Workers behaving sadly

The therapeutic apparatus of the British state is poised to undergo a rapid and far-reaching expansion. At a recent meeting of the UK prime minister’s Strategy Unit (1), the following measures were proposed:

• Five thousand extra psycho-therapists to be trained in Cognitive Behavioural Therapy;
• A doubling of the number of clinical psychologists and psychiatrists;
• All new GPs to receive training in psychiatry focusing on treatment of depression and anxiety in the community.

The architect of these proposals, the economist Lord Richard Layard, believes that mental illness has overtaken poverty and unemployment to become Britain’s biggest social problem: ‘there are now more mentally ill people drawing incapacity benefits than there are unemployed people on jobseekers’ allowance.’ (2) Certainly, the number of Incapacity Benefit claimants has increased four-fold since the early 1980s and currently stands at well over two million, nearly 40 per cent of whom are suffering from mental illness (3).

Layard goes on to point out that a third of people attending their family doctor have mental health problems. All of this represents a substantial sum of human misery, but in terms of persuading Treasury civil servants, Layard’s economic argument is likely to be more persuasive. He estimates that mental illness costs £25billion per annum – over two per cent of GDP – much of which is borne by the Exchequer. The cost of expanding mental health services may be high, but Layard calculates that every £1,000 spent on treatment will yield a return of £3,000.

Others are also lobbying for expansion. The Sainsbury Centre for Mental Health has recently published a report that also calls for a widening of mental health services to see through the ‘unfinished revolution’ in mental health services begun in 1985 (4). The report notes that each year nearly a third of workers take sick leave because of mental distress, yet less than 10 per cent consult a mental health specialist.

The Mental Health charity MIND also focuses on mental health and work in a report published to coincide with ‘Mind Week’, in which they argue that work stress costs the economy £100billion per annum (5). Given that work stress is presumably a sub-set of mental illness it seems logically inconsistent that the cost of the former should be four times greater than Layard’s figure for the latter, but the point stands that the economic costs of work stress are high, give or take the odd £75billion. MIND cites poor working conditions and heavy workload as key causes of stress at work and a range of work stress interventions are suggested, ranging from job redesign to counselling.

A common set of assumptions lie behind current arguments for tackling the stress epidemic. A central theme is the pathologisation of ‘speed’, whether that be the speed of social change, the speed of economic growth, the speed of technological development, the speed of modern communication, or the speeding up of the working day. There is an assumption that the speed of modern life has outstripped the human capacity to cope, both mentally and physically; that modern life and modern work are increasingly pushing us beyond the limits of human endurance and into misery and mental illness. The dominant existential metaphor of contemporary life is that of a fast car racing away out of control. It is not just the speed of the car, but our incapacity to keep it on the road that is assumed to constitute the problem.

There are two dominant responses to the pathologisation of speed. The traditional one is to encourage the state to stamp on the brakes – or at least put up a few speed cameras. Attempts to limit the length of the working week to a maximum of 48 hours is an example of this strategy. Members of the European Parliament (MEPs) recently voted to scrap Britain’s ‘opt out’ of the working time directive – the implication being that workers who choose to put in extra hours to boost their career prospects or earn more money need to be protected from themselves. Although these heavy-handed attempts to stamp on the brakes are often presented as ways of increasing productivity (the claim being that workers produce more when they are free from stress and adequately rested), the British government is sceptical of the claim that we can work less and earn more. Hence the pledge of the ever-prudent UK chancellor, Gordon Brown, to oppose ending Britain’s opt-out of the working time directive.

The question for the government is how to defray the economic costs of the work stress epidemic and ballooning rates of Incapacity Benefit claims without derailing productivity and growth. The New Labour response to this dilemma is not to stamp on the brakes, but to make us better drivers. That is why Lord Layard’s proposals for a radical extension of the therapeutic state apparatus have been so warmly received in Downing Street. The claim is that the new army of psychotherapists will be able to use techniques like Cognitive Behavioural Therapy (CBT) to teach us how to navigate the problems of everyday working life; in effect to provide ‘driving lessons’ for the soul.

