The Cost of Caring
Neoliberalism, commodification, individualisation and medicalization
This is a paper I gave at the Fabian Society in Wellington, on Monday May the 8th, 2017
You can listen to the audio here or read the full paper below…
I intend to be quite ambitious, and wide ranging in this paper. I will be talking about the People’s Mental Health Review, and our report, but mostly I want to consider the political, cultural and economic factors that mean we find ourselves in this position where we are having to defend not just a public mental health model, but good mental health treatment.
I’m going to look briefly at our culture of individualism, how that is formed, and accentuated by a generation of neo liberal policies, and how an individualised culture makes us more susceptible to mental health difficulties.
I will consider how the dominant narrative within mental health care, at least in this country is the bio-medical approach and how it has become an unintentional reinforcer of this individualised world view.
I want to consider, and hopefully for us to discuss, how all of this has lead to a pseudo-privatised, and ultimately “commodified” economic approach to mental wellbeing, typified by the Social Investment approach, and as we saw last week in the Health Ministers speech, although light on detail, we now should expect the Social Investment approach to be forming a larger part of mental health services in this country, under a National Government.
Now, I am not pretending to be a Sociologist, an economist, a policy expert or an expert of the Social Investment approach. Most of the time I have enough trouble pretending to be a psychotherapist. So I will be leaving ample time tonight for questions and comments, so if I appear to not have something quite right, I look forward to hearing your learned comments, and corrections.
Individualisation – lack of collectivism
For me the burning, and obvious societal problem, if not THE key crisis of our generation, globally is economic inequality. Inequality is a driver of mental ill-health, many preventable health disorders, addiction and many health issues.
We also know that the so called “austerity” approaches adopted by many Western democracies post the GFC seemed to have a directly measurable negative impact on health outcomes.
Just one example: people who are looking for work are more than twice as likely to end their lives than those who are working. (The Body Economic: Why Austerity Kills” Stuckler and Basu they are public health epidemiologists.)
More than this though, recent studies seem to suggest that economic inequality has some particular psychological effects.
I’m reading here from a recent article on the Conversation website:
“For example, there is evidence that people in more unequal societies tend to have lower levels of life satisfaction and higher rates of depression. These and other psychological effects on individuals may help to explain the larger scale social effects of inequality.
An important new review article makes a strong case for the explanatory role of two phenomena in particular. Nicholas Buttrick and Shigehiro Oishi argue economic inequality breeds mistrust and status competition. These have downstream effects on health and well-being in more unequal societies.”
This lack of trust is amplified by high levels of class-based segregation in unequal societies, which reduces opportunities for people to interact outside their socioeconomic bubbles. The combination of distrust and unfamiliarity contributes to a lack of social cohesion and a sense that socioeconomic divides are deep and inevitable.
In short: inequality severs collective bonds, creates fractured in groups and out groups, and increases individualistic views about our society.
Now this is bad for everyone. I know I’m preaching to the converted at this point, but by far and away my favourite conclusion from the excellent summary of the wider social impacts of inequality, “The Spirit Level” by Wilkinson and Pickett is how relative inequality is bad for all members of a society.
In short: Within each first world country, so called “rich” countires health, and death rates are directly related to incomes. It’s a clear relationship, that holds true for pretty much all health markers. This supports the notion that relative inequality is a key driver.
However for me the striking result, is that if you pick any decile, low middle or bottom, and compare them between more and less equal countries, the more equal countries do better across all income ranges.
Even the most wealthy are better off in more equal societies.
And this is a point I believe we have not done a good enough job explain to people about the benefits of a collective approach to health, and the benefits of tackling inequality: partly because it does seem counter-intuitive.
So how does this relate to our mental heath system? Well as you are all aware the government has clearly admitted that there is an “increase in demand”, the most recent numbers I’ve seen suggesting a 60% increase in users of mental and addiction services since 2007. However, no one has made any attempt, at least in official circles to explain this to the public.
Occasionally people have dragged the convenient “P scourge” explanation out of the cupboard, and while there is some evidence to suggest methamphetamine use is on the rise, what is inconvenient about that argument is that WHO and epidemiological data cited above also makes clear the relationship between relative inequality and addiction to all drugs.
It is a symptom, not an explanation.
It has also been raised that perhaps the increased demand is due to the excellent work of de-stigmatisation campaigns, in short more people are coming forward.
I have some sympathy for this argument, but it doesn’t explain the fact that across the western world, and in particular those following an austerity programme since 2008 we have seen consistent rises in the rates of depression and anxiety. We did not see these rises in quite the same way prior to the GFC, whilst were still engaging quite actively in de-stigmatization work as a society.
