The power of positive thinking.
The government invests a lot of time and money in “nudging” people to accept the unacceptable.
George Osborne announced in the budget that the government will be funding a “package of measures” to improve employment outcomes which will entail putting Cognitive Behaviour therapists in more than 350 job centres to provide “support” to those with “common mental health conditions,” and making online access to Cognitive Behaviour Therapy available for people who are claiming employment support allowance (ESA) and job seekers allowance (JSA).
“Budget 2015 also announces a package of measures to improve employment outcomes for people with mental health conditions. Starting from early 2016, the government will provide online Cognitive Behavioural Therapy (CBT) to 40,000 Employment and Support Allowance and Jobseeker’s Allowance claimants and individuals being supported by Fit for Work. From summer 2015, the government will also begin to co-locate Improving Access to Psychological Therapies (IAPT) therapists in over 350 Jobcentres, to provide integrated employment and mental health support to claimants with common mental health conditions.”
The government put up an online contract notice which specifically states:
“This provision is designed to support people with common mental health conditions to prepare for and move into work, with intervention at the earliest possible point in a claim to benefit or access to the Fit for Work service.”
Under the government’s plans, therapists from the NHS’s Improving Access to Psychological Therapies (IAPT) programme would support jobcentre staff to assess and treat claimants, who may be referred to online cognitive behavioural therapy (CBT) courses.
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.
Cognitive Behaviour Therapy (CBT) is used to change how you think (“Cognitive”) and what you do (“Behaviour”). It bypasses emotions, personal history and narrative, to a large extent, and tends to focus on the “here and now.”
CBT is an approach that 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 is of course premised on the assumption that interpreting situations “negatively” is a bad thing, and that thinking positively about difficult or distressing events is beneficial.
The onus is on the individual to adapt to their distress and difficult circumstances by perceiving their circumstances in a stoical and purely rational way.
So we need to ask what are the circumstances that the government are expecting people claiming welfare support to accept stoically. 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? Stigma? Starvation and destitution? State punishment and exclusion?
It’s all very well challenging people’s thoughts but for whom is CBT being used, and for what purpose? Seems to me that this is about helping those people on the wrong side of punitive government policy to accept and accommodate that, and to mute negative responses to negative situations. CBT in this context is not based on a genuinely liberational approach, nor is it based on any sort of democratic dialogue. It’s all about modifying and controlling behaviour, particularly when it’s aimed at such a narrow, politically defined and highly specific outcome.
CBT is too often founded on blunt oversimplifications of what causes human distress – for example, in this case it is assumed that the causes of unemployment are psychological rather than sociopolitical, and that assumption authorises intrusive state interventions that encode a distinctly Conservative moral framework which places responsibility on the individual, who is characterised as “faulty” in some way.
There is also an underpinning assumption that working is good for mental health, and that being in employment indicates mental wellbeing. However, isn’t it more likely the case that healthier people are in work, those who aren’t well enough to work don’t?
It’s well-established that poverty is strongly linked with a higher likelihood of being diagnosed with a mental illness. But that does not mean working is therefore somehow “good” in some way, for mental wellbeing. Therapy does not address social conditions and context, and so it permits society to look the other way, while the government continue to present mental disorder as an individual weakness or vulnerability, and a consequence of “worklessness” rather than a fairly predictable result of living a stigmatised, marginalised existence of material deprivation.
Inequality and poverty are political constructions and arise because of ideology and policy-formulated socioeconomic circumstances, but the Conservatives have transformed established explanations into a project of constructing behavioural and emotional problems as “medical diagnoses” for politically-created (and wholly ideologically endorsed) socioeconomic problems.
Austerity, which targets the poorest citizens disproportionately for cuts to their lifeline income and essential services, was one ideologically-driven political decision taken among alternative, effective and more humane choices.
The government are not strangers to behaviour modification techniques and have been applying crude behaviourism to public policy, drawing on the “expertise”of the Behavioural Insights Team (BIT) – the “Nudge Unit” – that they established and installed in the Cabinet Office in 2010. (See Mind the Mindspace, which outlines some of the implications of a government extending operant conditioning via policies to an unconsenting public.)
It is disadvantaged people and excluded groups who are the primary targets of enormously pseudoscientific, coercive and punitive psychopolicy interventions. It’s a kind of technocratic ‘fix’, designed solely to align the perceptions and behaviours of those citizens failed and harmed by our current socioeconomic organisation to nonetheless accommodate and accept neoliberal outcomes.
