January 6, 2008
Is Britain going mad?
Mental illness can be a terrible affliction. It can drive those suffering from it to despair – even to suicide. I can also drive those affected by it, as loved ones of the afflicted person or as carers for yo, to despair – even to suicide. Because it can be such a terrible disease, it is important that it does not get trivialised by over-egging the problem. Because it can be such as terrible affliction, it is important that the treatment offered be the best one available, and that that such treatment be available regardless of ability to pay. The notion that a quick, cheap and easy fix is available is, well, madness.
Mental illness can be hidden or faked
Many varieties of mental illness, especially depression and manic-depressive illness are not easily diagnosed, even by professionals. This means that it is often possible for those truly ill to hide their condition, if it is advantageous to do so for professional, reputational or other reasons, such as being engaged in an adoption process. It is also possible for persons who are not mentally ill to fake it. There is enough information readily available on the web for anyone with an IQ in triple digits to put together an appropriate package of symptoms that will suitably impress a GP, psychiatrist, psychiatric social worker, psychologist, analyst or other therapist. Lower back pain is the only other medical condition that can be faked as easily.
Many people tell lies easily and effortlessly
Much of economics is based on the assumption, verified daily and universally, that almost everybody responds predictably to simple selfish material incentives. It also is clear that many (most?) people view honesty as a tactical option rather than something intrinsically valuable. They lie if it is to their advantage to do so. If you don’t lie it’s not because lying is wrong or sinful, but because the cost-benefit analysis of lying shows the costs (fear of detection and punishment, damage to reputation) to be higher than the benefits. The fact that so many people take a purely instrumental view of truth telling is consistent with the observation that lying and cheating are a regular and recurrent phenomenon both when it comes to reporting taxable income and when it comes to claiming benefits. This unfortunate moral state of affairs – people tell the truth only if it is in their interest to do so - is a standard assumption in most economic analyses in which truth telling plays a role.
Mental illness as a (self-) reported cause of disability
In May 2007 there were around 2.64million recipients of Incapacity Benefit or Severe Disablement Allowance (as against 2.66 million in August 1999). In addition there were around 335 thousand recipients of the Disability Living Allowance in May 2007 (figures are not available for 1999).
Thanks to the Department for Work and Pensions’ wonderful Accessible Tabulation Tool (every government department in every country should have one!) I was able to verify that in February 2005, of the 2,387 thousand IB claimants, 925.7 thousand, just under 39 percent, claimed because of Mental and Behavioural Disorders; of the 1,444.8 thousand IB beneficiaries, 460.9 thousand (around 32 percent), qualified because of Mental and Behavioural Disorders; of the 295 thousand Severe Disablement Allowance claimants, 117.6 thousand (almost 40 percent) claimed because of Mental and Behavioural Disorders.
About 504 thousand people below the age of 35 were claiming incapacity benefit or severe disablement allowance compared with 443 thousand claiming Job Seeker’s allowance in May of 2007. More than sixty percent of the claimants of IB under the age of 35 and more than fifty percent of the beneficiaries of IB, claimed IB for “Mental and Behavioural Disorders”, including depression and stress.
If you are Richard Layard and see these figures, you conclude that mental illness is rampant anno 2007 in neo-Liberal Britain, and that it is a major cause of incapacity and disability for all age groups and both genders, but especially for the young.
When I see these figures, my first reaction is: I just don’t believe it! Could these figures have anything to do with the fact that the typical weekly incapacity benefit is £81, while the corresponding jobseekers allowance is £20 less, and carries with it the obligation to actively seek a job? The Dutch experience, where the (high and rising) numbers of disabled working-age persons were suspiciously correlated over time with the generosity of the disability allowance and the severity of the effective eligibility criteria, makes me highly suspicious. This was reinforced by the markedly lower incidence of (reported) lower back pain, chronic fatigue syndrome and assorted mental illnesses in Belgium and other countries with demographic characteristics similar to the Netherlands.
