Workfare coercion in the UK: an assault on persons with disabilities and their human rights by Anne-Laure Donskoy, Survivor researcher, UK
“While there is a lot of focus on coercion organised and implemented in psychiatry, less attention is being paid to state engineered welfare measures based on libertarian paternalism, which have coercive practices at their core. Among them are policies that strongly support behavioural change using positive psychology and cognitive behavioural therapy. Freidli and Stearn (2015) call this “psychocompulsion”. These policies and measures are increasingly used to ambush and coerce persons with disabilities and the long term sick into adopting new ways of being and living conditions under the constant threat of sanctions. They have driven many to attempt to their lives. This paper builds on the work of Friedli and Stearn as an attempt to highlight current coercive welfare policies, including forcing ‘therapy’ on individuals, as human rights violation of the CRPD.”
Recovery In The Bin complained to BMJ (details below) on 3rd November 2015. They never responded in spite of being sent four e-mail reminders.
Recovery in the Bin, an Internet based group with a large following, is writing to express its disappointment and concerns about your decision not to publish a piece by ‘SECTIONED’ in 7 November 2015 issue, which focused on coercion in psychiatry. The BMJ effectively implemented a policy of censorship by demanding a number of deletions of what is regarded as legally sensitive content, as a condition for publication.
These deletions included key testimonies of service user experiences of coercion and force in psychiatric hospitals. We believe it is essential that your readership hears about the nature of this coercion, especially as detainment under the Mental Health Act has risen by 10% in England, data collected by Health and Social Care Information Centre (HSCIC).
This Group profoundly objects to the author being told that they could not mention their personal experiences of forced treatment unless the staff involved had been prosecuted. This represents a disproportionately high threshold for submission, thus preventing genuine exposure of unethical practice being aired in a spirit of openness and learning. We believe on the contrary that the BMJ should be leading the way by drawing attention to these experiences, in a truthful fashion, and we perceive the risks of being sued for doing so is very doubtful. It is in fact more likely that such testimonies would be dismissed as the expression of someone’s ‘paranoia’, ‘illness’ and ‘delusion’.
While this Group has always believed that the BMJ’s vocation was to disseminate robust research findings and experiences of shared learning, with a view to modify and improve clinical practice, it appears to us that in this instance the BMJ’s judgement is at odds with its own principles and objectives. This raises the following questions: Is the BMJ lacking foresight in its refusal to support difficult experiences that show up the failings of the mental health system? Would it act in the same way had the author of the piece been a mental health practitioner?
The government has allocated £22 million towards recruiting presenting officers at benefit claims tribunals over the next two years. The detail was buried in the Budget announced on 16th March. They claim this is to support the department in personal independent payments and employment and support allowance tribunals. The money will pay for 180 new presenting officers.
Personal independence payments (PIPs) are gradually replacing disability living allowance (DLA), which is supposed to help with the extra costs that come with living with a disability. In January next year, the formula used to calculate PIP’s daily living component will change. 290,000 disabled people will lose the payment completely and 80,000 will have their benefit cut. The government clearly expects to be fighting more claims over reduced disability benefits in the coming years.
A DWP spokesperson said: “Presenting Officers assist tribunals by giving both the legal case for the appeal, the Department’s case for upholding the original decision but also by drawing attention to any new and relevant evidence. By increasing the number of Presenting Officers, we will help ensure the right decision is achieved at each appeal.”
But there’s a problem
In its consultation paper; Proposals for the Reform of Legal Aid, the Ministry of Justice proposes to save £22 million by removing welfare benefits matters from the scope of legal aid funding. This is part of a plan to cut a quarter of the legal aid budget, with social welfare law the main target. Social security is the largest subject area being removed from the scope of legal aid after families. From 1st April 2013 legal aid was no longer available for advice on how to challenge benefits decisions.
People with mental health diagnoses often find it hard to fill out ESA/ PIP forms let alone represent themselves at tribunals. Especially those with more severe conditions such as schizophrenia. It doesn’t take much to figure that people in these situations are going to find it harder to get the representation they need.
On top of this there is evidence that the tests themselves are leading to greater stress, either exacerbating preexisting conditions or negatively impacting on the mental health of people with other disabilities. A study published by the Journal of Epidemiology and Community Health in November 2015, showed a correlation between worsening mental health and assessments under the WCA, published last week, that linked the WCA tests with a possible additional 590 suicides, increased mental health problems and hundreds of thousands of antidepressant prescriptions. Volunteers such as ours could help lessen that distress.
Here’s what we’re doing about it
We have asked Welfare trainer Tom Messere, author of the Big Book of Benefits, if he would train 20 volunteers in the basics that they will support people up to these tribunals to give them a bit more of a fighting chance. And whilst we have Tom at our disposal we are also we will be training the volunteers to help fill out the often complex and confusing forms, so that less have to go to tribunal in the first place. The training will be on ESA and PIP, form filling, getting any available medical and informal evidence correctly pitched (what the person needs to ask for), possible calls, key pointers for accompanying, and up to tribunals.
You can join us
We are hoping you can donate to help pay for the training, the venue, transport and accommodation for Tom, and as we are recruiting volunteers, many on low incomes themselves, and as we will need to have representatives in as many places as we can (sorry, we wish we could provide for everywhere) then we are trying to raise as much help for their travel as well.
This is the Mental Wealth Foundation (coalition of professional, grassroots, academic and survivor campaigns and movements) letter on ‘therapists in job centres’ plans co-signed by RITB
Mental Wealth Foundation is a broad, inclusive coalition of professional, grassroots, academic and survivor campaigns and movements. We bear collective witness and support collective action in response to the destructive impact of the new paradigm in health, social care, welfare and employment. We oppose the individualisation and medicalisation of the social, political and material causes of hardship and distress, which are increasing as a result of austerity cuts to services and welfare and the unjust shift of responsibility onto people on low incomes and welfare benefits. Our recent conference focused on Welfare Reforms and Mental Health, Resisting the Impact of Sanctions, Assessments and Psychological Coercion.
