Tag: behaviourism

The first digital antipsychotic pill with tracking. In an authoritarian state, what could possibly go right?

In the United State, regulators have approved the first “digital pill” with a tracking system. According the Financial Times, this is a pill with an inbuilt sensor, which opens up a new front in pharmaceuticals and the “internet of things”. 

The tablet can be tracked inside the stomach, relaying data on whether, and when, patients have taken “vital medication”. So far, the US Food and Drug Administration has given the green light for it to be used in an antipsychotic medication with the aim that the data can be used “to help doctors and patients better manage treatment.”

Patients who agree to take the digital medication, a version of the antipsychotic drug Abilify, can sign consent forms allowing their doctors and up to four other people, including family members, to receive electronic data showing the date and time pills are ingested.

Dr. Peter Kramer, a psychiatrist and the author of Listening to Prozac, raised concerns about “packaging a medication with a tattletale.”

While ethical for “a fully competent patient who wants to lash him or herself to the mast,” he said, “‘digital drug’ sounds like a potentially coercive tool.”

Other companies are developing digital medication technologies, including another ingestible sensor and visual recognition technology capable of confirming whether a patient has placed a pill on the tongue and has swallowed it. 

The newly approved pill, called Abilify MyCite, is a collaboration between Abilify’s manufacturer, Otsuka, and the Silicon Valley based Proteus Digital Health, the company that created the sensor.

The sensor, which contains copper, magnesium and silicon, generates an electrical signal when splashed by stomach fluid, “like a potato battery,” according to Andrew Thompson, Proteus’s president and chief executive.

After several minutes, the signal is detected by a Band-Aid-like patch that must be worn on the left rib cage and replaced after seven days, said Andrew Wright, Otsuka America’s vice president for digital medicine. The patch then sends the date and time of pill ingestion and the patient’s activity level via Bluetooth to a cellphone app.

Abilify is prescribed to people with schizophrenia, bipolar disorder and, in conjunction with an antidepressant, major depressive disorder. The symptoms of schizophrenia and related disorders can include paranoia and delusions, so you do have to wonder how widely digital Abilify will be accepted, given that it is designed to monitor behaviours and transmit signals from within a person’s body to communicate with their doctor.  

Dr. Jeffrey Lieberman, chairman of psychiatry at Columbia University and New York-Presbyterian Hospital, said many psychiatrists would likely want to try digital Abilify, especially for patients who just experienced their first psychotic episode and are at risk of stopping medication after feeling better.

But he noted it has only been approved to track doses, and has not yet been shown to improve compliance with treatment regimes.

He added, “There’s an irony in it being given to people with mental disorders that can include delusions. It’s like a biomedical Big Brother.”

The FT article goes on to say: “Poor compliance with drug regimes, particularly among sufferers of chronic diseases, is a pervasive problem for pharma companies and health systems, leading to lower consumption of the industry’s products and higher costs for payers when patients’ conditions deteriorate as a result of missing treatment.”

 You can see precisely where the emphasis and priorities lie in that statement. Not a word about the poor dehumanised “patients'” wellbeing and importantly, about their choice. It’s assumed that pharma industry’s products don’t have any adverse effects at all, and that taking the medication is always in the patient’s best interest. It’s assumed that medications will improve someone’s mental health. Apparently the key to good mental health is keeping costs low to tax payers while keeping the pharma industry in business, ensuring that they can keep making profits.

Andrew Thompson, Proteus chief executive, said the technology would allow people with serious mental illness “to engage with their care team about their treatment plan in a new way”. Patients will be able to use a mobile phone to track and “manage” their medication. Worryingly, he is already in talks with other major pharma companies about using the technology in treatments for various chronic conditions.

The tablets contain a sensor, so that when they are swallowed, a signal is sent to a patch worn on the patient’s body, which in turn connects to an app on their phones, showing that they have taken their dose. The doctor who has prescribed the medicine will automatically be sent the data and patients can also choose to nominate family and care team members to receive it.

The wearable patch will also be used to track how much patients are moving around — considered a key indicator of overall health — and allows them to self-report their mood and sleep quality via the app. 

There are some problems with the assumptions behind the development of digital pill, and its proposed use. Firstly, it’s a myth that people with mental health conditions are not very good at taking their medication. Studies have shown that “compliance” with a medication regime is no worse in people with mental health conditions like schizophrenia than it is in long-term physical ailments such as asthma or high blood pressure. In fact demographic factors such as whether a person is single or in a relationship are more likely to play a role in medication compliance.

It is also a taken for granted assumption that pharmaceutical solutions are the best guarantee of positive outcomes for people with mental health conditions. Before concentrating on specific medication issues it is important to remember that medication is not the sole focus of a mental health intervention. This is because the causes of mental illness are complex and various, and quite often do not arise solely from “within” individuals, rather, it often arises because of interactions between environmental factors, circumstances, and individual predispositions and vulnerabilities (including both psychological and biological). Some psychiatrists have stated that mental illness – in all its forms – is intrinsically social.

We know, for example, that discrimination plays a part in explaining why certain groups in our society are more likely to experience poor mental health compared to others. Direct experiences of prejudice and harassment impact negatively on mental wellbeing, while indirect factors such as deprivation and social exclusion also contribute to poor mental health. Studies have highlighted the role that prejudice, stigma and discrimination can play in poor mental health.

It is only by fully acknowledging and understanding the external risk factors for poor mental health that we can develop our understanding of protective factors for good mental health at the individual, community and societal level. 

Sometimes causes are confused with effects

Despite controversies in psychiatry regarding the very complex aetiology of mental illness, including the role of sociological practices, political practices and economic conditions, it is widely held that mental illness arises “within” the individual and has a purely neurobiological origin. Yet there is no conclusive evidence to demonstrate that major mental illnesses are “proven biological diseases of the brain” and that emotional distress results from “chemical imbalances.”

One attempt to explain a physical cause of schizophrenia is the dopamine hypothesis. Dopamine is a neurotransmitter. It is one of the chemicals in the brain which causes neurons to fire. The original dopamine hypothesis stated that people with schizophrenia suffered from an excessive amount of dopamine. This causes the neurons that use dopamine to fire too often and transmit too many “messages”. High dopamine activity leads to acute episodes, and positive symptoms which include delusions, hallucinations and “confused thinking.”

Evidence for this hypothesis comes from that fact that amphetamines increase the amounts of dopamine. Large doses of amphetamine given to people with no history of psychological disorders produce behavior which is very similar to paranoid schizophrenia. Small doses given to people already suffering from schizophrenia tend to worsen their symptoms.

However, the problem with this hypothesis is that we don’t know if the raised dopamine levels are the cause of the schizophrenia, or if the raised dopamine level is the result of schizophrenia. It is not clear which comes first. 

One of the biggest criticisms of the dopamine hypothesis came when Farde et al found no difference between levels of dopamine in people with schizophrenia compared with “healthy” individuals in 1990.

Another problem is that schizophrenia is something of an umbrella term that encompasses a wide array of symptoms, and can be reached by multiple routes that may, nevertheless, impact the same biological pathways. However, there is emerging evidence that different routes to experiences currently deemed indicative of schizophrenia may need different treatments.

For example, preliminary evidence suggests that people with a history of childhood trauma who are diagnosed with schizophrenia are less likely to be helped by antipsychotic drugs. However, more research into this is needed. It has also been suggested that some cases of schizophrenia are actually a form of autoimmune encephalitis, which means that the most effective treatment may be immunotherapy and corticosteroids. People with autoimmune illness such as lupus are also at an increased risk of developing autoimmune mediated psychosis.

Some interventions, such as the family-therapy based dialogue approach, show some promise for many people with schizophrenia diagnoses. Both general interventions and specific ones, tailored to someone’s personal route to the experiences associated with schizophrenia, may be needed. It’s therefore crucial that psychiatrists ask people about all the potentially relevant circumstances and routes.

For example, suffering childhood adversityusing cannabis and having childhood viral infections of the central nervous system all increase the odds of someone being diagnosed with a psychotic disorder (such as schizophrenia) by at least two – to threefold. 

Although the exact causes of most mental illnesses are not known, it is becoming clear through extensive research that many conditions are caused by a complex combination of biological, psychological, social, cultural, political, economic and environmental factors. It’s widely recognised that poverty, social isolation, being unemployed or highly stressed in work can all have an effect on an individual’s mental health. 

Adults in the poorest fifth of the population are much more at risk of developing a mental illness as those on average incomes: around 24% compared with 14%. Those who have an existing mental illness are significantly more likely to be living in poverty, also. 

Poverty can therefore be both a causal factor and a consequence of mental ill-health. Mental health is shaped by the wide-ranging characteristics (including inequalities) of the social, economic, political and physical environments in which people live.

Successfully supporting the mental health and wellbeing of people living in poverty, and reducing the number of people with mental health problems experiencing poverty, requires an engagement with this complexity. Simply medicating a person is neither sufficient nor appropriate. Nor is it ethical. Pharmaceutical companies tend to promote the assumption that mental illness is entirely biomedical. The relationship between economics and health is complex and politically fraught. But it is too important to ignore.

Psychiatric diagnosis tends to reify the complexity of people’s problems. However, in the UK, the political (mis)use of behaviourism has also resulted in the reification of social and economic problems. The government here extend the view that unemployment is evidence of both personal failure and psychological deficit. The use of crude behaviourist psychology in the delivery of social security denies the individuals’ experience of the effects of social and economic inequalities, and has been used to authorise the extension of the state and to justify state-contracted surveillance to individuals’ psychological characteristics.  

In a “business friendly” environoment, with a distinctly authoritarian government, I can’t help but wonder how long will it be before we see the increasingy intrusive Conservative state locking up or drugging patients whose diseases are defined not by organic dysfunction but by politically defined “socially unacceptable behaviours”.

I’m a critic of state entanglement with psychiatry AND psychology. For people with mental health problems in the UK, policies are being formulated to act upon them as if they are objects, rather than autonomous human subjects. Such a dehumanising approach has contributed significantly to a wider process of  social outgrouping, increasing stigmatisation and ultimately, to further socioeconomic and mental health inequalities. Most government policies aimed at ill and disabled people more generally are about cutting costs and removing lifeline support. This has been increasingly justified by a narrative that focuses on problematising sick role behaviours, rather than on the real impacts of illness and the additional needs that being chronically ill invariably generates. 

Earlier this year, George Freeman, Conservative MP for Norfolk and chair of the Prime Minister’s Policy Board, defended the government’s decision to subvert the judicial system, by disregarding the rulings of two independent tribunals concerning Personal Independence Payment (PIP) for disabled people. The government ushered in an “emergency” legislation to reverse the legal decisions in order to cut cost. In an interview on Pienaar’s Politics, on BBC 5 Live, Freeman said: 

“These tweaks [new regulations to cut PIP eligibility] are actually about rolling back some bizarre decisions by tribunals that now mean benefits are being given to people who are taking pills at home, who suffer from anxiety”.

He claimed that the “bizarre” upper tribunal rulings meant that“claimants with psychological problems, who are unable to travel without help, should be treated in a similar way to those who are blind.”

He said: “We want to make sure we get the money to the really disabled people who need it.”

He added that both he and the Prime Minister “totally” understood anxiety, and went on to say: “We’ve set out in the mental health strategy how seriously we take it.” 

He said: “Personal Independence Payments reforms were needed to roll back the bizarre decisions of tribunals.” 

Freeman’s controversial comments about people with anxiety “at home taking pills” implies that those with mental health problems are somehow faking their disability. He trivialises the often wide-ranging disabling consequences of mental ill health, and clearly implies that he regards mental illnesses as somehow not “real” disabilities.

His comments contradict the government’s pledge to ensure that mental health and physical health are given a parity of esteem, just months after the Prime Minister pledged to take action to tackle the stigma around mental health problems. 

Yet people with the following mental health conditions are likely to be affected by the reversal of the Independent Tribunal’s ruling on PIP mobility awards – those in particular who suffer “overwhelming psychological distress” when travelling alone:

Mood disorders – Other / type not known, Psychotic disorders – Other / type not known, Schizophrenia, Schizoaffective disorder, Phobia – Social Panic disorder, Learning disability – Other / type not known, Generalized anxiety disorder, Agoraphobia, Alcohol misuse, Anxiety and depressive disorders – mixed Anxiety disorders – Other / type not known, Autism, Bipolar affective disorder (Hypomania / Mania), Cognitive disorder due to stroke, Cognitive disorders – Other / type not known, Dementia, Depressive disorder, Drug misuse, Stress reaction disorders – Other / type not known, Post-traumatic stress disorder (PTSD), Phobia – Specific Personality disorder, Obsessive compulsive disorder (OCD).