So in summary, I put to you that relative economic inequality provides a kind of double whammy when it comes to mental health. Economic deprivation and poverty is, in and of itself, bad for health. But inequality also makes things worse for all of us. Mental health rates are up to three times higher in countries where in equality has taken hold, such as the USA, the UK, Australia and NZ.
And of course a system that has caused the problem, is not going to be very motivated to address the wider issues. In fact it is going to favour an individualistic explanation that doesn’t take into account wider issues when it comes to mental health.
The Biomedical approach – empirical individualism
There’s a weird way that talking about the bio-medical approach being wrong is hard, as someone who has worked in the system, and in many ways is fluent in “psychiatric language” it is a powerful, and all pervasive frame of reference.
Docotors are, at least clinically in charge in health . (We all now know accountants are really in charge) but “clinical responsibility” in the Mental Health system falls at the feet of the medically trained.
What I want to suggest though, is that the biomedical model has been co-opted, due to a “goodness of fit” with individualised, self responsibility focussed, neo-liberal ways of understanding human distress and suffering.
Now don’t get me wrong. This is not a criticism of psychiatrists (some of my best friends are psychiatrists) – this is critique of the model, and paradigm of a biological understanding of mental health difficulties.
So I’m going to read from the report of the Mr. Dainius Pūras Special Rapporteur to the UN Human Rights Council on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. He is, incidentally a Lithuanian Psychiatrist.
The World Health Day – 7 April 2017
Depression: Let’s talk about how we address mental health
“Evidence and the experience of rights-holders now tells us that the dominant biomedical narrative of depression as a “burden” on individuals and societies is shortsighted and insufficient for developing appropriate responses in policy and in practice. This is a widespread and systemic public health and human rights issue which demands urgent reconsideration of how we invest in mental health and how we manage conditions such as depression …
The longstanding biomedical tradition of medicalizing various forms of psychosocial distress and human suffering has cast a long shadow over the importance of addressing the social and underlying determinants of health. This not only undermines the right to health, it also ignores a rapidly growing evidence base.
Regrettably, recent decades have been marked with excessive medicalization of mental health and the overuse of biomedical interventions, including in the treatment of depression and suicide prevention. The biased and selective use of research outcomes has negatively influenced mental health policies and services.
Important stakeholders, including the general public, rights holders using mental health services, policymakers, medical students, and medical doctors have been misinformed.
The use of psychotropic medications as the first line treatment for depression and other conditions is, quite simply, unsupported by the evidence. The excessive use of medications and other biomedical interventions, based on a reductive neurobiological paradigm causes more harm than good, undermines the right to health, and must be abandoned”
Strong stuff, and but completely in line with the clinical literature. We know equivocally for instance, first line treatment for mild to moderate depression is talk therapy, and that SSRI anti depressants (Prozac, Aropax etc.) are largely ineffective, until one reaches a more severe depression. And even then we know that medication and therapy together, is more effective than either on it’s own.
We also know, as I’ve just outlined that depression is not “a biological illness”. It is a complex response to a set of internal and external factors.
However, I would like to suggest, that when some of those factors are abuse, power dynamics, gender and poverty: there is a political attractiveness to locating the causes of peoples mental distress inside them: it lets everyone else off the hook.
It has the added bonus of also meaning the solutions provided can be provided relatively cheaply, namely medication. Generic SSRI’s are extremely cheap when compared to talk therapy.
The main downside of this approach is that it is wrong, and not enabling people to get well. It also entrenches people in the idea that they will “suffer” from their particular disorder for life, and idea which is not only wrong but disabling and stigmatising.
Lets consider a less obvious, but important example: Resilience.
Resilience training is one of the big things in Mental Health and trauma right now, and one of the responses used at times by the Ministry of Health in the suicide prevention space.
I can’t stand it. Not because there’s anything wrong per se with resilience itself as an idea, the research is solid, it’s a useful construct, and there is little question it is interesting how you can take a group of more or less similar people that have been subjected to more or less the same stressors or trauma, and some develop difficulties, and some don’t. The difference theorised as being “resilience.’
However, the application of this is where it falls apart for me, and consider this. You are living in the Far North. Your town has seen a spate of suicides of high school students. You have high unemployment, high levels of gang participation, and drug problems. There are no jobs, and no industries.
In response to this spate of suicides, a group of health professionals turns up, from Auckland, to teach “resilience skills”.
You can see the problem. The message is this: the problem is inside you.
We ignore the wider sociopolitical context, we treat suicide as a discrete individualised response, and provide some skills training to help you be more resilient to your circumstances.
