may find your employees asking for more hours or for help with building their skills. You can play a role in this – helping your business become more productive.”
So, employers “can” but workers “must”, despite the substantial imbalance of power, made worse by the fact that workers are being coerced into “flexibility”. That invariably means lowering their expectations of employers and of the conditions of their employment.
The publicly stated aim of Universal Credit, for which there was orginally general support across the political divide, was to simplify the welfare system, making it more “efficient” and easy to access at a single claim point. Despite these claims, many have complained that Universal Credit is bafflingly complex, unreliable and difficult to manage, particularly if you are without internet access, and that Universal Credit staff are often poorly trained. The combination of these problems is leaving people in precarious and very vulnerable circumstances.
For families and lone parents in particular, there are barriers to taking short term low paid work, as continuity of income and availability of childcare are key priorities for parents.
The Conservatives have also claimed that the new benefit will provide incentives for people to work rather than stay on benefits. Perhaps it’s worth noting that only 34% of people claiming state welfare are of working age, the majority – 66% – are people of pension age.
The government say “It is intended that by introducing a single in-work and out-of-work benefit, previous barriers to employment such as taking up temporary employment or fewer hours are removed, therefore making it easier for claimants to take up any work and changing claimant perceptions of work and welfare, and their employment behaviours, at an individual and household level.”
The Conservatives go on to claim that employment levels are at a record high, because Universal Credit is “working”. Some 80% of men are in work, the joint highest employment rate since 1991. And over 70% of women are in work, the highest employment rate since records began in 1971. But that increase is down, partly, to state pension age changes which mean fewer women are retiring between the ages of 60 and 65.
However, as I have indicated, the structure of the employment market also matters. Zero hours contracts and hyper-flexible employment might be welcomed by some for the options they offer, but they work against collective bargaining agreements on earnings, keeping wages low. And low wages, not lack of incentives, are the reason why people need welfare support. The trade union wage gap, the difference in earnings of union members compared with non-members, is 16.9% in the public sector and 7.1% in the private sector (which employs well over 80% of people). There cannot be any genuine economic ‘bounce back’ until the UK’s decade-long stagnation in wages ends.
Universal Credit was supposedly intended as a payment to help people with living costs. It’s for those on a low income or out of work. As of February this year, the number of people on Universal Credit was 770 thousand. Of these people 300 thousand were in employment. The intention embedded in the design of Universal Credit to force up to a million low-paid workers to seek more hours or move to higher-paid jobs, under threat of financial sanctions (in-work conditionality), is another ticking bomb.
It is being introduced in stages across the country. People claiming Universal Credit receive a single monthly household payment, paid into a bank account in the same way as a monthly salary; support with housing costs will usually go direct to the person claiming as part of their monthly payment.
People will usually make a claim for Universal Credit online, during which initial claim verification will take place. This entails people providing evidence of their identity. However, there have been some problems highighted with the government’s verification framework.
MP for Liverpool Walton, Dan Carden, called on the Department of Work and Pensions (DWP) to postpone the roll-out of Universal Credit in his constituency until after Christmas and highlighted an issue with people having to pay out for a driving licence as one of many administrative problems with the new system.
In a letter to the secretary of state, Amber Rudd MP, Carden said: “We have families experiencing poverty on an unprecedented scale and now facing further avoidable hardship in the run up to Christmas.
“I have now been informed that job centres across Liverpool are advancing payments to my constituents to obtain provisional driving licences for the purposes of identification and then deducting the cost from their benefits.
“Constituents are also having to pay for postal orders, passport photographs and postage, just to obtain provisional licences.”
He explained that the DVLA says there is a five-week wait for provisional licences, and highlighted the delays before the first payments are made when someone is transferred on to Universal Credit.
The controversial benefit is being rolled out in many parts of Liverpool this week. Carden added: “Continuing with this roll-out will leave many of the most vulnerable families in Liverpool Walton destitute by Christmas and I am therefore asking you to intervene as a matter of urgency.”
Rudd’s response was to say Carden was ‘scaremongering’, and she denied that ID was needed to claim Universal Credit. However, it seems she failed to bother checking her own government’s web site for advice and evidence. The site which outlines how to claim Universal Credit completely contradicts Rudd’s claims, it says on the government’s site:
When people apply for Universal Credit they are asked to verify their identity online via the GOV.Verify service.
To do so, you need either;
- A valid UK driving license
- A valid UK passport.
On the government document it says “Universal Credit cannot be paid to a claimant whose identity has not been verified. Failure to provide identity documentation means that there is no valid claim.”
Of course this creates significant problems for those without the required documents. Their Universal Credit claim cannot go ‘live’ without conforming to the ID verification framework. People generally can’t get an advance because their claim isn’t live. Once they’ve received their new ID document, (takes around 6-8 weeks usually), it’s then a further 5 weeks (at least) until their first Universal Credit payment. That’s a very long time to go without support that is intended to meet people’s most basic living needs: food, fuel and shelter.
According to the government web site, you can only apply for an advance on your first payment if you have already verified your identity. It says:
You can apply for an advance payment in your online account or through your Jobcentre Plus work coach.
You’ll need to:
- explain why you need an advance
- verify your identity (you do this online when you submit your Universal Credit claim or at your first Jobcentre Plus interview)
- provide bank account details for the advance (talk to your work coach if you cannot open an account.)
The claim date is the date that a claimant completes this process and submits their claim. After making a claim, an initial interview will take place with the claimant, where the eligibility for Universal Credit will be confirmed and the claimant will accept a Claimant Commitment. Failure to comply with the Commitment without ‘good reason’ will result in a sanction. What constitutes a ‘good reason’ unfortunately varies from area to area and even among advisors in the same building. One of the many criticisms of welfare sanctions is how arbitrary they are. Universal Credit is a far stricter regime than the previous ones, and indications are that people are being sanctioned more frequently.
The Universal Credit project was passed through legislation in 2011 under the patronage of its loudest champion, former secretary of state for work and pensions Iain Duncan Smith. The plan was to roll it out across the UK by 2017. However, a series of management failures, expensive IT blunders and design faults mean it has fallen at least five years behind schedule.
Under the current schedule it will be fully implemented to include about 7 million claimants by 2022-23, when it is estimated that it will account for around £63bn of spending. A substantial proportion of that is due to administration blunders. Earlier this year, the National Audit Office said “The benefits that it set out to achieve through Universal Credit, such as increased employment and lower administration costs, are unlikely to be achieved.”