Mental Health Resistance Network
Disabled People Against Cuts
Recovery in the Bin
The Survivors Trust
Alliance for Counselling and Psychotherapy
College of Psychoanalysts
Psychotherapists and Counsellors for Social Responsibility
Psychologists Against Austerity
Free Psychotherapy Network
Psychotherapists and Counsellors Union
Social Work Action Network (Mental Health Charter)
National Unemployed Workers Combine
Merseyside County Association of Trades Union Councils
Scottish Unemployed Workers’ Network
Critical Mental Health Nurses Network
British Association for Behavioural and Cognitive Psychotherapies
British Association for Counselling and Psychotherapy
British Psychoanalytic Council
British Psychological Society
United Kingdom Council for Psychotherapy
Professional bodies scrutinise Government ‘therapists in job centres’ plans
We write in response to your joint public statement of 7 March 2016 outlining the outcome of your meetings with the Government’s new Joint Health and Work Unit and your scrutiny of the Government’s plans to place therapists in job centres .
There is no indication that any consultation has taken place with members of your organisations with knowledge of these matters nor with service users, clients and their representative organisations. This lack of consultation and opportunity for wider reflection has contributed to your organisations departing from your own ethical structures and frameworks, and being seen as agents of harmful government policy . It is by now generally accepted that the consequences of the DWP and government policy in this area are far reaching for physically and mentally disabled people on social security benefits. Inexplicably your organisations’ scrutiny of government plans has failed to recognise this.
The joining of Government Health and Work Departments is not helpful, and current DWP policy intended to reduce the socio-economic causes of mental illness to the one simple fact of unemployment is clinically and intellectually ridiculous. The resulting policy promoting work as cure, which your organisations are now supporting, is offensive and dangerous. It is wrong for therapy organisations to buy into the unthinking praise for ‘work’ that often forms part of the rhetoric of governments.
While for some clients improving employment prospects may be an objective, for many others this is not the case and may be profoundly damaging. Indeed, for some people, their mental health problems may have begun because of work e.g. through experiences of bullying in the workplace. This one size fits all approach is simplistic. Premature return to work can result in loss of confidence and relapses affecting future ability to get back to work. This can also lead to prolonged periods without benefits and no income .
You state that plans must be aimed at improving mental health and wellbeing rather than as a means of getting people back to work. These are not the aims and objectives being expressed by the people who are implementing the programme right now, involving targeting ‘hard to help’ clients who are likely to be people with enduring physical or mental health difficulties. For example in the Islington pilot project Councillor Richard Watts has stated, “We think there is much more that health services can do to promote the idea of employment for people with health conditions.” In the Islington CCG Commissioners’ report in November calling for employment services in GP surgeries to reach ‘hard to help’ claimants, they state that, “to improve the system we need to…maximise the contribution of all local services to boost employment, making it a priority for health, housing, social care and training. We need to open up how we talk to people about employment, including asking healthcare professionals to have conversations about work with patients, as part of their recovery. We need to give professionals the information and tools to help them to do this.” . For all clients, establishing a trusting relationship is the first priority, involving respecting their current needs, perspectives and autonomy.
Jobs advertised on the BACP website in November 2015 have the explicit aim of getting clients back to work and engaging with employment services e.g. “your role will include: producing tailored health action plans for each client, focusing on improving their health and moving them closer to work…generate health and wellbeing referrals to ensure continued engagement with employment advisers” . Similarly G4S advertise jobs for BABCP accredited CBT practitioners with job roles including: “Targeted on the level, number and effectiveness of interventions in re-engaging Customers and Customer progression into work” .
We respectfully submit that information about these jobs was known to all of your organisations when you issued your joint statement. This inconsistency is seriously misleading.
We are glad that you oppose conditionality, coercion and sanctions. Clearly such punitive measures have no place in the therapeutic relationship. We fail to share your reassurance from the government that these measures will not be pursued against clients. DWP have repeatedly claimed that sanctions are a last resort and only happen in a tiny minority of cases. The reality is that millions of people have been sanctioned. In the twelve months to September 2015 alone, over 350,000 ESA and JSA claimants were sanctioned . In the Employment Support Allowance Work Related Activity Group the majority of sanctions were of people who have been placed in the group specifically because they are experiencing mental health issues and research shows that benefit sanctions on people with mental health problems has increased by 600% .
It is not possible to consider this issue without considering the context of sanctions, cuts and persecution which is endemic in the current system. You fail to acknowledge that attending this proposed therapy may not be explicitly linked to conditions/sanctions but will feel so for many of its prospective clients who are on benefits. There is a structural power imbalance between job centre employees and those on benefits. With their income under threat, those on benefits will be especially susceptible to cues, suggestibility and positive reinforcement when attending job centres. Many on benefits have experienced oppressive power relations for much of their lives. Saying no in relation to an apparent free choice in this context is hugely difficult, especially when saying no has uncertain consequences  .
Attempts to coerce people into work are detrimental not only to their health but to their safety and, in many cases, present a risk to life. The extreme fear and distress caused by the current welfare reforms, including changes in disability benefits and the new Work Capability Assessments, is widely reported including instances that have led to suicide . Therapy alongside this coercive system breaches the ethical principle of non-maleficence.
You state that there must be choice as to location of therapy. There is a clear danger in putting DWP representatives into GP surgeries, community centres and food banks that are seen as safe havens for people on low incomes and benefits. The presence of DWP compromises this. DWP/Maximus workers in the GP surgery, with access to medical records, will serve as a deterrent to people visiting their family doctor. The model currently in use in Islington allows Remploy/Maximus workers to access and write into GP records; this jeopardises any commitment to client privacy and confidentiality .
The choice of method of therapy is an illusion and therapists of all modalities are subject to the stresses of an unjust target driven culture . We are concerned that under-qualified and inexperienced staff, such as job centre coaches, will be in a position to make referrals to Health and Work programs. This is exacerbated by the fact that referrals are likely to be to IAPT workers, many of whom themselves lack in-depth training and experience of severe mental health issues. Inappropriate referrals are increasingly likely in a target-driven culture.
We are not reassured that the feasibility trials planned by the government will contribute to knowledge and understanding and are not reassured by your echoing what government is saying. Instead you and government must listen to the voices of survivors who describe the reality of government plans on their lives and are fighting for services with a vision of humanity beyond work .
