Reaction to the news that the UK Government have been discussing linking employment support payments to undergoing mental health assessments among the psychiatric population. This short article has a particular focus on the authoritarianism behind this move.
Last Saturday The Telegraph ran a story on the UK Government’s plans to couple unemployment welfare payments to the mandatory undertaking of a course of cognitive behavioural therapy (CBT). According to their report these proposals put forward that anyone with a psychiatric diagnosis who is deemed to be capable of work will have to undergo treatment or face sanctions. This latest reinforcement of conditionality is part of an increasingly obvious authoritarian capitalism in the UK.
You can’t force someone into therapy, but...
This truism has been one of the most repeated objections to the proposals that I’ve seen. Since Eysenck’s 1952 study into the efficacy of various forms of psychotherapy there has been controversy over whether therapy helps anyone at all 1 . While that debate goes on there has been increased emphasis on the therapeutic relationship coming from all medico-therapeutic professions especially in psychotherapy, counselling and mental health nursing2 . In these fields the nature of the relationship between the worker and the client is being emphasised as the mechanism of therapeutic change: it is the relationship between me and you that does the work of therapy.
All existing therapy is conditioned by a multitude of inequalities and power differentials, but in the present case we’re looking at a relationship that can be called one of coercion. Whatever the therapist’s feelings on the subject they operate as an agent of professional and state power over a subjugated body. Under these conditions therapy can’t be realistically expected to work, and is more likely to make matters a lot worse.
But this is only a part of the picture. While it’s true that therapy can’t be coercive and be expected to work, it’s also true that a large proportion of psychological therapy is coerced. A lot of people go to psychological therapy not because they want to explore their rich inner world or to address the wounds in their subjectivity but because others have effectively forced them. Coercive agents can include families, partners and friends, as well as juridical and medical institutions. It’s not uncommon for courts to order violent offenders to go to anger management, or people with addiction problems to attend treatment centres and/or group therapy. There is also the continued existence of involuntary in-patient treatment and compulsory treatment orders beyond clinical settings. So the objection is right but wrong: it’s right because when it's enforced therapy ceases to be therapy, but it’s wrong because people are routinely forced into therapy.
What is really at stake is the extension of a specific set of disciplinary techniques to the unemployed that simply threatens them with the prospects of starvation and homelessness to ensure compliance. As nikolas Rose has argued therapeutic techniques are often employed to give authoritarianism ‘a kind of ethical cast’ 3 . While this ethical appearance has backfired in this case critique still remains within the ethical register. The real problem only emerges when we shift to these political considerations. The real problem is that the use (in this case) of a technics for changing how people think and act against their will has historical precedence. A policy of mandatory re-education coupled to a policy of mandatory unpaid labour producing a distributed gulag: The Tory Party morphs into a weird neoliberal Stalinism4 .
Can’t buy you happiness, but...
Yesterday the Independent featured an interview with British economist Richard Layard. The article’s headline features Layard proclaiming that ‘money is not the only thing affecting people’s happiness’. Layard has written two books in which he claims that not enough is done for the mental wellbeing of citizens despite the massive costs to the economy. Layard is one of the champions of the happiness index that David Cameron has previously voiced support for. The index would measure wellbeing of citizens and thereby displace GDP as a measure of national success 5
The political effect and (we could speculate) aim is the very erasure of the depression and anxiety caused by unemployment as political and economic questions. I have already demonstrated elsewhere that depression and anxiety are caused by unemployment. In the government’s proposed enforced therapy regime this causal picture is reversed: the unemployed are unemployed because they are depressed. CBT operates with the assumption that there is something faulty, inappropriate or, in its purest expressions, irrational about people’s behaviour. Even where a thought is rational it may still be counted as “unhelpful”: you might be right about the world being shit, but you’re wrong to be right about it!
With the proffering of CBT as the treatment modality of enforced therapy for unemployed workers the implication is that their unemployment is the result of their irrationality. This is the already too familiar strategy of responsibilisation that seeks to locate blame for social conditions with individuals. By a magical sleight of hand the decades of neoliberal decomposition of labour vanish and its political sculptors and benefactors slide out of view. This is evident even in the way that happiness economics moves its categories from labour to citizen and workers to individuals. Here again we collide with the idea that people just need a little re-education and to get back into the workplace.
In the Independent, Layard makes the economic case for all this. CBT costs a one-off payment of £650 per person to treat depression. If they treatment is successful then this would save £650 a month of ESA payments, plus a total of £10m in nhs costs. CBT is so cheap because it is easy to teach and easy to deliver. It’s also an economist’s favourite treatment due to its very time-limited nature and its simple to quantify outcome metrics. Affordable, simple, flexible, and measurable, CBT represents a revitalisation of Taylorist principles carried into the management of subjectivity by maximising the efficiency of psychological workers. It isn’t at all incidental that part of the CBT approach is also to do with minimising the “irrationality” of its subjects or, in other words, maximising patient's adaptability to the demand of the market. We can imagine this increased efficiency of unemployed workers amounting to suppressing shame and anxiety in favour of “at least it’s a job” thinking.
This proposal isn’t just a disciplinary measure; it’s also a job creation scheme. In the same 2005 report Layard recommended ‘10,000 extra psychological therapists’, an ‘extra 5000 clinical psychologists’ which would be a ‘doubling’ of their ranks, a doubling of the number of psychiatrists. Layard also recommended the by-now standard inclusion of ‘private providers’, augmented by self-help and ‘welfare-to-work’. This proposal will act to reinforce the shame felt by workless people whilst furthering the destruction of class consciousness as parts of the (“cognitive”) working class pathologise and control other parts of the (“low skilled”) working class8 .