Serious statistical study of the relationship between IB claims based on mental and behavioural disorders and possible non-medical drivers of such claims (such as the relative magnitudes of unemployment benefit/jobseekers allowance and IB, the degree of severity of the formal IB eligibility criteria and the effectiveness of their enforcement etc.) would be most helpful for achieving clarity on this matter. Even the best statistical study, however, will leave much room for debate, because of the complexity of the relationship between the number of IB claims/beneficiaries and the pecuniary incentives for lodging such claims. For instance, the political mechanism may well deliver higher IB benefits when the number of IB claimants increases. Sometimes the timing of policy reforms permits the identification conundrum to be overcome, but that is by no means always the case.
A more conclusive test of the proposition that some non-trivial share of the IB claims based on mental health problems represents bogus claims, would be provided by a comprehensive re-testing of the claimant population by qualified psychiatric experts. We may get some of that, but not, I fear, what we need. The government are proposing tougher disability tests for all IB claimants (not just those claiming on grounds of mental and behavioural disorders) to start in October 2008. The Tories are also proposing a comprehensive re-testing of all 2.64million UK incapacity benefit claimants. Those judged to be fit for work after an independent medical evaluation would lose their entitlement to incapacity benefit immediately and would be put on the £ 20 per week lower jobseekers allowance and its requirement to seek work.
I think neither the government nor the opposition know how complicated, costly and ultimately inconclusive would be a the creation of a high-quality process to verify a person’s inability to work because of mental health problems (or indeed lower back pain). It can only be done by experts with an appropriate medical degree. It may take multiple assessments over an extended period of time. And it will have to be repeated periodically.
I believe the Tories propose that the initial assessment would be done by non-MDs, who would refer to qualified MDs, those claimants they felt unable to assess. That would no doubt work with claimants whose claim is based on the absence of a limb. It will not work when it comes to any claim based on mental or behavioural disorders or indeed on medical claims based on anything other than the absence of some readily visible organ essential for employability. The cost of a serious ‘Personal Capability Assessment’ for 2.64 million IB claimants would be massive. The Conservative proposal would drown in Type 1 and Type 2 errors.
A similar denial of the obvious characterises Richard’s Layard’s proposal (which is, unfortunately, about to be funded and implemented by the government) for the training of an army of 10,000 cognitive behavioural therapists to stem and reverse the tide of anxiety and depression that he believes is threatening the fabric of society. As stated earlier, I don’t believe the figures on the incidence of mental illness in the UK that Richard Layard brandishes about. They are either self-reported by ‘patients’ many of whom have a pecuniary interest in the diagnosis, or reported by providers of mental health services who have an obvious conflict of interest in the matter.
The picture of 10,000 hastily trained cognitive-behavioural therapists let loose on the British public is a frightening one – like 10.000 semi-skilled plumbers taking charge of brain surgery in the UK. It’s a politically popular gimmick because (a) it is a lot cheaper than letting the mentally ill be treated by properly qualified professionals, and (b) it involves large numbers and motion – the illusion of decisive action. It is, at best, ineffective motion rather than action. At worst, it is inappropriate psychobabble that can do untold damage if these half-trained cbt operatives are left alone at any time with patients suffering from serious anxiety or depression.
Mental illness is a terrible thing. Effective treatments, that is, treatments that achieve a sustained improvement in the self-reported well-being of the patient (not just in any particular symptom) and in yo’s objectively verified ability to function effectively in the job market and other dimensions of yo’s life, are few and far between, except for some varieties of depression and manic-depressive illness. I have seen no convincing evidence that the true incidence of mental illness has increased significantly in the UK in the past forty years. Overstating its incidence, whether by fraudulent IB claimants, by self-interested sellers of mental health care services, or by deluded professors of economics, does not help the mentally ill.