The administrative cost of every Universal Credit claim is an eye-watering £699 per case against an ultimate target of just £173, others in the field are calling to stop this utter shambles now and reconsider all options.
The Department is seriously criticised for “a lack of regard in failing to understand the hardship faced by some claimants”. Forget normal Whitehall tact, here are eight years of unrelenting failure, ploughing on despite alarms as costs rose to £2bn. One of the most urgent needs is to restore the £23bn that George Osborne cut from the budget, which is due to cause a record 37% of children in poverty by 2022, according to the Institute for Fiscal Studies. That’s likely to be a conservative estimate.
Despite a few minor changes, such as shortening the waiting period by a week, huge underlying problems remain with Universal Credit. Multibillion-pound cuts to work allowances imposed by the former chancellor have left it hollowed out. According to the Resolution Foundation thinktank, Universal Credit will leave about 2.5 million low-income working households more than £1,000 a year worse off. Reversing those cuts requires a political decision, not more tinkering around the edges and technical fixes.
Universal Credit is paid monthly, in arrears, so people have to wait one calendar month from the date they submitted their application before their first UC payment is made. This is called the assessment period. People then have to wait up to seven days for the payment to reach your bank account. That is of course providing everything goes right.
So far, the ‘customer’ experience of Universal Credit for too many people (and other stakeholders, such as landlords) has been utterly dismal. Critics argue that Treasury cuts to the benefit mean it is now far less likely to incentivise people to move into work, or to work more hours – what the Conservatives call ‘in-work progression’. As a result of cuts, Universal Credit is significantly less generous than originally intended, leaving many claimants worse off when they move on to it than they were while claiming legacy benefits. Added to that are design flaws and administrative glitches that put poorer claimants especially at heightened risk of hunger, debt and rent arrears, ill-health and homelessness.
Their report is intended to help the Council and partners to further develop the approach to supporting those affected by current and future welfare reforms.
It builds on Sheffield Hallam University research published in March 2016 which suggested that welfare reforms have cost the city’s economy the equivalent of £157M per year, set to rise to £292M per year by 2020. Liverpool City Council has had a 58% cut in central government funding since 2010 and has to find another £90M in savings by 2020, is having to use around £7M of those reduced funds to help with rent top ups and crisis payments.
Liverpool Food People are part of a food insecurity sub group that reports into The Mayoral Action Group on Fairness and Tackling Poverty – food has been identified as one of the basic needs – and a recommendation within the report is that action to address food poverty and fuel poverty is coordinated across the city and that research is carried out on the level of food insecurity (both moderate and severe) across the city.
New research conducted for Gateshead council concludes that Universal credit has become a serious threat to public health after the study revealed that the stress of coping with the new benefits system had so profoundly affected peoples’ mental health that some considered suicide.
The researchers found overwhelmingly negative experiences among vulnerable citizens claiming Universal Credit, including high levels of anxiety and depression, as well as physical problems and social isolation, all of which was exacerbated by hunger and destitution.
The Gateshead study comes as the United Nation’s special rapporteur on extreme poverty and human rights, Philip Alston, prepares to publish a report of the impact of Conservative austerity in the UK. Alston has been collecting evidence and testimonies on the effects of the welfare reforms, council funding cuts, and Universal Credit during a two-week visit of the UK.
This research is highly likely to raise fresh calls for the system’s rollout to be halted, or at the very least, paused to attempt to fix the fundamental design flaws and ensure adequate protections are in place for the most vulnerable people claiming it.
Approximately 750,000 chronically ill and disabled claimants are expected to transfer on to Universal Credit from 2019. Yet earlier this year, the first legal challenge against Universal Credit found that the government unlawfully discriminated against two men with severe disabilities who were required to claim the new benefit after moving into new local authority areas. Both saw their benefits dramatically reduced when they moved to a different Local Authority and were required to claim Universal Credit instead of Employment and Support Allowance.
The study findings are yet another indication of how unfit for purpose Universal Credit is. Six of the participants in the study reported that claiming Universal Credit had made them so depressed that they considered taking their own lives. The lead researcher, Mandy Cheetham, said the participant interviews were so distressing she undertook a suicide prevention course midway through the study.
The report says: “Universal Credit is not only failing to achieve its stated aim of moving people into employment, it is punishing people to such an extent that the mental health and wellbeing of claimants, their families and of [support] staff is being undermined.”
One participant told the researchers: “When you feel like ‘I can’t feed myself, I can’t pay my electric bill, I can’t pay my rent,’ well, all you can feel is the world collapsing around you. It does a lot of damage, physically and mentally … there were points where I did think about ending my life.”
An armed forces veteran said that helplessness and despair over Universal Credit had triggered insomnia and depression, for which he was taking medication. “Universal Credit was the straw that broke the camel’s back. It really did sort of drag me to a low position where I don’t want to be sort of thrown into again.”
Unsurprisingly, the report concludes that Universal Credit is actively creating poverty and destitution, and says it is not fit for purpose for many people with disabilities, mental illness or chronic health conditions. It calls for a radical overhaul of the system before the next phase of its rollout next year.
Alice Wiseman, the director of public health at Gateshead council, which commissioned the study, said: “I consider Universal Credit, in the context of wider austerity, as a threat to the public’s health.” She said many of her public health colleagues around the country shared her concerns.
Wiseman said that Universal Credit is “seriously undermining” efforts to prevent ill-health in one of the UK’s most deprived areas.
She added “This is not political, this is about the lives of vulnerable people in Gateshead. They are a group that should be protected but they haven’t been.”
The qualitative study focused on those claimants with disabilities, mental illness and long-term health conditions, as well as homeless people, veterans and care leavers.
The respondents found that compared to the legacy benefits, Universal Credit is less accessible, remote, inflexible, demeaning and intrusive. It was less sensitive to claimants’ health and personal circumstances, the researchers said. This heightened peoples’ anxiety, sense of shame, guilt, and feelings of loss of dignity and control.
The Universal Credit system itself was described by those claiming it as dysfunctional and prone to administrative error. People experienced the system as “hostile, punitive and difficult to navigate,” and struggled to cope with payment delays that left them in debt, unable to eat regularly, and reliant on food banks.
The government claimed that people making a new claim are expected to wait five weeks for a first payment. That’s a long time to wait with no money for basic living requirements. However, the average wait for participants on the study was seven and a half weeks, with some waiting as long as three months. Researchers were told of respondents who were so desperate and broke they turned to begging or shoplifting.
