Mental health is on the news agenda — and not just that of the Chancellor of the Exchequer, silently weeping through Wednesday’s PMQs, nor that of the anxious traders who panicked straight afterwards. The collapse of the government’s welfare reform plans, smashing yet another black hole into Rachel Reeves’s budget calculations, has put the issue of benefits for those with psychological disorders in the spotlight. The figures are indeed eye-watering: 44% of people currently claiming disability payments cite a mental or behavioural problem as their main issue, amounting to 3.3% of the working-age population.
Operating separately to incapacity benefits, it’s the system of Personal Independence Payments (Pips) now attracting most attention, largely thanks to the Government’s crass attempts to reform it before U-turning earlier this week. Pip is intended to aid people aged 16 or over with medium- or long-term disabilities who “have difficulties doing certain everyday tasks or getting around”, with corresponding money available for “daily living” and “mobility”. It isn’t means-tested, is compatible with being in work — although most who receive it are not — and there is no requirement you spend the money on particular forms of assistance. (As Hertfordshire County Council helpfully points out, it “can be spent on whatever you wish, such as outings, special interests or holidays, or put away into a savings account”.) Pips for anxiety and depression now account for 16% of spending, and 1.4 million are claiming for “psychiatric disorders” including autism and ADHD.
One obviously significant factor here is that mental disorders are now full-blown cultural identities for many, with impressively technical-sounding labels for human suffering being collected like Pokémon cards. Encouraged by GPs and therapists, millions of people treat lists of psychological symptoms almost mystically, as if they were a kind of science-backed cipher for the enigmas of the human soul. Given the speed at which proliferating diagnoses become “disabilities”, the Government’s decision to tackle welfare reform would have been a good time to do some joined-up thinking about what happens when therapy culture meets benefits street.
Instead, the DWP attempted to deal with the trend covertly, proposing complicated and overly generalised reforms that would have unfairly taken from physically disabled people too. And I understand why they were underhand about it. Talking honestly about the explosion of mental health conditions is intimidating, not least because of the numbers of outraged people steaming in to protest about imagined accusations of hypochondria or malingering. Yet, the observation that psychological conditions can ripple across populations like wind through wheat, being especially susceptible to social influences, is compatible with debilitating dysfunction and awful suffering happening at the individual level. There’s no split between “real” mental health disorders and culturally porous ones. The latter — which includes the vast majority of them — are as real as any other. And the suffering they bring feels the same from the inside, no matter what the source.
To acknowledge that genuine suffering is involved is one thing; to know what to do about it quite another. One of the many bizarre things about the current Pip situation is how counterproductive it looks for the anxious and depressed, in particular: keeping ruminating, avoidant, socially isolated people stuck in limbo, paid to stay away from the situations they fear most. The problem becomes yet more apparent when you compare two hypothetical claimants, each stuck at home: one with severe anxiety, and one with (say) cerebral palsy. Both may have trouble getting out of bed, dressing, doing housework, and going shopping, but for different reasons. Unlike for cerebral palsy, there are relatively cheap scenarios close to hand in which severe anxiety is controlled and eventually abates. Therapeutic buzzwords such as “behavioural activation” and “exposure therapy” underline the basic point. Yet, still we have a benefits system that incentivises some unhappy, world-avoidant people to stay that way.
The DWP crudely tried to kick away the crutch, but a better approach would be to acknowledge the complex interaction between macro and micro. As philosopher Ian Hacking noted decades ago, most mental health disorders exhibit “looping effects”, meaning that official diagnostic criteria shift over time in response to social pressures coming from below — including from the political activities of patients and the real-world classifications of mental health professionals. And equally, the concepts we collectively have for these disorders tend to “creep” vertically as they simultaneously “loop”: that is, they become targeted at less and less extreme kinds of experience and behaviour. We end up with unhelpfully broad concepts, at least in popular guises: “autistic spectrum disorder” which includes both profound non-verbal limitation and high-functioning quirkiness; OCD which comes in a “mild” flavour, raising the reasonable question of how this could count as an obsession or a compulsion at all.
