Will the drive for post-pandemic ‘wellness’ make us sicker?
As we begin to assess the ongoing damage wrought by the global Covid-19 pandemic, one thing is becoming clear: around the world, those who were already carrying the heaviest societal burdens are suffering the most from viral infection and from the demoralisation and distress that speaks of their harsh circumstances.
The ebb and flow of the pandemic has consistently exposed the outlines of those structural inequalities that all but define late capitalist neo-liberal societies, like the UK. Witness, for example, the disproportionately negative impact on the physical and mental wellbeing of ethnic minorities, those who have been given a diagnosis of schizophrenia, people in precarious employment, people with disabilities, older people, and carers everywhere (mostly women), including frontline employees in our overstretched and under-funded public health and social care services.
Some commentators have expressed the hope that the political and moral shock of this disaster may inspire politicians and communities to ‘build back better’ – toward a fairer society, focused upon human rights and the common good. Others are more pessimistic. They argue that, despite the pledges to build a better world after the pandemic, there is no sign of advance in the conditions or status of essential care and service workers; let alone in the lot of the poorest citizens. Notwithstanding these debates, given current predictions of a ‘mental health crisis’ emerging from this pandemic, one might hope and expect that the discipline of psychology and its applied arm of psychotherapy would play an important role in assisting a fair and compassionate societal response. Political analysts have called for the widescale recruitment of psychiatric nurses, doctors and psychotherapists to ‘restore the equilibrium of tens of thousands of adults and children […] tipped over the edge into mental illness.’
While this call for improved resourcing of mental health services is understandable, it is important to ask whether a ‘more of the same’ treatment approach could make things worse in the long term. Are the ideas and practices of mainstream psychology so intertwined with our damaging neo-liberal societal status quo that they may end up adding to the problems that they are supposed to solve?
How did we get here?
The Covid crisis has both revealed and amplified a profound societal malaise, decades in the making. Since the 1980s, governments in America, Europe, the UK and her former colonies have promoted economic competition and the myth of ‘free trade’ within a globalised economy as the crucibles of personal advancement and of civic pride. In this accountants’ reckoning of the good life, barriers to the flow of transnational capital have been steadily lowered, and corporate and wealth tax generously reduced. Organised labour has been stripped of its power to resist creeping privatisation of public services and casualisation of the workforce: smoothed along by the widespread introduction of computerised audit and surveillance. Rich people have become far richer, while the incomes and assets of the poor have stagnated at best, and for most have declined in real terms.
Since the financial crash of 2008, these troubles have intensified. A political system that works well for the perpetrators can be closer to a dystopian nightmare for its victims, the ones who get the most blame. The real progenitors of this economic crisis within the UK – the deregulated and financially reckless City of London and its siblings across the world – escaped any significant or lasting official censure, let alone punishment. Instead, the most vulnerable citizens were pilloried and then stigmatised by successive neoliberal administrations and by much of the mass media in Britain and in many other countries, as the supposed source of the problem: deemed the undeserving claimants of state largesse.
Millions of ordinary people in the liberal democracies have thus been subjected to official ‘austerity’ policies: ever deeper and more damaging cuts in government funding for public services, health care coverage, assistance for people who are unemployed or insecurely housed. Pensions, disability and sickness benefits and other state protections have been whittled down or removed. The social security system has become ever more punitive. For people of middling income and below, family and communal life are more precarious and fraught than at any time since the end of the second World War. In 2018, the UN Special Rapporteur on extreme poverty and human rights, commenting on the UK, noted the ‘the sense of deep despair that leads even the Government to appoint a minister for suicide prevention and civil society to report in depth on unheard levels of loneliness and isolation’.
At the start of the pandemic, 35 per cent of British children were living in relative poverty, personal indebtedness was at record levels, and thousands of citizens, including nurses and other care workers, depended upon charitable donations and food banks for survival. It is unsurprising that such social conditions gave rise to unprecedented rates of psychological distress before March 2020, as measured by community surveys, demand for mental health services, and prescriptions for anti-depressants and other psychiatric drugs. It is even less of a surprise that for many, the pandemic appears to have heightened these woes.
Mainstream psychology – noble advocate, or servant of power?
The discipline of mainstream psychology has played its part in supporting these socio-political developments, acting as a distorting mirror that both reflects and shapes our shared notions of what is claimed to be our own nature. As mercantile thinking has seeped into every aspect of our lives – from education to work and play – so a new kind of self has come of age. It’s a flexible consumer-entrepreneur, intent upon the enhancement of personal adjustment, performance and – above all – wellbeing.