Freeman’s comments signposts the Conservative’s “deserving” and “undeserving” narrative, implying that some disabled people are malingering. However, disabled people do not “cheat” the social security system: the system has been redesigned by the government to cheat disabled people.

When people are attacked, oppressed and controlled psychologically by a so-called democratic government that embeds punishment at the heart of public policies to target the poorest citizens, it’s hardly surprising they become increasingly anxious, depressed and mentally unwell.

An era of technocratic solutions for social problems

Some psychiatrists see a strengthening of psychiatry’s identity as essentially “applied neuroscience”. Although not discounting the importance of the neurological sciences and psychopharmacology, they have argued that psychiatry needs to move beyond the dominance of the current dominant technological paradigm. Such critical practitioners say that psychiatry ought to primarily involve engagement with the non-technical dimensions of their work such as relationships, meanings and values. Psychiatry has operated from within a technological paradigm that, although not ignoring these aspects of work, has kept them as secondary concerns.

Psychiatry sits within a predominantly biomedical idiom. This means that problems with feelings, thoughts, behaviours and relationships can be fully grasped with the same sort of scientific tools that we use to investigate physical problems with our kidneys, blood cells, lungs, and so on.

While psychiatry has generally focused a lot of attention on neuroscience, neuroscientists themselves have become more cautious about the value of reductionist and deterministic approaches to understanding the nature of human thought, emotion and behaviour.

The dominance of this paradigm can be seen in the importance attached to classification systems, causal models of understanding mental distress and the framing of psychiatric care as a series of discrete interventions that can be analysed and measured independent of context.

More recently, models of cognitive psychology, based on “information processing”, have been developed that work within the technological idiom. Psychiatry stubbornly operates within a positivist tradition, and subscribes to the following assumptions: mental health problems arise from faulty mechanisms or processes involving abnormal physiological or psychological events occurring within the individual, these processes can be modelled in causal terms.

These processes are regarded as not being context dependent. They reside “within” the individual. Technological interventions are instrumental and can be designed and studied independently of experiences, subjective states, relationships, and values. However, in 2013, psychiatrist Allen Frances said that “psychiatric diagnosis still relies exclusively on fallible subjective judgments rather than objective biological tests”.

Many people within the growing service user movement seek to reframe experiences of mental illness, distress and alienation by framing them as human experiences, rather than biomedical events, simplistic causal relationships and “scientific” challenges. In a study of users’ views of psychiatric services, Rogers et al found that many service users did not really value the “technical” expertise of professionals. Instead, they were much more concerned with the subjective experience and human elements of their encounters such as being listened to, taken seriously, and treated with dignity, kindness and respect.

Cutting the Stone (Bosch).jpg

The Extraction of the Stone of Madness by Hieronymus Boschfrom around 1494.

In his work, History of Madness, Michel Foucault says “Bosch’s famous doctor is far more insane than the patient he is attempting to cure, and his false knowledge does nothing more than reveal the worst excesses of a madness immediately apparent to all but himself.” 

I have to say I have never seen a person by looking at a brain.

It’s not all “in here”, it’s “out there”: the problem with locating mental illness “within” the individual

To paraphrase R.D Laing, “insanity”, mental illness and psychological distress may be seen as a perfectly rational adjustment to an insane world. Laing examined the nature of human experience from a phenomenological perspective, as well as exploring the possibilities for psychotherapy in an existentially distorted world. He challenges the whole idea of “normality” in society. 

It simply isn’t effective or appropriate to treat distress arising because of, say, socioeconomic problems or difficult relationships with psychotropic drugs alone, administered to people experiencing the consequences of political decision-making, the adverse consequences of socioeconomic organisation, exclusion, stigma, abuse or damaging parenting practices. 

Coping with past or current traumatic experiences such as abuse, bereavement or divorce will also strongly influence an individual’s mental and emotional state which can in turn have an influence on their wider mental health. Psychological interventions are therefore a crucial and integral part of effective treatment for mental illnesses.

However, in the UK, the current political-psychological model also locates social problems “within” the individual. The government plan to merge health and employment services. In a move that is both unethical and likely to present significant risk of harm to many patients, health professionals are being tasked to deliver benefit cuts for the Department for Work an Pensions. This involves measures to support the imposition of work cures, including setting employment as a clinical outcome and allowing medically unqualified job coaches to directly update a patient’s medical record.

The Conservatives have proposed more than once the mandatory treatment for people with long term conditions (which was first flagged up in the Conservative Party Manifesto) and this is currently under review, including whether benefit entitlements should be linked to “accepting appropriate treatments or support/taking reasonable steps towards “rehabilitation”.  The work, health and disability green paper and consultation suggests that people with the most severe illnesses in the support group may also be subjected to welfare conditionality and sanctions.

Such a move has extremely serious implications. It would be extremely unethical and makes the issue of consent to medical treatment very problematic if it is linked to the loss of lifeline support or the fear of loss of benefits. However this is clearly the direction that government policy is moving in and represents a serious threat to the human rights of patients and the independence of health professionals.

The digital pill in an age of surveillance has potential implications for civil liberties

For people with severe and enduring mental health problems, it is crucial that their context is also considered, and it’s important that people are provided with support with their living circumstances, and taking into account their wider social conditions, also. 

Furthermore, there is the important issue of drug tolerability to consider. Antipsychotic drugs are also associated with adverse effects that can lead to poor medication adherence, stigma, distress and impaired quality of life. For example, the stiffness, slowness of movement and tremor of antipsychotic-induced parkinsonism (See Dursun et al, 2004) can make it difficult for a patient to write, fasten buttons and tie shoelaces. Some antipsychotic medications can affect facial expressions, which flatten nonverbal communication and may impact on ordinary social interactions, potentially leading to stigma and further isolation.

Side effect or symptom?

The impact of drug side-effects on patients has not been sufficiently studied. Researchers have stressed the importance of the patient’s subjective experience, in which adverse effects have a role, and are considered and included in the assessment of drugs, though this doesn’t always happen. Although adverse effects are an important outcome, with many antipsychotics, they account for less treatment discontinuation than lack of efficacy; this finding has been noted in naturalistic studies and in Randomised Controlled Trials (RCTs). 

Both older and newer antipsychotic drugs can cause:

  • Uncontrollable movements, such as tics, tremors, or muscle spasms, blank facial expression and abnormal gait (risk is higher with first-generation antipsychotics)
  • Weight gain (risk is higher with second-generation antipsychotics)
  • Photosensitivity – increased sensitivity to sunlight
  • Anxiety
  • Drowsiness
  • Dizziness
  • Restlessness
  • Dry mouth
  • Constipation
  • Nausea
  • Vomiting
  • Blurred vision
  • Low blood pressure
  • Seizures
  • Low white blood cell count
  • Sexual dysfunction in both men and women
  • Menstruation problems in women and feminising effects such as abnormal breast growth and lactation in men. These latter problems are caused by the effect that the newer drugs have on a hormone in the blood called prolactin
  • Osteoporosis
  • Some neuroleptic drugs have withdrawal effects which can be very unpleasant

In addition some side effects of the newer antipsychotics may be confused with the symptoms of schizophrenia, such as apathy and withdrawal.

Antipsychotics can also cause bad interactions with other medications.

Bioethic considerations

One of the serious bioethic considerations is whether the digital medicine could be used coercively, on people against their will or as part of probation, healthcare or welfare conditions, for example.

Otsuka has said: “We intend that this system only be used with patient consent.”

However, here in the UK, the government have been kite-flying the idea of social security support being made conditional to imposed “health” regimes for a while. 

The Conservatives have already made proposals to strip obese or those who are ill because of substance misuse of their welfare benefits if they refuse treatment. This  violates medical ethics. The president of the British Psychological Society responded, at the time, Professor Jamie Hacker Hughes, said people should not be coerced into accepting psychological treatment and, if they were, evidence shows that it simply would not work.

He went on to say: “There is a major issue around consent, because as psychologists we offer interventions but everybody has got a right to accept or refuse treatment. So we have got a big concern about coercion.”

Hacker Hughes lent his voice to a chorus of criticism following the announcement of an official review to consider how best to get people suffering from obesity, drug addiction or alcoholism back into work. 

The government consultation paper, launched in 2015, that raised concerns acknowleged that strong ethical issues were at stake, but at the same time also questioned whether people should continue to receive benefits if they refused state provided treatment.

The government regard work as a health outcome, and believe that welfare creates “perverse incentives” that prevent people from finding employment. However, international research and evidence demonstrates that this is untrue, and that generous welfare states tend to be correlated with a stronger work ethic.

Hacker Hughes said claimants with obesity and addiction problems often faced complex mental health issues. But he warned the government against using sanctions to force people to accept interventions.

“It’s a problem firstly because we don’t believe people should be coerced into accepting any treatment, and secondly there is a problem because the evidence shows that if you are trying to change people’s behaviour, coercion doesn’t work,” he said.

There is a well-documented link between being out of work and psychological problems, but Hacker Hughes pointed out that the government’s plan risked “confusing the symptoms with the cause.”

Paul Atkinson, a London-based psychotherapist and member of the Alliance for Counselling and Psychotherapy, called the government’s proposals an outrage. He said: “It’s the same psychology from the government of punishing rather than working with people. Under a regime like welfare and jobcentres at the moment it is going to be felt as abuse, punitive and moralistic.”

Yes, and that’s because it is.

The government introduced “ordeals” into the welfare system to deter people from claiming the social security that most have paid for via national insurance and tax contributions, in order to “deter” what they see as “welfare dependency”. Yet labor market deregulation, anti-union legislation and other political decisions have also driven down wages, leaving many in work in poverty, also. The government’s “solution” to in-work poverty was to introduce further conditionality, in the form of extremely punitive financial sanctions for people who need to claim in-work welfare support, to “ensure they progress in work”. It is assumed that the problem of low pay resides “within the individual” rather than being the consequence of structural and labor market conditions, the profit incentive, “business friendly” political decision-making and board room choices. Ultimately, it’s down to the unequal distribution of power.

A gaslighting state: punitive psychopolicy interventions

No-one seems to be concerned with monitoring the impact of the government’s “behavioural change” agenda. Strict behavioural requirements and punishments in the form of sanctions are an integral part of the Conservative ideological pseudo-moralisation of welfare, and their  “reforms” aimed at making claiming benefits much less attractive than taking a low paid, insecure, exploitative job. 

Welfare has been redefined: it is preoccupied with assumptions about and modification of the behaviour and character of recipients rather than with the alleviation of poverty and ensuring economic and social wellbeing. Furthermore, the political stigmatisation of people needing benefits is designed purposefully to displace public sympathy for the poor, and to generate moral outrage, which is then used to further justify the steady dismantling of the welfare state. (See Stigmatising unemployment: the government has redefined it as a psychological disorder.)

However, the problems of austerity and the economy were not caused by people claiming welfare, or by any other powerless, scapegoated, marginalised group for that matter, such as migrants. The problems have arisen because of social conservatism and neoliberalism. The victims of the government’s policies and decision-making are being portrayed as miscreants – as perpetrators of the social problems caused by the government’s decisions, rather than as the casualities.

Under the government’s plans, therapists from the NHS’s Improving Access to Psychological Therapies (IAPT) programme are to support jobcentre staff to assess and treat claimants, who may be referred to online cognitive behavioural therapy (CBT) courses.

Again, we really must question the ethics of linking receipt of welfare with “state therapy,” which, upon closer scrutiny, is not therapy at all. Linked to such a narrow outcome – getting a job – this is nothing more than a blunt behaviour modification programme. The fact that the Conservatives plan to make receipt of benefits contingent on participation in “treatment” worryingly takes away the fundamental right of consent.

