On the Perversity of an Imagined Psychological Solution to very real Social Problems of Unemployment (Work-lessness) and Social Exclusion (Worth-lessness): A Group Analytic Critique

Introduction

To know and not to know, to be conscious of complete truthfulness while telling carefully constructed lies, to hold simultaneously two opinions which cancel out, knowing them to be contradictory and believing in both of them . . . and then, once again, to become unconscious of the act of hypnosis you had just performed . . . (excerpt from 1984, George Orwell)

This article builds upon previous work undertaken with my colleagues John Adlam and Caroline Pelletier (Scanlon and Adlam, 2010; 2011; 2013; Adlam, Pelletier and Scanlon, 2010) ¹ and draws upon group analytic concepts to explore ideas of social inclusion/exclusion and psycho-social perversity in our social groups and communities. In particular, it examines the social consequences of a range of social policies in the UK with the stated intention of enhancing social inclusion by improving access to psychological therapies for the un(der)employed and the socially excluded [sic]. The critique presented is that these policy initiatives establish, or at least reinforce, a boundary between a category of people called the included and those whom they exclude in ways that perversely maintain and perseverate the very problem such policies are designed to solve (Long, 2008 and 2012; Rizq, 2011; 2012; 2013). The rationale for attempting to improve access to psychological therapies for the un(der)employed and socially excluded—that for the purposes of this article I call the work-less and the worth-less respectively—is that it is they, rather than the socio-economic and political structures that construct them that is ‘the problem’. This framing of the undoubtedly problematic consequences of workless-ness or worthless-ness as a personal problem ascribes to the non-worker or the ‘hard-to-engage’ person a certain social role and a particular kind of psychological identity that then seeks to locate the problem of unemployment within this identity and within these associated social roles.

Through this socio-political sleight of hand work-lessness and worth-lessness are now problems that are not understood, or at least not discussed, as symptoms of a social dis-ease [sic] caused by the structural failures (or successes?) of national or international economic policy. Instead they are cast, as a set of personal diseases, or psychopathologies, that are projected into the individual and are then used to justify explicitly utilitarian, highly politicized and increasingly draconian and divisive ‘welfare to work’ ideologies that find their nadir/zenith in split discourses about feckless ‘scroungers and shirkers’ versus ‘strivers and decent hard-working-families’. This re-location of the ‘depression’ from outer social-space into inner-psychological space and the consequent failure to think together about our shared socio-economic ‘depression’ flies in the face of Foulkes’ formulation that ‘. . . the whole community must take a far greater responsibility for outbreaks of disturbing psychopathology generally (Foulkes, 1973: 225).’

Stein (2003; 2011; 2013) has suggested that this split perception about what is ‘social/public’ and what is ‘personal/private’ mirrors and recapitulates a wider pernicious societal bipolarity that oscillates between the (near?) psychotic ‘mania’ of the ‘haves’—who now totally control and arbitrate the public discourses of ‘worth’ and ‘work’ in the marketplace—and the crippling private ‘depression’ of the worth-less and the work-less ‘have-nots’ who are its unwitting victims. This dynamic is not new but an historical regression to a profoundly problematic split within the fabric of the western ‘democratic’ project: a split between those who imagine themselves to be on the inside of something called ‘society’ and those who are, and/or are imagined to be and/or who imagine themselves, to be on the outside of an exclusive and excluding ‘society’ (Jordan, 1996: Young, 1999; Dorling, 2010; Dean, 2010 inter alia).

Perverse Solutions and the Maintenance of Inequalities

The rich man in his castle,

The poor man at his gate,

God made them high and lowly,

And ordered their estate.

