Tag Archives: Psychosocial

Poverty is the enemy of good mental health. Why do Tories increase it?

Epidemiologist Richard Wilkinson. He ‘found that poverty and social inequality have direct and indirect effects on the social, mental and physical wellbeing of an individual,’ writes Maureen Tilford [Image: Linda Nylind for the Guardian].

It’s a classic example of failed Tory thinking.

They say they want the NHS to work properly, within the budgets set out for it – but then they worse conditions in society, forcing more people to seek medical help.

In this case, more people are seeking help with mental illnesses because of poverty that has been forced on them by stupid Tory austerity policies.

Only yesterday, This Site published an article on medical experts’ plans to record social issues including poverty as contributing factors to mental illness.

Now, people have been writing in to The Guardian to support political action against poverty – precisely to stop it affecting mental health.

Here’s Dr Maureen Tilford:

As far back as 1963, research by Langer and Michael found that psychiatric conditions not only occur at higher rates in the poorest areas, but also cluster together, usually in disintegrating inner-city communities. Money is not a guarantor of mental health, nor does its absence necessarily lead to mental illness. However, it is generally conceded that poverty can be both a determinant and a consequence of poor mental health.

More recently, the epidemiologist Richard Wilkinson found that poverty and social inequality have direct and indirect effects on the social, mental and physical wellbeing of an individual. It is clear that poverty and inequality are closely linked and that income inequality produces psychosocial stress.

The wealth gap in the UK is greater than at any time since the first world war and continues to grow. Unless this is addressed at a most senior level in government, the demand on the police will continue, not to mention the suffering of all those callers. This cannot be viewed as a purely health service issue. Allowing the wealth gap to spiral out of control is having serious adverse effects on the UK population on many levels.

And Reverend Paul Nicolson of Taxpayers Against Poverty has this to say:

Prevention of mental illness, and hunger created by low income and debt, requires an increase in taxation and unemployment benefits which many of us would be willing to accept. Central government is making households destitute by shredding unemployment incomes and then stopping them with the benefit sanction, allowing zero-hours contracts and by rolling out the universal credit. Local government then taxes the benefits and sends in the bailiffs to collect the inevitable arrears, adding court costs and huge bailiffs’ fees.

It takes a very rare degree of resilience for mental health to withstand three powerful government departments shelling out threats of bailiffs, prison, eviction and homelessness against a single debtor, who is often struggling to put food on the table for dependent relatives. As Psychologists Against Austerity have reported, such abuses of power are creating humiliation, shame, fear, distrust, instability, insecurity, isolation and loneliness in trapped and powerless citizens.

Source: Poverty is at the heart of mental health crisis | Letters | Society | The Guardian


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Links between benefits and mental ill-health could be recorded by doctors in new plan

[Image: Getty/iStock].

The link between disability benefit assessments, mental health problems and increases in suicide rates could be made explicit in a new plan announced in medical journal The Lancet.

Kate Allsopp and Peter Kinderman have called for mental health professionals to record psychosocial codes in official NHS records, to show whether a patient is suffering from the effects of social inequality, poverty or trauma.

Links between the Work Capability Assessment (WCA) and an increase in suicides, mental health problems, and prescription of antidepressants are specifically mentioned, following on from a study covered by This Site here.

The proposal in The Lancet states [boldings mine]:

It is well known that poverty and social inequity are major determinants of our mental health, and the United Nations Special Rapporteur characterises mental health care not as a crisis of individual conditions, but as a crisis of social obstacles, which hinders individual rights.

It is important, therefore, that the circumstances that have given rise to distress should be formally recorded alongside the distress itself. Psychosocial codes… incorporate descriptive information regarding adverse life experiences and living environments, but are almost never used or reported in clinical practice or academic publications.

These quasi-diagnostic codes document neglect, abandonment, and other maltreatment… homelessness, poverty, discrimination, and negative life events in childhood, including trauma… problems related to family upbringing, and housing and economic problems.

Broadening routine data capture within UK National Health Service records could establish more inclusive, social, systemic, and psychologically comprehensive patterns of difficulties, which could target information regarding established social determinants of mental health problems, such as inequality, poverty, and trauma.

Imagine if it were as serious to fail to document extreme poverty as it would be for a clinician to fail to identify severe depression.

We do not expect that clinicians should resolve such difficulties; it is not the job of mental health professionals to end poverty.

Nevertheless, proper recording of psychosocial… codes in the context of psychiatric diagnoses is imperative because of the close relationship between the two.