Not only is the government trespassing on an intimate, existential level; it is tampering with our perceptions and experiences, damaging and isolating the poorest, burdening them with the blame for the consequences of their own policies whilst editing out state responsibilities towards citizens. (See the The power of positive thinking is really political gaslighting, and IAPT is value-laden, non-prefigurative, non-dialogic, antidemocratic and reflects a political agenda.)

It’s very important that we don’t overlook the importance of context regarding psychological distress. The idea that mental “illness” arises strictly “within” the individual, therefore, requiring medicine as treatment, as opposed to, say, different socioeconomic policies, is a controversial one. People’s mental health is, after all, at least influenced by the social, political, cultural and economic spaces that they occupy. 

The current government has a 7 year history of decontextualing structural inequality and poverty, using narratives that “relocate” the causes and effects of an unequal distribution of power and wealth. Such narratives are about coercing the responsibility, internalisation and containment of social problems within some targeted individuals in some marginalised social groups. This process always involves projection, stigmatising, outgrouping and scapegoating. 

Earlier this year, the UK Council for Psychotherapy (UKCP) said that government policies – in particular, the Conservatives’ draconian “reforms” of social security payments and austerity regime – were to blame for a steep rise in the rates of severe anxiety and depression among unemployed people, as benefit cuts and sanctions, together with an extremely punitive and coercive welfare conditionality regime, “are having a toxic impact on mental health”.

It’s hardly ethical, appropriate or effective to impose a medical treatment on people who are suffering because of policies that bring about financial and psychological insecurity, hardships and harms.  

We have witnessed an ongoing attempt by the Conservatives to “rewrite the welfare contract” for disabled people, which has become a key site of controversy within UK welfare reform, and fierce debates about the circumstances in which the use of  conditionality may, or may not, be ethically justified. And denial from the government that their welfare policy is causing some of our most vulnerable citizens harm, hardship and distress. 

Wilkinson and Pickett’s key finding in their work, The Spirit Level: Why More Equal Societies Almost Always Do Better is that it is the inequality itself, and not the overall wealth of a society that is the key factor in creating various pathologies. The authors  show that for each of eleven different health and social problems: physical health, mental health, drug abuse, education, imprisonment, obesity, social mobility, trust and community life, violence, teenage pregnancies, and child wellbeing, outcomes are significantly worse in more unequal rich countries. The evidence also shows that poorer places with more equality have better overall social outcomes than wealthy ones marked by gross inequality. (See also The still face paradigm, the just world fallacy, inequality and the decline of empathy, for further discussion about how neoliberaism itself creates profound psychological trauma, and builds social “empathy walls”).

Theresa May has pledged new initiatives to end “stigma” around mental health and encourage schools and employers to provide mental health support. Despite government assurances mental health services would receive equal treatment to physical health, 40% of NHS trusts saw cuts to mental health services across 2015-2016.

But in the absence of genuine funding commitments, the Prime Minister has faced charges of hypocrisy from mental campaigners, for not doing anywhere near enough to address the root causes of problems faced by disabled and mentally ill people. 

At one point in 2014, there were no mental health beds available for adults in the whole of England, while an NSPCC survey published in October 2015 found that more than a fifth of children referred to child and adolescent mental health services (CAMHS) in England were refused access to support. 

There have recently been a number of high-profile cases reported more than once in the media across the UK when the necessary kind of hospital bed could not be found for mental health patients in England. The NHS Confederation’s Mental Health Network – the representative body for NHS-funded mental health service providers – also heard evidence from its members last year that “there are occasions when there are no routine acute mental health assessment beds available across the country.”

Importantly, Psychologists Against Austerity have said: “Addressing mental health is not just about ensuring more ‘treatment’ is available and stigma is reduced, although they are important. It is fundamentally also about the evidence that ideological economic policies, like the continued austerity programme, have hit the most vulnerable citizens the hardest and have been toxic for mental health.”

The government’s “employment and support programme” for sick and disabled people coincided with at least 590 “additional” suicides, 279,000 cases of mental illness and 725,000 more prescriptions for antidepressants – and one mental health charity found that at least 21 per cent of their patients had experienced suicidal thoughts due to the stress of the draconian Work Capability Assessments. 

It’s crucially important that a positive therapeutic alliance based on trust is developed  between doctors and patients. Specific problems with the therapeutic alliance include doctors failing to acknowledge patients’ concerns, an example of which is the failure to respond to patients who talk about their auditory halluci­nations in schizophrenia (McCabe et al, 2002). Furthermore, doctors appear not to appreciate the degree of distress caused by certain antipsychotic side-effects (Day et al, 1998). There is, therefore a fundamental need for doctors to listen more effectively to patients and elicit their particular concerns about their illness and its treatments. In fact Poor doctor-patient relationships have been cited by recent research as a key factor that influences a patient’s attitude towards treatment.

Critics of psychiatry commonly express a concern that the path of diagnosis and treatment is primarily shaped by profit prerogatives, echoing a common criticism of general medical practice, particularly in the United States, and increasingly, in the UK, where many of the largest psychopharmaceutical producers are based.

It’s an inbuilt “cognitive bias”. 

This critique is not meant to imply that physiological factors in mental illnesss can or should be ignored. However, as I’ve pointed out, the biomedical model avoids the personal, social, cultural, political and economic dimensions of mental illness, in the same way that the political behaviourist (behavioural economics, used in public policy) model does.

One concern is that both the behaviourist and biomedical model protects those formulating provision and care from the pain experienced by those needing support. The temptation to retreat into objectification of those identified as mentally ill may also be a factor in a state cost cutting exercise. 

The UK government has already demonstrated a worrying overreliance on individualistic approaches to socioeconomic problems that prioritise citizen responsibility and “self help”. The behavioural turn has been powerfully influenced by libertarian paternalism – itself a political doctirne, despite its claims to “value-neutrality”.

The Conservatives’ neoliberal policies increasingly embed behaviour modification techniques that aim to quantifiably change the perceptions and behaviours of citizens, aligning them with narrow neoliberal outcomes through rewards or “consequences.” Rewards, such as tax cuts, are aimed at the wealthiest, whereas the most vulnerable citizens who are the poorest are simply presented with imposed cuts to their lifeline support as an “incentive” to not be poor. Taking money from the poorest is apparently “for their own good”, according to the government, as it reduces “dependency”. 

“Dependency” and “need” have somehow become conflated, the government have resisted urges to acknowledge that some citizens have more needs than others for a wide array of reasons, including their mental health status.

Defining human agency and rationality in terms of economic outcomes is extremely problematic. And dehumanising. Despite the alleged value-neutrality of behavioural economic theory and CBT, both have become invariably biased towards the status quo rather than progressive change and social justice.

Behavoural economics theory has permited policy-makers to indulge ideological impulses whilst presenting them as “objective science.” From a libertarian paternalist perspective, the problems of neoliberalism don’t lie in the market, or in growing inequality and poverty: neoliberalism isn’t flawed, nor are governments – we are. Governments and behavioural economists don’t make mistakes – only citizens do. No-one is nudging the nudgers.

It’s assumed that their decision-making is infallible and they have no whopping cognitive biases of their own. One assumption that has become embedded in the poliical narrative is that an adequate level of social security to meet people’s basic survival needs is somehow mutually exclusive from encouraging people to find a suitable job.

In the current political context, it’s easy to see how the medicalisation of political, economic, cultural and social problems may be politically misused, especially by an authoritarian government, and in an ideological era that extolls the virtues of a “small state” and austerity, to exempt the state completely from its fundamental responsibility towards the prosperity, health and wellbeing of citizens.

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Choice architecture, neoliberalism and the politics of compliance

 

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The point for neoliberalism is not to make a model that is more adequate to the real world, but to make the real world more adequate to its model” – Simon Clarke (2005). (See also If You Look Behind Neoliberal Economists, You’ll Discover the Rich: How Economic Theories Serve Big Business. The road to serfdom – sponsored by big business).

Nudge: when the luxury of making choices has been commodified and packaged

Choice architecture is a term was coined by libertarian paternalists Richard Thaler and Cass Sunstein (2008). It refers to the practice of influencing choice by changing the manner in which options are presented to people.

For example, this can be done by setting defaults, framing, or adding decoy options. 

Choice architecture influences decision-making by simplifying the presentation of choices, by automatically evoking particular associations, or by making one option more salient or “easier” to choose than the alternatives. It works “beneath” our rational and reflective processes.

Personally, I see choice architecture as starkly lit Orwellian features along the short road and cul-de-sac to choiceless choices. It’s a reductive and determined journey, which ends by the state deciding and determining how citizens ought to be

A government that is acting upon the perceptions and behaviours of citizens in order to align them with politically defined socioeconomic outcomes turns democracy on its head. It detaches public policies from genuine wider public needs and interests. Governments are elected in the expectation that they will behave in ways that meet the needs of a population.

Democracy entails a dialogue between government and citizens. However, nudge closes down that dialogue, and restricts human agency – the capacity of individuals to act independently and to make their own free choices. Policies are increasingly about the government instructing us how to behave. How to be.

Choice architecture redesigns our experiences without our consent. Diversion from the path of those choices chosen for us by choice architects is considered to be pathological. Nudge doesn’t accommodate creative opportunity, critical thinking or any form of genuine learning. It simply claims that we each operate within the confines of bounded rationality. We are cognitively flawed. But nudge doesn’t present the opportunity for citizens to develop awareness of potential limits, to problem-solve or to learn how to become better cognitively equipped.

It’s precisely because we are ALL cognitively flawed that the production of knowledge for governance itself needs be governed.  In this respect, behavioural econmics displays an arrogance and epistemoloical authoritarianism in that it is assumed the theories it’s founded on somehow escape the confines of rational boundaries that everyone else is unable to transcend. It’s like saying “that’s your “human nature”, but not ours”. If we are all cognitively flawed, then no-one is exempt from that rule.

Nudge reduces our experiences to measured, measurable, politically defned quantitative “outcomes”, at the expense of the crucial qualitative accounts and participation of citizens that contribute to a functioning democracy.

Thaler and Sunstein define a “nudge” as:

Any aspect of the choice architecture that alters people’s behaviour in a predictable way without forbidding any options or significantly changing their economic incentives.”

This statement puzzles me. If a behaviour is altered in a predictable way, then how will we know if any of the other potential options were forbidden or not, and surely, it means at the very least that the other possibilities – alternative choices – have been foreclosed intentionally by the choice architect. If it didn’t mean that, then why use nudge at all, how exactly does nudging work, and why are we funding it?

Libertarian paternalism or “nudging” is a mechanism to exploit the ways that individuals deviate from rational choice in order to benefit themselves or society at large – for instance, by using our bias toward the status quo to encourage employees to put more of their paychecks into savings.

This benefits employees because it means they will be able to afford to live when they hit hard times, as state provision such as unemployment support and pensions have been incrementally cut away to almost nothing. The powers that be in the UK regard any kind of welfare provision as a “perverse incentive”. This benefits the government because if everyone pays for their own pension, periods of unemployment, sickness and so on, then the government can spend your national insurance contributions and taxes on other things. Like very wealthy people’s tax cuts. 

The privatisation of choice and consent

Power is defined in the social sciences as the ability to influence (“soft power”) or shape and outright control the behaviour of people (“hard power”). Attempts by a government to shape and control the behaviour of citizens (including the targeting of specific social groups), either via policies or by brute force, isn’t generally considered to be compatible with democracy, social justice or notions of inclusion.

Thaler and Sunstein have claimed that governments always influence citizens’ behaviours. We have laws to deter clearly defined crimes such as murder, theft and so on. However, those laws are clearly stated and citizens are aware of their purpose and that they aim to control socially harmful behaviours. They are transparent. Most people would  agree that they are necessary to protect citizens, and most are aware of the probable consequences of being found breaking those laws.

These are overt attempts to dissuade people from behaving in potentially harmful ways towards others and wider society generally tends to endorse them, regarding them as necessary. Such laws permit us to engage our rational processes precisely because they are visible to us. Nudge is designed to bypass our critical and rational capacities.

Nudge or “behavioural economics” is the attempt to shape people’s socioeconomic behaviours without people being aware of the process or the aim. Nudge ceases to work when people become aware that they are being nudged – it only works “in the dark”. 

The Nudge Unit was part-privatised in 2014, which means it is protected from public scrutiny.  It is no longer subject to the Freedom of Information Act, and it can sue for libel.

