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Depression, Anti-Psychiatry, Christianity

August 10, 2013

Content note – discusses the experience of depression, mentions suicide and self-harm in passing.

In his Guardian column today, Fr. Giles Fraser presents an argument which, has, in various guises, been with us since at least the 1960s: that mental illness, and specifically depression, is the ‘pathologisation of sadness’, and that biochemical treatments for depression are an example of ‘the scientists [being] called in to reinforce generally conservative norms of appropriate behaviour’. This post responds to his article by assessing the ‘anti-psychiatry’ tradition within which it falls, discussing some differences between sadness and depression, examining this difference in the Old Testament, and suggesting a Christian response to mental illness based on the stories of healings and exorcisms performed by Jesus in the Gospels.

Anti-psychiatry, sadness, and depression

Thomas Szasz presented a similar argument from a right-libertarian political perspective, arguing that the major function of psychiatric diagnoses was to provide a justification for individuals failing to take personal responsibility (while also making them more reliant on The State). R. D. Laing argued that the schizophrenic state was one of special insight, which could be ‘worked through’ via methods including regression to childhood (as in the case of Mary Barnes) rather than medication. Michel Foucault considers the advent of ‘mental illness’ as a necessary result of the Enlightenment, a ‘monologue of reason about madness’ which, as Fr. Giles argues, ‘can be just another way of shutting people up’.

All these writers raise an important question about psychiatric therapy – the extent to which medical interventions for mental illness violate the basic sense of free will which underpins social relationships. Given that, as Foucault argues, mental illnesses are described, categorized and treated under the philosophical rubric of the Enlightenment, with all the culture-, class-, and gender-bound elements this implies, does treating mental illness represent the stifling of dissent, the denial of harm done by the dominant politico-cultural narratives by relegating their effects to a spontaneous function of neurochemistry?

The answer, as so often, has to be ‘yes and no’. There is clear evidence, as traced most comprehensively by feminist historians of mental illness including Phyllis Chesler and Elaine Showalter, that categories of mental illness interact with preexisting socio-economic assumptions in order to delegitimize valid critiques of the social order. The category of ‘hysteria’, for example, was often invoked to silence a woman who was, unfortunately, intelligent enough to recognize the limiting influence of patriarchy and raise her voice against it (c.f. political cartoons vs. women’s suffrage). Similarly, it is important that work continues to analyze and critique the contents of and assumptions behind each new iteration of criteria such as the DSM (Diagnostic and Statistical Manual of Mental Illnesses) and ICD (International Classification of Diseases) (see for example the removal of an exception for diagnosing depression following the death of a loved one in the DSM 5) in order to detect instances of ‘mission creep’.

However, just because the concept of mental illness has been used as a tool of political repression doesn’t mean that it doesn’t also describe a recognizable cognitive phenomenon. Anyone who has experience of depression will recognize the feeling of frustration and hopelessness which comes with the realization that, no, they won’t be able to do anything but lie in bed crying today, or the spontaneous, intractable cataloguing of all of one’s past mistakes, from which no attempt at distraction (running, reading, playing video games, meeting friends) can provide an escape. This experience is different in kind to sadness, or even grief, and possesses a specific phenomenological profile, encompassing not just affect (‘I feel sad’), but also cognition (‘That was a stupid thing to do’) and sense of self (‘I am worthless’). The experience of depression goes beyond mere ‘feeling’ to dramatically alter an individual’s whole way of being-in-the-world.

In such circumstances, the effect of antidepressants can be near-miraculous. While the oft-repeated claim that depression is the result of a ‘chemical imbalance’ is at best an oversimplification and at worst a neurobiological fiction, it is true that, by reducing the amount of neurotransmitters such as serotonin, norepinephrine/noradrenaline, and dopamine which are reabsorbed after release, the physiological and psychological symptoms which lead to a diagnosis of depression can be greatly lifted. In these cases, antidepressants, far from ‘silencing’ individuals with psychiatric diagnoses, actually allow them to speak. I’m pretty sure, for example, that I’d not be in a position to be writing a PhD about mental illness and theatre if it wasn’t for the fact that I’m taking venlafaxine. While the precise mechanisms relating to many mental illnesses are still outside the descriptive power of neuroscience, and the placebo effect may be responsible for at least some of the positive impacts of psychiatric medication,[1] it is both inaccurate and potentially harmful to assert that, rather than medication having a positive effect, the effect is a myth leaving the individual disempowered and merely shoring up a failing system.

Sadness and Depression in the Old Testament

Given his line of work, it would not be unreasonable to expect Fr. Giles to be more alive to the cross-cultural nuance of psychological distress. Comparing, for example, the stories of Job and Elijah, provides ample evidence for the fact that situational and pathological sadnesses were distinguishable in a period well before an entity called ‘consumer capitalism’ can be identified. Job is a prosperous man, who is visited with misfortune in order to determine whether his fear of God (properly conceptualized as an amalgam of awe, reverence, love, worship, respect and fear) is merely a result of his prosperity. His response to his misfortune is as follows (Job 1: 20-21):

20 Then Job arose, tore his robe, shaved his head, and fell on the ground and worshipped. 21 He said, ‘Naked I came from my mother’s womb, and naked shall I return there; the Lord gave, and the Lord has taken away; blessed be the name of the Lord.’

The rending of garments, known as keriah, is a specific, culturally sanctioned expression of grief – a way of expressing what Fr. Giles would conceptualize as legitimate unhappiness arising from a recognizable stressor.