It is clear from your public statement that you have failed to critically examine and scrutinise the ongoing activities of the Government Joint Work and Health Unit. We call on you to cease your engagement with this unit and instead hold a national stakeholder event which is guaranteed to involve the participation of representative organisations for service users and therapists with direct knowledge of the area, as well as professional bodies like yours. There should be no government involvement in such an event. From it, a representative group can be selected that will adequately represent the views of service users and therapists to the appropriate government departments as well as to the opposition.
A speech by Denise McKenna from the Mental Health Resistance Network (MHRN) at the “Welfare Reforms and Mental Health – Resisting Sanctions, Assessments and Psychological Coercion” conference on Saturday 5 March 2016, organised by MHRN, Disabled People Against Cuts and Alliance for Psychotherapy
I’m so pleased we are having this day to talk about, and to plan, our resistance to the neoliberal Welfare Reforms that are being imposed on us. We all know how much suffering they are causing. As well as planning strategies we want to explore how mental health service users, or survivors as we call ourselves, can campaign most effectively with psychologists, therapists and other mental health professionals. This might include how we interact together and how we best use our unique experiences, skills and positions to strategise our resistance. Perhaps we can explore how we cope individually with having this repugnant ideology forced on us in what is fast becoming a totalitarian society. For some benefit claimants coping can literally be about staying alive.
To set the ball in motion for this conference I want to say something about how the campaigning issues of survivors have changed in the past decade or more. I am speaking from the perspective of a survivor and a benefit claimant. I want to take you back to the early 1990s when I first became involved in the survivor movement after a few unhelpful admissions to psychiatric wards. As you might know, the survivor movement opposes the medical model of mental distress and has been campaigning for decades for care to be provided from the perspective of a social model. We have also been fighting the power imbalance between healthcare provider and service user, an imbalance that is enshrined in law; I’m referring to the Mental Health Act. This imbalance was compounded for me by the fact that I am working class and many psychiatrists and psychologists are middle class. Anyway, whatever our backgrounds, survivors who rely on benefits are usually living in poverty.
I was a member of the hospital user group then and had become an expert in the minutiae of inpatient life. In about 2004 I went to a Labour Party meeting with a fellow survivor to ask the councillors to visit the acute psychiatric units which were in their constituency to see how bad they were. One councillor was sympathetic so we arranged to meet her in the hospital user room and show her around. When she arrived she wasn’t alone; she was with a senior hospital manager. The councillor’s attitude towards us had changed; she no longer wanted to see the wards. She was hostile and told us we should be out working instead of, I quote, “sitting around smoking and drinking coffee all day”. As it is, I have never smoked and don’t drink much coffee, although it’s commonplace for survivors to be accused of excessive smoking and caffeine consumption. There is some truth in that accusation; I think it’s called self-medication. Anyway, from her behaviour I knew that something significant had changed.
Soon we were being bombarded with back to work propaganda from the New Labour government. Our local MP, Harriet Harman, even came to the hospital to give us a lecture on it.
I had worked in the past but in recent years had been a revolving door psychiatric patient. No one at the hospital was suggesting that I return to work; on the contrary they were busy sectioning me and giving me drugs and ECT. Anyway, I knew that I was now in a predicament; unable to work and uncertain that my benefits would continue. I wasn’t the only one in this predicament. In the mad community people come and go, some leave the system and move on, some kill themselves and others stay for a long time.
There was soon widespread panic about the back to work sword of Damocles hanging over our heads. The survivor movement had been looking inwards, preoccupied with psychiatry. We were suddenly confronted with the outside world and it seemed at the time that the fight against organised psychiatry had to be put on the back burner.
Soon, the user group was closed down and user involvement was controlled by managers at the hospital which was now a Foundation Trust. Over time day centres closed while the press were going crazy demonising us for being scroungers and liars and we were still being pumped full of powerful drugs. Loads of people were discharged from secondary care and left without support. People were isolated and in 2008 many started losing their benefits.
In 2010 the Tory/Lib Dem coalition came into power and we knew things were set to get much worse. That December a couple of us called a meeting with other survivors and we formed the Mental Health Resistance Network. At first we were just campaigning to have the Work Capability Assessment (WCA) scrapped, thinking this was our main problem. We took the DWP to court in a judicial review which was about them taking responsibility for obtaining further medical evidence for mental health ESA claimants. We won the case, although not in its entirety. The WCA was found to “substantially disadvantage people with mental health problems” but there was only a recommendation for the DWP to remedy this disadvantage, not an order to do so. The DWP agreed to set up a pilot to test the suggested reasonable adjustment to remedy this disadvantage. Two years later we are still waiting for this pilot to start.
During the court case the DWP fought hard against us but at the same time they did passport loads of people into the support group of ESA. All the indicators are that this happened for two reasons, one, because Atos was struggling to keep up with its workload and two, because questions were being raised in court about the low numbers of people being put into the support group, so even though we haven’t yet changed the WCA lots of people did benefit from the case. It was a strike against the enemy that hit two important targets at the same time, one we were aiming at and another unexpected one!
Eventually we linked up with campaigners with physical disabilities, however we felt like phoneys; many of us didn’t identify as disabled. Also, we had slightly different issues with developing our own social model. Nonetheless it was one good thing to come out of all this; we were finally out of the isolation of the psychiatric system, at least as campaigners.
I mention this history because I want to emphasise the enormity of the shift we have already made in campaigning. We are now out in the world standing side by side with other oppressed people. We always knew that the medical model of what they called mental illness was based on denial of the social context of our distress and that that denial served a political ideology. We knew that mental distress was caused by social factors, poverty, discrimination, domestic abuse, bullying, and so on and we weren’t convinced that the chemical imbalance in the brain story was the whole story or even any part of it. We also knew that the big pharmaceutical companies were behind a lot of the drug pushing. We were arguing for our pain and madness to be contextualised.