Wiseman made a point that many campaigners have made, and said that alongside the human costs, Universal Credit was placing extra burdens on NHS and social care, as well as charities such as food banks. It also affected the wellbeing of advice staff, who reported high stress levels and burnout from dealing with the fallout on those claiming the benefit.
Guy Pilkington, a GP in Newcastle said that the benefits system had always been tough, but under Universal Credit, those claiming faced a higher risk of destitution.
“For me the biggest [change] is the ease with which claimants can fall into a Victorian-style system that allows you to starve. That’s really shocking, and that’s new,” he said.
A spokesperson for the Department for Work and Pensions (DWP) said: “This survey of 33 claimants doesn’t match the broader experience of more than 9,000 people receiving Universal Credit in Gateshead, who are taking advantage of its flexibility and personalised support to find work.”
“We have just announced a £4.5bn package of support so people can earn £1,000 more before their credit payment begins to be reduced, and we are providing an additional two weeks’ payments for people being moved from the old system.”
That will still leave people with nothing to live on or to cover their rent for at least three weeks. The study focused on those less likely to be able to work – people with disabilities, mental illness or chronic health conditions. The DWP failed to recognise that this group have different needs and experiences than the broader population, which leave them much more likely to become vulnerable when they cannot meet their needs.
Vulnerable people are suffering great harm and some are dying because of this government’s policies. It is not appropriate to attempt to compare those peoples’ experiences with some larger group who have not died or have not yet experienced those harms. Where is the empirical evidence of these claims, anyway? Where is the DWP’s study report?
Callousness and indifference to the suffering and needs of disadvantaged citizens – disadvantaged because of discriminatory policies – has become so normalised to this government that they no longer see or care how utterly repugnant and dangerous it is.
The DWP are not ‘providing’ anything. Social security is a publicly funded safety net, paid for by the public FOR the public. It’s a reasonable expectation that citizens, most of who have worked and contributed towards welfare provision, should be able to access a system of support when they experience difficulties – that is what social security was designed to provide, so that no one in the UK need to face absolute poverty. It’s supposed to be there so that everyone can meet their basic survival needs.
What people in their time of need find instead is a system that has been redesigned to administer punishments, shame and psychological abuse. What kind of government kicks people hard when they are already down?
Universal Credit was considered the antidote for the Conservative’s ‘welfare dependency’ myth, yet there has never been any empirical evidence to support their claims of the existence of a ‘culture of dependency’ and that’s despite the dogged research conducted by Keith Joseph some years ago, when he made similar claims. He never found any evidence despite trying very hard. Most people move in and out of work, because jobs have become increasingly precarious over the last few years.
In fact over recent years, an international study of social safety nets from The Massachusetts Institute of Technology (MIT) and Harvard economists categorically refutes the Conservative ‘scrounger’ stereotype and dependency rhetoric. Gabriel Kreindler, Benjamin Olken and colleagues re-analyzed data from seven randomized experiments evaluating cash programs in poor countries and found “no systematic evidence that cash transfer programmes discourage work.”
The phrase ‘welfare dependency’ diverts us from political class discrimination via policies, increasing inequality, and it serves to disperse public sympathies towards the poorest citizens, normalising the inequality and prejudice embedded in neoliberal ideology and resetting social norm defaults that then permit the state to target protected social groups for further punitive and cost-cutting interventions to ‘incentivise’ them towards ‘behavioural change.’ Outrageously, the behavioural change required by the state is that the public do not use publicly funded welfare services.
Stepping back from this, it becomes clear that the policy driver is ‘small state’, antiwelfarist neoliberal ideology. This is being propped up by pseudoscientific behavioural economic rationalisations.
There is mounting evidence, according to local authority researchers in Liverpool, for example, that shows the actual effect is the reverse of what was claimed was intended; Universal Credit is harming the very people it was designed to support. It is forcing households into debt, causing severe poverty including to those in work, leaving too many people, including children, facing food insecurity, destitution and eviction. Liverpool council’s welfare reform cumulative impact analysis last year shows that the groups most adversely affected by the Government’s raft of ‘welfare reforms’ are the long-term sick and disabled, families with children, women, young adults and the 40-59 age group who live in social housing.
Many working households are suffering a shortfall in Housing Benefit, Housing Allowance and a reduction and removal of many other benefits, all set against the backdrop of ever increasing living costs. Poverty disincentives people.
In recent years welfare conditionality has become conflated with severe financial penalities (sanctions), and has mutated into an ever more stringent, complex, demanding set of often arbitrary requirements, involving frequent and rigid jobcentre appointments, meeting job application targets, providing evidence of job searches and mandatory participation in workfare schemes. The emphasis of welfare provision has shifted from providing support for people seeking employment to increasing conditionality of conduct, enforcing particular patterns of behaviour and monitoring citizen compliance.
Government Statistics tell us that more people get sanctioned under Universal Credit than under the existing legacy benefits system.
Sanctions are “penalties that reduce or terminate welfare payments in cases where claimants are deemed to be out of compliance with requirements.” They are, in many respects, the neoliberal-paternalist tool of discipline par excellence – the threat that puts a big stick behind coercive welfare programme rules and “incentivises” citizen compliance with a heavily monitoring and supervisory administration. The Conservatives have broadened the scope of behaviours that are subject to sanction, and have widened the application to include previously protected social groups, such as sick and disabled people and lone parents.
There is plenty of evidence that sanctions don’t help people to find work, and that the punitive application of severe financial penalities is having a detrimental and sometimes catastrophic impact on people’s lives. We can see from a growing body of research how sanctions are not working in the way the government claim they intended.
Sanctions, under which people lose benefit payments for between four weeks and three years for “non-compliance”, have come under fire for being unfair, punitive, failing to increase job prospects, and causing hunger, debt and ill-health among jobseekers. And sometimes, even causing death.
However, if people are already needing to claim financial assistance which was designed to meet only very basic needs, such as provision for food, fuel and shelter, then imposing further financial penalities will simply reduce those people to a struggle for basic survival, which will inevitably demotivate them and stifle their potential.
The current government demand an empirical rigour from those presenting criticism of their policy, yet they curiously fail in meeting the same exacting standards that they demand of others. Often, the claim that “no causal link has been established” is used as a way of ensuring that established correlative relationships, (which often do imply causality,) are not investigated further.
Qualitative evidence – case studies, for example – is very often rather undemocratically dismissed as ‘anecdotal,’ or as ‘scaremongering’ which of course stifles further opportunities for research and inquiry.