The UK government programme of reassessing disability benefits… using the Work Capability Assessment has been associated with an increase in suicides, mental health problems, and prescription of antidepressants.

Transitions into poverty (relevant to codes [on] inadequate housing… lack of adequate food… extreme poverty; and… low income) have been associated with increased odds of children developing socioemotional behavioural difficulties, and individuals who have had an institutional upbringing… are approximately 11 times more likely to experience paranoia compared with those with a less disrupted early history.

As clinicians, we might be better able to serve our clients if we can use such data capture to apply more effective pressure on the political system and drive wider system reform.

Source: A proposal to introduce formal recording of psychosocial adversities associated with mental health using ICD-10 codes – The Lancet Psychiatry


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Unum, Atos, the DWP and the WCA; Who gets the blame for the biopsychosocial saga?

Mansel Aylward, former chief medical officer at the Department of Work and Pensions, now director of the (UnumProvident) Centre for Psychosocial and Disability Research at Cardiff University: Architect of misery?

Mansel Aylward, former chief medical officer at the Department of Work and Pensions, now director of the (UnumProvident) Centre for Psychosocial and Disability Research at Cardiff University: Architect of misery?

If we know anything at all about the Work Capability Assessment for sickness and disability benefits, we know that it doesn’t work. In fact, it kills. There is a wealth of evidence proving this, and if any readers are in doubt, please take a look at the other article I am publishing today, MPs tell their own Atos horror stories.

Much has been made of this fact, without properly – in my opinion – addressing why it doesn’t work. The apparent intention is an honourable one – to help people who have been ‘parked’ on disability benefits back into work, if it is now possible for them to take employment again, and to provide support for those who cannot work at all. What went wrong?

Let’s start at the beginning. The WCA is, at least nominally, based on the biopsychosocial model developed by George Engel. He wanted to broaden the way people think about illness, taking into account not only biological factors but psychological and social influences as well. He contended that these non-biological influences may interfere with a patient’s healing process.

The idea has been developed to suggest that, once identified, the non-biological factors inhibiting healing would be neutralised via a variety of support methods. Stressful events in a person’s life or environmental factors are acknowledged as having real effects on their illness, and it can be seen that this confers a certain amount of legitimacy on symptoms that are not currently explainable by medicine.

Engel stated, in 1961, “Many illnesses are largely subjective – at least until we as observers discover the parameters and framework within which we can also make objective observations. Hyperparathyroidism… was a purely subjective experience for many patients until we discovered what to look for and which instruments to use in the search.” He also warned that people engaged in research should “see what everyone else has seen and think what nobody else has thought” – as long as they don’t automatically assume that their new thought must be correct.

The Engels theory forms the basis of the system of insurance claims management adopted by US giant Unum when its bosses realised that their profits were being threatened by falling interest rates – meaning the company’s investments were losing value – and a rise in claims for “subjective illnesses” which had no clear biological markers – Myalgic Encephalomyelitis (ME), also known as Chronic Fatigue Syndrome (CFS), Fibromyalgia, Chronic Pain, Multiple Sclerosis, Lyme Disease, even Irritable Bowel Syndrome (IBS).

As I wrote on Wednesday, Unum adapted the biopsychosocial model into a new medical examination that stripped it of its ‘bio’ and ‘social’ aspects in order to concentrate on the ‘psycho’ – with a relentless emphasis on an individual claimant’s beliefs and attitudes.

The new test aggressively disputed whether the claimant was ill, questioning illnesses that were “self-reported”, labelling some disabling conditions as “psychological”, and playing up the “subjective” nature of “mental” and “nervous” claims.   The thinking behind it was: Sickness is temporary. Illness is a behaviour – all the things that people say and do that express and communicate their feelings of being unwell. The degree of this behaviour is dependent on the attitudes and beliefs of the individual, as well as the social context and culture. Illness is a personal choice. In other words: “It’s all in the mind; these people are fit to work.” (as I mentioned in When big business dabbles with welfare; a cautionary tale)

Already we can see that this is a perversion of Professor Engel’s theory, using it to call an individual’s illness into question, not to treat it. Yet this is the model that was put forward to the Department of Social Security (later the Department of Work and Pensions) by its then-chief medical officer, Mansel Aylward, in tandem with Unum’s then-second vice president, John LoCascio.

Together they devised a new ‘All Work Test’ that would not actually focus on whether an individual could do their job; instead it would assess their general capacity to work through a series of ‘descriptors’. Decisions on eligibility for benefit would be made by non-medical adjudication officers within the government department, advised by doctors trained by Mr LoCascio. Claimants’ own doctors would be marginalised.