As the attacks on the welfare state started to come fast and furiously, the wider political context of psychiatric abuse came into view more clearly. Now the causes of all our problems were deemed to be due to something within us as individuals, not just the biochemistry of our brains but our rotten genes, our stinking thinking, our moral failures, our bad attitudes, our laziness, and our choices, above all it was about our choices. Bear in mind that this refers to many people who have suffered sometimes horrendous abuse and misfortune as children; to talk about choices is the ultimate insult.
Psychiatry had been unable to bring an end to much mental distress. It wasn’t curing us. Survivors came up with a Recovery Model which was about finding fulfilment in our lives on our own terms. However this model was stolen from us, transformed, and used against us. It is re-presented to us as being about changing our attitudes and all the other negative things we are guilty of. The sole purpose of the Recovery Model now is to move us away from the benefits system and pretend we are moving towards work. It has no therapeutic purpose.
Recovery could now be interpreted as a drive for conformity which means being compliant in our own subservience to neoliberalism, to be grateful to our oppressors, submission and humiliation being built into this notion of recovery. There’s a Mickey Mouse Recovery Star used to measure the areas of our lives that we have to work on to get better, apparently it measures our progress. People are resisting this twisted version of Recovery, I’m thinking of the Recovery in the Bin group, and there is a growing Mad Studies movement now. RiTB has come up with a brilliant Unrecovery Star that measures all the social causes of mental distress.
I am not an academic or a political expert. I am just one of the people that the neoliberals have little need for other than as part of a reserve workforce to be used to drive down wages and working conditions, and as a possible example of what can happen to you if you don’t submit to the demands of their preferred society. I am fighting for my life and for the lives of my friends. But I hope it doesn’t sound too dramatic if I say that I am also fighting for what it means to be human and to be civilised, for how we value ourselves and each other. I am fighting against the lie that the only value to be found in our lives is as workers making the rich even richer. We have higher purpose than that.
So let’s just recap on the position we find ourselves in. Conditionality means that if we don’t perform impossible tasks we are sanctioned and face destitution. And the benefits system is now conflated with healthcare. First our distress is decontextualised, it always has been, and then we are then told that one of the consequences of our distress, our unemployment and need of benefits, is the source of our distress and not a consequence of it. Our unemployment is now the context that affects our mental health, so having first been removed from its social context, our distress is now being re-contextualised into a false social context. It is our unemployment that now needs to be cured. When we see our healthcare professionals we are guarded in everything we say and do; we are walking a tightrope. We have to pretend we believe in something we know to be a lie. We have to fake feeling positive even when we are suicidal; pretend all we want to do is work when what’s really on our minds are terrifying thoughts, voices and strange experiences. On the one hand we have to show a positive attitude not to be sanctioned while on the other we have to talk about how bad we feel in order to try to get the money we need to survive. And all the time we have to make a show of loving our abuser who we really hate. It’s a complete head-fuck! We are being driven mad.
By turning psychology and the caring professions into weapons of abuse the government is trying to destroy the institutions that help to uphold our values, our empathy and respect, and even our love for each other. As though it’s not enough that they want to abuse us, they want to delegate the abusing so that we abuse each other. We have to fight to save the integrity of these professional and academic disciplines. I don’t think it’s too extreme to say they are trying to annihilate our humanity.
Anyway, back to the here and now! It is an honour to have the opportunity to work with psychologists, therapists and other professionals. In the past, for many of us, our dealings with professionals have often taken place within the power imbalance I mentioned earlier, with us as the weaker partner. We must remind ourselves that we are now working together as equals with professionals while at the same time remembering that society still sees us as lesser. Our views don’t seem to hold as much weight. The professionals’ area of expertise is still deemed more valuable than ours. Sometimes the system has even tried to infantilise us and society has only been interested in our lives as sensationalism, a kind of prurience. Part of the battle for us sometimes is just being able to hold our heads up high.
I know the professionals here today do not want a power imbalance, you want a true partnership and we welcome that. We are all harmed by the systems that support capitalism. It is not just benefit claimants who have something to lose if we fail to jump through degrading hoops; professionals are at risk too, we need to be aware that there are many people who feel they can’t put their head above the parapet for fear of losing their livelihood. It would be too easy for those of us who are unemployed to feel that our suffering is worse. We may be closer to the edge than those who are able to work, but we are all vulnerable.
Neoliberalism has been proven to be a failure for the majority of people and the idea of personal culpability, decontextualising everything in our lives, is central to forcing people to accept something that is harmful to them.
We can continue to speak up to try to bring about the mind set changes that we all want and that is an ongoing activity that we are all engaged in. I still like the old fashioned term, “consciousness raising”. We can also make the imposition of their ideology on us impossible to manage. We need to become impossible to manage. Finally we need to be realistic, live in the day and try to help those at risk to survive the assaults.
Today is a day to begin planning our strategies of resistance and I know there are loads of great people with brilliant ideas here in this room. I think it’s going to be a fantastic conference, I’m really excited. Thank you.
Mental Health Resistance Network (MHRN)
The concept of “mental illness,” arguably like all concepts of disease and in fact the whole of human language, is a social construct. Unlike single-issue anti-psychiatry groups RITB sees the medical model in social, political, economic and historical context rather than as an autonomous entity. Accepting or rejecting social constructs, which to some extent we rely on, depends entirely on whether these constructs are any good or not. Some of us are very sceptical about the medical model but would NEVER make light of the reality of emotional distress and human suffering just to try to undermine this model because we know from personal experience that these things are all too real. Many of us reluctantly take medication, but see SOCIAL issues like welfare, housing, and appropriate forms of support as our priority issues RITB has space for debate – that’s part of what it’s for – as long as its members broadly accept its principles.
Which brings us on to UnRecovery. Who doesn’t want to recover, feel better, negotiate the world/life with greater ease? Taken from our principles:
We believe that the term ‘UnRecovered’ is a valid and legitimate political self-definition (not a permanent description of anyone’s mental state) and we emphasise its political and social contrast to ‘Recovered’. This doesn’t mean we want to remain ‘unwell’ or ‘ill’ but that we reject the new neoliberal intrusion on the word ‘recovery’ that has been redefined, and taken over by market forces, humiliating treatment techniques and homogenising outcome measurements.