The Conservative shift in emphasis from structural to psychological explanations of poverty has far-reaching consequences. The partisan reconceptualision of poverty makes it much harder to define and very difficult to measure. Such a conceptual change disconnects poverty from more than a century of detailed empirical and theoretical research, and we are witnessing an increasingly experimental approach to policy-making, aimed at changing the behaviour of individuals, without their consent.
This approach isolates citizens from the broader structural political, economic, sociocultural and reciprocal contexts that invariably influence and shape an individuals’s experiences, meanings, motivations, behaviours and attitudes, causing a problematic duality between context and cognition. It places unfair and unreasonable responsibility on citizens for circumstances which lie outside of their control, such as the socioeconomic consequences of political decision-making.
I want to discuss two further considerations to add to the growing criticism of the extended use of sanctioning, which are related to why sanctions don’t work. One is that imposing such severe financial penalities on people who need social security support to meet their basic needs cannot possibly bring about positive “behaviour change” or incentivise people to find employment, as claimed. This is because of the evidenced and documented broad-ranging negative impacts of financial insecurity and deprivation – particularly food poverty – on human physical health, motivation, behaviour and mental states.
The second related consideration is that “behavioural theories” on which the government rests the case for extending and increasing benefit sanctions are simply inadequate and flawed, having been imported from a limited behavioural economics model (otherwise known as nudge” and libertarian paternalism) which is itself ideologically premised.
Sanctions and workfare arose from and were justified by nudge theory, which is now institutionalised and deeply embedded in Conservative policy-making. Sanctions entail the manipulation of a specific theoretical cognitive bias called loss aversion.
At best, the new “behavioural theories” are merely theoretical propositions, at a broadly experimental stage, and therefore profoundly limited in terms of scope and academic rigour, as a mechanism of explanation, and in terms of capacity for generating comprehensive, coherent accounts and understanding about human motivation and behaviour.
I reviewed research and explored existing empirical evidence regarding the negative impacts of food poverty on physical health, motivation and mental health. In particular, I focussed on the Minnesota Semistarvation Experiment and linked the study findings with Abraham Maslow’s central idea about cognitive priority, which is embedded in the iconic hierarchy of needs pyramid. Maslow’s central proposition is verified by empirical evidence from the Minnesota Experiment.
The Minnesota Experiment explored the physical impacts of hunger in depth, but also studied the effects on attitude, cognitive and social functioning and the behaviour patterns of those who have experienced semistarvation. The experiment highlighted a marked loss of ambition, self-discipline, motivation and willpower amongst the subjects once food deprivation commenced. There was a marked flattening of affect, and in the absence of other emotions, Doctor Ancel Keys observed the resignation and submission that continual hunger manifests.
The understanding that food deprivation dramatically alters emotions, motivation, personality and that nutrition directly and predictably affects the mind as well as the body is one of the legacies of the experiment.
The experiment highlighted very clearly that there’s a striking sense of immediacy and fixation that arises when there are barriers to fulfiling basic physical needs – human motivation is frozen to meet survival needs, which take precedence over all other needs. This is observed and reflected in both the researcher’s and the subject’s accounts throughout the study. If a person is starving, the desire to obtain food will trump all other goals and dominate the person’s thought processes.
In a nutshell, this means that if people can’t meet their basic survival needs, it is extremely unlikely that they will have either the capability or motivation to meet higher level psychosocial needs, including social obligations and responsibilities to seek work. Abraham Maslow’s humanist account of motivation also highlights the same connection between fundamental motives and immediate situational threats.
Ancel Keys published a full report about the experiment in 1950. It was a substantial two-volume work titled The Biology of Human Starvation. To this day, it remains the most comprehensive scientific examination of the physical and psychological effects of hunger.
Keys emphasised the dramatic effect that semistarvation has on motivation, mental attitude and personality, and he concluded that democracy and nation building would not be possible in a population that did not have access to sufficient food.
I also explored the link between deprivation and an increased risk of mental illnesses, including schizophrenia, depression, anxiety and substance addiction. Poverty can act as both a causal factor (e.g. stress resulting from poverty triggering depression) and a consequence of mental illness (e.g. schizophrenic symptoms leading to decreased socioeconomic status and prospects).
Poverty is a significant risk factor in a wide range of psychological illnesses. Researchers recently reviewed evidence for the effects of socioeconomic status on three categories: schizophrenia, mood and anxiety disorders and substance abuse. Whilst not a comprehensive list of conditions associated with poverty, the issues raised in these three areas can be generalised, and have clear relevance for policy-makers.
The researchers concluded: “Fundamentally, poverty is an economic issue, not a psychological one. Understanding the psychological processes associated with poverty can improve the efficacy of economically focused reform, but is not a panacea. The proposals suggested here would supplement a focused economic strategy aimed at reducing poverty.” (Source: A review of psychological research into the causes and consequences of poverty – Ben Fell, Miles Hewstone, 2015.)
There is no evidence that keeping benefits at below subsistence level or imposing punitive sanctions ‘incentivises’ people to work and research indicates it is likely to have the opposite effect.
Food banks have reported that demand for charity food goes up significantly when Universal Credit is introduced into the local area.
The Trussell Trust has expressed concern that, given the links between Universal Credit, financial hardship, and foodbank use, the next stage of the roll out could lead to further increased financial need and more demand for foodbanks. Their report uses referral data from Trussell Trust foodbank vouchers to examine the impact of Universal Credit on foodbank use. Their key findings were:
- On average, 12 months after rollout, foodbanks see at least a 52% increase in demand, compared to 13% in areas with Universal Credit for 3 months or less. This increase cannot be attributed to randomness and exists even after accounting for seasonal and other variations.
- Benefit transitions, most likely due to people moving onto Universal Credit, are increasingly accounting for more referrals and are likely driving up need in areas of full Universal Credit rollout. Waiting for the first payment is a key cause, while for many, simply the act of moving over to a new system is causing serious hardship.
The Trussell Trust says that poor administration, the long wait for the first payment, and repayments for loans and debts are driving some people into severe financial need. This is particularly acute for families with dependent children and disabled people.
Ministers still claim that evidence from early official trials shows people claiming Universal Credit were more likely to get a job. However, the Office for Budgetary Responsibility (OBR) has said there remains insufficient evidence for this claim. Other researchers have found that the low benefit amounts coupled with rigid conditionality and sanctions profoundly disincentivise people to find work or progress in work. Evidence supports the latter proposition.