(From ‘All things Bright a Beautiful’, Anglican Hymn, 1848)

Jacque Rancière (1983; 2007), the French critical theorist, makes a distinction between two definitions of democracy. One is a type of society, consisting of constitutions, institutions and other components of a stable system of governance. The other is conceived of as a transformative intervention: an emergent and evolving process of becoming that challenges the existing social order by making its inherent inconsistency apparent. Rancière’s work thus raises interesting questions about the relationship between democracy, citizenship, inclusion, subjection and their relationships to the predominant discourses of the ‘powers that be’. For instance, if inclusion, and by implication participation, is the defining characteristic or ideal of a modern western-style democracy, can inclusion and participation be improved by the efforts of state mechanisms, such as health, welfare, educational or correctional systems? To answer this question in the positive assumes a model of inclusion by which ‘they’, these excluded non-participant ‘outsiders’, are brought in, and included by those of us who are, or who imagine ourselves to be, already on the inside.

This conceptualization of inclusion assumes that what ‘insiders’ do and how they do it is, by definition, worthy and so constructs the doings of those who are imagined to be, or imagine themselves to be, on the outside as less worthy and, by extension, less democratic and/or more delinquent. This colonial vision of inclusion has similar characteristics and meanings depending on whether it is played out between neighbours, between different social groupings or between different conceptual positions and ideologies within political systems. It is also discernible in certain historical and contemporary claims that a country may only be considered to be democratic when it is made to meet certain conditions for its ordered governance by other, more powerful countries who imagine themselves to be more democratic. This is the case whether the imagined-to-be ‘more democratic’ state in question is brutally expansionist or apparently more benevolent and out-reaching. As Orwell (1945) might have observed, from within this worldview there is clearly an over-valued (mad), insider idea that even while making statements about liberty and equality—there remains an opinion that some, like the pigs in Animal Farm, imagine themselves to be more equal than others.

Rancière also suggests that by making ‘equality’ and ‘democracy’ future goals—something to be worked towards—the anxiety about our current state is also projected into an endlessly deferred and mortgaged future. It is an attitude towards a future where we are probably already squandering any possibility of a generative legacy for our children and the future of our planet (Weintrobe, 2012; Lertzman, 2012). Indeed, Mark Stein (2003; 2011; 2013) suggests that these modern neo-con/liberal discourses are only able to continue through the operation of narcissistically driven ‘manic’ defences that refuse to face the truth and about the real socioeconomic causes of our ‘depression’. Slavoj Žižek (1997: xv) similarly suggests that by making social security and social inclusion into a future goal we run the risk of not noticing or even legitimizing present social inequalities, making them seem like a given, acceptable distribution of resources in the here-and-now. For instance, charging social workers, teachers, psychotherapists, group-analysts or any other ‘public servants’ with the task of making people more included presumes that they are not included in the present. It is therefore a way of explaining inequality and social exclusion, of making it appear in some ways reasonable, as if it were a given: a matter of fact—and in so doing invites us all into a perverse collusion with this formulation. In these ways claims about how we might promote social inclusion serve, not only to explain a differentiated and hierarchical social order, but also serve to justify it. It is a modus operandi that reveals the perverse qualities of the shared unconscious social dynamics that prevail in our deeply divided and traumatized communities (Hopper, 2003a; 2003b, 2012; Long, 2008; 2012).

The power of this denial and its costliness as a social defence mechanism in relation to work and un(der)employement is illustrated by Žižek (1997) who suggests that as a society we are invited to live in a split world and to hold two competing and contradictory conceptualizations about un(der)employment. On the one hand we seem to know that un(der)employment is a consequence of the failures of national, international and multi-national systems of financial and economic governance. Yet on the other hand, we are also seem to believe that it is also a result of the unwillingness of certain individuals’ and subgroups’ to work and/or participate. Žižek suggests that we prefer to live in this contradiction in order to manage, or to have managed for us, what might otherwise become either, an overwhelming fear of psycho-social helplessness, or a an equally overwhelming fear of the necessity of personal and social change.