We are not malingerers, time-wasters,or any other patronising, condescending, dismissive term that is commonly used to describe those of us who don’t recover in the allotted time-limited, compassion-restricted, resource-poor format. We are however resistant, we resist the prevailing ideology, we resist neoliberalism and its implications for mental health services and we resist being shoved on the recovery conveyor belt – we simply don’t fit there.
UnRecovery is about saying we don’t all recover, or perhaps we don’t recover in the way expected of us, and that is ok if we are allowed and facilitated to live our lives as we are. We don’t say that no one can recover (or other preferred term/phrase/concept) or everyone can or should, but the dominant discourse OBLIGATES everyone to do so and in a prescribed format that makes it the flip side of the medical model coin, it’s just another tyranny, a more insidious tyranny. It’s pretty easy to argue against being chemically coshed, but it’s hard to argue against being ‘well’. What the medical model and the recovery model have in common is that both are a process of reducing the social and political down to the individual, blaming them for their distress while ignoring the material realities of their lives.
A paper just published in British Journal of Psychiatry Open has met with criticism and anger in some quarters. The paper, co-authored by Sebastião Viola and Joanna Moncrieff, prominent members of the Critical Psychiatry Network, analysed trends in claims for sickness benefits from 1995 to 2014 using data from the Department of Work and Pensions (http://bjpo.rcpsych.org/content/2/1/18 ). They examined changes in the prevalence of claims attributable to mental disorders compared with other major categories of medical condition and changes in long-term claims. They found that the number of people claiming benefits for more than 5 years had increased since 1995, largely because of a rise in long-term claims for mental disorders. In contrast, claims for other disorders such as musculo-skeletal conditions fell, with the result that mental disorders are the largest single medical cause of benefit claims, accounting for almost half of all claims in 2014.
Critical comments appeared on the Council for Evidence Based Psychiatry’s website (see http://cepuk.org/2016/01/25/new-study-shows-disability-claims-for-mental-disorders-in-uk-has-doubled-over-past-20-years/ ), where a link to the paper appeared, and on the anti-austerity critical mental health survivor Face Book page Recovery in the Bin (RitB). For example, one commentator notes that the paper ‘…isn’t helpful in the current climate where MH claimants are being targeted with impunity & the problems that people have are also rooted in the society they live in, as for “less stigma” [an argument developed in the paper] you have to be joking you really have taken your eye off the ball to state that.’ (my emphasis) A comment on Recovery in the Bin (RitB) observes that ‘…when social justice is at an all time low…all social support demands people are on meds at least on paper, and our govnt [sic] is targeting people with a mental illness dx [sic] who are claimants. They won’t look at this and think maybe we should fund different sorts of services, it will just be another stick to beat people with.’ A person with disabilities and mental health problems points out that ‘It seems that there is a campaign against the idea of people with mental health problems being classed as disabled under the Equality Act and therefore receiving ESA and PIP. Unfortunately it all seems to result from underlying stigma of mental health problems and the idea that we are not *really* unwell or disabled in the same way that people with more visible health conditions or illnesses may be.’ Another person comments that ‘An economist at the Kings fund said to me once pompously [sic]… the key to being able to provide more services (he meant health care) was to increase productivity in the economy. So I asked him “what if the things that increase productivity… longer hours and more work… are the things that make people sick?” He went glassy eyed and wandered off to spead [sic] more of his productivity gospel…’
These comments raise a number of questions. First, why was this study undertaken? The authors say that since the changes to the benefit system introduced by the last Labour government in 2008 there has been no systematic study of the impact of these changes, aimed at encouraging long-term benefit claimants back to work, in the UK. Indeed the paper’s opening sentence refers to the cost of benefit support for long-term sickness being an international concern.
This raises the question of power. The mighty, the privileged, and those who have a voice are seen to be bearing down on and pointing the fickle finger of morality at those who are powerless, under-privileged, and who are voiceless. I am certainly not accusing the authors of this paper of making moral judgements about the subjects of their study, but it is important to recognize that the wider context is one in which others are already doing so.
This raises another issue. The NHS has an extensive system of ethical checks and balances through Multi-centre and Local Research Ethics Committees, who scrutinize research on NHS patients to safeguard their interests and safety. There is however no reference in this paper to ethical scrutiny (there usually is in papers published in medical journals). The authors will doubtless argue that NHS ethical scrutiny was unnecessary because their data originated not from NHS sources but from the DWP (though a freedom of information request). If that’s so, then perhaps the NHS needs to consider extending its ethical scrutiny to such work.
What worries me most of all about this paper is its failure to contextualise the study politically. Here, I’m referring to the impact of government austerity policies on income and other forms of inequality. We know that the UK has the second highest levels of income inequality in the Global North, second only to the USA. We know that income inequality is very closely related to a broad spectrum of physical and mental health problems, indices of family and social dysfunction, and long-term unemployment. Yet there is no reference in the paper to austerity and inequality. Instead it argues tamely and unconvincingly that the increase in the proportion of benefit claimants with mental health problems arises from the success of anti-stigma campaigns making it more socially acceptable for claimants to admit to mental health problems. Yet they adduce no evidence to support this.
Maybe those of us who are critical of this study are mistaken. I’d like to imagine it’s the first in a series of well thought out papers from critical psychiatrists criticizing the benefits system, and that next the authors will turn their attention to the ideology of neoliberalism that many of us consider to be the principle author of inequality and the widespread social injustices that spring from this. Joanna Moncrieff’s work is rightly highly regarded. In the past she has demonstrated great integrity and courage by publishing important papers and books that challenge and question what in my view is the harmful dogma that masquerades as psychiatric theory. She has also published thoughtful critical papers on neoliberalism, biomedical psychiatry and the pharmaceutical industry in the past.
This paper is an aberration, but perhaps this is what happens when you try to publish your work in a mainstream psychiatric journal. The British Journal of Psychiatry would after all be most unlikely to publish a paper analyzing trends in benefit claims from people with mental health problems against the context of neoliberal austerity. But then consider the implications of this paper as it stands; how will it be interpreted by policy makers, politicians and government? This is another reason for more careful ethical scrutiny of research undertaken by NHS employees on NHS patients using data that has not originated from NHS sources. Sadly, in my opinion, it would appear to be a case of un-critical psychiatry.