But the government simply responds by labelling researchers and campaigners as ‘scaremongers’ and continues to deny the well-evidenced and documented experiences of citizens which demonstrate that Universal Credit is harmful, creating distress and entrenching inequality and absolute poverty.
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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 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 adversity, using 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.
The Extraction of the Stone of Madness by Hieronymus Bosch, from 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
- Dry mouth
- Blurred vision
- Low blood pressure
- 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
- 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.
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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“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.
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
“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 harm, hardship 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.
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.
<=== You are here
Sherry Arnstein’s Ladder of Citizen Participation and Power
I’m currently writing a longer and more in-depth critique of behavioural economics, which will be published very soon.
I don’t make any money from my work. I am disabled because of illness and have a very limited income. But you can help by making a donation to help me continue to research and write informative, insightful and independent articles, and to provide support to others. The smallest amount is much appreciated – thank you.
Arnstein’s ladder of citizen participation and inclusion. It represents the redistribution of power that enables marginalised citizens, presently excluded from the political and economic processes, to be purposefully included in the future.
The government’s Work and Health Programme, due to be rolled out this autumn, involves a plan to integrate health and employment services, aligning the outcome frameworks of health services, Improving Access to Psychological Therapies (IAPT), Jobcentre Plus and the Work Programme.
But the government’s aim to prompt public services and commissioned providers to “speak with one voice” is founded on traditional Conservative prejudices about people who need support. This proposed multi-agency approach is reductive, rather than being about formulating expansive, coherent, comprehensive and importantly, responsive mental health provision.
What’s on offer is psychopolitics, not therapy. It’s about (re)defining the experience and reality of a marginalised social group to justify dismantling public services (especially welfare). In linking receipt of welfare with health services and state therapy, with the single politically intended outcome of employment, the government is purposefully conflating citizens’ widely varied needs with economic outcomes and diktats, which will isolate people from traditionally non-partisan networks of unconditional support, such as the health service, social services, community services and mental health services.
Services “speaking with one voice” will invariably make accessing support conditional, and further isolate marginalised social groups. It will damage trust between people needing support and professionals who are meant to deliver essential public services, rather than simply extending government dogma, prejudices and discrimination. And meeting ideologically designed targets.
As neoliberals, the Conservatives see the state as a means to reshape social institutions and social relationships hierarchically, based on a 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 and modified. Social groups that don’t conform to ideologically defined economic outcomes and politically defined norms are stigmatised and outgrouped.
Othering and outgrouping have become common political practices, it seems.
The Work and Health Programme is a welfare-to-work programme for people with disabilities, mental health problems and for long-term unemployed people, due to be rolled out in the autumn. In the recent Work, Health and Disability green paper, the government mentioned new mandatory “health and work conversations” in which work coaches will use “specially designed techniques” to “help” those people in the ESA Support Group – those assessed by their own doctors and the state as being unlikely to work in the near future – “identify their health and work goals, draw out their strengths, make realistic plans, and build resilience and motivation.”
Apparently these “conversations” were “co-designed” by the Behavioural Insights Team.
Democracy is based on a process of dialogue between the public and government, ensuring that the public are represented: that governments are responsive, shaping policies that address identified social needs.
However, policies increasingly reflect a behaviourist turn. They are no longer about reflecting citizens’ needs: they are increasingly about telling some citizens how to be. This has some profound implications for democracy.
Neoliberal policies increasingly extend 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”.
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.
“There’s no reason to think that markets always drive people to what’s good for them.” Richard Thaler.
There’s no reason whatsoever to think that markets are good for people at all. Let’s not confuse economics with psychology, or competitive individualism and economic Darwinism with collectivism and mutual aid. Behavioural economics may offer us titbit theories explaining individual consumer’s decision making, but it’s been rather unreliable in explaining socioeconomic and political contexts and complex systems such as financial crises, and of course behavioual economists don’t feel the same pressing need to explore the decision making and “cognitive bias” of the handful of people who cause those.
It wasn’t those with mental health problems currently claiming social security. They do much less damage to the economy, in fact IAPT means vulture capitalist private companies like G4S and trusts like Southern Care can turn a profit offering “support”.
The current emphasis on quantitative methodology and standardisation has led to an overwhelming focus on measurement in IAPT settings. Mental health services are now dominated by IAPT, which focuses exclusively on “evidence-based” and short-term interventions for clients with particular diagnoses – mostly anxiety disorders and depression. Most workers in IAPT services offer CBT, often by minimally trained psychological wellbeing practitioners offering “low-intensity” interventions over few sessions.
Verificationism and standardisation leads to a focus on measurement in IAPT settings. CBT mutes the causes of distress, which do not reside “within” the individual: they are intersubjectively constructed, with cultural, socioeconomic and political dimensions. Furthermore, there is little room left for authentic dialogue – qualitative accounts of client’s experiences are not accommodated. In this context, CBT is authoritarian, rather than being prefigurative and genuinely dialogic.
Under the government’s plans, therapists from the IAPT programme are to support jobcentre staff to assess and treat claimants, who may be referred to online cognitive behavioural therapy (CBT) courses.
We 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 – it amounts to little more than a blunt behaviour modification programme. The fact that the Conservatives have planned to make receipt of benefits contingent on participation in “treatment” also worryingly takes away the fundamental right of consent.
CBT facilitates the identification of “negative thinking patterns” and associated “problematic behaviours” and “challenges” them. This approach is at first glance a problem-solving approach, however, it’s of course premised on the assumption that interpreting situations “negatively” is a bad thing, and that thinking positively about bad events is beneficial.
The onus is on the individual to adapt by perceiving their circumstances in a stoical and purely “rational” way.
So we need to ask what are the circumstances that we expect people to accept stoically. Socioeconomic inequality? Precarity? Absolute poverty? Sanctions? Work fare? Being forced to accept very poorly paid work, abysmal working conditions and no security? The loss of social support, public services and essential safety nets? Starvation and destitution?
It’s all very well challenging people’s thoughts but for whom is CBT being used. For what purpose? It seems to me that this is about coercing those people on the wrong side of draconian government policy to accommodate that; to mute negative responses to negative situations. CBT in this context is not based on a genuinely liberational approach, nor is it based on democratic dialogue. It’s about modifying and controlling behaviour, particularly when it’s aimed at such narrow, politically defined and specific economic outcomes, which extend and perpetuate inequality. In this context, CBT becomes state “therapy” used only as an ideological prop for neoliberalism.