Ian Dunt said at the time of the Nudge Unit’s privatisation: “The secrecy and legal might of private firms offering public services is morally indefensible whatever the sector. But in the case of nudge it is particularly dangerous, because this is an organisation specifically tasked with implementing policy on the subconscious of the British public.

However sympathetic we are to the goals nudge is trying to achieve – such as reducing car accidents or increasing tax collection – we should be deeply sceptical of its tactics, which involve influencing the public without them knowing it is happening.

This is what makes nudge so toxic an idea. While it seems more liberal than using legislation to clamp down on unhealthy behaviour, it is actually more pernicious. At least when something is banned, you know you are being prevented from doing it. With nudge, you will never know.”

The application of nudge tends to be asymmetrical – is targeted disproportionately at poor citizens. This is because of the political belief – a weighted bias – that poor people are poor because they make “irrational” and “wrong” choice. Conversly, wealthy people are deemed “rational” precisely because they are wealthy. This is a line of teleological reasoning – rather than being causal explanation of the phenomenon of inequality, the aims, ends, or intentions of the observed phenomenon or behaviour are used to explain the process. Teleology refers to a view that justifies certain phenomena, which are explained by reference to their purposes.  The Conservatives see inequality as functional, because it “encourages competition” and serves as an “incentive”. Social scientific arguments among positivists in particular quite often rest on rational short cuts like this. This short cut is a weighted bias that becomes embedded in the process of how particular areas of research are chosen, how the research is designed, and how interpretation of the results and conclusions are framed. Rather than the “scientific method” in social research serving to ensure value neutrality, quite often it simply distils the ideological premises of it.

Nudge reduces a persons’ choices to one choice – that of the state or “choice architects”. Nudge tends to draw on punishments, threats of punishment and negative reinforcements to change the behaviours of poor people – such as those embedded in welfare conditionality and sanctions, which exploit a cognitive bias we have, apparently, called “loss aversion”

Something that the government and libertarian paternalists choose to ignore is that it is poverty itself that restricts choices, not poor people’s cognitive “abilities” or decision-making. A good example is how the use of credit scoring ultimately leads to the poorest people having to pay the most interest on credit, if they manage to get any at all. Being poor limits our choices for credit, and other ways out of financial hardship. It’s difficult to find work that pays an adequate wage to support an adequate standard of living, especially when you have so few resources that you can’t meet all of your basic needs, let alone pay your broadband bill and meet travel costs.

It’s a very dangerously slippery slope when a group of technocrats claim they have perfected the art of knowing what is best for us, and what our best interests are, especially when it is especially geared towards the political goal of fulfilling “small state” ideology. 

Psychopaths see others as a means to an end, they also like to define other people’s “best interests”. They use justification narratives for their behaviours to manipulate people, which are often plausible, but ultimately, this is simply to get their own way.

Similarly, the Conservatives’ use of nudge reflects their ideological agenda, and their justification narratives reflect an authoritarian turn. 

The rise of nudge refects a miserly neoliberal government with an ideological agenda

If people who are poor are struggling with decision-making, then nudging people – even if “opt out” provision is made (and it generally isn’t) – without their knowledge or informed consent cannot be justified as a “non intrusive” intervention, as behavioural economists try to argue. Nudging reduces our autonomy and imposes a framework of psychological reductionism and determinism.

Nudge reflects a basic “stimulus-response” view of human shaping behaviour, except the word “incentive” has replaced “stimulus” in the old behaviourist terminology. Many behavioural economists talk about cognitive processes, and how flawed most people’s are. But nudge methodology reflects a behaviourist approach – there’s no opportunity for learning, and no consideration of human subjectivity – our inner states, meanings, understandings and so on – all that matters is getting people to comply and behave the way the “choice architects” think we should. Cause and effect.

Nudge was introduced as a policy strategy as a way of cutting costs. Libertarian paternalism is a political doctrine, and is therefore not value-neutral. However, libertarian paternalists argue that their methodology – Randomised Controlled Trials (RTCs) – validates their claim to value neutrality.  Behavioural economists argue that the evidence gathered from RTCs is a better, more reliable and valid form of knowledge than the knowledge of “experts”. But such knowledge is insufficient if it is abstracted from the political side of policymaking in which problems are framed and knowledge given meaning. Furthermore, the RTCs are used to add credibility to the theoretical knowledge of “experts”. But often, those presenting a case for evidence-based policies often ignore the multiplicity of evidence relevant to the policy in question. In this respect, RTCs may be used to filter out alternative accounts of the issue being addressed, and so justifying interventions that are inappropriate or may have unintended (or undeclared and ideologically determined, intended) consequences. 

RTCs are an effective way of determining whether or not a particular intervention has been successful at achieving a specific outcome. One significant concern is that RCTs  are being promoted as the ‘gold standard’ in a hierarchy of evidence that marginalises qualitative research, and the accounts of citizens’ experiences – crucial to a functioning democracy. The government has frequently dismissed citizens accounts of policy impacts as “anecdotal”, claiming that “no causal link” between policy and impact can be demonstrated. Given that some of these accounts have been first hand, and about serious harm caused by policy,  it’s easy to see how the use of  a”scientific methodology” so easily becomes a tool for stifling criticism, debate and a mechanism for political expediency. 

RTCs have been the standard of medical research, and are useful for establishing whether cause-effect relationships exist between treatments and outcomes and for assessing the cost effectiveness of a treatment. However, their use in influencing and quantifying an array of complex human behaviours marks a return of the determinism and reductionism that was central to behaviourist perspectives. 

We must also question the appropriateness of the use of a medical model to frame social problems. Poverty, inequality and the unequal distribution of power doesn’t happen because of some disease process: it is because of government policy and decision-making. No amount of blaming individual citizens’ decision-making and applying “behavioural medicine” to the victims of free neoliberal socioeconomics will remedy that. 

Behaviourism is basically the theory that human and animal behaviour can be explained in terms of conditioning, without appeal to “internal” states -thoughts or feelings – and that psychological disorders are best treated “externally” by altering “faulty” behaviour patterns. Because nudge is used asymmetrically, and targets poor people disproportionately, it is founded on assumptions that reflect traditional prejudices and assumptions about the causes of poverty, and also serves to endorse and extend existing inequalities in wealth, resources and power. Nudge assummes that poor people’s decision-making is the cause of poverty, rather than institutionalised prejudices and the political decision-making that shapes our socioeconomic environment.

One of our fundamental freedoms as human beings is that of decision-making regarding our own lives and experiences. To be responsible for our own thoughts, reflections, intentions and actions is generally felt to be an essential part of what it means to be human.

Of course there are social and legal constraints on some intentions and actions, especially those that may result in harming others, and quite rightly so.

There are other constraints which limit choices, too, insofar that choices are context-bound. We don’t act in an infinite space of opportunities, alternatives, time, information, nor do we have limitless cognitive abilities, for example.

In other words, there are always some limitations on what we can choose to do, and we are further limited because our rationality is bounded. Most people accept this with few problems, because we are still left ultimately with the liberty to operate within those outlined parameters, some of which may be extended to a degree – our capacity for rationality and critical thinking, for example, can be learned and improved upon. But our thoughts, reflections, decisions and actions are our own, held within the realm of our own individual, unique experiences.

However, the government, and the group of behavioural economists and “decision-making psychologists” (employed at the “Nudge” Unit) claim to have found a “practical” and (somehow) “objective way” from the (impossible) perspective of an “outside observer” – in this case, the government – to define our best interests and to prompt us to act in ways that conform to their views. Without our informed consent. “Compliance” is the defintely the governments’ buzzword. Compliance frameworks are embedded in our welfare system and most of our public services. 

Sunstein and Thaler argue that policymakers can preserve an individual’s liberty while still nudging a person towards choices that are supposedly in their best interests. However, since no-one can escape their bounds of their own subjectivity to find some mind-independent vantage point, and since all humans operate within a framework of bounded rationality, the behavioural economists’ claim to value-neutrality, and technocratic appeal to the validity of a “scientific” methodology doesn’t stand up to scrutiny.

The claim to an “objective” scientific methodology does nothing to compensate for the ideological perspectives of the researcher that invariably influence the choice of an area of study, or the nature of generated hypotheses that are tested in artificial environments – “laboratory” conditions. Isolated, tested, short-range hypotheses cannot tell us much about the vast array of complex processes involved in human decision-making, and take any meaningful account of the influence and depth of a cultural, political, social, economic and historical context. As such, they cannot provide a reliable basis for making inferences to real world circumstances.

The results depend on the interpretation and nature of the data used and the reason for the analysis in the first place. Simple causal explanations of behaviour embody reductionism and determinism – and therefore deny human autonomy. Bounded rationality is a theory that proposes we have limited choices, but behaviourist perspectives inform us that basically, we have none. 

Nudge doesn’t take into account that political decision-making also succumbs to the limits of bounded rationality, and that socioeconomic policies impact upon citizens, rather than citizens making choices – “right” or “wrong” ones – about our socioeconomic organisation.  

Medical RCTs are done within the confine a strict ethical framework, with informed consent being central to that framework. The government is conducting experiments on the population without their informed consent. There are no ethical safeguards in place to monitor and acknowledge any potential harm that arises as a consequence of nudging. This is precisely why there is a  need to incorporate qualitative insights into RTCs used to test pubic policy interventions. 

Nudge ignores the negative impact of the attitudes and behaviours of the wealthy and powerful on society

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“People who are poorer should be prepared to take the biggest risks; they’ve got least to lose.” Lord Freud, 2012

The risk-taking and greedy behaviours of wealthy people caused a global financial crash, which has ultimately led to countries like the UK imposing austerity on the poorest citizens. Excess in risk taking by and excessive leverage of banks meant that the finance class ignored externalities and relied on bail-outs by the government following the crisis.

The incentive structure of banks encouraged strategies that increased aggregate risk in the economy, and regulators allowed banks to use their own models to calculate and report riskiness. Deregulation is at the core of the 2008 Financial Crisis. The attempt to decrease government involvement in the financial system backfired. Ultimately, deregulation put depositors, consumers, and banks at risk. Those paying the price for the decision-making behaviours of those in positions of power are the poorest citizens. Austerity has been used as a diversion from where the responsibility for the banking crisis lies, and has become a mechanism of administering disipline and ensuring the conformity of the poorest citizens.

Yet their remains a widespread lack of concern for the financial system’s risk to the economy. No lessons appear to have been learned, and no-one is concerned with “changing the behaviours” of the perpetrators of the global recession.

“If we must talk about “poor choices” then we have to address all poor choices. Not just those “poor choices made by the Poor.” Hubert Huzzah

Austerity measures have caused an unacceptable level of harmhardship and absolute poverty – lacking the means to meet basic survival needs, such as food, fuel and shelter – that we haven’t witnessed as a society since before the establishment of the post-war welfare state. We have also witnessed the violation of the human rights of some socially marginalised groups. This point indicates to me that it isn’t poor people who need “behaviour change” programmes: it’s the rich and powerful who create adverse or “pathological” socioeconomic circumstances and events

“Nudge” bears the hallmark of oppression and is symptom of an authoritarian state. It permits those whose decisions have truly devastating impacts on others and our society to simply carry on doing as they choose, whilst punishing those who are blameless, powerless and don’t participate in decisions regarding how our society is organised. 

As such, nudge has become a prop for neoliberal hegemony and New Right Conservative ideology. It’s a technocratic fix to a socioeconomic system that is not only failing, it’s causing distress and harming many citizens.

Nudge addresses the needs of policy-makers. Not the wider public. The behaviourist educational function, made patronisingly explicit by the Nudge Unit, is now operating on many levels, including through policy programmes, institutionalised attitudes and behaviours, in schools, in forms of “expertise”, and even through the state’s influence on the mass media, other cultural systems and at a subliminal level: it’s embedded in the very language that is being used in political narrative.

Thaler acknowledges that regardless of the original intentions, nudge may be skewed by governments, organisations or individuals looking to capitalise on the cognitive biases of people. Whenever he is asked to sign a copy of his book , he writes “nudge for good” which is a plea, he says, to improve the lives of people and avoid “insidious behaviour.”

In the UK, choice architects work to simply maintain the status quo. Therefore nudge doesn’t and cannot offer us any scope for improving people’s lives.