Elijah (1 Kings 19:1-15), on the other hand, experiences a very different kind of emotional experience. By all accounts, he has been successful in his line of work (as a prophet). His faith allowed him to demonstrate God’s power in a contest with the priests of Ba’al on Mount Horeb, by praying for fire to spontaneously light a drenched pyre on which was placed a bull as an offering. His prayer had also been answered as he predicted the end of an extended drought. As a result of this, Jezebel, the queen, is threatening to have him killed, which is a potential stressor, but could also be seen as being an occupational hazard of being an Old Testament prophet. Within the narrative, Elijah’s emotional response comes out of the blue, and has much in common with the symptom cluster we now call depression – he is physically exhausted, convinced of his own status as a failure despite evidence to the contrary, and desires death:

4 But he himself went a day’s journey into the wilderness, and came and sat down under a solitary broom tree. He asked that he might die: ‘It is enough; now, O Lord, take away my life, for I am no better than my ancestors.’ 5 Then he lay down under the broom tree and fell asleep.

God’s response to this state is to provide food, water, and encouragement from an angel, before revealing Himself to Elijah in a still, small voice. This is treatment beyond ‘doing a bit more exercise or being more sociable’ as prescribed by Fr. Giles – it is rather a wide-ranging intervention taking into account the physical (sleeping, eating, walking), psychological (emotional, interpersonal support from the angel), and spiritual (food from heaven, an encounter with the divine) aspects of Elijah’s experience. I am not here equating SSRIs with an experience of God, but rather suggesting that an intervention beyond mere political, social, or physical change is necessary in cases of depression, because depression is different in kind from sadness.

The New Testament and Treating Mental Illness

It is a commonplace to note that those described as ‘demoniacs’ in both Old and New Testaments are likely experiencing similar conditions to those we would now characterize as mental illnesses. Before we congratulate ourselves on how much more enlightened we are now we conceptualize these phenomena as treatable illnesses, it’s worth dwelling on just how familiar the Gerasene demoniac in Mark 5 is to any of us who live or work in large cities, and have to pass through those intermediate zones which serve as meeting places for increasing numbers of homeless people:

5 They came to the other side of the lake, to the country of the Gerasenes. 2 And when he had stepped out of the boat, immediately a man out of the tombs with an unclean spirit met him. 3 He lived among the tombs; and no one could restrain him any more, even with a chain; 4 for he had often been restrained with shackles and chains, but the chains he wrenched apart, and the shackles he broke in pieces; and no one had the strength to subdue him. 5 Night and day among the tombs and on the mountains he was always howling and bruising himself with stones.

Leave aside the shackles, or think of them as the limited attempts of family and friends to help a mentally-ill person while experiencing socio-economic difficulties of their own, and this could be a picture of any homeless person down on their luck, moaning in the doorway of a boarded up shop. The experience of mental distress has led to the ties which kept this man within the community being severed. The imagery of broken chains here takes on another metaphorical aspect, making clear the importance of social connections to an individual’s sense of self.

Jesus’s response to the Gerasene demoniac fits into a similar pattern to his other healings, and involves three parts – the transgression of social expectation by interacting with an individual who fell outside social structures, the healing of the illness, and the reintegration of the individual within his or her social milieu. In the New Testament, it is clear that there are both social and physical aspects to illness, and especially to mental distress, and the two cannot be distinguished or treated separately. As with Elijah, the demoniac is treated for the physical elements of his condition, but this also leads to social change. While, in the story of Elijah, this involved the local issue of driving out or killing the prophets of Ba’al, the message in the passage from Mark is significantly more far-reaching.

It is clear from the fact that there are swineherds at all that the story takes place in a non-Jewish area, and as Greg Carey points out (http://www.huffingtonpost.com/greg-carey/mark-5-1-20-exorcism-and-community_b_1628605.html) the driving of a demon called Legion into a herd of pigs which then drowns contains a powerfully anti-Roman message for Jews in occupied Judea. However, the key here is just how transformative (and divisive) Jesus’s exorcisms could be: on seeing what had happened, the locals ‘began to beg Jesus to leave their neighbourhood’ (Mk 5:17), while the demoniac himself, having been reunited with his friends, also finds a renewed sense of purpose, proclaiming the things Jesus had done (as Dominic Crossan has argued, there is a good chance that this was a subversive political message).

Conclusion

Fr. Giles, in pointing to the socio-political contexts for mental illness, highlights an important element of such conditions – the extent to which they both cause and are caused by disadvantageous socio-economic phenomena. However, by leaving the whole blame for this at the feet of antidepressants and Big Pharma, he exacerbates the isolation of those experiencing depression. Whether we’re Christian or not, the narratives discussed above suggest that mental illness is a feature of human culture in all time-periods, and that it can best be treated in a holistic manner – by reaching out to those who are suffering, even and especially when this means going against the conventions of a culture which encourages us to insulate ourselves from any experience of empathy, by ensuring access to the best medical treatment available, whether that’s spiritual, biomedical, or both, and by making the effort to continue to build a community and society within which those experiencing mental illness are integrated, valued, and supported.

As both Foucault and the story of the Geresene demoniac make clear, this integration requires a radical challenge to the social conditions which simultaneously exacerbate and downplay mental illness. The political challenge which Fr. Giles desires will come, not from the elimination of psychiatric drugs from society, but by their judicious use (always guarding against mission-creep and over-diagnosis) and the fostering of support structures which ensure those experiencing depression are supported, rather than being told that they are ‘just’ sad, and would get better if they went for a run.


[1] This is unsurprising, since the placebo effect itself is under-researched, and points to the sheer complexity of brain function – taking a placebo is not, as is commonly supposed, identical to taking nothing, since the very act of swallowing a pill will have an effect on brain function which would not be present in the absence of any stimulus at all.

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There’s No Stigma – Get Back to Work

October 9, 2012

NB: Articles like this suggest that the idea of there being ‘no stigma’ attached to celebrity depression is too simplistic. Although workplace discrimination is probably not as much of an issue for ‘celebrities’, those in that position instead face suspicion of the ‘how can you be depressed if you’re dating a supermodel and driving a Ferrari’ type – a suspicion which may in turn make life more difficult for those of us without equally famous partners or supercars.

