The following blog post has been contributed by Jonathan Gadsby.
This week in the Guardian newspaper published an opinion piece by columnist George Monbiot on the subject of neoliberalism. Those interested in critical ideas about mental health will have noticed that it is a word which gets mentioned increasingly. Before Monbiot’s piece, I would have recommended David Harvey’s introductory book (see below), but Monbiot hits the major themes in just a few thousand words.
Monbiot’s claim is that our collective lack of understanding of that word is like imagining that the people of the Soviet Union had never heard of Communism. So asking where does the rubber of neoliberalism hit the road of mental health practice? turns out to be a complex question: other people have frameworks and ideologies, but we see the world as it is… our own assumptions are always more difficult to spot than those of others. Yet neoliberalism arguably finds expressions from service commissioning to the most intimate of our conversations.
In this post, instead of trying to capture that wide-angle view, I just want to focus on one element. This surrounds the way that employment and mental health are becoming viewed as the same thing. Here is Anna Kirkland, editor of a fabulous 2010 book about health and morality:
My thought about this began with a beautiful idea of the geographer David Harvey. Harvey writes fabulously polemical books about how globalization affects people’s visceral lives. In Spaces of Hope, Harvey writes that under capitalism sickness is defined as the inability to work. When I first read that thought, I could not breathe in the face of its profound truth (Kirkland, 2010, p28).
Here, the words are globalisation and capitalism; neoliberalism is a term which overlaps with both, a particular ideology of free-market self-regulating capitalism, with a particular kind of selfhood.
Essentially what is being said here is that (without denying that what people do with their time has an important effect on their mental health) there is something about our current culture which has made paid work – of any quality – a primary measure of health. It has become common to think that if a person is working then they are not unwell or not unwell anymore. It isn’t long before nursing becomes hijacked with the idea that getting someone back to paid work, or ensuring they do not lose it, is our primary purpose, or at least one of them. Recovery means working, working means recovered. On a related note, can anyone remember when it was that we mental health nurses routinely started to use the word ‘functioning’? I’m sure we used to think people had ‘activities of daily living’, didn’t we?
Some nurses may not feel that this is a problem. Don’t we all know that, deep down, our self-esteem is very much attached to what we do? Why shouldn’t we try hard to find similar meaningful roles for our service-users? There is so much that could be said. We could talk about what exactly these meaningful roles are. I was recently CPN to a young woman who felt she had failed in employment because of her poor performance at the one job she had tried (helped into by her previous care-coordinator): full-time cold-calling telephone sales. There was a big screen displaying the ranking of each worker in terms of sales; she was always at the bottom and was sacked after a month. I have worked in one or two difficult work environments, but I cannot imagine I would survive that job for long (or be able to guarantee the safety of the screen, either). But questions such as these aside (they are very important questions about the changing nature of work under neoliberalism), it is important to note that we nurses are not quite on the sharpest end of this idea. We might support our service-users with employers or employment, we might come up with various suggestions, but actually we are not the people who they mostly have to talk to about these things.
And that is why what is going on in Job Centres right now is very important. There are several strands to this. The first is simply that in linking mental health and employment, those in distress in society, even those experiencing the extreme mental states we mental health nurses care for, are viewed, first and foremost, as being in desperate need of a job. Is this what the fine ideals behind ‘the Recovery Movement’ and ‘social inclusion’ have become? Last month, a letter by the Mental Wealth Foundation took issue with this simplistic idea, putting it in a way I doubt many mental health nurses could disagree with:
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.
I recommend reading the letter in full, partly because it is a good letter, and partly because the Critical Mental Health Nurses’ Network chose to sign it, along with a plethora of activist groups. The letter is written in response to a statement by the British Association of Counselling and Psychotherapy about government plans to include psychology input in Job Centres. It might seem strange to pick up this thread in the middle of correspondence like this, but (a) I think the letter holds many of the main points and (b) this is not just an internal affair within psychology. In fact, part of what has prompted this post are discussions I have witnessed between mental health nurses considering taking up positions in Job Centres – and some already have.