Žižek (1997) further states that the welfare of, and the welfare within, contemporary society relies on these contradictory statements being made at the same time and is perhaps a very clear example of how a problematic attribution of responsibility becomes a form of structural or systemic violence where the victim is blamed for his/her own victimhood (Gilligan, 1996; 2011; Žižek, 2008). Failure to find useful employment, and so ‘to be in your proper place’ (Scanlon and Adlam, 2013), is seen as a personal failure which is understood in relation to the seeker’s imagined laziness and indigence or because s/he is depressed or in some other way mentally disordered or antisocial.

Michel Foucault (1961) in his seminal work charted a similar historical and societal dynamic that links ‘work-lessness’ and ‘worth-lessness’ to the primary task of modern psychiatry in the 1656 mission statement of the Hôpital Général in Paris, that was to prevent ‘mendicancy and idleness as the source of all disorders’ (Foucault, 1961: 43). Thus the ‘mad’, the ‘bad’, the ‘sad’ and ‘the lazy’ were all grouped together in relation to the overarching category of ‘in need of remedial, state-ordered and socially controlled psychiatric intervention—as a way of preventing the spread of this psycho-socially contaminating this virulent dis-ease [sic] of mendicancy and idleness’.

Picking up this theme, another French philosopher Patrick Declerk (2006) starkly suggests that ‘we’ hate the homeless because in their refusal to work they are experienced as ‘mocking everything that the mainstream of society holds dear: hope, self-betterment, personal relationships, procreation, bringing up children, and even simply getting up in the morning’. According to this attitude the work-less and the worth-less are at liberty to choose and so must be de-liberating [sic] themselves by deliberately choosing not to join in (Scanlon and Adlam, 2013). The clear implication is that if they were more willing to apply their cognitive faculties to the problem, they could behave differently and so choose to liberate and include themselves. Since they do not do this they must be ‘choosing a lifestyle’ and so we do not need to think about any redistribution of resources to address their welfare needs.

It becomes apparent that the endeavour to ‘include/exclude’ in these ways is marking a border around the object of inclusion—the community, and setting conditional terms of engagement that the excluded must meet prior to being admitted. In this context any attempt to ‘socially include’ is always made by those powerful sub-groups who are, or make a claim to being, worth-more and from within this psycho-social bubble make spurious claims to being more democratic. They are seeking to colonize, to confine and to control those who are, are imagined to be, or imagine themselves to be worth-less and/ or are not in their proper place in this provisional and contingent version of democracy.

Personalization, Individual Choice: Anybody can be Anything

The pernicious ‘positive psychology’ that underpins these attitudes has been critiqued by Ehrenreich (2009) who describes it as a smoke-and-mirror trick that ‘Fooled America and the World’. To illustrate her point Ehrenreich quotes one of its leading proponents, Martin Seligman, who vociferously attacks those, who are seen as promoting what he defines as irrational beliefs about ‘lack of choosing’ and ‘victimhood’:-

[I]n general when things go wrong we have a culture which supports the belief that this was done to you by some larger force, as opposed to, you brought it on yourself by your character or your decisions. (Seligman cited in Ehrenreich, 2009:169)

This self-serving, and in my view, near-manic ‘positivity’ mirrors wider discourses that wilfully disregards the overwhelming evidence that poverty, rising youth unemployment and a wide range of other de(op)ressing health and social problems are caused and exacerbated by adverse childhood experiences linked to the crippling differentials between those of us who have the ‘capacity’ to choose and the those of us who have less capacity to choose (see Jordan, 1996; Gilligan, 1996; 2011; Felitti et al., 1998; Young, 1999; Scourfield and Drakeford, 2002; Charlesworth et al., 2004; Declerk, 2006; Joseph Rowntree Foundation, 2013; Žižek, 2008; Wilkinson and Pickett, 2009; Dorling, 2010; Hutton, 2010; Dean, 2010 inter alia). In this sense incoherent discourses about ‘individual freedom’, ‘personalized’ health and social care, ‘recovery’ and ‘lifestyle choice’ all clump together to form, a massified (Hopper, 2003) and highly utilitarian political ideology whereby victims are blamed for their predicaments by those who simultaneously project a false-hope into this endlessly deferred, totally mortgaged and possibly already bankrupted future by promising ‘jam tomorrow’ (Carroll, 1871).