None of this happens on purpose. It’s just the way that patterns of mental dysfunction tend to go, when they don’t have an easily-identifiable biological basis and are indexed to prevailing social norms. Meanwhile, back at the micro-level, once an individual gets a new diagnosis — even for relatively mild symptoms — a very 21st-century response is to make it a core part of his personal identity. As this narrative embeds, modifying his incoming experiences in the light of it, suffering can easily worsen, symptoms get exacerbated, and lassitude and defeatism set in. Again, this is just how pattern-recognising, habit-forming brains tend to work.
Loopers-in-chief include affluent tastemakers, always on the lookout for a freshly interesting story to tell about the self. Get diagnosed with arthritis (or indeed, schizophrenia) and nobody really cares; get diagnosed with ADHD plus depression, and immediately become an object of touchingly relatable fascination for lifestyle editors. Middle-class parents are also complicit in shifting diagnostic criteria through pressure — albeit inadvertently and from understandable motives — anxiously monitoring their offspring’s behaviour in terms of currently fashionable disorders, and translating their worries into entreaties to teachers and doctors.
But school is nothing compared to what comes next on the typical “mental health journey” — otherwise known as the place where personal resilience goes to die. In universities, mental health classifications do not so much slowly shift over time as rapidly collapse into meaninglessness, occasionally nuzzled back into a vague semblance of coherence by a passing support alpaca.
Many young people arrive already primed with letters from GPs or therapists, attesting to conditions like autism, anxiety, or depression; and if they don’t have a diagnosis yet, they can get one soon enough. No matter what their circumstances, these all now count as disabled students, for which reasonable adjustments must be made according to the terms of the Equality Act. Underfunded and desperate for good publicity, swamped with miserable customers, and tyrannised by the awful prospect of student suicide, university managers often take the path of least resistance and try to just give students whatever it is they say they want — on the condition that it doesn’t cost too much money. Removing anxious students because they are unfit to study is bad, because their fees go with them; putting trigger warnings on books is good, mostly because it is cheap.
“Many young people arrive already primed with letters from GPs or therapists, attesting to conditions like autism, anxiety, or depression.”
My knowledge here is not just abstract. When I worked in universities, at least a quarter of the students in each class had a mental health diagnosis, emblazoned in coloured lettering on the register so I wouldn’t forget. There weren’t enough individual exam rooms or scribes for all those who requested one. Non-attendance was easy to get away with, as long as you said the right things. Sometimes absentee names on registers were only connected to faces at the final degree ceremony, where their mysterious owners rose again Lazarus-like, teetering across the stage on vertiginous heels.
At the beginning of each term, I would be sent details of particular students who did not want to be asked questions in class. By the time I left my job, many exams were being phased out altogether in the name of the anxiety-ridden and attention-depleted — just in time for ChatGPT to sweep in and win all the prizes, quite literally. None of this was specific to my institution; from what I hear of other places, it was absolutely typical, though perhaps things have improved since.
It’s hard to inspire students to become less frightened of life, when their lecturers also seem frightened of them. Scale up this attitude to society at large and we definitely have a problem. Yet it remains difficult to make an obvious point in response: that mental disorders/disabilities, although limiting and distressing, are significantly unlike bodily disorders/disabilities in at least one important respect. This is: on average, they are much more responsive to good habit-formation, in terms of the thought patterns you foster and the behavioural routines you adopt. Indeed, this very point is presupposed by the existence of the therapy industry, whose raison d’être is, precisely, to change thought and behaviour patterns for the better. In contrast, when you go to your GP with a broken leg or a gallstone, she is unlikely to suggest CBT as a first resort.
Articulating this basic point, so blindingly obvious to laypeople, is difficult partly because academia makes it so. Thousands of sophisticated-sounding articles tell us that mental disorders are brain-based, and so “physical” too; that mental illness often accompanies physical illness, and vice versa; that anxiety and depression can exacerbate bodily pain as well as stem from it; that the mental and physical realms deserve “parity of esteem”; and so on.
All of these things may be true; but they only show that bodily disorders and mental disorders are interrelated in complex ways. They do not establish that they are exactly the same thing; and nor that they should be treated identically, whether by the NHS or the DWP. As the campaigning slogan goes, it is indeed time to talk about mental health — but not in the sense of yet more pointless navel-gazing or individual soul-searching. As Rachel Reeves probably said to herself on Thursday morning: when it comes to turning the page on old, sad stories, every day is a new day.