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Grenfell is a stark monument to the systematic disempowerment of citizens because of the decisions made by the architects of neoliberal policies and the utter disregard and negligence of those in positions of power.

Residents of Grenfell Tower had previously raised serious concerns that a catastrophic event could happen. It did. An action group of Grenfell residents said their warnings fell on “deaf ears” after highlighting major safety concerns about the block. The neoliberalisation of the housing market entailed councils part-privatising public housing – putting them into housing associations or ALMOs (arms length management organisations). This management arrangement was distant and remote – a bureaucratic mechanism rather than a democratic community organisation. 

Austerity was (re)introduced in 2010. Public and social housing budgets were slashed and housing associations encouraged to become more commercial and borrow from banks instead of receiving public funding. At the same time, social security and funding for local government were dramatically cut back. In London alone, 10 fire stations, 27 fire engines and more than 600 firefighters have been lost to cuts since 2010. These undermined emergency responses and efforts to prevent fires by inspecting buildings and taking enforcement action under fire safety regulations.

Government hostility to regulation played a significant role in the unfolding of this terrible tragedy. Following a smaller fatal 2009 fire in South London, a series of recommendations including installing sprinkler systems and reviewing the “stay put” advice given to residents living in higher floors in the event of a fire. These recommendations were sat on, ignored, and delayed despite efforts from parliamentarians and campaigners, and even the magazine representing housing professionals. The requirement to carry out a Fire Risk Safety Assessment by the Fire Brigade was changed to make it the responsibility of landlords – Kensington and Chelsea Council opted to use the cheapest company available to them. 

These assessments are not transparent or public and are now the subject of huge public scrutiny along with the series of decisions that led to Grenfell Tower being “re-clad” in the cheap material that facilitated the rapid spread of the fire.

What is clear is that government decision-making, the ideology of deregulation, of privatising, of austerity, combined to kill people in their homes. Their safety and their lives were not valued by the government nor the system they put in place, nor were their voices heard until it was far too late. 

If we must talk about “poor choices” then we must address all poor choices. Not just those “poor choices” made by the poorest and most disempowered citizens.arnstein-ladder-citizenship-participation

 

 

 

 

 

 

 

 

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Sherry Arnstein’s Ladder of Citizen Participation and Power

Related

The importance of citizen’s qualitative accounts in democratic inclusion and political participation

The connection between Universal Credit, ordeals and experiments in electrocuting laboratory rats

 

I’m currently writing a longer and more in-depth critique of behavioural economics, which will be published very soon.

 


 

I don’t make any money from my work. I am disabled because of illness and have a very limited income. But you can help by making a donation to help me continue to research and write informative, insightful and independent articles, and to provide support to others. The smallest amount is much appreciated – thank you.

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IAPT is value-laden, non-prefigurative, non-dialogic, antidemocratic and reflects a political agenda

arnstein-ladder-citizenship-participation

Arnstein’s ladder of citizen participation and inclusion. It represents the redistribution of power that enables marginalised citizens, presently excluded from the political and economic processes, to be purposefully included in the future.

The government’s Work and Health Programme, due to be rolled out this autumn, involves a plan to integrate health and employment services, aligning the outcome frameworks of health services, Improving Access to Psychological Therapies (IAPT), Jobcentre Plus and the Work Programme.

But the government’s aim to prompt public services and commissioned providers to “speak with one voice” is founded on traditional Conservative prejudices about people who need support. This proposed multi-agency approach is reductive, rather than being about formulating expansive, coherent, comprehensive and importantly, responsive mental health provision.

What’s on offer is psychopolitics, not therapy. It’s about (re)defining the experience and reality of a marginalised social group to justify dismantling public services (especially welfare). In linking receipt of welfare with health services and state therapy, with the single politically intended outcome of employment, the government is purposefully conflating citizens’ widely varied needs with economic outcomes and diktats, which will isolate people from traditionally non-partisan networks of unconditional support, such as the health service, social services, community services and mental health services.

Services “speaking with one voice” will invariably make accessing support conditional, and further isolate marginalised social groups. It will damage trust between people needing support and professionals who are meant to deliver essential public services, rather than simply extending government dogma, prejudices and discrimination. And meeting ideologically designed targets.

As neoliberals, the Conservatives see the state as a means to reshape social institutions and social relationships hierarchically, based on a model of a competitive market place. This requires a highly invasive power and mechanisms of persuasion, manifested in an authoritarian turn. Public interests are conflated with narrow economic outcomes. Public behaviours are politically micromanaged and modified. Social groups that don’t conform to ideologically defined economic outcomes and politically defined norms are stigmatised and outgrouped. 

Othering and outgrouping have become common political practices, it seems.

The Work and Health Programme is a welfare-to-work programme for people with disabilities, mental health problems and for long-term unemployed people, due to be rolled out in the autumn. In the recent Work, Health and Disability green paper, the government mentioned new mandatory “health and work conversations” in which work coaches will use “specially designed techniques” to “help” those people in the ESA Support Group – those assessed by their own doctors and the state as being unlikely to work in the near future – “identify their health and work goals, draw out their strengths, make realistic plans, and build resilience and motivation.” 

Apparently these “conversations” were “co-designed” by the Behavioural Insights Team.

Democracy is based on a process of dialogue between the public and government, ensuring that the public are represented: that governments are responsive, shaping policies that address identified social needs.

However, policies increasingly reflect a behaviourist turn. They are no longer about reflecting citizens’ needs: they are increasingly about telling some citizens how to be. This has some profound implications for democracy.

Neoliberal policies increasingly extend behaviour modification techniques that aim to quantifiably change the perceptions and behaviours of citizens, aligning them with narrow neoliberal outcomes through rewards or “consequences.” Rewards, such as tax cuts, are aimed at the wealthiest, whereas the most vulnerable citizens who are the poorest are simply presented with imposed cuts to their lifeline support as an “incentive” to not be poor. Taking money from the poorest is apparently “for their own good”.   

Defining human agency and rationality in terms of economic outcomes is extremely problematic. And dehumanising. Despite the alleged value-neutrality of behavioural economic theory and CBT, both have become invariably biased towards the status quo rather than progressive change and social justice.

Behavoural economics theory has permited policy-makers to indulge ideological impulses whilst presenting them as “objective science.” From a libertarian paternalist perspective, the problems of neoliberalism don’t lie in the market, or in growing inequality and poverty: neoliberalism isn’t flawed, nor are governments – we are. Governments and behavioural economists don’t make mistakes – only citizens do. No-one is nudging the nudgers. It’s assumed that their decision-making is infallible and they have no whopping cognitive biases of their own. 

“There’s no reason to think that markets always drive people to what’s good for them.” Richard Thaler.

There’s no reason whatsoever to think that markets are good for people at all. Let’s not confuse economics with psychology, or competitive individualism and economic Darwinism with collectivism and mutual aid. Behavioural economics may offer us titbit theories explaining individual consumer’s decision making, but it’s been rather unreliable in explaining socioeconomic and political contexts and complex systems such as financial crises, and of course behavioual economists don’t feel the same pressing need to explore the decision making and “cognitive bias” of the handful of people who cause those.

It wasn’t those with mental health problems currently claiming social security. They do much less damage to the economy, in fact IAPT means vulture capitalist private companies like G4S and trusts like Southern Care can turn a profit offering “support”. 

The current emphasis on quantitative methodology and standardisation has led to an overwhelming focus on measurement in IAPT settings. Mental health services are now dominated by IAPT, which focuses exclusively on “evidence-based” and short-term interventions for clients with particular diagnoses – mostly anxiety disorders and depression. Most workers in IAPT services offer CBT, often by minimally trained psychological wellbeing practitioners offering “low-intensity” interventions over few sessions.

Verificationism and standardisation leads to a focus on measurement in IAPT settings. CBT mutes the causes of distress, which do not reside “within” the individual: they are intersubjectively constructed, with cultural, socioeconomic and political dimensions. Furthermore, there is little room left for authentic dialogue – qualitative accounts of client’s experiences are not accommodated. In this context, CBT is authoritarian, rather than being prefigurative and genuinely dialogic.

Under the government’s plans, therapists from the IAPT programme are to support jobcentre staff to assess and treat claimants, who may be referred to online cognitive behavioural therapy (CBT) courses. 

We must question the ethics of linking receipt of welfare with “state therapy,” which, upon closer scrutiny, is not therapy at all. Linked to such a narrow outcome – getting a job – it amounts to little more than a blunt behaviour modification programme. The fact that the Conservatives have planned to make receipt of benefits contingent on participation in “treatment” also worryingly takes away the fundamental right of consent.

CBT facilitates the identification of “negative thinking patterns” and associated “problematic behaviours” and “challenges” them. This approach is at first glance a problem-solving approach, however, it’s of course premised on the assumption that interpreting situations “negatively” is a bad thing, and that thinking positively about bad events is beneficial.

The onus is on the individual to adapt by perceiving their circumstances in a stoical and purely “rational” way. 

So we need to ask what are the circumstances that we expect people to accept stoically. Socioeconomic inequality? Precarity? Absolute poverty? Sanctions? Work fare? Being forced to accept very poorly paid work, abysmal working conditions and no security? The loss of social support, public services and essential safety nets? Starvation and destitution?  

It’s all very well challenging people’s thoughts but for whom is CBT being used. For what purpose? It seems to me that this is about coercing those people on the wrong side of draconian government policy to accommodate that; to mute negative responses to negative situations. CBT in this context is not based on a genuinely liberational approach, nor is it based on democratic dialogue. It’s about modifying and controlling behaviour, particularly when it’s aimed at such narrow, politically defined and specific economic outcomes, which extend and perpetuate inequality. In this context, CBT becomes state “therapy” used only as an ideological prop for neoliberalism.

CBT tends to generate oversimplifications of the causes human distress. It’s not about helping people make better choices, it’s about coercing people to make the choices that policymakers want them to make. Those “choices” are based on enforced conformity to the ideological commitments of policymakers.

It’s assumed that the causes of unemployment are personal and attitudinal rather than sociopolitical or because of health barriers, and that particular assumption authorises intrusive state interventions that encode a Conservative moral framework, which places responsibility on the individual, who is characterised as “faulty” in some way. The deeply flawed political/economic system that entrenches inequality isn’t challenged at all: its victims are discredited and stigmatised instead.

Yet historically (and empirically), it has been widely accepted that poverty significantly increases the risk of mental health problems and can be both a causal factor and a consequence of mental ill health. Mental health is shaped by the wide-ranging characteristics and circumstances (including inequalities) of the social, economic and physical environments in which people live. Successfully supporting the mental health and wellbeing of people living in poverty, and reducing the number of people with mental health problems experiencing poverty, requires engagement with this complexity.

There is also widely held assumption that working is good for mental health, and that being in employment indicates mental wellbeing. It’s well-established that poverty is strongly linked with a higher likelihood of being diagnosed with a mental illness. That does not mean working is therefore somehow “good” for mental health. Encouraging people to work should entail genuine support, it shouldn’t entail taking away their lifeline income as punishment “incentive” if they can’t work.

An adequate level of social security to meet people’s basic survival needs is not mutually exclusive from encouraging people to find a suitable job.

It’s worth noting that research indicates in countries with an adequate social safety net, poor employment (low pay, short-term contracts), rather than “worklessness”, has the biggest detrimental impact on mental health. 

CBT does not address the socioeconomic and political context. It permits society to look the other way, whilst the government continue to present mental illness as an individual weakness or vulnerability, and a consequence of “worklessness” rather than a fairly predictable result of living a distressing, stigmatised, excluded existence and material deprivation in an increasingly unequal society.

Inequality and poverty arise because of ideology and policy-formulated socioeconomic circumstances, but the government have transformed established explanations into a project of constructing behavioural and cognitive problems as “medical diagnoses” for politically created socioeconomic problems. Austerity targets the poorest disproportionately for cuts to income and essential services, it’s one ideologically-driven political decision taken amongst alternative, effective and more humane choices.

Both nudge and CBT are being used to prop up austerity and reflect neoliberal managementspeak at its very worst. Neoliberal policies are causing profound damage, harm and distress to those they were never actually designed to “help”. Let’s not permit techniques of neutralisation: the use of rhetoric to obscure the real intention behind policies. It’s nothing less than political gaslighting.