The twitter spat between MIND and India Knight over the latter’s column on celebrity depression memoirs has been, mostly, of a predictable pattern: columnist writes piece with enough controversy to ensure readers are interested, campaigning group draws attention to it, frustrations are vented at the author, the author responds with a return fire of abuse, both sides go away feeling kind of angry and like the other side is stupid and illiterate.

Of course, the famous Times paywall compounded the problem, as many of the people complaining about the article had been unable to read it, and the piece was somewhat misrepresented by MIND in the first instance. (Although her comparison between bipolar disorder and a cocaine binge hardly suggests real sympathy – at best, you feel she acts sympathetic because she feels socially obliged to do so).

Allistair Campbell wrote a strong response to the two major errors in Knight’s piece, which can be found here. However, in this case, both sides have made some good points.

Where Knight is right is if you read her argument as saying not ‘there’s no stigma around depression’, but, as she has later insisted ‘there’s no stigma around celebrity depression. Now, this is a very generous reading of her article, and were she more honest she would accept that the sense of what actually appears in print elides this distinction (although it’s clear she did intend to make the distinction). I don’t accept the terminology of ‘stigma’, for reasons I’ve made clear elsewhere, but the discrimination experienced by people with depression is often linked to their material circumstances.

An actor may be able to get away with being a little unpredictable, or a newspaper columnist who works from home can do so from the comfort of a bed with the covers over her head and the blinds drawn. There is more leeway if your name itself is part of your value. On the other hand, in the context of an increasingly precarious labour market, someone struggling to pay the bills in a minimum wage job, who knows that there are hundreds of other people just waiting to take that job, is unlikely to want to disclose that, due to depression, they may need a couple of days off, sometimes. Certainly they won’t want to put it down to chronic illness.

Similarly, Knight’s point about the ‘depression memoir’ is important – celebrities are in a far better position from which to recover from mental illness, simply due to their having more money. Easy stories of depressed celebrities recovering after a visit to the Priory whitewash the experience of those who are caught on interminable waiting lists for group CBT, or trying to recover in a financially struggling and understaffed acute unit. It’s easy to recover from depression if you don’t have to put on a death-mask for work each morning, and if you receive treatment as soon as the condition emerges.

The other problem with celebrity depression memoirs is that they don’t seek to normalise the experience. If they are akin to anything, it’s the ghoulish visits to Bethlem Hospital to gawp at the loons – we don’t tend to view celebrities as ‘like us’, so their tragedies provide a safe, vicarious distance from which to experience a more emotionally extreme life.

So much for where Knight gets it right, then. The real problem with her article isn’t the easy cliches of ‘everyone gets depressed’ or ‘we all understand’, but her characterisation of the differences between celebrities and ‘normal people’. She says “You long for someone to say: “I felt like crap for two years and then I got over it.” Which is, by the way, what normal people do.”

This narrative of illness as trivial life event which is a minor inconvenience which then goes away, and the suggestion that celebrity accounts which don’t fit this narrative are somehow ‘abnormal’ is part of the same narrative of illness used to justify government cuts to the disability budget. Everyone gets depressed. Everyone gets over it. Celebrities use it to sell books, it’s not a big deal, and if you let it be anything more than that you’re both abnormal and somehow attempting to gain unearned benefit from it. Knight accuses JK Rowling of using her depression to increase her book sales, but she might as well be accusing benefit claimants, as the argument is the same – ‘normal people’ get over it, but ‘you’ expect special treatment.

It is this that is truly harmful about Knight’s article – not the factual inaccuracies which anyway pepper most popular discourse on mental illness, and which must be corrected each time they appear, but her reinforcement of the harmful narrative that any ‘invisible’ illness is no illness at all. Until you are ‘rummaging in bins’, you’re fine – so get back to work, don’t make a fuss, keep calm and carry on like ‘normal people’ do. Her article is exactly the kind of narrative which perpetuates discrimination around mental illnesses, but worse than that, in the context of austerity, with the lifelines which many seriously mentally ill people rely on just to survive being severed, the picture of depression painted by Knight contributes to society turning a blind eye while its most vulnerable members die of political invisibility.

Why I’ll continue calling out attacks on mental illness

March 25, 2012

NB: I WILL COME BACK AND REFERENCE THIS PROPERLY IN THE FUTURE – THIS IS A PROVISIONAL PIECE WRITTEN WITHOUT ACCESS TO MY NOTES.

One of the topics that gets me the most abuse on twitter is when I suggest that accusing people whose actions or politics they disagree with are ‘mentally ill’, or have a specific mental illness, is an unhelpful approach. The claim is often that these comments are ‘jokes’ or that, because the DSM and ICD are so problematic, the democratisation of diagnosis is inevitable, and the best use of these tools is to attack and deligitimise political opponents.

Notwithstanding the issues surrounding the Welfare Reform Bill, this tactic is inherently problematic.

Now, by saying this, I *don’t* mean that political discourse cannot contribute to mental illness and mental health issues. Indeed, I think that, on both sides of the political divide, the rhetoric used by tabloid media and the government is often likely to fuel symptoms of paranoia, self-hatred, agorophobia and sociopathy. It is even possible that these results are, to a certain attempt, intended, as a fearful electorate is often a compliant electorate.

However, I also do not believe that there is enough evidence to support the line of writers like Thomas Szasz, RD Laing and, to a certain extent, Sigmund Freud, in attributing mental illness purely to socio-political (environmental) factors, or ‘problems in living’. Problematic though bio-medical models of mental illness are, medical (psycho-pharmaceutical) interventions have a positive impact on symptoms in enough cases as to suggest that the small steps we are taking forward in neuroscientific understandings of the brain/mind are gradually improving outcomes, despite the problematic influence of pharmaceutical companies.