CBT tends to generate oversimplifications of the causes human distress. It’s not about helping people make better choices, it’s about coercing people to make the choices that policymakers want them to make. Those “choices” are based on enforced conformity to the ideological commitments of policymakers.
It’s assumed that the causes of unemployment are personal and attitudinal rather than sociopolitical or because of health barriers, and that particular assumption authorises intrusive state interventions that encode a Conservative moral framework, which places responsibility on the individual, who is characterised as “faulty” in some way. The deeply flawed political/economic system that entrenches inequality isn’t challenged at all: its victims are discredited and stigmatised instead.
Yet historically (and empirically), it has been widely accepted that poverty significantly increases the risk of mental health problems and can be both a causal factor and a consequence of mental ill health. Mental health is shaped by the wide-ranging characteristics and circumstances (including inequalities) of the social, economic 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 engagement with this complexity.
There is also widely held assumption that working is good for mental health, and that being in employment indicates mental wellbeing. It’s well-established that poverty is strongly linked with a higher likelihood of being diagnosed with a mental illness. That does not mean working is therefore somehow “good” for mental health. Encouraging people to work should entail genuine support, it shouldn’t entail taking away their lifeline income as
punishment “incentive” if they can’t work.
An adequate level of social security to meet people’s basic survival needs is not mutually exclusive from encouraging people to find a suitable job.
It’s worth noting that research indicates in countries with an adequate social safety net, poor employment (low pay, short-term contracts), rather than “worklessness”, has the biggest detrimental impact on mental health.
CBT does not address the socioeconomic and political context. It permits society to look the other way, whilst the government continue to present mental illness as an individual weakness or vulnerability, and a consequence of “worklessness” rather than a fairly predictable result of living a distressing, stigmatised, excluded existence and material deprivation in an increasingly unequal society.
Inequality and poverty arise because of ideology and policy-formulated socioeconomic circumstances, but the government have transformed established explanations into a project of constructing behavioural and cognitive problems as “medical diagnoses” for politically created socioeconomic problems. Austerity targets the poorest disproportionately for cuts to income and essential services, it’s one ideologically-driven political decision taken amongst alternative, effective and more humane choices.
Both nudge and CBT are being used to prop up austerity and reflect neoliberal managementspeak at its very worst. Neoliberal policies are causing profound damage, harm and distress to those they were never actually designed to “help”. Let’s not permit techniques of neutralisation: the use of rhetoric to obscure the real intention behind policies. It’s nothing less than political gaslighting.
The government’s profound antiwelfarist rhetoric indicates that there’s no genuine intention to support those people with mental health problems and others in need, despite their semantic thrifts and diversions.
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, all citizen’s 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, partly because the government employs the widespread use of linguistic strategies and techniques of persuasion to intentionally divert us from the aims and consequences of their ideologically driven and increasingly dehumanising policies. Furthermore, policies have become increasingly detached from public interests and needs.
For people with mental health problems, 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.
It’s the government that need to change their behaviour.
It’s us that need to make a stand against hegemonic neoliberal discourse and injustice.
This article was written for a zine to mark the protest at the 10th annual New Savoy conference on 15 March in London #newsavoy2017. You can read the zine, with other people’s excellent contributions, here.
You can read about the background to the Mental Wealth Alliance and the New Savoy demo and lobby here.
You can watch the video here from Let Me Look TV: Protest at the 10th Annual New Savoy Conference 15 March 2017.
I don’t make any money from my work. I am disabled because of illness and have a very limited income. The budget didn’t do me any favours at all.
But you can help by making a donation to help me continue to research and write informative, insightful and independent articles, and to provide support to others. The smallest amount is much appreciated – thank you.
Abbie and her late father, James Harrison.
Julia Savage is a manager at Birkenhead Benefit Centre in Liverpool. She wrote a letter addressed to a GP regarding a seriously ill patient. It said:
“We have decided your patient is capable of work from and including January 10, 2016.
“This means you do not have to give your patient more medical certificates for employment and support allowance purposes unless they appeal against this decision.
“You may need to again if their condition worsens significantly, or they have a new medical condition.”
The patient, James Harrison, had been declared “fit for work” and the letter stated that he should not get further medical certificates.
However, 10 months after the Department for Work and Pensions (DWP) contacted his doctor without telling him, James died, aged 55, the Daily Record has reported.
He was clearly not fit for work.
His grieving daughter, Abbie, said: “It’s a disgrace that managers at the Jobcentre, who know nothing about medicine, should interfere in any way in the relationship between a doctor and a patient.
“They have no place at all telling a doctor what they should or shouldn’t give a patient. It has nothing to do with them.
“When the Jobcentre starts to get involved in telling doctors about the health of their patients, that’s a really slippery slope.”
Abbie said James had worked since leaving school at a community centre near his home. But his already poor health went downhill after the centre was shut down because of austerity cuts.
James had a serious lung condition and a hernia before the centre closed, and also developed depression and anxiety afterwards.
Abbie said: “He’d worked all his life. He wasn’t the kind of guy who knew anything about benefits.
“But as his health deteriorated, there wasn’t any chance he could do a job. He applied for employment and support allowance.”
James received Employment and Support Allowance (ESA), but only at the low rate of £70 a week, the same amount as jobseekers’ allowance. He was then sent to attend one of the DWP’s controversial Work Capability Assessments – and declared fit for work.
Despite that decision, Abbie said James remained in constant need of medical help and had to visit his doctor regularly.
However, the GP concerned repeatedly refused to give him a sick note, and James began to suspect the Jobcentre were to blame for this.
Abbie said: “He really needed a note. He was too ill to go to the constant appointments at the Jobcentre and he didn’t want to be sanctioned.
“He became convinced the DWP had been talking to his doctor behind his back.”
Although Abbie felt her father was confused, and didn’t think his explanation was right at the time, she later asked to see her father’s medical records. She found the letter in his file from Julia Savage, the manager at Birkenhead Benefit Centre, in James’s home city of Liverpool.
The letter was addressed to James’s GP.
Context: Government claims that work is a “health outcome”
James Harrison was very worried that his ill health interfered with his obligation to comply with the inflexible and constant conditions attached to his eligibility for welfare support, and that this would lead to sanctions – the withdrawal of his lifeline support, which was calculated to meet basic survival needs only.
The GP should have provided evidence that this was the case. The doctor was advised not to provide further fit notes by the DWP, however, unless James appealed. Yet the circumstances warranted that the GP provide a fit note.