The letter also describes concern over the very idea of merging DWP activity (such as Job Centres) with health activity. This is the second strand of concern, about the combination of mental health promotion/psychology and unemployment services. In response to this idea, Friedli and Stearn wrote:
Increasingly, [activities required to receive benefits] include interventions intended to modify attitudes, beliefs and personality, notably through the imposition of positive affect. Labour on the self in order to achieve characteristics said to increase employability is now widely promoted. This work and the discourse on it are central to the experience of many claimants and contribute to the view that unemployment is evidence of both personal failure and psychological deficit. The use of psychology in the delivery of workfare functions to erase the experience and effects of social and economic inequalities, to construct a psychological ideal that links unemployment to psychological deficit, and so to authorise the extension of state—and state-contracted—surveillance to psychological characteristics (Friedli and Stearn, 2015, p40).
Just how serious is this problem? Haven’t we all had to do ‘labour on the self in order to achieve characteristics said to increase employability’? Perhaps, although employability is not simply about personal characteristics, is it? And what begins with ‘positive psychology’ (not psychology’s most well-evidenced idea) to be more employable can startlingly quickly become a new way to fail and be sanctioned, perhaps even ending up with a new quasi-psychiatric label: ’employment resistant personality’. This delightful term has been coined by Adam Perkins of the Institute of Psychiatry at Kings in London, author of ‘The Welfare Trait’ And yes, Adam Perkins is a eugenicist. Sounds a little bit extreme? Then try this article by him, in which he claims that welfare dependancy can be bred out.
The idea that people deserve their position in society, either intrinsically because of their genetic inheritance, or else because of their attitudes and characteristics, is one simple and easy way for people to account for all the inequality, as Owen Jones, author of The Establishment: And how they get away with it, said on Ian Hislop’s recent BBC documentary. It seems that this idea (essentially ‘meritocracy’), post banking-bailouts and Panama Papers, is wearing more than a little thin. Positive psychology for the unemployed is part of a political attempt to make the unemployed wholly responsible for their unemployment, the distressed responsible for their distress. Once the ‘psychological defect’ of unemployment becomes a new kind of ‘personality disorder’, Perkins’ style of genetic posturing (it is not genetic science) may not be far behind.
One unusual aspect about this issue is that it has the potential to unite nurses who don’t agree about the causes of mental health problems. It really doesn’t matter if you think that distress is caused by broken genes, broken brains, broken thoughts, broken families or broken Britain – supported with whatever ‘evidence’ you enjoy most – you can still probably agree that your service-user is not going to be miraculously ‘fixed’ by a call-centre job. You may feel comfortable describing all this as an illness-related ‘disability rights’ issue, or perhaps you are at the other extreme, seeing it as a further oppression of the State in addition to the oppression of diagnosis following the oppression of discrimination and inequality; whatever your views, this merging of Job Centre and health service compromises your role and greatly over-emphasises the idea that paid work – of any quality – is the cure for distress. To then reinforce that view with the very real threat of actual destitution is just plain scary. Even if you are a nurse who has been fully recruited into the neoliberal philosophy that distress is a failure to take responsibility for oneself, you would probably feel aggrieved if an untrained and inexperienced Job Centre employee, perhaps subcontracted by G4S (yes, that was included in the letter, too), started telling you what your service-user needs (or, more likely, not telling you at all).
What can I do about all this?
There are many things that can be done. Here are two. Feel free to add more:
- If Monbiot is right and our collective knowledge about neoliberalism is so limited that it would be like people of the Soviet Republic not having heard of Communism, then we are at a stage when raising awareness is a primary concern. We need to be reading books like the three listed below to learn how health is being used to promote certain values that we may not agree with, or at very least have not had adequate chance to think through. If we do not reflect on these issues, we mental health nurses are destined to reproduce them instead.
- Many nurses would agree that it is important for us to dissent from the parts of our roles which are not about health but are about other people’s political agendas. With mental health nursing, that has always been a very hard thing to decide upon – some are going to feel that most of what we do is unproblematically health related, others are going to feel that we are pawns of the State the moment we so much as pick up a biro. But this issue – this dangerous combination of workfare + psychological input + sanctions is something that even the most trusting of us should be concerned about. Dissent comes in many forms. I have been inspired by the group Psychologists Against Austerity. I am indebted to Recovery in the Bin collective. I think Jay Watts has hit the nail on the head. It is a moment to seek out allies of all kinds and have some dialogue. But, above all, to come back to our best instinct: when in doubt, be kind. The Job Centre is not a kind place right now.
Friedli, L., Stearn, R., 2015. Positive affect as coercive strategy: conditionality, activation and the role of psychology in UK government workfare programmes. Med Humanities 41, 40–47. doi:10.1136/medhum-2014-010622
Harvey, D., 2007. A brief History of Neoliberalism. OUP Oxford.