So, to clarify, mental illness and mental health issues are most likely, when the latest studies are taken into account, a result of a combination of biological, socio-political and environmental factors. However, due to the speculative nature of a lot of current research, the balance between these is open to question (whether biological factors make certain socio-political factors more likely to have an effect, or whether certain relationships between the environment and the socio-political landscape precipitate changes in brain chemistry, or whether any combination in any order has the potential to have these effects.)

So much for mental illness as something which affects individuals. The point of this post is statements which suggest that the EDL are all ‘loons’, or that people who read a certain newspaper are ‘mentally ill’, or (as I noted in a post at the Madness and Theatre blog, that all mass-murders are ‘lone psychos’). Such statements are defended on a number of grounds, which I’ll address in turn:

1a) That this is a ‘joke’, suggesting wrongness, possibly with a hint of truth.

1b) That jokes about mental illness can transform attitudes towards it, thus reducing discrimination.

2) That it’s clear that an individual or group are experiencing mental illness, because no normal person would act like that.

3) That it’s ok to claim that others are mentally ill if you experience mental illness yourself.

Responses

1a) It’snot ok to use mental illness as a synonym for ‘wrongness’. For a start, this privileges the enlightenment concept of ‘rationality’ which forms the basis for bourgeois individualism and capitalism. The ‘rational’ decision is one uncomplicated by emotions (whether ‘normal’ emotions, or ‘pathological’ emotions attributed to mental illness). It is rational to look after one’s own interests, and those of one’s family, but altruism is irrational because you gain nothing from it.

Secondly (and fairly obviously) this implies that mentally ill people are ‘wrong’. It’s easy to justify this implication – after all, objectively, the voices which result from psychosis are not there: the individual’s perception is wrong. Even with ‘neurotic’ conditions such as depression or anxiety, there’s no reason for the individual to experience the feelings the are – these feelings are wrong. However, wrongness of emotional response doesn’t necessarily mean wrongness of intellectual response. It is possible to, for example, read and agree with the Daily Mail without suffering from a diagnosable mental illness. It’s possible to read and agree with the Mail, suffer from depression, and for those things to be unconnected. It’s also possible that there is an interaction between reading the paper and feelings that society is collapsing which feed into depression – but that doesn’t make the paper the cause: such an analysis is simplistic. By the same token it’s possible for an anti-Tory campaigner to campaign partly because she hears voices telling her to – this doesn’t make her position inherently intellectually right or wrong.

1b) It is, of course, possible to utilise comedy as a political tool, to overcome prejudice against mental illness, disability, a certain political position, a certain sexuality, or a certain gender identity. This isn’t at issue. By the same token, of course, it’s possible for ‘jokes’ to be made at the expense of people in these groups, even jokes which don’t make these groups their target. Without any further content, there is little difference between ‘Sunday Sun readers are mentally ill’ and ‘Sunday Sun readers are gay’. Something being a joke does not automatically render it harmless – indeed, by normalising a view within an apparently harmless context it can ingrain it.

2) This is the most problematic position. I was once accused of being ‘elitist’ for claiming that people shouldn’t attempt to diagnose public figures, especially if they don’t work in mental health. Whether the perpetrators of mass murder, or celebrities accused of having a ‘breakdown’ after separating from their partners, it has become culturally ubiquitous to offer more or less knowledgeable opinions on the state of someone’s mental health. When applied to public figures, this is often just insensitive and inappropriate, but when applied to political opponents, particularly as a group, it is downright dangerous.

Foucault’s accounts of psychiatric power suggest that the ascription of the label ‘mentally ill’ to individuals with problematic characteristics has long been a large part of psychiatric practice. This view is shared by the historian Andrew Skull and, to a lesser extent, Roy Porter, even when these writers (rightly) attack the historiographical issues in Foucault’s work. Indeed, from the incarceration of the Marquis de Sade after the French Revolution, to the pathologisation of homosexuality and later ‘ego-dystonic homosexuality’ (see this recent Guardian article for a harrowing account of the impact of this diagnosis), there are many examples of this tendency to be found. Although, in the West, it’s common to mock the pathologisation of political opposition in China, even the DSM lists ‘Oppositional Defiant Disorder’ as a potential diagnosis, and the DSM-V may lead to a further widening of potential categories (the reference is the the Guardian here because it’s a Sunday night and I want to get to the pub!).

In this context, for political campaigners to ‘diagnose’ their political opponents, or those whose actions they disagree with, has problematic political overtones, which are not limited to the ‘identity politics’ of disability. For me, the major problem with pathologising political opposition is not that it trivialises and problematises the experience of people suffering from mental illness, but that it justifies the broader abuse of psychiatry for purposes of controlling dissent. This does not only threaten freedom of expression, but also the future treatment of mental illness, since it has the potential to split the loyalties of researchers.

One final point on this – suggesting that those who commit terrible acts of mass murder, or who are persuaded to take part in group acts such as the mass murders in Rwanda, or the Nazi regime in Germany, or any other situation like this, are, by definition, mentally ill, is obviously a safe and reassuring proposition. However, it is most probably not true. The propaganda which works on individuals in situations like this plays on normal brain function – the identification of ‘others’ who are outside and in opposition to the status quo which would enable ‘myself’ to fulfill my potential. The propaganda may lead to some people becoming mentally ill – but not everyone who goes along with will be, or at least not simply as a result of doing so. This is, in part, because ‘mental illness’ is defined against societal norms. However, it is also important to remember because to assume that those involved in those situations were ‘ill’, we can differentiate ourselves from them – “I’m not ‘ill’, so I can’t possibly be implicated in anything like this”. Such a view allows people to take their eyes off the political ball, and may even contribute to the perpetration of such acts.

3) Personal experience of mental illness *does* provide patient knowledge which may enable you to recognise the signs of mental illness more easily in friends and others who are close to you. However, it does not justify mentioning your suspicions to anyone other than the person involved (or possibly their closer family), and it especially does not justify using your suspicions to delegitimise that individual. Mental illness does not delegitimise the opinions of individuals, and when used in this way it can impact on the credibility of mentally ill people in general.