P.S. For those who have noticed, I am indeed trying out ‘yo’ as a replacement for he/she/it, him, her, and ‘yo’s’ for his/her/its. It’s the only hope for George W. Bush to leave a positive legacy in any area of life.
This article represents the most outragreous example of stigmatisation against the mentally ill in the UK that I have ever seen. I suffer from Bipolar Disorder (incidentally I am the Director of a not-for-profit Mental Health company in Nottingham… not some unemployed/IB claiming layabout that this article assumes I am), and I feel that Professor Buiter has the a complete and total miscomprehension of the issues involved in mental health and the related socio-economic impact that Mental Illness has.
First and foremost Professor Buiter implies that the majority of people claiming IB for Mental Health reasons are doing so because it gets you £20 per week more and you don’t have to look for a job, when in fact they could actually work… “This
unfortunate moral state of affairs – people tell the truth only if it is in
their interest to do so - is a standard assumption in most economic analyses.” This is essentially asserting that those with Mental Health problems are by and large immoral parasites of society, who do not contribute because they see an easy way out through the Incapacity Benefit system.
Secondly, he ignores the fact that the medical profession already has control of whether one can receive IB or health related benefits by the process of diagnosis, which forms the basis of all claims. Receiving a diagnosis is fundamental in order to access services, including welfare services such as IB and DLA.
Thirdly, Professor Buiter seems to think that a Doctor (Psychiatrist) who dishes out mind altering medications with scant regard for how they impact on someone’s life, and who’s only true concerns are treating psychosis (which if you have, you most probably cannot work) and preventing either self harm or harm to others, would be best situated to decide the extent to which someone can work. Professor Buiter does not understand that when you have an appointment to see your Psychiatrist, you only get 15 minutes. How on earth is a psychiatrist expected to assess a) what is wrong with a patient, b) how to treat them, c) how to treat side effects when they arise, d) complete a full evaluation designed to ascertain the extent to which someone can work…… all within 15 minutes???
Also, Professor Buiter ignores the fact that many Mental Illnesses are cyclical in nature. A person may be genuinely ill for 6 months and then better for 6 months before becoming ill again. Maybe, if he is such a fantastic economist, he should look into ways of providing stability for people with mental health problems through a flexible benefits system that allows you to work when you are well, and receive benefits and care when you are not within a single system that reduces stress for people with Mental Illness diagnoses. I would say that such an approach would save a lot of taxpayers money, and would allow sufferers of mental illness to get a foothold that would allow them to get back into society, while providing a safety net if they become ill again, instead of being left on the scrap heap.
Finally, the army of 10,000 CBT specialists that the government is introducing is in direct response to pressure from mental health service user groups for effectiev treatments of mental illness and mental distress in place of or alongside medications. This kind of treatment allows people to overcome the barriers of illness so that the IMPACT of the illness is less on the person. This isn’t happening because doctors, nurses, social workers or ECONOMISTS want it to…. it is happening because the patients say it is helpful and useful.
In closing, I would like to add that medical treatments of mental disorders like antipsychotic medications nearly always give off side effects that preclude people from work. If Professor Buiter really wants to analyse some data, then he should see how many IB claimants take Anti-Psychotic medication. If he is still unconvinced, he should take 5mg of Haloperidol for 1 week (a standard “maintenance” dose). If he did, he wouldn’t be able to work, but at least there would be an upside… he wouldn’t be able to sully the name of the LSE with this kind of poorly researched, right wing, discriminative, stigmatising, innaccurate dross.