The government’s profound antiwelfarist rhetoric indicates that there’s no genuine intention to support those people with mental health problems and others in need, despite their semantic thrifts and diversions.

Policies are expressed political intentions regarding how our society is organised and governed. They have calculated social and economic aims and consequences. In democratic societies, all citizen’s accounts of the impacts of policies ought to matter. 

However, in the UK, the way that policies are justified is being increasingly detached from their aims and consequences, partly because democratic processes and basic human rights are being disassembled or side-stepped, partly because the government employs the widespread use of linguistic strategies and techniques of persuasion to intentionally divert us from the aims and consequences of their ideologically driven and increasingly dehumanising policies. Furthermore, policies have become increasingly detached from public interests and needs. 

For people with mental health problems, policies are being formulated to act upon them as if they are objects, rather than autonomous human subjects. Such a dehumanising approach has contributed significantly to a wider process of social outgrouping, increasing stigmatisation and ultimately, to further socioeconomic and mental health inequalities.

It’s the government that need to change their behaviour.

It’s us that need to make a stand against hegemonic neoliberal discourse and injustice.

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This article was written for a zine to mark the protest at the 10th annual New Savoy conference on 15 March in London #newsavoy2017. You can read the zine, with other people’s excellent contributions, here.

Also, see: New Savoy Protest against psycho-compulsion of MH claimants – 15th March 2017.

You can read about the background to the Mental Wealth Alliance and the New Savoy demo and lobby here.

You can watch the video here from Let Me Look TV: Protest at the 10th Annual New Savoy Conference 15 March 2017.

Please share.

Related

The power of positive thinking is really political gaslighting

The importance of citizen’s qualitative accounts in democratic inclusion and political participation

A critique of the ‘Origins of Happiness’ study

A critique of Conservative notions of social research

Research finds damaging mental health discrimination ‘built into’ Work Capability Assessment. Again.

The Conservative approach to social research – that way madness lies


 

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Jobcentre tells GP to stop issuing sick notes to patient assessed as ‘fit for work’ and he died.

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Abbie and her late father, James Harrison.

Julia Savage is a manager at Birkenhead Benefit Centre in Liverpool. She wrote a letter addressed to a GP regarding a seriously ill patient. It said:

“We have decided your patient is capable of work from and including January 10, 2016.

“This means you do not have to give your patient more medical certificates for employment and support allowance purposes unless they appeal against this decision.

“You may need to again if their condition worsens significantly, or they have a new medical condition.” 

The patient, James Harrison, had been declared “fit for work” and the letter stated that he should not get further medical certificates. 

However, 10 months after the Department for Work and Pensions (DWP) contacted his doctor without telling him, James died, aged 55, the Daily Record has reported.

He was clearly not fit for work.

His grieving daughter, Abbie, said: “It’s a disgrace that managers at the Jobcentre, who know nothing about medicine, should interfere in any way in the relationship between a doctor and a patient.

“They have no place at all telling a doctor what they should or shouldn’t give a patient. It has nothing to do with them.

“When the Jobcentre starts to get involved in telling doctors about the health of their patients, that’s a really slippery slope.”

Abbie said James had worked since leaving school at a community centre near his home. But his already poor health went downhill after the centre was shut down because of austerity cuts.

James had a serious lung condition and a hernia before the centre closed, and also developed depression and anxiety afterwards.

Abbie said: “He’d worked all his life. He wasn’t the kind of guy who knew anything about benefits.

“But as his health deteriorated, there wasn’t any chance he could do a job. He applied for employment and support allowance.”

James received Employment and Support Allowance (ESA), but only at the low rate of £70 a week, the same amount as jobseekers’ allowance. He was then sent to attend one of the DWP’s controversial Work Capability Assessments – and declared fit for work.

Despite that decision, Abbie said James remained in constant need of medical help and had to visit his doctor regularly.

However, the GP concerned repeatedly refused to give him a sick note, and James began to suspect the Jobcentre were to blame for this.

Abbie said: “He really needed a note. He was too ill to go to the constant appointments at the Jobcentre and he didn’t want to be sanctioned.

“He became convinced the DWP had been talking to his doctor behind his back.”

Although Abbie felt her father was confused, and didn’t think his explanation was right at the time, she later asked to see her father’s medical records. She found the letter in his file from Julia Savage, the manager at Birkenhead Benefit Centre, in James’s home city of Liverpool.

The letter was addressed to James’s GP.

Context: Government claims that work is a “health outcome”

James Harrison was very worried that his ill health interfered with his obligation to comply with the inflexible and constant conditions attached to his eligibility for welfare support, and that this would lead to sanctions – the withdrawal of his lifeline support, which was calculated to meet basic survival needs only.

The GP should have provided evidence that this was the case. The doctor was advised not to provide further fit notes by the DWP, however, unless James appealed. Yet the circumstances warranted that the GP provide a fit note. 

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Last year, the Department for Work and Pensions issued an ideologically directed new guidance to GPs regarding when they should issue a Fit Note. This was updated in December 2016.

In the document, doctors are warned of the dangers of “worklessness” and told they must consider “the vital role that work can play in your patient’s health”.  According to the department, “the evidence is clear that patients benefit from being in some kind of regular work”.

The biopsychosocial model, with a current political emphasis on the psychological element, has become a disingenuous euphemism for psychosomatic illness, which has been exploited by successive governments (and rogue insurance companies) to limit or deny access to social security, medical and social care.

Nobody would deny that illness has biological, psychological and social dimensions, however, the model has been adapted to fit a neoliberal “small state” ideology – one that rests almost entirely on Conservative individualist notions of citizen responsibility, as opposed to a rights-based approach and provision of publicly funded state support.

This approach to disability and ill health has been used by the government to purposefully question the extent to which people claiming social security bear personal responsibility for their own health status, rehabilitation and prompt return to work. It also leads to the alleged concern that a welfare system which was originally designed to provide a livable income to those with disabling health problems, may provide “perverse incentives” for perverse behaviours, entrenching “worklessness” and a “culture of dependency”. It’s worth pointing out at this point that there has never been any empirical evidence to support the Conservative notion of welfare “dependency”. 

Instead of being viewed as a way of diversifying risk and supporting those who have suffered misfortune and ill health, social and private insurance systems are to be understood as perverse incentives that pay people, absurdly, to remain ill and keep them from being economically productive.

The idea that people remain ill deliberately to avoid returning to work  – what Iain Duncan Smith and David Cameron have termed “the sickness benefit culture” – is not only absurd, it’s very offensive. This is a government that not only disregards the professional judgements of doctors, it also disregards the judgements of sick and disabled people. However, we have learned over the last decade that political “management” of people’s medical conditions does not make people healthier or suddenly able to work. Government policies, designed to “change behaviours” of sick and disabled people have resulted in harm, distress and sometimes, in premature deaths

The government have made it clear that there are plans to merge health and employment services. In a move that is both unethical and likely to present significant risk of harm to many patients, health professionals are being tasked to deliver benefit cuts for the DWP. This involves measures to support the imposition of work cures, including setting employment as a clinical outcome and allowing medically unqualified job coaches to directly update a patient’s medical record.

The Conservatives (and the Reform think tank) have also proposed mandatory treatment for people with long term conditions (which was first flagged up in the Conservative Party Manifesto) and this is currently under review, including whether benefit entitlements should be linked to “accepting appropriate treatments or support/taking reasonable steps towards “rehabilitation”.  The work, health and disability green paper and consultation suggests that people with the most severe illnesses in the support group may be subjected to welfare conditionality and sanctions.

Many campaigners have raised concerns about the DWP interfering with people’s medical care and accessing their medical files. I wrote an article last year about how the government plans to merge health and employment services and are now attempting to redefine work as a clinical outcome. I raised concerns about the fact that unemployment has been stigmatised and politically redefined as a psychological disorder, and that the government claims, somewhat incoherently, that the “cure” for unemployment due to illness and disability, and sickness absence from work, is work.

In a critical analysis of the recent work, health and disability green paper, I said: 

“And apparently qualified doctors, the public and our entire health and welfare systems have ingrained “wrong” ideas about sickness and disability, especially doctors, who the government feels should not be responsible for issuing the Conservatives recent Orwellian “fit notes” any more, since they haven’t “worked” as intended and made every single citizen economically productive from their sick beds.

It seems likely, then, that a new “independent” assessment and some multinational private company will most likely very soon have a lucrative role to ensure the government get the “right” results.”

The medical specialists are to be replaced by another profiteering corporate giant who will enforce a political agenda in return for big bucks from the public purse. Health care specialists are seeing their roles being incrementally and systematically  de-professionalised. That means more atrocious and highly irrational attempts from an increasingly authoritarian government at imposing an ideological “cure” – entailing the withdrawal of any support and imposing punitive “behavioural incentives” – on people with medical conditions and disabilities. Doctors, who are clever enough to recognise, diagnose and treat illness, are suddenly deemed by this government to be insufficiently clever to judge if patients are fit for work.

The political de-professionalisation of medicine, medical science and specialisms (consider, for example, the implications of permitting job coaches to update patient medical files), the merging of health and employment services and the recent absurd declaration that work is a clinical “health” outcome, are all carefully calculated strategies that serve as an ideological prop and add to the justification rhetoric regarding the intentional political process of dismantling publicly funded state provision, and the subsequent stealthy privatisation of Social Security and the National Health Service. 

“De-medicalising” illness is also a part of that process:

“Behavioural approaches try to extinguish observed illness behaviour by withdrawal of negative reinforcements such as medication, sympathetic attention, rest, and release from duties, and to encourage healthy behaviour by positive reinforcement: ‘operant-conditioning’ using strong feedback on progress.” Gordon Waddell and Kim Burton in Concepts of rehabilitation for the management of common health problems. The Corporate Medical Group, Department for Work and Pensions, UK. 

Waddell and Burton are cited frequently by the DWP as providing “evidence” that their policies are “evidence based.” Yet the DWP have selectively funded their research, which unfortunately frames and constrains the theoretical starting point, research processes and the outcomes with a heavy ideological bias. 

This framing simply shifts the focus from the medical conditions that cause illness and disability to the “incentives”, behaviours and perceptions of patients and ultimately, to neoliberal notions of personal responsibility and self-sufficient citizenship in a context of a night watchman, non-welfare state. 

Medication, rest, release from duties, sympathetic understanding – the remedies to illness – are being appallingly redefined as “perverse incentives” for ill health, yet the symptoms necessarily precede the prescription of medication, the Orwellian renamed (and political rather than medical) “fit note” and exemption from work duties. Notions of “rehabilitation” and medicine are being redefined as behaviour modification: here it is proposed that operant conditioning in the form of negative reinforcement – which the authors seem to have confused with punishment – will “cure” ill health. 

People cannot simply be “incentivised” into not being ill. 

The political use of the biopsychosocial model to cut costs at the expense of people who are ill will undoubtedly have further extremely serious implications. Such an approach, which draws on behaviourism and punishment (such as the threat and implementation of sanctions) is extremely unethical and makes the issue of consent to medical treatment very problematic if it is linked to the loss of lifeline support or the fear of loss of benefits.

This is clearly the direction that government policy is moving in and this represents a serious threat to the health, welfare, wellbeing and human rights of patients and the political independence of health professionals.

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Dr. Robert J. Lifton’s Eight Criteria for Thought Reform, cult thinking and neoliberalism

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Dr Robert J. Lifton is a psychologist who studied and identified the techniques of mass persuasion and groupthink used in propaganda and in cults (from political to religious). I found his interesting article about the eight criteria for “thought reform” on the International Cultic Studies Association (ICSA) site.

What struck me immediately about Lifton’s criteria is how easily they may be applied to neoliberalism – a totalising, authoritarian New Right ideology, imposed by an elite of very financially secure and powerful oppressors. Over the last few years, much of the rest of the population in the UK have experienced growing inequality and increasingly precarious socioeconomic circumstances, exacerbated by class-contingent neoliberal austerity and “small state” policies.

The neoliberal approach to public policy has become naturalised. Political theorist Francis Fukuyama, announced in 1992 that the great ideological battles between “east and west” were over, and that western liberal democracy had triumphed. He was dubbed the “court philosopher of [post-industrial] global capitalism” by John Gray.