So, at the risk of becoming embroiled in more twitter arguments, I’ll continue to tell people when I believe that their attribution of mental illness is unhelpful, obfuscatory and possibly dangerous. Hopefully, being able to link people to this blog will help explain my position, and maybe save unnecessary arguments.

A Cautious Welcome to the ‘Black Dog Tribe’

March 21, 2012

Before I start this post, I want to say outright that any community, online or not, which provides help, support and a safe space for people experiencing mental health problems is always a Good Thing. Therefore, I welcome Ruby Wax’s ‘Black Dog Tribe‘ project, a website which is a forum-cum-social network for people experiencing mental health issues, and especially depression. I personally found the US based website Crazy Boards incredibly helpful when I was at my lowest points with depression.

However, I’m worried about the wider use of the project. Firstly, aside from my personal concerns about the rhetoric of ‘stigma’ in mental health campaigning (see my guest post for NAMI Massachusetts on this subject), I think that ‘identity politics’ as a way to tackling the prejudice and discrimination surrounding mental illness is doomed to be ineffective. Very few people will willingly adopt the ‘identity’ of depression, in the way that they might an LGBT+ identity, since, although mental illness can be a large part of a person’s identity, it is very rarely a positive element. The Mad Pride movement has had some success advocating Gay Pride style approaches, and their direct action is important. However, the ‘Black Dog Tribe’ project equivocates on this, attempting to use one identity to mediate the negative effects of another. Marjory Wallace, Chief Executive of SANE puts it this way:

It’s easier to say that you have had a Black Dog time than that you’ve been away suffering from depression.

This is true, but is a result of discrimination and prejudice, so probably not an effective way to fight these issues. It’s important that depressed people can express themselves comfortably, and euphemism is a crucial element of this – but that’s not a reason to make a euphemism a campaign tool.

The second problem is connected to the first. Although the idea of a ‘tribe’ positively suggests mutual support, shared experience and solidarity among members, it also suggests more negative attributes. The word ‘tribe’ in modern, Western society, immediately implies a sense of ‘otherness’. Even in the strictest sense, a ‘tribal’ society is a pre-State society, and thus one opposed to (and possibly threatening) the structures of Western society. This can be seen from the term’s use as a contemptuous collective at least as far back as Shakespeare:

Not mine own fears, nor the prophetic soul
Of the wide world dreaming on things to come,
Can yet the lease of my true love control,
Supposed as forfeit to a confined doom.
The mortal moon hath her eclipse endured
And the sad augurs mock their own presage;
Incertainties now crown themselves assured
And peace proclaims olives of endless age.
Now with the drops of this most balmy time
My love looks fresh, and death to me subscribes,
Since, spite of him, I’ll live in this poor rhyme,
While he insults o’er dull and speechless tribes:
And thou in this shalt find thy monument,
When tyrants’ crests and tombs of brass are spent.

More recently, the term ‘tribe’ has been associated more explicitly with threats to the fabric of respectable Western society, being used, according to the OED, to describe ‘a group of hippies or drop-outs’ in the 1960s and 70s.

As a result of these associations, and of Marjory Wallace’s comments, I’m not optimistic about the use of the ‘Black Dog Tribe’ as a campaigning tool. It’s more a transfer from one set of problematic terms (those of mental illness and depression) to another (those of the threatening ‘Other’). This doesn’t mean  the project won’t be useful, and I sincerely hope that people experiencing mental distress can find mutual support, help and acceptance through the forum.

Work, the Social Model, and the Welfare Reform Bill

February 6, 2012

The question of work for disabled people has been artfully reduced to a simple ‘fit for work’ binary by the rhetoric of successive governments, and this has become even more entrenched in discussions about the Welfare Reform Bill (WRB) currently passing (or being forced) through Parliament. The debate has been become a simplistic question of whether disabled people are ‘entitled’ to receive disability benefits, or whether they are ‘scroungers’. If you are in favour of the WRB, you believe, de facto, that some people are just scroungers, and where they are not, they are constrained by their position within the ‘Sick Role’, which leads to an erroneous belief that they cannot work, a belief which would be dispelled by cutting their benefits and forcing them to ‘get a job’. This is the compassionate thing to do, akin to throwing a child into the deep end of the swimming pool to make them swim. Tough love, as it were.

If you are against the WRB, you have to believe that the current situation is absolutely fine, that there are no problems with the position of disabled people in society as essentially State-dependents. To argue that there are disabled people who would like to work and are prevented from doing so not entirely by their ‘impairment’ (borrowing the ‘disability/impairment’ distinction from Vic Finkelstein’s Social Model of Disability) but also by structural features in society is to slip imperceptibly back into the rhetoric which has characterised the WRB – the argument seems to culminate in the DWP’s claim that “it would be wrong not to give those with a terminal illness the same opportunities as others”.

The situation is more nuanced than this. As I noted in a previous post, evidence that work is ‘good’ for disabled people is based on a very narrow definition of work, of a kind that doesn’t characterise much of the UK labour market at the moment. It would also be wrong to uncritically support what is a kind of State-dependency (a different thing from the ‘welfare dependency’ so often shrieked about by the tabloids) for disabled people. The reported increases in disability hate crime demonstrate just what a precarious position this kind of dependency places disabled people in – essentially owned by the government to be deployed as a useful scapegoat in difficult economic times, with no real recourse or protection. This is not a situation which should be allowed to be repeated, and in order to prevent it happening again it is necessary to loosen this relationship, which proliferated as a result of increased unemployment under Margret Thatcher (whether or not this was a deliberate policy or a side-effect is open to question, however).