If that weren’t far enough, Layard also argues that
‘For most people with mental problems, activity is an important path to recovery, and work (where it can be managed) is one of the most therapeutic activities’.
Activity is conflated with work and work is reduced to employment (paid or unpaid). This isn’t exactly cutting edge in the world of mental health. The token-economies of wards once issued well behaved patients with tokens or cigarettes that operated as currency, often as a reward for doing work on the ward or around the hospital grounds thereby replicating the capitalist wage relation. Here the token economy is transplanted into the labour market and is redeployed within it: the psy-function of reinforcing capitalist reality generalised beyond the Asylum’s walls. Work on the self is the cure for being a bad capitalist subject; an ideology of the maximisation of happiness conceals the actual maximisation of compliance and efficiency.
Should it work?
I can’t address the question of CBT’s effectiveness and efficacy here as that would be a much bigger task. That said it is enough to point out that there are seriously contradictory reports on this subject in relation to depression, anxiety and psychosis. That CBT appears to be the most effective therapy may be a product of its place as the most extensively research form of talk therapy, and this may have to do with its being a bundle of techniques (some of which are stupidly common-sense). Some studies have even indicated that CBT is no better than befriending, the practice whereby a volunteer simply show up and hangs out with someone who has a diagnosis. It is also impossible to double-blind studies in psychotherapies meaning that in control trials the patients and the therapists both know what is going on, and this can bias the outcomes.
Whatever the case, there is a general feeling that CBT isn’t a panacea that can be applied indifferently to all people in all places. My own feelings as someone who has been trained in CBT up to an introductory level, uses it in microcounselling form and sees it used every day at work, is that it fundamentally misunderstands human beings. It fails to understand how human affectivity and desire operates, and is held in thrall to a model of rationality that is both exclusionary of madness and which generalises a certain capitalist utopian ideal of homo economus, the masculine ideal of the human being who makes rational economic decisions. I have seen women who’ve had their children taken away from them by social services asked to think “how this can be seen as a positive”. I’ve seen people struggle with physiological and phenomenological drug dependencies asked to think about how appropriate their behaviour is when they dare to talk about drugs. I’ve seen schizophrenics challenged on their validity of their beliefs, allowing workers not to have to bother to try to establish any rapport or even attempt to find intelligibility to their paranoias or their voices.
Given all that’s been covered in this article so far we are also able to put forward the accusation that CBT might work if that means assisting in adapting people to the conditions that have created their problems in the first place. Our first concern must be political. There can be no therapeutics that is not a political therapeutics.
Slavoj Zizek calls happiness our new biomorality, and CBT is the therapy for the maximisation of happiness,9
. Perhaps this is truer of one of CBT’s offspring, positive psychology, but nonetheless we’ve seen how cognitive behavioural therapy is coupled to a concept of happiness that conceals efficient productivity. We’ve also seen how CBT is a quick, cheap method for fixing people up and sending them back to work, for getting all those unproductive bodies back into the workplace, and had hints at the continued use of CBT as self-help, allowing it to act as everyday prophylactic. Capitalism has never just been about the production of material goods, it has always tended to the production of subjectivities as well. Capitalism makes goods, yes; but it makes kind of people too. Psychology of any stripe under capitalism is one of the chief means for producing and regulating those subjectivities. Psychology tells us what our interiority consists of, and in no small part therefore shapes it, conditions it, constrains affordances and lets other blossom. CBT is no exception. It works for capitalism and the state, and, despite the benefits people do reap from it, it forms part of the new authoritarian norm.
We can conclude of CBT what Guery and Deleule10 concluded of as such:
This therefore is the task of modern psychology: to proceed in such a manner that the living machine, in its ordinary functioning, becomes as adapted as possible to the social mechanism into which it is, in fact, integrated, so that its productive act develops in optimal conditions and its gears don’t grind to loudly.
- 1Eysenck, H.J. 1952. The effects of psychotherapy: An evaluation. Journal of Consulting Psychology 16: 319–24.
- 2The literature is to extensive to cover here. Rest assured during my training I had the words "therapeutic relationship" and "therapeutic alliance" permanently ingrained into my brain. They'll be the last things left after the dementia kicks in. For an overview, see Wiki: http://en.wikipedia.org/wiki/Therapeutic_relationship
- 3 Rose, n. Power in therapy: techne and ethos. Here.
- 4 This clumsy phrase is meant to resonate with the idea of market Stalinism: the neoliberal acceleration of bureaucracy and PR. It can also be placed within a constellation of what is an increasing paranoiac-fascist state
- 5. The use of psychological technics among the relative surplus population of the unemployed serves as part of this renewed utilitarianism.
- 6 That this plan was introduced in 2005, and that Layard was one of the people involved in the role out of the Improving Access to Psychological Therapies- the program responsible for making CBT the UK's most available therapy- suggests rationally paranoid conclusions.
- 7 All further references to Layard refer to: Layrard. R. 2012. Mental health: Britain's biggest social problem? Here. He also noted that CBT doubled the return-to-work rate of unemployed people. What work will the masses of people find in an economy with more applicants than jobs? Casualised zero-hour jobs that are themselves detrimental to mental health? But that’s not the point.
- 8 I include the bracketed terms not to support some distinction between material and immaterial labour but in order to show how psychology is deployed as part of the attempt to produce that split as absolute. In fact this is merely the old division between intellectual labour and manual labour and as such forms part of the division of labour that should be refused rather than celebrated
- 9 Zizek, S. 2008. In defence of lost causes. London: Verso. 45
- 10 Guery, F. and Deleule. D. 2014 . The productive body. London: Zero Books. p.118.