In his book The End of History and the Last Man, Fukuyama wrote:

“At the end of history, it is not necessary that all societies become successful liberal societies, merely that they end their ideological pretensions of representing different and higher forms of human society…..What we are witnessing, is not just the end of the cold war, or a passing of a particular period of postwar history, but the end of history as such: that is, the end point of mankind’s ideological evolution and the universalisation of western liberal democracy as the final form of human government.”

I always saw Fukuyama as an ardent champion of ultra-neoliberalism, he disguised his conservatism behind apparently benign virtue words and phrases (as part of a propaganda technique called Glittering Generalities), such as “Man’s universal right to freedom.” 

He meant the same sort of self-interested “freedom” as Ayn Rand: “a free mind and a free market are corollaries.” He meant the same kind of implicit social Darwinist notions long held by Conservatives like Herbert Spencer – where the conditions of the market rather than evolution decides who is “free,” who survives, and as we know, the market is rigged by the invisible hand of government.

Fukuyama’s ideas have been absorbed culturally, and serve to normalise the dominance of the right, and stifle the rationale for critical debate.

Fukuyama’s work is a celebration of neoliberal hegemony. It’s an important work to discuss simply because it has been so widely and tacitly accepted, and because of that, some of the implicit, taken-for-granted assumptions and ramifications need to be made explicit. 

Neoliberalism requires an authoritarian approach to public administration. Rather than an elected government recognising and meeting public needs, instead, we now have a government manipulating citizens to adapt their views, behaviours and circumstances to meet the politically defined needs of the state. This turns democracy on its head. It is also presents us with a political framework that is incompatible with the UK’s international human rights obligations and equality legislation. 

Government policies have become increasingly irrational.  We have a government that has decided work is a health outcome, for example. In an absurd world where medical sick notes have been politically redefined as fit notes, sick and disabled people are apparently no longer exempt from work, which is now held to be a magic “cure”. The only way out of the politically imposed punitive and increasing poverty for those who cannot work is… to work. (See: Let’s keep the job centre out of GP surgeries and the DWP out of our confidential medical records.) 

Neoliberalism has become a doxa in the Western world. Here in the UK, citizen behaviours are being aligned with politically defined neoliberal outcomes, via policies that extend behaviour modification techniques, based on methodological behaviourism. Policies that “incentivise” have become the norm. This is a psychocratic approach to administration: the government are delivering public policies that have an expressed design and aim to act upon individuals, with an implicit set of instructions that inform citizens how they should be

Aversives and punishment protocols are most commonly used. Coercive welfare policies are one example of this. The recent eugenics by stealth policy entailing the restricting of welfare support to two children only is another. Both were introduced with the explicitly stated political intention of “changing behaviours” of poorer citizens. Those that cannot or will not conform are politically stigmatised and outgrouped, as well as being being further “disciplined” by state-imposed economic sanctions.

Another particularly successful way of neutralising opposition to an ideology is to ensure that only those ideas that are consistent with that ideology saturate the media and are presented as orthodoxy. Every Conservative campaign has been a thoroughly dispiriting and ruthless masterclass in media control.

Communication in the media is geared towards establishing a dominant paradigm and maintaining an illusion of a consensus. This ultimately serves to reduce democratic choices. Such tactics are nothing less than a political micro-management of your beliefs and are ultimately aimed at nudging your voting decisions and maintaining a profoundly unbalanced, pathological status quo. (See also: Inverted totalitarianism and neoliberalism.)

As a frame of analysis, Lifton’s criteria are very useful in highlighting parallels between cult thinking and how political dogma may gain an illusion of consensus; how it becomes a dominant paradigm and is accepted as everyday “common sense.” 

Kitty.

Lifton’s criteria for “thought reform” are:

  1. Milieu Control.  This involves the control of information and communication both within the environment and, ultimately, within the individual, resulting in a significant degree of isolation from society at large.

  2. Mystical Manipulation.  There is manipulation of experiences that appear spontaneous but in fact were planned and orchestrated by the group or its leaders in order to demonstrate divine authority or spiritual advancement or some special gift or talent that will then allow the leader to reinterpret events, scripture, and experiences as he or she wishes. (This can include “natural order” ideas and political doxa.) 
  3. Demand for Purity.  The world is viewed as black and white and the members are constantly exhorted to conform to the ideology of the group and strive for perfection.  The induction of guilt and/or shame is a powerful control device used here. (Stigma and political outgrouping is used to deter and exile non-conformists.)
  4. Confession.  Sins, as defined by the group, are to be confessed either to a personal monitor or publicly to the group.  There is no confidentiality; members’ “sins,” “attitudes,” and “faults” are discussed and exploited by the leaders. (Mainstream media have bombarded us with “confessions” of “scroungers”, for example. The lives and experiences of those out of work have become public moral “property.”)
  5. Sacred Science.  The group’s doctrine or ideology is considered to be the ultimate Truth, beyond all questioning or dispute.  Truth is not to be found outside the group.  The leader, as the spokesperson for God or for all humanity, is likewise above criticism. (Ties in with Conservative notions of a “natural social order”)
  6. Loading the Language.  The group interprets or uses words and phrases in new ways so that often the outside world does not understand.  This jargon consists of thought-terminating cliches, which serve to alter members’ thought processes to conform to the group’s way of thinking. (See Glittering Generalities and The Conservatives are colonising progressive rhetoric.)
  7. Doctrine over person.  Member’s personal experiences are subordinated to the sacred science and any contrary experiences must be denied or reinterpreted to fit the ideology of the group. 
  8. Dispensing of existence.  The group has the prerogative to decide who has the right to exist and who does not.  This is usually not literal but means that those in the outside world are not saved, unenlightened, unconscious and they must be converted to the group’s ideology.  If they do not join the group or are critical of the group, then they must be rejected by the  members.  Thus, the outside world loses all credibility.  In conjunction, should any member leave the group, he or she must be rejected also.  (Lifton, 1989)

*Italics in blue added by me.

Related

Nudging conformity and benefit sanctions: a state experiment in behaviour modification

The new Work and Health Programme: government plan social experiments to “nudge” sick and disabled people into work

Cameron’s Nudge that knocked democracy down: mind the Mindspace.

 

Link: The Government Communication Service guide to communications and behaviour changegcs-guide-to-communications-and-behaviour-change1


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Two key studies show that punitive benefit sanctions don’t ‘incentivise’ people to work, as claimed by the government

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Satirical Twitter response after Welfare Weekly used a Freedom of Information request to reveal that the Department for Work and Pensions had been using fake claimants and made-up comments to justify the use of punitive welfare sanctions

The government’s controversial benefit sanctions regime can cause “damage to the wellbeing of vulnerable claimants and can lead to hunger, debt and destitution”, according to a damning new report, which debunks Tory myths that benefit sanctions – denying people who are already struggling the only means by which to support themselves and their families – “incentivise people into work.”

In a report titled Benefit Conditionality and Sanctions in Salford – One Year on, commissioned by Salford City Council in 2014, comprised of a task force of Salford’s Financial Inclusion Practitioner’s Group (FIPG), it was concluded that, far from than “incentivising” people to move into work, the sanctions regime actually serves as a demotivator and barrier, preventing people from engaging in appropriate training, volunteering and employment-related activities.

Furthermore, the sudden loss of income caused by removing benefits – through the imposition of a punitive sanctions regime – often damages people’s mental health, creates tensions within family relationships and may cause individuals to turn to crime in order to meet their basic survival needs.

The report says: “Despite the drop in numbers in Salford receiving a benefit sanction, for those who are sanctioned the impact is devastating. 

“A ‘financial shock’ such as a sanction causes both immediate and longer term impact as most people do not have the means to save, so have no safety net. This presents an emergency need for money to buy food, pay for heating and essential travel costs.”

The report also says that the rate of people being sanctioned in the area has not reduced over the previous 12 month period. But, critically, it adds: “Register sizes are decreasing and we believe this is in part due to a growing number of “disappeared“. These are claimants who drop their benefit claim or who move off benefit but do not take up employment. The Government has refused to publish destination data.”  (See also: Government under fire for massaging unemployment figures via benefit sanctions from Commons Select Committee.)

The report goes on to say: “From the wide range of responses we have received from Salford agencies working with claimants, despite the fall in sanctions, the impact of sanctions both on claimants and services within the City cannot be overstated and the harsh regime will be expected to include additional groups as Universal Credit rolls out nationally this year.”

The report follows on from an interim study, published in October 2014, which predicted that sanctioning would most likely lead to extreme material hardship, mental health problems such as depression, and an increasing reliance on loan sharks. The interim report was submitted as evidence to the parliamentary inquiry into the impact of benefit sanctions.

Salford City Mayor, Paul Dennett said: “People on benefits are already struggling to afford food, heating and essential costs. They can’t save so they have no financial safety net. They live in dread of being sanctioned  which isn’t the right frame of mind for job hunting, volunteering or going back into education.” 

Rebecca Long Bailey, the Labour MP for Salford and Eccles, has said that the research “shows charities are increasingly having to step in to support claimants who are thrown into crisis due to delays and sanctions”. 

She added: “As an MP, I have seen some truly horrific cases, where the effects have been severe damage to my constituents’ mental and physical health, as well as the tragic case of David Clapson, who was found dead in his flat from diabetic ketoacidosis, two weeks after his benefits were suspended. His sister discovered her brother’s body and found his electricity had been cut off, meaning the fridge where he stored his insulin was no longer working. They must know that sanctioning people with diabetes is very dangerous but the system treats people as statistics and numbers. 

This report shows where we are in Salford today, one year on from the original report. Sadly, it illustrates the devastating impact sanctions have on the lives of people who are already struggling to make ends meet.”

Earlier this month, another collaborative research project, which is based at York university, also launched the publication of first wave findings from an ongoing study on the effects and ethics of welfare conditionality. This project started in 2013 and will finish in 2018. The researchers, from a variety of universities across the UK, draw on data from interviews with 52 policy stakeholders, 27 focus groups conducted with practitioners, and 480 “wave a” qualitative longitudinal interviews with nine groups of welfare service users in England and Scotland.  The study includes 480 people living in Bath, Bristol, Edinburgh, Glasgow, Greater Manchester, Inverness, London, Peterborough, Sheffield and Warrington, and is aimed at determining what longer-term effects the sanctions and employment “support” are having.

Most respondents report negative experiences of conditional welfare interventions. Linking continued receipt of benefit and services to mandatory behavioural requirements under threat of sanction has created widespread anxiety and feelings of disempowerment among claimants.

The impacts of benefit sanctions are universally reported by welfare service users as profoundly negative. Routinely, sanctions had severely detrimental financial, material, emotional and health impacts on those subject to them. There was evidence of certain individuals disengaging from services or being pushed toward “survival crime”. Harsh, disproportionate or inappropriate sanctioning created deep resentment and feelings of injustice. 

A recurring theme in peoples’ experiences was that sanctions or other enforcement measures were out of proportion to the “offence”, such as being a few minutes late for an appointment. Many reported being sanctioned following administrative mistakes by Jobcentre or Work Programme staff.

The Claimant Commitment was criticised for not taking sufficient account of individuals’ capabilities, wider responsibilities and/or vulnerabilities. Many saw Jobcentre Plus in particular as being primarily concerned with monitoring compliancy with behavioural requirements, imposing discipline and enforcement, rather than providing any meaningful support.

At the heart of welfare conditionality is an unfounded belief that it will change service users’ behaviour. Research to date in this first wave of findings has found very little evidence of welfare conditionality bringing about positive behaviour change in terms of preparing for or finding paid work and/or ending what is assumed to be “irresponsible behaviour” (rather than a consequence of the realities of labour market and socioeconomic constraints.)

Many welfare service users challenged the notion that they did not want to work. Virtually all interviewees in this study expressed a desire to work in the future when, and if, their personal situations made this possible. 

If you want to take part in this study, please get in touch if you live in one of these areas: Bath, Bristol, Edinburgh, Glasgow, Greater Manchester, Inverness, London, Peterborough, Sheffield and Warrington. Your personal details will be kept confidential.