For emphasis, I repeat, however, that I’m not arguing for the forcing of disabled people who have been ‘duped’ into thinking they are incapable of work back into the labour market, as it is clear that the current state of employment is toxic even to those who have jobs, and work most certainly does not ‘make free’. The failure to engage with this was the limitation of Brendan O’Neill’s Telegraph article which is one of the few pieces to suggest that there may be a left-wing case for welfare reform. In addition, Finkelstein’s Social Model is criticised by many disabled people for catering solely for ‘white men in wheelchairs’, and not taking into account the effects of disability which cannot be adjusted for by simple access improvements. This problem can be demonstrated by one of Finkelstein’s earlier writings, which conceptualises the problems of disability entirely through wheelchair use, although extrapolated to other disabilities. As twitter user ‘@allbigideas’ notes, ‘you can’t make an adjustment for pain’.

However, this does not change the fact that there is a phenomenon by which unemployment is depoliticised by making it a question of disability. Nor is it possible to ignore the effects of medicalisation which lead to the marketing of more and more drugs, and a tendency to treat mental illnesses with pills and short-term CBT rather than longer term counseling. Medicalisation and medicine are two separate phenomena, as medicine is undoubtedly to the advantage of disabled people, while medicalisation extends the influence of medicine beyond the clinical remit of treatment to become a moral-financial imperative, striving more to benefit financial interests than the individual patients (the current Health and Social Care Bill is thus an example of ‘medicalisation’, as it represents the intersection of medical and financial power).

So – we need to navigate a way between, on the one hand, the medicalisation and State-dependency of disabled people, which limits agency and enables scapegoating, and on the other the highly damaging WRB, which takes no account of medical knowledge or evidence, instead suggesting that merely removing benefits from people will liberate a ‘depoliticised’ workforce, currently believing itself incapable when in reality it is no such thing. Both these ‘solutions’ come at the expense of the dignity and humanity of the individual. I believe that the solution to this problem is a comprehensive reassessment of our toxic labour market, and this reassessment and reformulation must come before any reassessment of benefits. In our current economy, disability benefits provide dignity for individuals, allowing social engagement, and should not be cut in the name of some kind of ‘liberation’ which would be meaningless without a society which takes Finkelstein’s social model much further.

Rather than just offering adjustment for wheelchair-users, a fully conceptualised ‘Social Model’ would also take into account questions of pain, mental illness, and the side-effects of medication. If the labour market in general related to people as individuals rather than units of labour power, then although pain could not be adjusted for, it could be tolerated within the system. However, as I write this, I realise that I am arguing further towards Finklestein’s later ‘radical social model’ – a model Lord Freud certainly does NOT endorse, whatever he has told the House, as it is constructed as follows:

I believe that we cannot understand or deal with disability without dealing with the essential nature of society itself. To do this disabled people must find ways of engaging in the class struggle where the historical direction of society is fought, won or lost. It is in this arena that the boundaries of knowledge that have put disabled people aside from the ‘normal’ can and have to be openly questioned. For me repossessing the social model of disability means searching for openings in the structures of society where we might effectively contribute with others in the restructuring of society so that it is neither competitive nor disabling for all people.

In the current situation, this shift is unthinkable, and for many probably even undesirable. In this case, then, the problems of medicalisation and State-dependency in disability issues will always be the lesser of two evils – disability benefits provide income and the possibility of dignity for disabled people who are not ‘fit to work’ in the current, broken social structure. Attempting to ‘accommodate’ disability within this society by removing benefits and forcing people into work has no evidence base, and is merely an example of what Finklestein calls the ‘liberal right’s’ attempt to ‘inherit the ideological underpinnings of the social model of disability’ – which is what the biopsychosocial model of disability and the WRB are doing. Until society undergoes the kind of radical change Finkelstein argues for, we must continue to argue for the moral imperative of maintaining the independence, dignity and right to social life of disabled people – regardless of the severity of their condition. The Welfare Reform Bill will not combat the issue of State-dependence, only render the price the state pays for its ownership of individuals less expensive while maintaining its scapegoating power (see Maria Miller’s comments about unemployment today, and remember she’s Minister for (Against?) Disabled People). Disabled people, in general, *want* to work, and their exclusion from the labour market is not voluntary. However, cutting benefits is not the solution to this (as detailed in my previous blog). Instead, there must be a commitment to improving understanding of disability issues, not least the fact that unemployability is often the result of employers being unwilling/unable to take what amounts to a financial risk employing a disabled person, rather than unwillingness on the part of the individual.

Is the Welfare Reform Bill ‘Best’ for Disabled People?

January 30, 2012

The purpose of this discussion is to demonstrate that the Welfare Reform Bill currently passing through Parliament is unsuitable for its stated aim and, in certain respects, contradicts the evidence provided to the DWP. It is mainly based on evidence from the meta-analysis contained in the 2006 report ‘Is Work Good for You?’, focussing on this report’s discussion of disability. What it shows is that, although the principle of employment is important (a view shared, after all, by even the most radical disability campaigners, Vic Finkelstein), this view is contextualised in a number of specific ways, the nuances of which are lost in welfare reform which focuses its rhetoric on ‘scroungers’ and the ‘fake disabled’.

What is ‘employment’?

Before examining the evidence to be found in the report, it’s important to be sure what we mean when discussing ‘work’. The report for the DWP concludes:

Despite the diverse nature of the evidence and its limitations in certain areas, this review has built a strong evidence base showing that work is generally good for physical and mental health and well-being. Worklessness is associated with poorer physical and mental health and well-being. Work can be therapeutic and can reverse the adverse health effects of unemployment. That is true for healthy people of working age, for many disabled people, for most people with common health problems and for social security beneficiaries. (38)

This formulation appears to oppose ‘unemployment’ to ‘work’, as though work were defined entirely as a traditional, 9-5 paid employment. However, the use of terms in the report is confused, since earlier in the report ‘work’ and ’employment’ (and indeed ‘worklessness’ and ‘unemployment’) are distinguished. ‘Work’ is defined as follows:

the application of physical or mental effort, skills, knowledge or other personal resources, usually involves commitment over time, and has connotations of effort and a need to labour or exert oneself. Work is not only ‘a job’ or paid employment, but includes unpaid or voluntary work, education and training, family responsibilities and caring (4).