The effect of this rhetoric and consequent social policy initiatives that seek to ‘personalize’ (Department of Health, 2006; 2007) and so to ‘privatize’ the psycho-social sources of mental and emotional distress is that this suffering, and the people who suffer it, are made into a commodity for exploitation by the market. Instead of debating the causes and continuance of systemic socio-economic factors that exclude ‘them’ from the common-wealth the individual is made to feel personally responsible for their personalised ill-health, incapacity and related work-lessness (Cromby et al., 2007; Cornes, 2013; West, 2013).

Improving Access to Psychological Therapies (IAPT): a Rational Choice for the Work-less and the Worth-less?

They constantly try to escape

From the darkness outside and within

By dreams of systems so perfect

That no one will need to be good . . .

(Choruses from the Rock, T.S. Eliot, 1934)

It is against this historical background that I wish to foreground one contemporary endeavour to promote social inclusion by the Improving Access to Psychological Therapies (IAPT) initiative in the UK. I describe how, despite its most noble and best intentions, it signally and spectacularly fails to take into account the very real feelings of helplessness and despair arising from psycho-social, socio-economic and political problems outlined above. The focus of the discussion will be on the dynamics of the welfare state and upon those who stand in intimate relationship to those who are work-less and considered worth-less and as a consequence suffer ‘depression’ and related types of psycho-socially constructed dis-ease [sic]. My contention is that this apparently ‘inclusive’ initiative, like many others before it and many others to come (?), has as an implicit, if not explicit, agenda to ensure that we all remain in our ‘proper place’: that is to say, in the places, occupations and lifestyles that are ascribed to us by the demands of an exclusive neo-con/liberal metropolitan elite that has lost its way (Scanlon and Adlam, 2011; 2013).

The IAPT initiative is a multi-million pound government programme, sponsored and supported by the pharmaceutical industry and the English Department of Health (DH). At its launch, it noted that depression and anxiety are ‘expensive to the taxpayer and businesses which must bear the costs of inadequate NHS treatment, loss of employee productivity and benefit payments . . .’ (DH, 2007: 2) and proposes that IAPT will ‘promote social inclusion and improve economic productivity’ (DH, 2007: 5). It goes on to pronounce that the benefits of the programme for ‘adults of working age [my italics]’, above all will be delivered by means of ‘relieving their illness, improving their ability to work and reducing their dependence on benefits’. At this point we might pause to wonder, with Tim Dartington (2010) whether this focus on ‘adults of working age’ is itself a comment on the ‘worth’ of older people—who seem not to have had their access to psychological therapies significantly improved. We might also wonder what, if anything this policy has to say to the 25% of un(der)employed young people who seem to have little prospect of finding meaningful work—or secure housing—in our minimum wage ‘service economy’.

So under the auspices of this programme psychological therapies (mostly manualized cognitive-behavioural therapies) have been rolled out as a rational treatment for the depressed and the relatively unproductive (DH, 2007; Layard, 2006; Clarke et al., 2009) despite the fact that there is very little evidence to support its effectiveness or efficacy. Indeed, Ehrenreich (2009) argues, that this ‘psychologizing’ of ‘depression’ is an ideologically driven ‘professionalizing’ agenda on a scale so large that the sheer volume of publications has produced what Cuipjers et al. (2010) have recently described as a publication bias. This publication bias gives an impression of efficacy and effectiveness that is based on the (deliberately?) obfuscating multiplication of a small effect in a huge number of short-term studies. The results are not replicated by more careful meta-analyses that review the long-term effects of these short-term interventions (Lynch et al., 2009; Risq, 2011; 2012).