What disability benefit trends tell us about psychiatric treatments and the economy
joannamoncrieff / January 29, 2016
Sickness and disability benefits are a hot topic in the United Kingdom at the moment. The government’s new system means that everyone’s benefit entitlement is being reviewed, and this is causing huge stress and anxiety for many people, including my patients. Some people have suggested that for this reason, I should not have published the recent paper on trends in sickness and disability benefits that I published with a colleague, Sebastiao Viola (1, http://bjpo.rcpsych.org/content/2/1/18.) It was unethical and should not have been allowed, apparently (2, http://www.philipfthomas.com/index.php/blogs/28-un-critical-psychiatry), even though almost all the data is already in the public domain – on the Department for Work and Pensions’s website – in the name of transparency.
But we cannot simply ignore or suppress such a seismic shift in social trends. When I looked at benefit statistics in the 1990s, musculo-skeletal disorders (principally back pain) were overwhelmingly the biggest and fastest growing cause of receiving what were then called incapacity benefits, and cardiovascular disorders were the second most common cause in men. In 1994-1995, mental disorders accounted for just 20% of days on which benefits were claimed (3, http://jpubhealth.oxfordjournals.org/content/22/1/59.long).
Since that time, mental disorders have far outstripped all other types of medical conditions and become the leading cause of claiming sickness and disability benefits. While the number of people claiming benefits for other medical conditions fell by 35% between 1995 and 2014, the number of people claiming benefits for mental disorders more than doubled. In 2014, 47% of all claims for disability benefits – almost half- were made by people whose primary condition is a mental disorder. 1.1 million people in the UK, or 2.7% of the working age population, claim disability benefits due to a mental disorder (4). The costs to the individuals who are unable to support themselves, and to the society as a whole, are huge.
These figures are important for what they tell us about the success or otherwise of current approaches to helping people with common mental health problems, and for what they say about the economy, and the nature of modern work.
I started looking at disability benefits back in the 1990s in order to find some objective measure of the performance of people diagnosed with depression Depression and anxiety disorders account for the majority of disability claims by people with mental disorders. In 2014, almost half (44.2%) of disability benefits awarded to people with a mental disorder were for depression and two thirds were for depression or anxiety (66.8%) (1). These proportions have not changed much since the 1990s.
In the early 1990s, campaigns like the Defeat Depression Campaign publicised the message that large numbers of people were depressed without knowing it, and that they should go and get the new and wonderful antidepressants that had just come onto the market (the SSRIs of course!). Since that time, the use of antidepressants has increased four times! In England, prescriptions have risen over 10% a year since 1998 (4, http://bjp.rcpsych.org/content/200/5/393.long).
If antidepressants are effective, and people with depression are more likely to be prescribed them, then you would expect the consequences of depression to start to lessen. One of those consequences, according to government statistics, is being out of work. But what we see is quite the opposite: Increasing use of antidepressants correlates with increased numbers of people with depression who are out of work and claiming benefits, and increasingly on a long-term basis. And this is at a time when disability due to other medical conditions has fallen.
The idea that conditions like depression and anxiety can be quickly and effectively treated with medication or short courses of therapy that re-adjust your thinking is not borne out by the evidence. Rather than helping people improve their lives and get on their feet again, this approach seems to create ever rising numbers of people who are viewed, and may come to themselves, as chronically sick. Far from helping people towards a meaningful recovery, taking an antidepressant may simply be a daily reminder of the idea that you are permanenelty flawed.
One of the ways our current approach is wrong is that we are looking for the problem in the individual- inside the brain. Instead we need to ask what it is about our society that means that so many people feel too unhappy, worried or mentally frail to work. Having a ‘decent’ job is an incredibly important part of people’s lives, and most people want one. Research shows that even people with severe mental disorders would like to be in work, if they could (5,6). A good job is a source of satisfaction, purpose and camaraderie. People without work easily lose confidence and become socially isolated.
Fewer and fewer ‘decent’ jobs exist, however, especially at the unskilled end of the jobs market. Most jobs, even fairly menial ones, have become increasingly competitive and demanding, with performance targets and micro-management. I heard one radio journalist describe how he had attempted to apply for a job as a local petrol station attendant. He had to complete complex questionnaires designed to assess his levels of motivation and dedication, as if the application were for a high flying executive position. Despite his University education, he failed miserably to qualify, and wondered how anyone without a degree in management consultancy was able to get shortlisted.
Unskilled jobs have either gone altogether, or have become increasingly casualised. With the increase in agency work and zero-hours contracts, there are fewer jobs with paid sick leave and holidays. For these reasons, some analysts have referred to the problem of ‘disguised unemployment,’ indicating that many disability claimants are willing and able to work if suitable employment opportunities existed (7). But they need jobs that will accommodate the fact that they might not always be performing at 100% efficiency (like everyone, of course), and they might need to take time off occasionally. They need understanding employers, who respect and value their contribution, not agencies which can simply hire someone else.
Working in a highly pressured, insecure and competitive situation is bad for everyone. Rising disability benefits are a sign that we need to do something about modern employment conditions. We need to provide more opportunities to work in a supportive and accommodating environment. This is especially important for people with mental health problems, but it would benefit us all.
4) Do not under any circumstances harm yourself. (This will more than likely be seen as a) manipulative b) attention seeking c) a communication of your distress caused by your underlying PD).
5) Do not make statements, which can be interpreted as black and white thinking. For example, the nurses all hate me. Try instead to make unrealistic, robot like, rational statements such as ‘Enid, Mary, Silvia, John, Mark and Boteng have all shown epic disdain at my presence on the ward, but an agency nurse once smiled at me in 1992.’
6) Do not admire or pin any hope to a professional who appears to understand the social context of your distress (this is idealization, my dear).
7) Do not complain about anything. Ever.
8) Try to avoid working with professionals who look a bit tired. If they eventually go off sick you will inevitably be blamed for this. (Of course, because you are a difficult patient).