One of the problems with the current debate is that, in political rhetoric and media commentary, this important distinction does not exist (see, for example, the Conservative Party’s statement on Jobs and Welfare). Indeed, the principle, proposed by UnumProvident and upheld by the government to ‘ensure that work always pay better than benefits, and is clearly seen to be doing so’ ensures that, where the studies include all forms of productive activity within the category ‘work’ when assessing its effect on health outcomes, policy cannot.

Is Work Good for You?

With specific reference to disability, the evidence for the overall good of ‘work’ (whether taken to mean ’employment’ or ‘any productive activity’) is admitted to be contingent, even within this report:

The policy statements and guidance in Table 3 are based upon and reflect the available evidence, yet they are essentially expert opinions. Several refer to the evidence on the health benefits of work and the detrimental effects of unemployment in healthy people. Others discuss in general terms the harmful effects of prolonged sickness absence and avoidable incapacity, and the beneficial effects of work for sick people. However, there is little direct reference or linkage to scientific evidence on the physical or mental health benefits of (early) (return to) work for sick or disabled people. (21).

This lack of direct evidence is made clearer when the studies assessed by the report are examined. Taking into account the problems of evidence and referencing for the benefits of work detailed in my earlier post and the UK Action for ME report referenced above, it is interesting to note that much of the information cited in support of the benefits of early return to work for disabled people does not meet the criteria for being most strongly supported. For example, the report is clear that ‘work is not harmful to the psychiatric condition or mental health of people with severe mental illness although, conversely, it has no direct beneficial impact on their mental condition either.’ Indeed, it states categorically that only 30-50% of people with severe mental health problems are capable of work (21).

Things become more complicated, and much less easy to quantify, when the study moves on to discussing ‘common mental health problems’. The information discussed in this area is as follows:

Emotional symptoms and minor psychological morbidity are very common in the working age population: most people cope with these most of the time without health care or sickness absence from work. (Ursin 1997; Glozier 2002)

People with mental health problems are more likely to be or to become workless (sickness, disability, unemployment), with a risk of a downward spiral of worklessness, deterioration in mental health and consequent reduced chances of gaining employment.
(Merz et al. 2001; RCP 2002; Seymour & Grove 2005)

There is a general consensus that work is important in promoting mental health
and recovery from mental health problems and that losing one’s job is detrimental.
(RCP 2002;Thomas et al. 2002; Seymour & Grove 2005)

There is limited evidence about the impact of (return to) work on (people with) mild/moderate mental health problems, despite their epidemiological and social importance. However, there is much more evidence on ‘stress’, which may be the best modern exemplar of common mental health problems.

The elision of ‘common mental health problems’ into ‘stress’ is problematic, as no direct evidence is given for the utility of such a discussion. This problem is made worse by the way in which ‘stress’ is discussed. Rather than assessing the prevalence of different forms of common mental health problem in the workplace, the review complains of an elision between ‘stressor’ and ‘stress response’ in the literature (I do not deny that this is an important distinction to maintain), and the lack of precision in the terms used. In addition to this, the subjective nature of ‘stress’ is bemoaned:

stressors and stress responses and the relationship between them are subjective perceptions, self-reported, open to modulation by the mental state identified as ‘stress’ (whatever its cause), and with confounding of cause and effect (23).

This part of the argument is complex. It is obviously important to assess whether underlying depression or anxiety is making the workplace intolerable, rather than an intolerable workplace being necessarily the cause of anxiety. However, the authors of the report, having drawn attention to this, move on to an assertion by a number of members of the Wessley school of psychiatrists, who are concerned with determining psychosocial causes of diseases, often at the expense of examining physical morbidity, who argue:

The underlying problem is the fundamental assumption that work demands/stressors are necessarily a hazard with potential adverse mental health consequences (Cox 1993; Cox et al. 2000a; Cox et al. 2000b; Mackay et al. 2004), ignoring or failing to take sufficient account of the possibility that work might also be good for mental health (Lazarus & Folkman 1984; Edwards & Cooper 1988; Payne 1999; Salovey et al. 2000; Briner 2000; Adisesh 2003; Nelson & Simmons 2003; Wessely 2004; HSE/HSL 2005; Dodu 2005).

This area is controversial, and I do not pretend to have sufficient knowledge of the area to make an informed decision about the merits and demerits of the work of Wessley and his followers, but from a linguistic point of view, it seems to me that to move from ‘common mental health problems’, to ‘stress’, to the idea that work does not have a necessary risk for mental health is not necessarily one which moves in accordance with the evidence, but rather one which uses rhetorical strategies to give more weight to certain elements of an incomplete evidence set.

What is to be done?

From the above, it may appear that I am engaged in arguing that disabled people should never work, and that many respected scientists are just wrong. This is not the case. Along with the majority of disabled people and politicians, I believe that work (in the sense of productive activity) is an important part of life, and that increasing access to employment for disabled people is important. However, I do not believe that reducing the DLA caseload by 20%, or any of the other cuts to disability related benefits will achieve this. Indeed, the report under discussion also makes it clear that the ‘blunt instrument’ of benefit cuts is ineffective in working towards the social integration of disabled people:

After leaving benefits, many claimants go into poorly paid or low quality jobs, and insecure, unstable or unsustained employment. Many go on to further periods of unemployment or sickness, and further spell(s) on the same or other social security benefits.