The casual manner in which advocates of behaviourism dismiss the right of people to behave in accordance with their own feelings, intuition and instincts exposes their authoritarian (not “libertarian paternalistic”) ambitions.
It’s frankly terrifying that our so-called democratic government is waging an ideological crusade directed at altering citizens’ thoughts and behaviour, and avoiding any accountability, sidestepping any engagement in potentially difficult political debate about their policies and the impacts that they have.
The objectives adopted by the Nudge Unit choice architects, politico-therapists and psychocrats are entirely about the state micromanagement of public perceptions and behaviours.
These objectives resemble ambitions usually associated with totalitarian regimes. This is a gross state intrusion into a previously private domain – our thoughts, perceptions and behaviours. Not only is this government trespassing on an intimate, existential level; it is tampering with – editing – our perceptions and experiences, damaging and isolating the poorest citizens, burdening them with the blame for the consequences of state policies while also editing out state responsibilities towards citizens.
Both CBT and Nudge are aimed at pushing people in ways that bypass reasoning. The assumption is that because our decision-making ability is limited we need to use non-rational means to persuade people to do what is “good” for them. But who has the moral authority to decide that? This is not about helping people make better choices – it’s about coercing people to make the choices that policymakers want them to make. And again, those “choices” are based on enforcing conformity to the ideological commitments of policymakers.
This psychocratic turn is in diametric opposition to Enlightenment narratives – it fosters a profound anti-rationality and anti-autonomy approach, it’s not remotely democratic: it’s based on a ridiculous premise that people use their freedom and liberty poorly, but somehow, those passing that judgement on everyone else are exempted from such judgements themselves. It is also extends profoundly anti-humanistic consequences.
Apparently, some people think that everyone else is susceptible to flawed thinking and behaviours, but that theory magically excludes the theorist from such human failings, since they are claiming some objective, mind-independent vantage point – a position far away from the rest of us. It’s like saying: this is your “human nature” but not ours.
Whether or not we agree on the efficacy of CBT as a therapeutic model in principle is a small consideration which is overshadowed by the fact that the government are using such “therapeutic” techniques as a highly partisan tool – to enforce traditional Tory biases and prejudices and to achieve their ideologically-driven policy agenda.
CBT will be deployed in job centres to simply favour the political objectives of neoliberal Conservatism: propping up an anti-progressive austerity agenda, regressive ideology, endorsing an ever-shrinking state, while reflecting a profound Tory misanthropy.
The social problems arising because of a lack of provision will remain unaddressed and unchallenged because of the Conservative paradigm shift in positivist – causal explanations of political and social problems: it’s not down to policy, it’s all the fault of individuals (who are of course those individuals affected adversely by state policy.)
CBT is a short-term treatment, which is cheap and simple to deliver. I suspect this is one other reason for it becoming more popular with the Coalition than is warranted.
CBT has limitations for treating certain groups, including people with severe and treatment-resistant depression and those with personality disorders.
Studies concerning the efficacy of CBT have consistently found high drop-out rates compared to other treatments, with the numbers abandoning therapy often being more than five times higher than other treatments groups. (P. Cuijpers, A. van Straten, G. Andersson & P. Van Oppen. (2008)).
Researchers analysed several clinical trials that measured the efficacy of CBT administered to young people who self-injure. The researchers concluded that none of them were found to be efficacious. (See: Task force on the promotion and dissemination of psychological procedures: A reported adopted by the Division 12 Board – D. Chambless, K. Babich, P. Crits-Christoph, E. Frank, M. Gilson & R. Montgomery. (1993)).
CBT fails fundamentally on a theoretical level: it lacks basic clarity, depth and coherence. It doesn’t provide a definition of “clear and correct” thinking – curiously, CBT theorists develop a framework for determining distorted thinking without developing a framework for “cognitive clarity” or what would be deemed “healthy, normal thinking.” This has left a large space for partisan definitions and political agendas.
And why is irrational thinking considered to be a source of mental and emotional distress when there is no evidence of rational thinking causing psychological wellbeing? Furthermore, social psychology has never demonstrated that the normal cognitive processes (whatever they are) of the average person are irrational.
CBT is deterministic: it denies agency and any degree of free-will. Human behaviour, in this view, is determined by the cognitive processes invoked by external stimuli. It focuses on the former, ignoring the latter. CBT theory basically contends that what you feel is somehow not very important to why you do what you do and think what you think.