The cost of our shared unwillingness to think about the socio-economic depression/recession as a public socio-economic and political problem is that the responsibility becomes re-located into the private domain—into the mind of the individual. Another triumph of the neo-con/liberal drive to ‘privatize’ all things that could be more properly and more meaningfully discussed and understood if ‘publicly’ owned. In these ways the blame is projected into some of the most vulnerable individuals and sub-groups within society: projections with which, because of their psychosocial vulnerability and depression they all too readily, and too often, identify. As a result of these pernicious bullying and scapegoating processes of projective and introjective identification the ‘imagined’ depression that is shoved into individuals dis-places and re-places the denied socio-economic ‘depression’ that must not be talked about.

To illustrate the operation of this problematic dynamic in action at an organizational level elsewhere John Adlam and I describe how in a large mental health NHS Trust all services were, in the light of the socio-economic depression/recession, asked to make significant cuts (Scanlon and Adlam 2010). Despite political assurances that front-line services would not be effected and that ‘better vocational and information services’ would complement clinical interventions’ (DH, 2007:6), one of the first victims of these cuts were the benefits and housing advice workers, while the exclusively cognitive–behavioural therapy work of the IAPT service in the same organization continued to expand. It seems that despite knowing that the cuts were needed because of the social and political pressures that were contributing to increased unemployment (and ill health) and housing problems, this inner city state-funded mental health organization did not want to think about the perversity of reducing the availability of practical advice about housing and state benefits, whilst simultaneously increasing the provision of a service whose raison d’être is to enable people to take up jobs that no longer exist.

These attitudes also then provide a justification for the granting of professional license for psychotherapists to be deployed against what is construed as the real ‘enemy within’—the relationship problems, faulty cognitions and maladaptive behaviours of depressed and failing individuals. The psychological correction must continue, whilst psycho-socially informed advice about benefits, housing and social inclusion become superfluous. Viewed from this perspective the IAPT initiative, which sets out to increase personal responsibility and choice through correcting faulty cognitions and maladaptive schema, seems unable to apply these tenets to its own cognitive schematic distortions and so becomes a social inclusion initiative without a ‘social model’ for intervention (Hoggett, 2010; Layton, 2009; Scanlon and Adlam, 2010; 2013; Rizq, 2011; 2012). Viewed from this perspective rather than being an effective social policy IAPT becomes a perverse parody whereby ‘we’, the ‘hard-working’, invite ‘they’, the workless and the worth-less, to join ‘us’ in ‘our’ democracy on the condition that ‘they’ apply themselves in the approved manner—with the ever-present threat that if they do not do so their benefits, or at least advice about their entitlement to benefits, will be removed.

Concluding Remarks

It may seem perverse of me, as an erstwhile state-employed psychotherapist to argue against improving access to psychological therapies. It may even seem as if I am overly dismissive of the enormous good work done by my over-worked and under-paid IAPT therapists. Neither is the case I believe I have a healthy respect for the work my colleagues undertake under difficult circumstances in these straitened times often at great personal cost to themselves (Hutten, 2012). Rather my concern is that questions about how best to treat this imagined-to-be-psychological ‘depression’ are too often discussed as if it were simply a problem of deciding whose treatment ideology should prevail (Scheid, 1994). For instance whether it is better to offer Cognitive–Behavioural Therapy (CBT) or Dynamic Interpersonal Therapy (DIT) (Lemma et al., 2010; Gelman et al., 2010) (or for that matter any other three-letter acronym), rather than engaging with deeper questions about the (dis) organized nature of our communal ‘depression’ and the associated (socio-economic and political oppression and suppression that gives rise to it. The ethical personal and professional challenge, whether as group-analysts, psychotherapists, social workers, educators, managers, or in our social role as citizens, is to find ways to think together about how to meaningfully engage with these very real psychosocial problems in ways that avoid the patronizing and perverting languages of ‘worthless-ness’ (and ‘worthmore-ness’) that I have sought to highlight above? I hope that this article might contribute something to these discussions.