It is no accident that this is the form of personhood that many psychologists have been promoting since the 1980s – to begin with, via the ‘cognitive behavioural therapies’ together with numerous brands of ‘self-help technique’ and of psychotherapy and counselling; joined, in the early 21st century, by resilience training and mindfulness. Whilst the CBT therapies have retained their original stoic emphasis upon on the ‘management of emotions’, the many schools of resilience training and of ‘mindfulness’ have drawn much of their inspiration from the ideas of ‘positive psychology’, imported from the US, where the goal is to inculcate a warmer, calmer and more optimistic emotional state.
Over the decades, psychologists and clinical researchers have trumpeted what they take to be the scientific credentials of these therapies, all the while downplaying or ignoring the structural causes of the growing rates of misery in modern societies – and with troubling results. Not only are these therapies likely to encourage an acceptance of social injustice as an external climate to which all of us must adjust: they are also likely to convince their recipients that wellbeing is mainly a personal responsibility and achievement. No wonder that many Western governments and businesses have wholeheartedly adopted the so called ‘happiness’ agenda as a way of persuading us that our problems are due to our own ‘faulty thinking’ or unwise behaviour rather than to toxic social policies and practices.
Take, for example, the increasing investment by employers in ‘wellness’ programs for their staff. The aim is to nudge or to coerce them into taking more exercise, eating more healthily, and into using relaxation techniques like mindfulness. On the face of things, it might seem churlish to argue against the use of such practices, including initiatives like ‘The Big Soothe’, adopted by many NHS Trusts throughout the UK. Who, in the midst of a busy morning spent in front of a computer screen, could deny the refreshment to be had from a ten-minute spell of vipassana meditation, or from a mindful stroll outdoors? Assuming, of course, that the necessary tranquil and green spaces can be found?
Nevertheless, it is worth recalling the consistent epidemiological evidence, accumulated over many years, which shows that the nature of hierarchical organisations themselves are often significant contributors to employee ill health. The famous Whitehall study, for example, demonstrated that the lowest ranking British civil servants suffered threefold greater mortality when compared with their senior managers; even when mitigating personal health factors like exercise, diet, and access to medical care were taken into account. It was isolation and subordination – lack of personal control over the content and pacing of the job – that seemed to do the most damage. These conclusions have since been corroborated many times over, and for mental as well as for physical health.
Indeed, the main findings of the Whitehall study emerged in the last quarter of the 20th century, and were derived from a comparatively well unionised and protected segment of the labour force. In the ensuing 40 years of the neoliberal era, the ills identified in the Whitehall investigation have become closer to the norm. Legal powers that once allowed unions to organise and to challenge unhealthy working conditions, such as unreasonable productivity demands and poor remuneration, have been diluted or removed. Computer technology, short term and flexible zero hours contracts, low wages and managerial spying and control undreamt of in the pre-IT era have conspired to wilt employee solidarity. For many, perhaps most, workplaces are domains of chronic insecurity and stress. It is perhaps no surprise that those who benefit most from this situation enthusiastically embrace and promote individual level changes such as ‘well-being programs’ over structural level change in organisations of the kind that might threaten their power and their profits.
Within the public mental health services of the anglophile world, psychological therapies are branded and marketed upon the claim that they can be tailored to well-defined mental disorders. However, these claims are highly questionable. To begin with, there is scant evidence to support the clinical validity or reliability of the vast majority of psychiatric diagnoses. Our distress and how we express it resists the easy standardisation implied by diagnostic manuals like the DSM V. Our personal troubles reflect our very particular social and family circumstances, biology, and history. Moreover, careful scrutiny of the evidence base suggests that the potency of talking and behavioural treatments have been systematically overestimated by researchers and clinicians, if less often by recipients. Psychology is not alone in this respect. Thoughtful critics have long argued that the field of general medicine is riddled with biased research, linked to overdiagnosis and overtreatment with therapies that bring little or zero benefit for most people, in ‘real life’ conditions.
Before the pandemic, the UK government’s Improving Access to Psychological Therapies programme had transformed the landscape of counselling and psychological therapy across England. From its inception in 2006, IAPT has provided thousands of people experiencing depression and anxiety with talking therapy, largely in the form of highly manualised and time-limited sessions of CBT. With referrals in 2019 standing at 1.5 million, IAPT is set to be a core element of expanded mental health treatment services post-pandemic – offering more elements of mindfulness and of positive psychology, but essentially in the same mould.