In the document, doctors are warned of the dangers of “worklessness” and told they must consider “the vital role that work can play in your patient’s health”. According to the department, “the evidence is clear that patients benefit from being in some kind of regular work”.
The biopsychosocial model, with a current political emphasis on the psychological element, has become a disingenuous euphemism for psychosomatic illness, which has been exploited by successive governments (and rogue insurance companies) to limit or deny access to social security, medical and social care.
Nobody would deny that illness has biological, psychological and social dimensions, however, the model has been adapted to fit a neoliberal “small state” ideology – one that rests almost entirely on Conservative individualist notions of citizen responsibility, as opposed to a rights-based approach and provision of publicly funded state support.
This approach to disability and ill health has been used by the government to purposefully question the extent to which people claiming social security bear personal responsibility for their own health status, rehabilitation and prompt return to work. It also leads to the alleged concern that a welfare system which was originally designed to provide a livable income to those with disabling health problems, may provide “perverse incentives” for perverse behaviours, entrenching “worklessness” and a “culture of dependency”. It’s worth pointing out at this point that there has never been any empirical evidence to support the Conservative notion of welfare “dependency”.
Instead of being viewed as a way of diversifying risk and supporting those who have suffered misfortune and ill health, social and private insurance systems are to be understood as perverse incentives that pay people, absurdly, to remain ill and keep them from being economically productive.
The idea that people remain ill deliberately to avoid returning to work – what Iain Duncan Smith and David Cameron have termed “the sickness benefit culture” – is not only absurd, it’s very offensive. This is a government that not only disregards the professional judgements of doctors, it also disregards the judgements of sick and disabled people. However, we have learned over the last decade that political “management” of people’s medical conditions does not make people healthier or suddenly able to work. Government policies, designed to “change behaviours” of sick and disabled people have resulted in harm, distress and sometimes, in premature deaths.
The government have made it clear that there are plans 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 DWP. 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 (and the Reform think tank) have also proposed 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 be subjected to welfare conditionality and sanctions.
Many campaigners have raised concerns about the DWP interfering with people’s medical care and accessing their medical files. I wrote an article last year about how the government plans to merge health and employment services and are now attempting to redefine work as a clinical outcome. I raised concerns about the fact that unemployment has been stigmatised and politically redefined as a psychological disorder, and that the government claims, somewhat incoherently, that the “cure” for unemployment due to illness and disability, and sickness absence from work, is work.
In a critical analysis of the recent work, health and disability green paper, I said:
“And apparently qualified doctors, the public and our entire health and welfare systems have ingrained “wrong” ideas about sickness and disability, especially doctors, who the government feels should not be responsible for issuing the Conservatives recent Orwellian “fit notes” any more, since they haven’t “worked” as intended and made every single citizen economically productive from their sick beds.
It seems likely, then, that a new “independent” assessment and some multinational private company will most likely very soon have a lucrative role to ensure the government get the “right” results.”
The medical specialists are to be replaced by another profiteering corporate giant who will enforce a political agenda in return for big bucks from the public purse. Health care specialists are seeing their roles being incrementally and systematically de-professionalised. That means more atrocious and highly irrational attempts from an increasingly authoritarian government at imposing an ideological “cure” – entailing the withdrawal of any support and imposing punitive “behavioural incentives” – on people with medical conditions and disabilities. Doctors, who are clever enough to recognise, diagnose and treat illness, are suddenly deemed by this government to be insufficiently clever to judge if patients are fit for work.
The political de-professionalisation of medicine, medical science and specialisms (consider, for example, the implications of permitting job coaches to update patient medical files), the merging of health and employment services and the recent absurd declaration that work is a clinical “health” outcome, are all carefully calculated strategies that serve as an ideological prop and add to the justification rhetoric regarding the intentional political process of dismantling publicly funded state provision, and the subsequent stealthy privatisation of Social Security and the National Health Service.
“De-medicalising” illness is also a part of that process:
“Behavioural approaches try to extinguish observed illness behaviour by withdrawal of negative reinforcements such as medication, sympathetic attention, rest, and release from duties, and to encourage healthy behaviour by positive reinforcement: ‘operant-conditioning’ using strong feedback on progress.” Gordon Waddell and Kim Burton in Concepts of rehabilitation for the management of common health problems. The Corporate Medical Group, Department for Work and Pensions, UK.
Waddell and Burton are cited frequently by the DWP as providing “evidence” that their policies are “evidence based.” Yet the DWP have selectively funded their research, which unfortunately frames and constrains the theoretical starting point, research processes and the outcomes with a heavy ideological bias.
This framing simply shifts the focus from the medical conditions that cause illness and disability to the “incentives”, behaviours and perceptions of patients and ultimately, to neoliberal notions of personal responsibility and self-sufficient citizenship in a context of a night watchman, non-welfare state.
Medication, rest, release from duties, sympathetic understanding – the remedies to illness – are being appallingly redefined as “perverse incentives” for ill health, yet the symptoms necessarily precede the prescription of medication, the Orwellian renamed (and political rather than medical) “fit note” and exemption from work duties. Notions of “rehabilitation” and medicine are being redefined as behaviour modification: here it is proposed that operant conditioning in the form of negative reinforcement – which the authors seem to have confused with punishment – will “cure” ill health.
People cannot simply be “incentivised” into not being ill.
The political use of the biopsychosocial model to cut costs at the expense of people who are ill will undoubtedly have further extremely serious implications. Such an approach, which draws on behaviourism and punishment (such as the threat and implementation of sanctions) is 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.
This is clearly the direction that government policy is moving in and this represents a serious threat to the health, welfare, wellbeing and human rights of patients and the political independence of health professionals.
I don’t make any money from my work. But you can contribute by making a donation and help me continue to research and write informative, insightful and independent articles, and to provide support to others. The smallest amount is much appreciated – thank you.
Dr Robert J. Lifton is a psychologist who studied and identified the techniques of mass persuasion and groupthink used in propaganda and in cults (from political to religious). I found his interesting article about the eight criteria for “thought reform” on the International Cultic Studies Association (ICSA) site.
What struck me immediately about Lifton’s criteria is how easily they may be applied to neoliberalism – a totalising, authoritarian New Right ideology, imposed by an elite of very financially secure and powerful oppressors. Over the last few years, much of the rest of the population in the UK have experienced growing inequality and increasingly precarious socioeconomic circumstances, exacerbated by class-contingent neoliberal austerity and “small state” policies.