There are advantages to this approach. There is a substantial evidence base that supports the effectiveness of CBT, and the recent piloting of the government’s Pathways to Work initiative shows that, in combination with other interventions, CBT can reduce time spent on incapacity benefits and hasten the return to work. The approach also punctures one of the fundamental assumptions of the work stress myth – that we have somehow reached the end point of human resilience and that we need to impose limits on productivity and growth.

Unlike stress avoidance therapies, which encourage workers to run away from challenging situations, techniques like CBT recognise that it is not the speed of modern working life that disables the worker, but his subjective response it – a response that is highly malleable. The most progressive aspect of this approach is its optimistic appraisal of human potential; the tacit assumption that given appropriate cognitive skills there really is no ceiling on human achievement. So what’s the problem with CBT?

The problem with the CBT solution to work stress is not so much the content of the techniques, which for all the jargon amount to little more than the basic mental skills and competencies that most of us learned on the football pitch or the schoolyard, but the social relations that the individual enters into in order to learn these skills. Whether CBT is delivered through the state apparatus or through an employer’s occupational health system, or even through a private contract with a therapist, the individual must surrender a degree of sovereignty over his mental life.

In his presentation to the Cabinet Office, Lord Layard bemoans the fact that although about a third of us experience ‘mental illness’ at some time in our lives only a small proportion will receive specialist help: ‘Of all people with mental illness (whether treated or not) only three per cent have seen a psychiatrist in the last year and only two per cent a psychologist.’ Layard goes on to observe that most of NHS mental healthcare resources go to the one per cent of the population with severe psychoses, rather than to the much greater number of people suffering from anxiety or depression.

The notion that the worried or the glum could or should manage their own problems without therapeutic intervention is dismissed:

‘If someone has asthma, diabetes, chest pain, high blood pressure, skin disease, or neurological problems they are automatically referred to a consultant led clinic. Not so with major depression or other neurotic conditions. And if they are referred for psychological therapy, the average waiting time is very long – typically 6-9 months, and in some places evidence based therapy is not available at all. At the same time there are queues of people wanting to train as clinical psychologists, for whom there are not enough training places. So here is a problem that can be solved.’ (6)

But what are the consequences of solving the problem in this way? Expanding the therapeutic apparatus may give greater access to treatments and therapies that are of proven effectiveness. It may, as Layard claims, enable a million incapacity benefit claimants to return to work. However, expanding the realm of therapeutic intervention normalises the belief that we cannot autonomously cope with the emotional ups and downs of everyday life. Therapy might ameliorate symptoms, but it also gives rise to a new sense of selfhood; one in which notions of autonomy and agency may be fundamentally diminished.

Rather than complaining that many of the 30 per cent of patients consulting their GP with psychological problems do not get referred to a psychiatrist, we should ask why they are there in the first place. The unmet need for psychiatric intervention identified by Layard is a product of the risk-obsessed times we live in. Health scares, the creation of ‘diseases’ like repetitive strain injury, chronic fatigue syndrome and fibromyalgia for which no evidence of physical pathology can be found, the extension of psychiatric categories to include behaviours and emotions which earlier generations viewed as natural aspects of everyday life, have had the effect of creating a grossly inflated sense of mental and physical vulnerability.

Expanding the therapeutic apparatus to cater for this bogus demand can only contribute to the medicalisation of everyday life. Moreover, it is a demand that can never be met. The more we normalise the belief that our trials and tribulations are legitimate grounds for therapeutic intervention, the more the demand will grow.

(1) Mental Health, Prime Minister’s Strategy Unit

(2) Richard Layard (2004), Mental Health: Britain’s Biggest Social Problem?

(3) Sick of work?, by David Wainwright

(4) The Sainsbury Centre for Mental Health (2005), Beyond the Water Towers: The unfinished revolution in mental health services 1985-2005

(5) MIND (2005), Stress and Mental Health in the Workplace

(6) Richard Layard (2004), Mental Health: Britain’s Biggest Social Problem?