9) Things you can talk about: how medication is helping you, mood swings (BUT only extreme ones that last long enough to fit within a diagnosis of bipolar, that’s an ok one as Stephen Fry made it a bit edgy), Do talk about how much the system is helping you, be eternally grateful to every professional you meet, tip your hat slightly to the side and say the words ‘thanking you kindly for your ‘help sir’.
10) Things you should not talk about: Abuse – of any kind, patterns in your relationships because of this abuse, existential dilemmas, perceived flaws in the system or anything to do with individual staff members.
11) You never ever; over/under eat, drink, exercise, and are never impulsive with sex, shopping, driving and you LOVE being alone.
12) If you are from cultures seen as “traditional”, never say you even think about sex unless you are in a proper family approved heterosexual marriage.
13) To avoid BPD diagnosis you must not point out that the psychiatric teams are blaming you for their own inadequacies, their ‘externalised locus of control’ and ‘refusal to take responsibility’.
14) Do not tell the psychiatrist you think you may have PTSD. (Don’t be stupid now, everyone knows only soldiers can get this, are you a soldier?).
15) Try somehow not to be addicted to medication you are forced to take. Prepare yourself to be accused of lacking in coping skills when addiction inevitably does happen.
16) Talk with enthusiasm at the idea of being abandoned. Relish the idea whether it’s real and/or imagined.
17) If you attempt suicide make sure you are successful or it will be deemed attention seeking.
18) If you do by chance happen to self harm, make sure it is a life threatening, Stephen King style canyon of a gash, anything less than this will be clinically defined as ‘superficial’ adding to the likelihood of the PD label being applied.
19) BPD diagnosis is a mirror to professionals’ behavior, described as the personal characteristics of the service user.
20) Never phone the crisis team and say you’d like another visit (tick box dependency issues).
21) Hide any teddy bears or suchlike when they come round to visit (“too childish”).
22) Never refer to your psychiatrist’s affection for the DSM as ‘ideas of reference’…
23) When they suggest cutting back on support, appointments etc, pause and think and then say, “yes, that’s good, I feel I am ready to be more independent”.
24) Be attractive but not ‘coquettish’.
25) Do not at any point mention that you sometimes question who you are. You should know exactly who you are, be definite, unchanging about this (only people with PD ever question their identity
26) Do not change your hair colour too frequently. This will be interpreted as evidence of the above.
27) Always repeat when questioned that your attachment with your mother & father was always loving and supportive.
28) All depression, voice hearing and suicidality is ‘pseudo’ so please ensure the death certificate is recorded as ‘pseudo death’ and according to Joel Paris MD it was a ‘career’ so make sure your CV is updated posthumously.
29) Remember that inequality does not exist; it is your perception that is flawed.
30) Never, if you can manage it, express anger to MH professionals. Even when it’s understandable, genuine and valid!
31) The appropriate response following an OD to the question ‘how much did you take’ is ‘clearly not enough’. This is also likely to get you sectioned.
32) Never become a ‘skilled’ Service User. Understanding the games that nurses play will only get you described as ‘playing games’.
33) Your mental health team believes in its adequacy, despite all evidence. Do not do or say anything that threatens professionals’ fixed delusional beliefs, they may ‘decompensate’, becoming either coldly punitive and violent or weirdly smiley and dissociative, forcing you to have too much ‘service’ and then none at all.
34) Don’t ever ask a MH prof to ‘see you all the time and kiss your cuts better’ (as stated by a PD expert).
35) Act dumb as intelligence is viewed as a facet of PD (unlike psychosis where it’s assumed you’re less intelligent).
36) Failure to respond to medication or recover (or the CMHT needs to reduce numbers with discharges) means reclassification to PD.
Another Disclaimer: “You do not have the right to say anything without it being used against you. Anything you say can and will be used against you. You have the right to legal assistance. If you cannot afford legal assistance, you are buggered. Do you understand the rights I have just read to you? With these rights in mind, do you wish to engage in our therapeutic relationship?”
Shaw, C. & Proctor, G. (eds.) (2004) Women at the Margins: Special Issue on women and Borderline Personality Disorder. Asylum magazine 4(3).
Sulzer (2015) Does “difficult patient” status contribute to de facto demedicalization?
Joel Paris: Half in love with easeful death: https://drive.google.com/…/0B2o15rQwZLh7MlRjc2F…/view…
Linehan: https://www.nimh.nih.gov/news/media/2011/linehan.shtml For the research funding she had to choose between BPD and Major Depression as the named mental disorder – she chose BPD, the diagnosis was attached to fit the intervention for the funding. She wanted the most difficult & challenging patients. So who was in the control group?
Members of Recovery in the Bin have been writing to NHS Choices over their liver transplant page which stipulated that people dx with psychosis/bipolar wouldn’t receive new livers due to ability to follow the regime of follow-up appointments & immunosuppressant meds. Members challenged this and NHS Choices replied by the following:-
“Thank you for contacting us regarding the liver transplant topic on the NHS Choices website.
The section about mental health conditions you refer to is talking about the patient’s ability to follow the regime of follow-up appointments and immunosuppressant medication needed after a liver transplant.
No mental health condition, including bipolar disorder, will automatically exclude someone from having a liver transplant – but an assessment will be necessary on an individual basis to determine whether the condition is severe enough that it might impact on their post-transplant care.
We only mention bipolar as an example because some studies have looked at this issue specifically.
However, after reconsidering our information, we have decided to remove the examples of mental health conditions from our liver transplant topic, as it’s more the severity that’s important, rather than the specific condition. By only giving a couple of examples, we think it could potentially be misleading.
Thanks again for bringing this matter to our attention. We hope this response has been helpful.
Dear Luciana Berger – Shadow Minister for Mental Health, England and Wales.
We are writing to you to raise our concerns and priorities for Governmental Mental Health care and provision in the UK. We enclose the first of a number of our “position statements” that we intend to send to you.
We are a User Led Mental Health Activist Facebook Group campaigning for Social Justice and Equality in MH care and practice, with a focus on critiquing and challenging mainstream ‘recovery’ ideology. At the time of writing our membership stands at 474 and this is growing by the day.