Essentially, we victim blame from a position of professional power. And we keep people, including well meaning professionals from considering the wider sociopolitical context, and instead invite people to feel sick and defective.
I consider this an ethical problem, and believe professions should not only be taking a stronger political stance because of this: but seriously considering the question: is it ethical to engage in treating people suffering at the hands of the state, without also challenging the state?
Next I want to talk about the commodification of mental health, how creating a market around the provision of mental health, has impacted us. But to set the scene I will read a brief passage from the Jacobin, March this year, “New Zealand’s Neoliberal Drift” by Branko Marcetic
“Through the 1980s and 1990s — first under Labour, then under National Party rule — New Zealand ushered in neoliberal reform on an unprecedented scale. Controls on wages, prices, rents, interest rates, and more were scrapped. Finance markets were deregulated, and restrictions on foreign investment were removed or relaxed. Based on the belief that welfare helped create unemployment by encouraging dependency, the system was overhauled in ways that the government’s own official encyclopedia describes as “particularly swift and severe.”
“Government disinvestment from public services abandoned the most vulnerable citizens. Nearly all psychiatric hospitals closed down by the 1990s, their responsibilities passing on to nongovernmental organizations.”
It is easy to forget this, again because the neo-liberal “free market” approach has become so ingrained, but along with de-institutionalization came a form of pseudo-privatisation, in the form of mental health services being provided by the growing Non-Governmental Organizations or NGO sector.
Although, given that in the area of health almost all of the funding comes from the government, either via the Ministry of Health or the District Health Boards, it is actually slightly contradictory to be called an NGO. Government Contracted Organization might be a more accurate term, and would certainly make the nature of the power relationship more transparent.
Now again, don’t get me wrong. Some of my best friends are NGO’s, but what is the problem here is not the work that most NGO’s do: but the way in which the gradual contracting of services, services once core to the health system, and under direct state and collective employ, has been gradually shifted to organizations operating under contract.
The fundamental problem, which has become more and more true of late is the contracting. What Sir Michael Cullen recently described at a Fabians lecture in Auckland as the emergence of the “Contract State” one which he defined as being a relationship of inequity, between state and organization, marked by low trust and high compliance costs – including in many cases political compliance. I will return to this idea of political compliance in a moment.
So whilst a market has been created, it is fundamentally a distorted and unequal market. Due to this power inequality, and requirement for high compliance, we now have a situation where prices have been driven down, and organizations are increasingly under pressure to do more with less.
A further problem with an economic focus in mental health is mental wellness being defined as the ability to work. Conversely and of course, obviously, “unemployment” is not actually a psychiatric disorder.
In a Social Investment framework though the linking of these is of course inevitable, we have already seen it with the Social Bond schemes being attempted with “supporting” long term mental health consumers back into the work force. Once more we see the misapplication of a good idea. There is plenty of data to suggest people in work do better than those who aren’t working. However that does not mean that the inverse it true. In fact it may be downright wrong.
The UK are a lot further down this track than we are, in that have been subjecting their population to this kind of logic for some time. And some disturbing trends have started to emerge.
This from the Independent, in March this year describes the research in to the impacts of the so called “Work Capability Assessments”
“The research, conducted by academics at Edinburgh’s Heriot-Watt and Napier universities, found that the Work Capability Assessment experience “for many, caused a deterioration in people’s mental health which individuals did not recover from”.
It also established, through dozens of in-depth interviews of people who had been through the tests, that “in the worst cases, the WCA experience led to thoughts of suicide”. Mental health charities said the interviews’ contents “reflect what we hear from people every day”.
The study interviewed 30 people with existing mental health conditions who had taken the tests throughout 2016. Most suffered from depression or anxiety, while a smaller number had more complex issues like bipolar disorder or borderline personality disorder. In addition, researchers also interviewed a number of advocacy workers who had had close contact with the test.
The study’s participants reported a lack of expertise in mental health among WCA assessors and advice from the WCA that was not consistent with what they had been told by their own GPs…
Some study participants reported being in tears or having panic attacks during the tests, with others telling the interviewers that the assessments were “making me feel worse”.
The researchers said that the extreme stress having to deal with multiple stigmas of being unemployed and having a mental health condition became “self-reinforcing and self-perpetuating”, leading to the deterioration of claimants’ conditions.
Mental Health Awareness: Facts and figures
The Work Capability Assessment was introduced in 2008. It is contracted out to private company Maximus, having previously been run by Atos. The system’s failure rate is controversial; figures reported by The Independent last year found that more than half of appealed WCA decisions were found to be wrong when taken to tribunal.”
This is where as a country we’re heading.