Claimants whose benefit claims are disallowed often do not return to work but cycle between different benefits and often report a deterioration in mental health, quality of life and well-being. (29)

In addition to these specific pieces of evidence against the approach the government is taking, there is also much evidence within this report that there is action which could be taken to greatly improve the lives of disabled people, enable more disabled people to take part in meaningful work-activity, and reduce some of the much hated ‘costs to the taxpayer’ of disability support. I provide a lengthy quotation from the report:

work is generally good for your health and well-being, provided you have ‘a good job’. Good jobs are obviously better than bad jobs, but bad jobs might be either less beneficial or even harmful. It is then important to consider what constitutes a good job. Under UK and European legislation, employers have a statutory duty to conduct suitable risk assessments to identify hazards to health and safety, and to reduce the risks to employees as far as reasonably practicable. But health and safety should be distinguished. As well as controlling risks, it is equally important to make jobs accommodating of common health problems, sickness and disability. A ‘healthy working life’ goes even further: it is ‘one that continuously provides working- age people with the opportunity, ability, support and encouragement to work in ways and in an environment which allows them to sustain and improve their health and well-being’ (Scottish Executive 2004). ‘Work should be comfortable when we are well and accommodating when we are ill’ (Hadler 1997). The evidence reviewed here suggests that, in terms of promoting health and well-being, the characteristics that distinguish ‘good’ jobs and ‘good’ workplaces might include:

•    safety
•    fair pay
•    social gradients in health
•    job security
•    personal fulfilment and development; investing in human capital
•    accommodating, supportive & non-discriminatory
•    control/autonomy
•    job satisfaction
•    good communications

This list is tentative, but clearly goes far beyond physical and mental exposures, demands and risks. Further research is required into the characteristics of a ‘good’ job, and further consideration is required of the links between good jobs, health and productivity to support the principle that ‘good health is good business’.

In short – ‘work’ is good for health only when this work is mentally challenging and occurs in an inclusive, accessible and safe space. Given that the government’s current economic policy is determined to attack each and every one of the bullet points in the above list, it cannot also argue that work remains a ‘good’. The current situation is unsatisfactory to everyone – the work capability assessment and culture of hatred and suspicion towards disabled people offers no incentive to even attempt to get better, as disabled people are scared even to enjoy those days when they are able to participate fully in society due to the risk of being ‘shopped’ to the DWP. In addition, the government’s own literature makes it clear that removing benefits from people does not encourage a return to work – especially in an increasingly competitive job market where there is anecdotal evidence for a very low standard of ‘supportiveness’ from JC+ employees.

If the government wished to achieve its stated objectives, it would start by strengthening accessibility legislation, strengthening employee rights, improving wages and job security and investing in industries with a potential for job satisfaction. It would be supporting these measures with a retention of DLA, unassessed, to enable disabled people to afford the extra costs of disability and of the (negative) impacts of work on disability. It would not be undermining the labour market with unpaid ‘workfare’ programmes with what should be some of the largest local employers (for better or worse). In short, it should be supporting disabled people and workers in fact, not merely in rhetoric. And all the evidence for this can be found in its own report.

Meetings between DWP and Unum: Response to FoI request

January 28, 2012

This is the response to my (admittedly badly worded) FoI request for the connections between DWP employees and representatives of Unum. Despite my poor wording, the response contained some interesting information. I reproduce the whole response below, highlighting particularly interesting points. On monday I’ll also write up a report looking at how government policy doesn’t tally with its own research.

DWP Central Freedom of Information Team
Annex A 
 
e-mail: freedom-of-information
 
-[email address]
 
Our Ref: VTR 236


27 January 2012
Annex A 
Dear Mr Jones,

Thank you for the following Freedom of Information request, which was received on 20
January 2012.

I would be grateful if you could provide me with information stating how many meetings
between employees of Unum (previously UnumProvident) and employees of the DWP have occurred over the course of the relationship between these two bodies (since 1995).

Any additional information about these meetings (dates, times, places, agendas etc.) would also be gratefully received.

The department does not have a central database recording meeting details. As such to
comply fully with your request would entail contacting approximately 100,000 officials who are employed by the Department of Work and Pensions, as well as all Ministers and Special
Advisers, to find details of meetings that could relate to your enquiry. We estimate that the cost of complying with your request would exceed the appropriate limit. The appropriate limit has been specified in regulations and for central Government it is set at £600. This represents the estimated cost of one person spending 3½ working days in determining whether the Department holds the information, and locating, retrieving and extracting the information.

Under section 12 of the Freedom of Information Act the Department is not obliged to comply with your request and will not be processing your request further. However, if you wish to limit the scope of your query to a particular business area or subject matter, I may be able to provide the requested information.

The Department does have record of two meetings with Unum officials since May 2010. On 18 October 2010 a UNUM representative – as part of a delegation from UK Rehabilitation Council – met with the Minister for Welfare Reform and Department officials. 

In addition, on 14 February 2011, UNUM representatives met with Departmental officials involved in the independent review of sickness absence in Great Britain. 

Since October 2009 the Department has published a list of meetings held between Ministers and outside organisations. This can be accessed at http://www.dwp.gov.uk/publications/corporate-publications/ministers-meetings-overseas.shtml.

The Department also has records of the two working groups which were set up in 2006 to review the Personal Capability Assessment for Incapacity Benefit. One of these groups
reviewed the physical descriptors within the assessment; the other looked at the descriptors
which assessed mental function. The Department consults widely with stakeholders and sources of public and private sector expertise, to ensure that its policies are evidence-based.

Therefore these groups featured individuals from a wide range of relevant professional backgrounds. I can confirm that there was a representative from Unum Provident on each of the groups. 

On the physical descriptor working group, of the seven meetings of which we have a record, there were four meetings which the Unum Provident representative definitely did not attend.

On the mental function working group, of the five meetings of which we have a record, the Unum Provident representative was not recorded as being absent from any of them.

If you have any queries about this letter please contact me quoting the reference number
above.
Yours sincerely,

DWP Central FoI Team