The neoliberal approach to public policy has become naturalised. Political theorist Francis Fukuyama, announced in 1992 that the great ideological battles between “east and west” were over, and that western liberal democracy had triumphed. He was dubbed the “court philosopher of [post-industrial] global capitalism” by John Gray.
In his book The End of History and the Last Man, Fukuyama wrote:
“At the end of history, it is not necessary that all societies become successful liberal societies, merely that they end their ideological pretensions of representing different and higher forms of human society…..What we are witnessing, is not just the end of the cold war, or a passing of a particular period of postwar history, but the end of history as such: that is, the end point of mankind’s ideological evolution and the universalisation of western liberal democracy as the final form of human government.”
I always saw Fukuyama as an ardent champion of ultra-neoliberalism, he disguised his conservatism behind apparently benign virtue words and phrases (as part of a propaganda technique called Glittering Generalities), such as “Man’s universal right to freedom.”
He meant the same sort of self-interested “freedom” as Ayn Rand: “a free mind and a free market are corollaries.” He meant the same kind of implicit social Darwinist notions long held by Conservatives like Herbert Spencer – where the conditions of the market rather than evolution decides who is “free,” who survives, and as we know, the market is rigged by the invisible hand of government.
Fukuyama’s ideas have been absorbed culturally, and serve to normalise the dominance of the right, and stifle the rationale for critical debate. Additionally a political context has been created to pathologize the left.
Fukuyama’s work is a celebration of neoliberal hegemony. It’s an important work to discuss simply because it has been so widely and tacitly accepted, and because of that, some of the implicit, taken-for-granted assumptions and ramifications need to be made explicit.
Neoliberalism requires an authoritarian approach to public administration. Rather than an elected government recognising and meeting public needs, instead, we now have a government manipulating citizens to adapt their views, behaviours and circumstances to meet the politically defined needs of the state. This turns democracy on its head. It is also presents us with a political framework that is incompatible with the UK’s international human rights obligations and equality legislation.
Government policies have become increasingly irrational. We have a government that has decided work is a health outcome, for example. In an absurd world where medical sick notes have been politically redefined as fit notes, sick and disabled people are apparently no longer exempt from work, which is now held to be a magic “cure”. The only way out of the politically imposed punitive and increasing poverty for those who cannot work is… to work. (See: Let’s keep the job centre out of GP surgeries and the DWP out of our confidential medical records.)
Neoliberalism has become a doxa in the Western world. Here in the UK, citizen behaviours are being aligned with politically defined neoliberal outcomes, via policies that extend behaviour modification techniques, based on methodological behaviourism. Policies that “incentivise” have become the norm. This is a psychocratic approach to administration: the government are delivering public policies that have an expressed design and aim to act upon individuals, with an implicit set of instructions that inform citizens how they should be.
Aversives and punishment protocols are most commonly used. Coercive welfare policies are one example of this. The recent eugenics by stealth policy entailing the restricting of welfare support to two children only is another. Both were introduced with the explicitly stated political intention of “changing behaviours” of poorer citizens. Those that cannot or will not conform are politically stigmatised and outgrouped, as well as being being further “disciplined” by state-imposed economic sanctions.
Another particularly successful way of neutralising opposition to an ideology is to ensure that only those ideas that are consistent with that ideology saturate the media and are presented as orthodoxy. Every Conservative campaign has been a thoroughly dispiriting and ruthless masterclass in media control.
Communication in the media is geared towards establishing a dominant paradigm and maintaining an illusion of a consensus. This ultimately serves to reduce democratic choices. Such tactics are nothing less than a political micro-management of your beliefs and are ultimately aimed at nudging your voting decisions and maintaining a profoundly unbalanced, pathological status quo. (See also: Inverted totalitarianism and neoliberalism.)
As a frame of analysis, Lifton’s criteria are very useful in highlighting parallels between cult thinking and how political dogma may gain an illusion of consensus; how it becomes a dominant paradigm and is accepted as everyday “common sense.”
Lifton’s criteria for “thought reform” are:
Milieu Control. This involves the control of information and communication both within the environment and, ultimately, within the individual, resulting in a significant degree of isolation from society at large.
- Mystical Manipulation. There is manipulation of experiences that appear spontaneous but in fact were planned and orchestrated by the group or its leaders in order to demonstrate divine authority, spiritual advancement or some special gift or talent, such as claims of having a high IQ, that will then allow the leader to reinterpret events, scripture, and experiences as he or she wishes. (This can include “natural order” ideas and political doxa.)
- Demand for Purity. The world is viewed as black and white and the members are constantly exhorted to conform to the ideology of the group and strive for perfection. The induction of guilt and/or shame is a powerful control device used here. (Stigma and political outgrouping is used to deter and exile non-conformists.)
- Confession. Sins, as defined by the group, are to be confessed either to a personal monitor or publicly to the group. There is no confidentiality; members’ “sins,” “attitudes,” and “faults” are discussed and exploited by the leaders. (Mainstream media have bombarded us with “confessions” of “scroungers”, for example. The lives and experiences of those out of work have become public moral “property.”)
- Sacred Science. The group’s doctrine or ideology is considered to be the ultimate Truth, beyond all questioning or dispute. Truth is not to be found outside the group. The leader, as the spokesperson for God or for all humanity, is likewise above criticism. (Ties in with Conservative notions of a “natural social order.” But also, pseudoscience may be used to justify controversial policies.)
- Loading the Language. The group interprets or uses words and phrases in new ways so that often the outside world does not understand. This jargon consists of thought-terminating cliches; slogans which serve to alter members’ thought processes to conform to the group’s way of thinking. (See Glittering Generalities and The Conservatives are colonising progressive rhetoric.)
- Doctrine over person. Member’s personal experiences are subordinated to the sacred science and any contrary experiences must be denied or reinterpreted to fit the ideology of the group.
- Dispensing of existence. The group has the prerogative to decide who has the right to exist and who does not. This is usually not literal but means that those in the outside world are not saved, unenlightened, unconscious and they must be converted to the group’s ideology. If they do not join the group or are critical of the group, then they must be rejected by the members. Thus, the outside world loses all credibility. In conjunction, should any member leave the group, he or she must be rejected also. (Lifton, 1989)
*Italics in blue added by me.
I don’t make any money from my work. But you can support my work by making a donation and help me continue to research and write informative, insightful and independent articles, and to provide support to others. The smallest amount is much appreciated – thank you.