When New Labour came to power, Mansel Aylward was asked to change the test to reduce the flow of claimants with mental health problems. In came the ‘Personal Capability Assessment’, which again focused on what a person was able to do and how they could be supported back into work.

It is at this point that US IT corporation Atos Origin (now Atos Healthcare in the UK) became involved. The task of administrating the PCA was contracted out to a company which was taken over by Atos, meaning its employees – who had no medical training – could now assess claims for sickness and disability benefits, using the company’s Logical Integrated Medical Assessment tick-box computer system. These evaluations proved unreliable and the number of successful appeals against decisions skyrocketed.

So in 2003 the DWP introduced ‘Pathways to Work’, in which claimants – now labelled ‘customers’ – had to undertake a work-focused interview with a personal advisor. If they weren’t screened out by the interview, they would go on to mandatory monthly interviews where they would be encouraged to return to work and discuss work-focused activity. I can assure readers, from personal experience with Mrs Mike, that this activity remains a prominent part of the DWP’s sickness and disability benefit policy.

Mansel Aylward is no longer at the DWP, though. In 2004 he was appointed director of the UnumProvident Centre for Psychosocial and Disability Research at Cardiff University (it has since dropped the company title from its name). Was this as a reward for services rendered in getting Unum and its practices into the heart of the UK government?

Let’s have a look at some of the ‘descriptors’ that are being used to determine a claimant’s – sorry, customer’s – fitness for work in what is now called the ‘Work Capability Assessment’. I am grateful to Helen Goodman, Labour MP for Bishop Auckland, who provided this information during yesterday’s debate on the Atos WCA in the House of Commons. She said a person who…

“Cannot mount or descend two steps unaided by another person even with the support of a handrail”;

“Cannot, for the majority of the time, remain at a work station, either…standing unassisted by another person…or…sitting…for more than 30 minutes, before needing to move away in order to avoid significant discomfort or exhaustion”

“Cannot pick up and move a one litre carton full of liquid”;

“Cannot use a pencil or pen to make a meaningful mark”;

“Cannot use a suitable keyboard or mouse”;

“Is unable to navigate around unfamiliar surrounding, without being accompanied by another person, due to sensory impairment”;

“Is at risk of loss of control leading to extensive evacuation of the bowel and/or voiding of the bladder, sufficient to require cleaning and a change in clothing, not able to reach a toilet quickly”;

“At least once a month, has an involuntary episode of lost or altered consciousness resulting in significantly disrupted awareness or concentration”;

“Has an epileptic fit once a fortnight”;

“Cannot learn anything beyond a simple task, such as setting an alarm clock”;

“Has reduced awareness of everyday hazards leading to a significant risk of…injury to self or others; or…damage to property or possessions such that they frequently require supervision”;

“Cannot cope with minor planned change” such as a change to lunchtime;

“Is unable to get to a specified place with which they are familiar, without being accompanied by another person”

… is “fit for work”.

A person in the following category is also deemed fit for work, if: “Engagement in social contact with someone unfamiliar to the claimant is always precluded due to difficulty relating to others or significant distress experienced by the individual.”

Kate Green, Labour MP for Stretford and Urmston, added: “My constituents told me categorically last week that they believe that the whole system was deliberately designed and operated to trick them — to make them incriminate themselves and to catch them out.

“They firmly believe that the system is deliberately designed, not to assess and then help them into work if they are fit for it, but simply to stop paying benefits wherever possible.

“There are far too many instances of trickery and misleading people and of distorting what they have done, said and reported and drawing conclusions from that. That is happening far too often.

“It is an absolute disgrace that we should run a public assessment process in such a discredited way.”

It seems to be a result of Professor Aylward’s work that the main influence on government welfare reform has been a perversion of a perversion of a theory that has not been shown to work. Authentic evidence is disregarded by those in power, who clearly continue to persecute the sick while feeding the profits of private concerns.

I wonder what he would have to say, if he were to be confronted by the evidence of what his policies have done to the sick and disabled of this country – as spelled out, in the House of Commons, by MPs from many parties.

Afterthought: It should be noted that Professor Aylward is on record as having expressed doubts about the Work Capability Assessment and the current system, as run by the government, with the caveat that he has not been involved for several years.

He told the Black Triangle Campaign: “I will make myself aware … but I think that I’m a man of integrity … and if I think that the Work Capability Assessment … test or whatever … is not proper … I will speak out against it.”

In the light of what happened while he was at the DWP, I leave it to readers to judge whether he will.