But human beings are not automata: we are complex and multi-faceted. Our emotionality is a fundamental part of being human, too – our emotional bonds and attachments, and our interactions with significant others over time contribute hugely to shaping who we are: we are socially situated and contextualised. We are intersubjective, reciprocal and intentional beings. A therapy that sidelines how we feel must surely, at best, be regarded as superficial in its efficacy, scope and reach.
Moreover, in emphasising thought processes to the exclusion of complex and legitimate emotions, therapists may contribute to the harmful repression and denial of feelings.
CBT encourages an unhealthy avoidance of psychological discomfort and distress by diverting thoughts from the source of discomfort. CBT may rouse immature, neurotic and pathological defence mechanisms. It devalues resilience based on mature coping strategies such as openness, courage, mindfulness, acceptance and emotional self-sufficiency.
Not only is that psychologically unhealthy for a person, it’s bad for society as it desensitises and de-empathises people, stultifies learning from experience by disconnecting people’s thoughts from their circumstances and from others. It discourages personal development and stifles ‘resilience’.
Perhaps the most damning criticism of CBT is that it encourages self-deception and self-blame within clients and patients, because it maintains the status quo. The basic premise of cognitive therapy is: except for how the patient thinks, everything is okay. You can see why this would appeal to the Conservatives.
Poor mental health is often linked with poverty (Melzer et al. 2004) poor community integration, and competitiveness among social groups (Arrindell et al., 2003). Key questions arise as to the efficacy, therefore, of working with individuals, when much research suggests community work would be much more effective (Orford, 2008).
The Beacon Project (Stuteley, 2002) was pioneered by health workers who supported those with depression and other health problems by working with their whole community – addressing their basic social needs and developing mutual social support systems. There were significant changes in physical and mental health for the whole community, showing the benefits of fostering a psychology of mutual support, altruism, cooperation and collaboration: building social capital.
Human needs, public services and provisions, developmental processes, social relationships and contexts are important to any comprehensive model of mental health. Community work offers something that CBT can’t: unlimited scope and reach, sustainable, self-perpetuating, long-lasting provision with an inbuilt preventative agenda. It’s also a prefigurative model. As such, it is founded on democratic principles and the values of genuine dialogue.
But the government has no interest in addressing mental health and wellbeing or building social support provisions. The government insists that people’s problems are self-generated and endogenous. But the socioeconomic context, policy decisions and consequences are the fundamental cause of unemployment, poverty and much mental distress.
When people are affected by social problems with structural causes, such as poverty and inequality, this in turn leads to a lack of opportunity, economic disadvantage and deprivation, unemployment, ill-health, absolute poverty (increasingly), poor housing, political scapegoating and punishment via policy, it’s ludicrously and grossly unfair to further stigmatise them and claim that their problems arise because of how they think and behave.
For the Tories, the only aim of CBT is a strongly emphasised participation in the labour-market, with minimal expectations of the state and minimal reliance on public services.
“Social problems are often the consequence of the choices that people make.” David Cameron.
No. Social problems are most often the consequence of a government that uses policy to create social inequality, poverty, social exclusion and extremely challenging economic circumstances for those people who have the least to start with. The government uses denial and a process of individualising blame for the problems caused by this government’s ideological austerity programme, which is used to legitimise further cruel constraint by those socio-economic factors caused by the government.
The Tories would have us believe that poor people suddenly become inadequate whenever we have a Tory government. They don’t, but they do become poorer. They are then held responsible and punished for the consequences of Conservatism.
If anyone needs to change the way they think, it’s certainly the Conservatives.
Update June 26, 2015: Mental health workers protest at move to integrate clinic with jobcentre
“This month Prof Jamie Hacker Hughes, president of the British Psychological Society (BPS), pointed out recent research which presented evidence that claimants had been forced to accept psychological treatment. Researchers from Hubbub and Birkbeck, University of London, found unemployment was being rebranded as a psychological disorder in many advanced economies, with interventions being introduced to promote a positive outlook or leave claimants of welfare to face sanctions.
Dave Harper, a reader in clinical psychology at the University of East London, told the Guardian he believed there was an ideological agenda driving the government’s proposals.
“We are in a recession,” Harper said. “There are not many jobs out there and this is implying that unemployed people are to blame for their situation. It’s shifting the focus away from economic policy and on to the individual.”
As a BPS member, I was happy to see a clear, ethical statement from the President.
Pictures courtesy of Robert Livingstone
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