 

Related 

Exclusive: DWP Admit Using Fake Claimant’s Comments In Benefit Sanctions Leaflet

Benefit Sanctions Can’t Possibly ‘Incentivise’ People To Work – And Here’s Why

Nudging conformity and benefit sanctions

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The media need a nudge: the government using ‘behavioural science’ to manipulate the public isn’t a recent development, nudging has been happening since 2010

8+Ways+to+Protect+Yourself+From+Emotional+Manipulation

Last year I wrote a critical article about the government’s Nudge Unit. The ideas of libertarian paternalism were popularised around five years ago by the legal theorist Cass Sunstein and the behavioural economist Richard Thaler, in their bestselling book Nudge. Sunstein and Thaler argue that we are fundamentally “irrational” and that many of our choices are influenced negatively by “cognitive bias.” They go on to propose that policymakers can and ought to nudge citizens towards making choices that are supposedly in their best interests and in the best interests of society.

But who nudges the nudgers?

Who decides what is in our “best interests”?

And how can human interests be so narrowly defined and measured in terms of economic outcomes, within a highly competitive, “survival of the fittest” neoliberal framework? The Nudge Unit is concerned with behavioural economics, not human happiness and wellbeing.

The welfare reforms, especially the increased application of behavioural conditionality criteria and the extended use of benefit sanctions, are based on a principle borrowed from behavioural economics theory – the cognitive bias called “loss aversion.” It refers to the idea that people’s tendency is to strongly prefer avoiding losses to acquiring gains. The idea is embedded in the use of sanctions to “nudge” people towards compliance with welfare rules of conditionality, by using a threat of punitive financial loss, since the longstanding, underpinning Conservative assumption is that people are unemployed because of behavioural deficits.

I’ve argued elsewhere, however, that benefit sanctions are more closely aligned with operant conditioning (behaviourism) than “libertarian paternalism,” since sanctions are a severe punishment intended to modify behaviour and restrict choices to that of compliance and conformity or destitution. But nudge was always going to be an attractive presentation at the top of a very slippery slope all the way down to open state coercion. Most people think that nudge is just about helping men to pee on the right spot on urinals, getting us to pay our taxes on time, or to save for our old age. It isn’t.

How can sanctioning ever be considered a rational political action –  that taking away lifeline income from people who are already struggling to meet their basic needs is somehow justifiable, or “in their best interests” or about making welfare “fair”?  The government claim that sanctions “incentivise” people to look for work. But there is an established body of empirical evidence which demonstrates clearly that denying people the means of meeting basic needs, such as money for food and fuel, undermines their physical, emotional and psychological wellbeing, and serves to further “disincentivise” people who are already trapped at a basic level of struggling to simply survive.

The Minnesota Semistarvation Experiment for example, provided empirical evidence and a highly detailed account regarding the negative impacts of food deprivation on human motivation, behaviour, sociability, physical and psychological health. Abraham Maslow, a humanist psychologist who studied human potential, needs and motivation, said that if a person is starving, the desire to obtain food will trump all other goals and dominate the person’s thought processes. This idea of cognitive priority is also represented in his classic hierarchy of needs. 

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Maslow’s hierarchy of needs

In a nutshell, this means that if people can’t meet their basic survival needs, it is extremely unlikely that they will have either the capability or motivation to meet higher level psychosocial needs, including social obligations and responsibilities to job seek.

Libertarian paternalists claim that whilst it is legitimate for government, private and public institutions to affect behaviour the aims should be to ensure that “people should be free to opt out of specified arrangements if they choose to do so.” The nudges favoured by libertarian paternalists are also supposed to be “unobtrusive.” That clearly is not the case with the application of coercive, draconian Conservative welfare sanctions. (See Nudging conformity and benefit sanctions.)

Evidently the government have more than a few whopping cognitive biases of their own.

I have previously criticised nudge because of its fundamental incompatibility with traditional democratic principles, and human rights frameworks, amongst other things. Democracy is based on a process of dialogue between the public and government, ensuring that the public are represented: that governments are responsive, shaping policies that address identified social needs. However, policies are no longer about representing and reflecting citizen’s needs: they are all about telling us how to be.

I’ve also pointed out that nudge operates to manipulate at a much broader level, too. The intentional political construction of folk devils and purposeful culturally amplified references to a stereotype embodying fecklessness, idleness and irresponsibility, utilising moral panic and manufactured public outrage as an effective platform for punitive welfare reform legislation, is one example of the value-laden application of pseudoscientific “behavioural insights” theory. The new paternalists have drawn on our psychosocial inclinations towards conformity, which is evident in the increasing political use of manipulative normative messaging. (For example, see: The Behavioral Insights Team in the U.K. used social normative messages to increase tax compliance in 2011.) 

The paternalist’s behavioural theories have been used to increasingly normalise a moral narrative based on a crude underpinning “deserving” and “undeserving” dichotomy, that justifies state interventions imposing conditions of extreme deprivation amongst some social groups – especially those previously considered legally protected. Public rational and moral boundaries have been and continue to be nudged and shifted, incrementally. Gordon Allport outlined a remarkably similar process in his classic political psychology text, The Nature of Prejudice, which describes the psychosocial processes involved in the construction of categorical others, and the subsequent escalating scale of prejudice and discrimination.

So we really do need to ask exactly in whose “best interests” the new paternalist “economologists” are acting. Nudge is being targeted specifically at the casualties of inequality, which is itself an inevitability of neoliberalism. The premise of nudge theory is that poor people make “bad choices” rather than their circumstances being recognised as an inexorable consequence of a broader context in which political decisions and the economic Darwinism that neoliberalism entails creates “winners and losers.”

I have seen very little criticism of nudge in the mainstream media until very recently. On Monday the Independent published an article about how the Chancellor exploited our cognitive biases to secure his cuts to welfare, drawing particularly on the loss aversion theory. To reiterate, in economics decision theory, loss aversion refers to people’s tendency to strongly prefer avoiding losses to acquiring gains.

From the Independent article:

“Researchers have also found that people do not treat possible forgone gains resulting from a decision in the same way as equivalent potential out-of-pocket losses from that same decision. The forgone gains are much less psychologically painful to contemplate than the losses. Indeed, the gains are sometimes ignored altogether.

There was an apparent attempt to harness this particular psychological bias in George Osborne’s Autumn Statement. Of course the Chancellor was forced into a memorable U-turn on his wildly unpopular tax credit cuts. Millions of poor working families will now not see their benefits cut in cash terms next April. Yet the Chancellor still gets virtually all his previously targeted savings from the welfare bill by 2020.

How? Because the working age welfare system will still become much less generous in five years’ time. As research from the Institute for Fiscal Studies and the Resolution Foundation has shown, the typical low-income working family in 2020 will be hit just as hard as they were going to be before the Autumn Statement U-turn. The Chancellor seems to be calculating that the pain of future forgone gains will be less politically toxic than immediate cash losses.”

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It’s hardly a revelation that the Conservative government are manipulating public opinion, using scapegoating, outgrouping and the creation of folk devils in order desensitize the public to the plight of the poorest citizens and to justify dismantling the welfare state incrementally. As I’ve pointed out previously, this has been going on since 2010, hidden in plain view.

In the article, Ben Chu also goes on to say:

“Experiments by Daniel Kahneman, Jack Knetsch and Richard Thaler also suggest that this stealth approach fits with people’s sense of fairness. They found that in a time of recession and high unemployment most people they surveyed thought a hypothetical company that cut pay in cash terms was acting unfairly, while one that merely raised it by less than inflation was behaving fairly.

There was another exploitation of our psychological biases in the Autumn Statement. The Chancellor announced an increase in stamp duty for people buying residential properties to let. That underscored the fact that the Chancellor remains wedded to the stamp duty tax, despite pressure from public finance experts to shift to a more progressive and efficient annual property tax (perhaps an overhauled council tax).

But Mr Osborne, like all his recent predecessors, realises that stamp duty, for all its deficiencies, tends to be less resented as a form of taxing property. Why? Because of “anchoring”. When people buy a house they are mentally prepared to part with a huge sum, usually far bigger than any other transaction they will make in their lives. The additional stamp duty payable to the Treasury on top of this massive sum, large though it is, seems less offensive. People resent it less than they would if the tax were collected annually in the form of a property tax – even if, for most, it would actually make little difference over the longer term. Sticking with stamp duty is the path of least resistance.”

There is another economologist “experiment” that seems to have slipped under the radar of the media – an experiment to nudge sick and disabled people into work, attempting to utilise GPs in a blatant overextension of the intrusive and coercive arm of the state. It is aimed at ensuring sick and disabled people don’t claim benefits. I don’t recall any mention of behaviourist social experiments on the public in the Conservative manifesto.

When I am ill, I visit a doctor. I expect professional and expert support. I wouldn’t consider consulting Iain Duncan Smith about my medical conditions. Or the government more generally. There are very good reasons for that. I’m sure that Iain Duncan Smith has Dunning–Kruger syndrome. He thinks he knows better than doctors and unreliably informs us that work can set you free, it can help prevent and cure illness.  Yet I’ve never heard of a single case of work curing blindness, heart disease, rheumatoid arthritis, cerebral palsy, multiple sclerosis, cancer or even so much as a migraine. I’ve also yet to hear of a person’s missing limbs miraculously growing back. The Conservative “medical intervention” entails a single prescription: a work coach from the job centre. State medicine – a single dose to be taken daily: Conservative ideology, traditional prejudice and some patronising and extremely coercive paternalism. The blue pill.

I don’t agree with the conclusions that Ben Chu draws in his article. Whilst he acknowledges that:

“The Government has a Behavioural Insights Team (or “Nudge Unit”) whose objective is to exploit the public’s psychological biases,” he goes on to say that it’s merely “to push progressive policies, such as getting us to save more for retirement and helping us make “better choices”, perhaps by counteracting the negative impact of loss aversion. But, as we’ve seen, the Chancellor is not above exploiting our biases in a cynical fashion too.” 

Progressive policies? The draconian welfare “reforms” aren’t remotely “progressive.” In the UK, the growth and institutionalisation of prejudice and discrimination is reflected in the increasing tendency towards the transgression of international legal human rights frameworks at the level of public policy-making. Policies that target protected social groups with moralising, stereotypical (and nudge-driven) normative messages, accompanied with operant disciplinary measures, have led to extremely negative and harmful outcomes for the poorest and most vulnerable citizens, but there is a marked political and social indifference to the serious implications and consequences of such policies.

There is a relationship between the world that a person inhabits and that person’s actions. Any theory of behaviour and cognition that ignores context can at best be regarded as very limited and partial. Yet the libertarian paternalists overstep their narrow conceptual bounds, with the difficulty of reconciling individual and social interests somewhat glossed over. They conflate “social interests” with neoliberal outcomes.

The asymmetrical, class-contingent application of paternalistic libertarian “insights” establishes a hierarchy of decision-making “competence” and autonomy, which unsurprisingly corresponds with the hierarchy of wealth distribution.

So nudge inevitably will deepen and perpetuate existing inequality and prejudice, adding a dimension of patronising psycho-moral suprematism to add further insult to politically inflicted injury. Nudge is a technocratic fad that is overhyped, theoretically trivial, unreliable; a smokescreen, a prop for neoliberalism and monstrously unfair, bad policy-making.

Libertarian paternalists are narrowly and uncritically concerned only with the economic consequences of decisions within a neoliberal context, and therefore, their “interventions” will invariably encompass enforcing behavioural modifiers and ensuring adaptations to the context, rather than being genuinely and more broadly in our “best interests.” Defining human agency and rationality in terms of economic outcomes is extremely problematic. And despite the alleged value-neutrality of the new behavioural economics research it is invariably biased towards the status quo and social preservation rather than progressive social change.

At best, the new “behavioural science” is merely theoretical, at a broadly experimental stage, and therefore profoundly limited in terms of scope and academic rigour, as a mechanism of explanation, and in terms of its capacity for generating comprehensive and coherent accounts and understandings of human motivation and behaviour.

At worst, the rise of this new form of psychopolitical behaviourism reflects, and aims at perpetuating, the hegemonic nature of neoliberalism.

But for the record, when a government attempts to micromanage and manipulate the behaviour of citizens, we call that “totalitarianism” not “nudge.” 

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Related reading

A critique of Conservative notions of social research

The government plan social experiments to “nudge” sick and disabled people into work

Mind the MINDSPACE: the nudge that knocked democracy down

Nudging conformity and benefit sanctions