Kind regards
David Gow
Posted by: David Gow | January 8th, 2008 at 4:04 pm | Report this commentI have to question the Professor’s OWN balance of mind, if he seriously thinks that thousands of members of the public are lying about their mental health state, to obtain the ‘princely’ sum (DON’T spend it all at once, now!) of £85 a week from the Government! And what a cynical and sad position to be in - to view the rest of the world as ‘liars’ and not worthy of trust when compared to the medical profession - ‘exclusively qualified’, apparently, to discern truth from lies and real illness from feigned. Actually, of course, our esteemed medical profession is usually the CAUSE of all these labels pertaining to the poor state of patients’ ‘mental health’ - doctors these days are in far too much of a rush to give a hurried diagnosis and start pouring ill-tested psychiatric drugs - which have HORRIFYING side effects - down the necks of unsuspecting patients. The reason for this is two-fold, I suggest - the fact that pharmaceutical companies offer the most attractive incentive packages to doctors who can be persuaded to flog their products; and the fact that the most effective ‘talking therapies’ are considered too expensive to offer. Cognitive Behaviour Therapy being the cheapest, and therefore the one that is most widely available. Depression, by the way, is not a ‘DISEASE’ - it is an illness widely agreed to have its roots in emotional difficulties. Given the amount of stigma which surrounds ‘mental health problems’, I seriously doubt that most people would actually WANT such a label to follow them round for the rest of their lives, just so’s they can defraud the Government! And the few who do, unfortunately, ruin things for the vast majority of us, who are honest. Chronic Fatigue Syndrome, by the way, is NOT a ‘mental health problem’, but the Government is resisting efforts to have the condition correctly re-categorised as a ‘physical’ illness because of the possible flood of compensation claims it would receive if it was correctly re-categorised as stemming from environmental factors. I draw your attention, also, to the current Judicial Review being launched by the One-Click Group, against the NICE Guidelines - in which it has been DECREED that ALL patients with Chronic Fatigue Syndrome must be put on antidepressants. Those who know say this is absolutely THE WRONG thing to do with patients with CFS - but it’s easier than actually finding out how to treat the condition effectively, and the fat profits involved for all concerned were obviously too tempting. Lying and conning people, to make a fat profit for yourself? For the best examples of that, Professor Buiter, I suggest you look to YOUR OWN profession, the pharmaceutical industry and the Government - and if you want to see changes made, start having a go at those bodies, before rushing to blame the public you are all supposed to serve!
Posted by: Penny Bunn | January 9th, 2008 at 12:45 pm | Report this commentYears ago I had a few weeks off sick due to stress caused mainly by a work situation. Although things started to get a better as soon as I left the job, for a while I couldn’t think straight, lost all sense of competence and confidence, didn’t know what level of work I would realistically be able to cope with in future, and genuinely feared being unemployable. I was gradually able to use temporary and part-time work and short periods of unemployment to recover, and now believe that easy access to good CBT or similar could really help in a similar situation. Incidentally, I have a physical disability and was offered the chance of going onto Incapacity Benefit, which was then being actively promoted to keep down headline unemployment figures.
Despite the Disability Discrimination Act and some initiatives supporting people to test out returning to work, much of the benefits system remains broadly based on the all or nothing idea that disability or mental illness diagnosis equals permanent incapacity to work. Developing a competently administered benefits system that is genuinely responsive to variable health and capacity would be enormously helpful – but without this, thinking about coming off IB represents a great risk.
A nightmare scenario would be a combination of benefits reforms designed by economics graduates, employers who would never knowingly employ anyone who has ever been ill, and jobcentre staff who share Professor Buiter’s attitudes. Result –fear, intimidation, and people too scared to open letters or go to appointments falling right through the net.
Posted by: Joan Cook | January 10th, 2008 at 3:34 pm | Report this commentResponse to ‘Is Britain going mad?’
First paragraph: A binary is set up: those who suffer from mental illness – a terrible affliction – and the rest of the population who do not and conform to the government’s definition of acceptable citizens.
The government in their NICE clinical guidelines elaborates this distinction. The government separates mental illness into discrete entities: depression, anxiety, OCD, AHD, and so on. The government uses its clinical expertise to 1) define the component symptoms (inability to sleep, etc) and 2) parcel these symptoms up and give them a label – Anxiety and so on. GPs, instead of using their clinical judgment and listening skills, now use the government-approved tests for conditions such as depression. The results from these naff tests then inform the GP of what treatment should be offered.