And it strikes to the heart of the fundamental problem with the Social Investment approach: what do you measure. How can we define success in a narrow and simple manner, and what data do we rely upon to try and predict who will be impacted?
What is also apparent, from the above example, and very real already in New Zealand is an undermining and sidelining of professional opinions, especially if they don’t conform to the preset narrative.
Many documents coming out of the Ministry of health now also focus on the delivery of “interventions” CBT therapy, counseling services etc, without an explicit focus on the expertise of any one profession. Professions such as psychotherapy for instance, whose focus on trauma, wider understandings of psychological distress, and more open ended treatment, get sidelined. In favour are professions which, can at least promise “short term” symptoms focussed approaches, clinical psychology specifically, here in New Zealand.
Social Work is of course the other obvious example, and the way that one view of the changes in the child protection are has been to break the power and dominance of a professional group whose theories and models do not easily kow tow to free market economics.
The other anecdotal example I have heard, and interested in any you might have as well, is from a colleague in a small New Zealand city where the PHO was being rewarded and encouraged to “up skill” practice nurses to provide counselling for first presentation depression and anxiety, in primary care.
Now I’m sure many of those nurses would be fine in that role. And this isn’t about bagging on nurses, some of my best friends are nurses, but there is only one reason to structure the provision of an intervention in this manner: cost.
And before you argue availability, the person I heard this anecdote from was a therapist who had just lost their PHO therapy contract, along with a few other colleagues.
The Contract State in action.
And of course there have also been the more public examples of the attack of the Problem Gambling Foundation, and the defunding and closing of Relationships Aotearoa. One, in the case of the PGF of having an advocacy arm that was, rightly, lobbying for the reduction, or at least limiting the growth of poker machines. And the other who fell foul of cost cutting.
The thing about creating a market is you can decide what you buy, and what you choose not to buy. But when there is only one source of money, and an unequal power relationship, we don’t call that a market. We call that a racket, or more technically a monopsony, a market with many sellers but only one buyer.
From a purely theoretical point of view, this “power” has been seen as a good thing, as it enables the buyer (the government) to purchase services at the lowest possible price for the public.
However in practice this power relationship is problematic. Providers of services have little choice but to knuckle down and provide what is required to maintain contracts, and keep funding. Now before you call me paranoid, I have had numerous conversations with NGO’s that felt relieved we undertook the action of the People’s Mental Health Review, as they felt unable to talk publicly. We also had organizations decline to come to the public launch of our report for fear of jeopardising their funding.
Now just returning once more to the question of data: it depends on what you measure.
Mental Health outcomes are notoriously difficult to measure, and while we understand the relationship between many factors that lead to peoples struggles, the relationship is very well understood to be one of correlation, not causation, and as such making predictions even with large amounts of individualised data is going to be problematic.
We have already seen the limitations with the Vulnerable Children trials. A recent Treasury paper outlines that the relationship between the identified Risk factors, and the identified risk outcomes was weaker than expected.
For instance when they looked at the data, and the pool of children was around 300,000 from what I understand, just one example:
Approx 121,000 had two risk factors and so called “poor outcomes”
However 42,000 had two risk factors and no “poor outcomes”
You see we used to have a really useful tool for allocating treatment resources. People experiencing distress would make contact with their mental health services, they would be assessed by a clinician, and they would be allocated what resources they needed to recover.
The beauty of this model is it had a 100% success rate at predicting who required mental health treatment.
In all seriousness though, Social Investment it touted as a way to target services to those that need it, and in doing so make sure the state is being efficient in it’s spending.
In effect it is simply a way to cut costs, limit spending and remove power from professionals who already have clearly established, albeit patient focussed, not dollar focussed, decision making processes for treatment planning and resource allocation.
And as outlined earlier in this paper, when we are operating in a sociopolitical climate where there is high degree of acceptance of individualistic values, a decrease in the valuing of collective approaches to allocate resources, and a general suspicion of difference, whether that be racial or socioeconomic difference it can feel, frankly, hopeless.
However, the experiences we have had with the People’s Health Review gives me hope.
I want to finish tonight outlining why I feel hopeful, how what I have outlined so far in my mind underpins our recommendations, and lastly give you my somewhat aspirational view of what needs to change.
So why do I feel hopeful?
Fundamental to the power of the individualistic view, and the popularity of neo-liberal policies, is that many can see those requiring support from the state as “over there”, different in some way, and indeed deserving or otherwise self responsible for their own struggles.
However mental health problems are not discriminatory.
Whilst it is true that we see higher levels of mental distress in those in lower socio-economic groups, as well as in ethnic minorities, it is also as already outlined rates of diagnosable mental health problems are generally higher in more unequal societies.
