Un-Critical Psychiatry?

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.

The subjects of this study, those who experience long-term unemployment because of disabilities and mental health problems, are people who are despised, reviled and detested (see, for example http://www.theguardian.com/society/2012/feb/05/benefit-cuts-fuelling-abuse-disabled-people ). They are attacked in the tabloids and broadsheets, in so-called ‘poverty porn’ on television (see, for example Channel 4’s Benefits Street) and by leading politicians. Indeed, there is anecdotal evidence that welfare reforms are jeopardizing the mental health of claimants (see http://www.theguardian.com/society/2012/feb/05/benefit-cuts-fuelling-abuse-disabled-people )

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.