We believe ‘recovery’ has been colonised by MH services, commissioners and policy makers. We reject the new neoliberal intrusion on the word ‘recovery’ that has been redefined, and taken over by marketisation, language, techniques and outcomes. Some of us will never feel “Recovered” living under these intolerable and inhumane social pressures.
We believe access to quality housing and disability benefits designed for mental health claimants would give people a stable and secure environment to raise their quality of life and health. This would enable efforts towards going back to study, work IF people choose / aspire to this. Allowing people to volunteer indefinitely and claim benefits if this improves their quality of life and MH – and recognise how valuable this work is to society.
Our first “position statement” is about the Welfare State and Social Housing.
We will cover the following issues: –
Work Capability Assessment (WCA)
Personal Independence Payment (PIP)
CBT in Job Centres
Social Housing & Homelessness
We look forward to hearing from you about the matters we have raised.
Recovery In The Bin
Copy: Jeremy Corbyn MP and Leader of Labour Party.
John McDonnell MP and Shadow Chancellor.
Owen Smith MP, Shadow Secretary of State for Work and Pensions.
Mental Health Resistance Network.
Social Workers Action Network (SWAN).
Psychologists Against Austerity.
Critical Mental Health Nursing Network (CMHNN).
Critical Psychiatry Network.
Disabled People Against Cuts (DPAC).
The Peoples Assembly.
Welfare State and Social Housing
Work Capability Assessments (WCA)
The Work Capability Assessments (WCA) for Employment Support Allowance (ESA) appear to be weighted in favour of those with physical disabilities, and often fails to take into account fluctuating conditions, common to mental distress, such as anxiety and depression.
Access to welfare advisors and advocacy workers has been severely reduced due to cuts to funding, services and the legal aid budget.
We are aware of a number of deaths related to the “reforms”, including recent reports that a coroner has ruled that the WCA contributed directly to the suicide of a claimant, and that steps need to be taken by the DWP to prevent further such incidents. (The Independent 20.9.2015).
We believe the WCA needs to be abolished as a matter of urgency.
Sanctions remove the very means of existence, and as a consequence the related death toll is rising.
Those in the ‘Work Related Activity Group’ face huge cuts to their benefits in the near future, even if they manage to avoid being sanctioned.
Personal Independence Payment (PIP)
PIP is not MH orientated and self-harm/suicide risk factors have been removed from criteria.
MH claimants struggle to obtain the necessary medical evidence because MH services are now short term, and once discharged no specialist reports can be secured.
Loss of DLA/PIP to MH claimants who are not in receipt of ESA because they’re doing some part-time work or self-employment will be rendered unable to continue working or plunged into poverty, being under immense pressure to work more hours, which could lead to mental distress and deterioration.
There are approximately 700,000 vacancies and 2 million (possibly more if you count those who are sanctioned/on Workfare) applying for those 700,000 vacancies, therefore the maths don’t work here.
It’s evidenced that Workfare doesn’t work and only provides massive profits to private companies using public funds and plunges more people into sanctions/food banks.
MH claimants have been and are being targeted as the ‘low hanging fruit’ (their description) in the full knowledge that MH (and Learning Difficulties) has the lowest employment rates.
Temporary and zero contract hours shift work is evidenced as being bad for anyone’s mental (and physical) health, but this looks set to become more common for MH claimants who are at threat of sanction/workfare.
We often carry out highly valued long term voluntary work within Trusts, University’s and Charities, so chosen voluntary work (with appropriate evidence) needs to be considered as an additional outcome to employment, as for some people that’s the most ‘doable’, maintaining the best ‘stability’.
Voluntary work gives a person greater flexibility, and provides less pressure to work when s/he is not feeling up to it.
MH claimants have had benefit claims stopped/reviewed for doing voluntary work (even when organised by own MH Trust & MH professionals have had to intervene by advocating that it’s part of their treatment).
Cognitive Behavioural Therapy (CBT) in Jobcentres.
We believe getting back to work, especially after many years of unemployment, due to MH complexities, is unlikely to be resolved by a “quick fix” such as CBT.
Many of these initiatives are being piloted in Labour controlled authorities. For example, in June 2015, Service Users protested outside the Streatham Job Centre, which had been identified as a site for trialling the introduction of CBT inside Job centres.
Social Housing & Homelessness
Some Councils/Housing Associations are losing over 90% of their stock, and letting agencies/private landlords don’t want tenants on housing benefit. This is a significant factor with respect to the increasing levels of homelessness that should not be acceptable for any Government.
Very vulnerable mentally distressed people are ending up sleeping rough because of refusal to join groups in high support mental health housing, which means they have refused an offer of housing and are deemed voluntarily homeless.
Dear Recovery in the Bin Group,
Thank you so much for taking the time to get in touch with me.
Firstly, I want to apologise for the delay in getting back to you. Since my new role was recently announced I have been inundated with hundreds and hundreds of emails from people getting in touch to share their stories, and I want to get back to everyone individually.
I read your letter and your position statements with interest as I share many of the same concerns. The Labour Party has made a commitment to take a cross-departmental approach in addressing mental health challenges, and this is especially true when it comes to the impact of DWP policies on mental health. Many of the emails I have received since my appointment echo this.
Just before Christmas I opened Labour’s Opposition Day Speech on mental health, and highlighted a number of the things you mention in your letter, including capability assessments and benefit sanctions, and the fact that a majority of people on the Work Programme told Mind it made their mental health worse. You can watch it here.
I have also been using Parliamentary Questions to probe the Government’s policies, including on the services in Job Centres that you mentioned.
Currently, I am working with John Healey to ensure Labour’s policies on housing and homelessness are developed with mental health in mind.
The point you raised about volunteering having a detrimental impact on welfare claims is a concerning one, and something I plan to ask the Government to clarify their position.
My immediate priority is to hold ministers to account for their broken promises on mental health, and to speak up for people who are being let down. Thank you for sharing your ideas with me which I will feed in to the work I continue to do to hold the Government to account. We must work together to tackle taboos, challenge stigma, and redesign services to match the needs of so many people.
In the coming weeks and months I may circulate updates of what I have been doing in my shadow ministerial role on mental health. Please let me know if you would not like to be included in this mailing list.