At any one time around 1 in 4 will be experiencing mental distress, and across our lifetimes 1 in 2 will.
This universality, in my view, experientially for many, cuts counter to the individualistic narrative. We heard time and time again from people impacted by the struggle of accessing mental health services for themselves or family: across all groups in society. In this way I believe, with the exception of the housing issues in Auckland (although sadly not so much homelessness) this universality has lead to high public and media engagement.
I also think many saw the cruel irony that at the same time we are actively promoting people engage with help, via de-stigmatiztion campaigns and other public efforts, too often there is no (affordable) help available.
So to our recommendations. I hope most of you will have read our report, but for those who haven’t a quick refresher;
- An urgent funding increase for mental health services for acute and community based mental health services nationally. This requires a focus on increasing community based service access and treatment choices for people using mental health services to provide interventions early. It is also essential to support the people who work in mental health services, by easing workload pressures and enabling them to offer the services and support people want and need.
- Fully independent oversight of the mental health system in line with minimum obligations set out in the Convention on the Rights of Persons with Disabilities. This could be in the form of restoring the Mental Health Commission, the creation of an independent Disability Commission, or the inclusion of dedicated Mental Health Commissioners under the current Human Rights Commission. These would include clearly designated roles for those with lived experience.
- An urgent independent inquiry into the structure and provision of mental health services in New Zealand. The terms of this inquiry should be informed by New Zealand’s obligations under the Convention on the Rights of People with Disabilities and the need to provide for healthy families and healthy communities, and should allow for the increasing numbers of people seeking support from mental health services. We also recommend that a Royal Commission of Inquiry be carried out into the long-term and entrenched problems highlighted by this review.
- A national education programme to support all New Zealanders to understand what mental health is, and what mental health services provide, that operates in the education system and wider society. This will ensure that the work of change is understood by all New Zealanders so people with lived experience are included by our society rather than having to endure prejudice and discrimination.
So hopefully you can see how what I have discussed tonight feed into our recommendations. Personally there is little debate over the need for more urgent funding, but it needs to be put in the right places: in my view this means acute and community services. When people in crisis reach out for help, it has to be there. I don’t believe this is controversial, and there is increasingly political agreement about the need to meet demand and improve access.
Independent oversight is vital to address the power imbalance created by the “Contract State.” Further more it is my belief that this power imbalance has without doubt flowed through the system, and made avenues of complaint difficult for clients and their families. Their needs to be a balance towards a re-formed Mental Health Commission (in whatever form that might take) representing the voices of people with lived experience, and addressing the very real power imbalance between those who use the service, and those who provide and fund it.
A fully independent review should look to address funding and structural problems, and ensure services are being provided are not only adequate, but also clinically supported. The wider question of the impact of pseudo-privatisation, and the “contract state” structure may be more suited for a Royal Commission, hence it also be included here as a recommendation.
And out last recommendation, I would hope would extend upon the de-stigmatization work already done, and more fully inform the public about what good treatment looks like, what they should expect from any mental health service, and more fully empower citizens to demand those services from those who fund them.
Lastly, I want to offer my view, my vision for what I would like to see us as a country move towards, and why.
If we start at the top, I believe we need a Minister of Mental Health. The Scottish Parliament has made such an appointment, and the Labour Party in the UK have a “shadow” minister.
It seems to me a very real way to take the national crisis we face seriously. Further more I see a relationship between the triad of a Minister, a Ministry of Mental Health, and Mental Health Commission being one that represents respectively the interests of the government, as the funder, the professionals – including but moving beyond a reliance on the bio-medical model; and clients and citizens.
We need to defracture, and re organize the entire system. I would be in favour of centralising, via re-nationalisation of mental health services, or at the very least, centralizing the organizing and funding arrangements.
I would like to see ALL mental health activities, currently spread across Justice, MSD, Vulnerable Children and Health rationalised under one roof. I personally wonder weather services need to be moved out of DHB control, and centralised as a standalone National Mental Health Service. There would be room for NGO’s and separate entities, but with more centralised governance and transparent, non-comeptitve funding – the end of the “contract state.”
Lastly, all of the above would allow for one single point of access, no matter what help you may require this access could be promoted and encouraged.
I would hope that a sort of national therapy provision, or “EAP” scheme would form an important part of prevention and ongoing health. Any citizen could access a guaranteed number of sessions with the health provider of their choice, with further treatment provided after a more full assessment.
There is ample evidence that early intervention, even in the form of a handful of sessions can be enough to stave off further difficulties, and in the long term would, dare I say represent a true “investment” in our future.