This link between government-defined symptoms of psychic suffering and government-recommended treatment is based on ‘scientific’ evidence of evidence-based practice. A risk-analysis (in the Donaldson Report the ‘Health Industry’ is defined, many times, as high risk and compared with Chernobyl, Alpha-Piper and aircraft pilots crashing aircraft. In all these scenarios, there is a loss of life) and a cost-benefit analysis gets included in the evidence-based practice. It is little wonder that evidence-based practice recommends a ‘quick, cheap and easy fix’ as the only permitted and standard treatment.
Second paragraph: ‘Mental illness can be hidden or faked.’ I agree with this paragraph.
In addition, I note that the government is driving this definition of mental illness – a term I do not use. Many of the symptoms vilified as mental illness by the government, occur, in my practice, in what the government would define as acceptable citizens. When did you last feel very anxious or depressed? In my case, last weekend. These symptoms have to be heard in each individual’s context not added up into a machine for eliminating ‘mental illness’.
Third paragraph: ‘Many people tell lies easily and effortlessly’. I agree with this paragraph. There is anecdotal evidence that victims of government-controlled counselling and therapies do fill in feedback forms positively at the end of sessions so they can escape. Jacques Lacan has commented on the use of lies by subjects. A psychoanalyst is interested in the meaning of the lie.
Fourth Section: I agree with much of this economic analysis. Indeed, given my rudimentary understanding of economics, I am impressed by it. This does not stop me from commenting:
I agree a serious statistical study of the relationship between IB claims based on mental and behavioural disorders and possible non-medical drivers of such claims would be useful.
However, I fear that qualified psychiatric experts, using the government-approved NICE clinical guidelines, will not provide the conclusive test outlined. The reason? The logic of NICE guidelines has been purloined from industry or elsewhere. (See Janet Low/Letters/Therapy Today/November 2007) It is a logic which produces certainty that is very far from the uncertain processes involving relationships used by most talking therapists. Qualified psychiatric specialists have been reduced to collaborators who implement the government’s orders. There are always exceptions who work against the standard being forced on them.
‘The creation of a high-quality process to verify a person’s inability to work’. The only reason the doctor to patient coupling works is because of the relationship of trust. Read Dame Janet Smith on Shipman. A human-being is not an object to be judged as in an industry-based quality control process. Of course, the claimant will know what is the objective of the interview and will distrust the relationship. If you were under suspicion in Stalinist Russia, would you trust a member of the secret police who has been sent to interview you? I agree that the government is wrapped up in cloud cuckoo land.
I agree with the dismissal of the Tories position and Lotd Layard’s position.
I agree with the comments on hastily trained cognitive-behavioural therapists. Two points: cbt is effective with some people in some situations. My argument is that the government must stop controlling what treatments are available. 2) The government’s clinical judgment is being exercised in many more areas of mental distress than anxiety and depression.
Last paragraph: I agree with this. If I had written it, I would substitute psychic distress for mental illness. All subjects suffer from psychic distress.
In talking about his latest book ‘Violence’, the philospher Slavoj Zizek states governments use a cycle to justify implementing their control systems. The cycle is: definition of a threat: with mental illness this varies from fear of all Health workers becoming murderously deluded as Dr Shipman to the mentally ill being as Jews in the Third Reich: deceitful, undesirable and not one of us. The government comes to our rescue by protecting us (safeguarding in the Health Professions Order 2001) and curing all the undesirables through the provision of Lord Layard’s Happiness Centres (Improved Access to Psychological Therapies.)
And in Education, Social Work, the provision of Identity cards, the registration and regulation of all therapists, counsellors and therapists, etc., so far apathy or collaboration seems to be winning.
Julia Evans
Posted by: julia Evans | January 24th, 2008 at 10:21 am | Report this commentwww.psychoanalysislondon.org.uk