Successive governments have relentlessly blazoned the success of this program. But all that glitters is not gold. The official outcome measures used by the service are both superficial and malleable. Less than a third of the people referred to the programme end up completing it. Symptom improvement rates – when assessed by more impartial external investigators – are typically slight, and upon closer examination, turn out to have even less influence upon the emotional problems that clients face in their day to day lives.  What can be said, and with some confidence, is that after 15 years of IAPT, the world – including the mental health of the general population – has not improved, and may be getting worse. If IAPT and the similarly industrialised mental health treatment programmes that are burgeoning throughout the NHS can offer only shallow rituals of cure, then they are likely to do more harm than good in the long run. Their continued existence, despite such a poor evidence base, suggests that they serve a politically convenient myth: that there are simple bargain basement answers to widespread psychological suffering.
Indeed, the parallel with the recent fall from grace of many commonly used psychiatric drug treatments is plain.Notwithstanding their questionable evidence base, so called anti-depressants and anti-psychotics continue to be promoted, as the ‘silver bullets’ of the mental health field. Whilst psychological therapies can offer comfort and clarification, they cannot reliably bring about lasting improvement, especially for those who must live in a damaging world.
To help us to ‘build back better’, we need an evidence-based alternative to the mainstream
If orthodox psychology has promoted the regnant image – or rather, the myth – of the autonomous and resilient individual, then the critical reading of the evidence-base for psychological interventions discussed above implies a very different picture. One that behoves psychologists to take seriously the evidence of hundreds of epidemiological studies into the social and material origins of personal distress alongside neuropsychological research into the roots of our day-to-day subjectivity and decision-making. Our very being, especially our experience of ease or misery, is woven – not ‘inside of the brain’ or even ‘within the mind’ conceived as hardware and software, respectively – but within a resonant nexus comprised of our embodied feelings and thoughts, and of the environments that enable us when we are lucky, but against which we must sometimes struggle (structured as they are by social, economic and material power).
These powers emerge as the manifold carrots and sticks which continually shape our ideas and conduct; often by appealing to our unspoken interests – whether perceived or actual – but seldom within the scope of our full awareness.  The tragedy is that the same networks of social and material power that spawn our woes can work to obscure their ultimate causes, seducing us into a set of stories and feelings about the world and ourselves that encourage us to seek answers that are misleading, or simply false.
Psychologists have always dealt in metaphors, some of them more accurate and fruitful than others. As creatures of community and history, humans are more like the dynamically networked trees described by forestry ecologists than they might resemble the autonomous and strategising software beloved by too many cognitive scientists, economists – and talking therapists. Faced with a world-wide economic slump and gathering climate breakdown, the task is to build upon the lessons of the Covid pandemic and to work toward a more equal and sustainable society. If it is to aid, rather than hinder, then we need a new and more sober kind of psychology, equipped to stand against the illusions of neoliberalism. Rather than facile optimism, it will have to acknowledge the fragile and tragic elements of human existence, the impossibility of personal change via the shuffling of thoughts and other simplistic techniques. Above all, it must encourage the habit of ‘outsight’ into our wider milieu, as a facet of what can be called a social-materialist psychology – that recognises the roots of our ills and the importance of compassionate solidarity with others. In line, perhaps, with what the environmental activist Kimberley Nicholas calls ‘the regeneration mind set’: focused upon care for one another and for the biosphere, prevention rather than treatment, and the creation of materially and ecologically resilient communities.
In this scenario, psychology would shift its research priorities away from individual interventions toward social ones, and with due caution even here. To the extent that individual treatment was still pursued, then practitioners might aspire instead toward ‘gentle medicine’, as advocated by the philosopher Jacob Stegenga. Rather than the firing of supposed magic bullets in the form of branded therapies, this would come down to a modest attempt to validate the experience of distress, and to help the sufferer to make such environmental and lifestyle changes as might be open to them.
A small minority of readers, including the editor of this magazine, tell us that they believe social-materialist psychology to be firmly in the mainstream – whether overtly, or tacitly. There may indeed be many therapeutic psychologists who identify with the points we have argued here. It is little surprise that many of them, working on the ground in public health services, notice the toxic effects of economic insecurity or of outright poverty on the lives of the people that they try to help. Indeed, the British Psychological Society’s Senate has voted twice in recent years for campaigns intended to tackle poverty and class-based discrimination within the UK, respectively.
However, there is a profound disconnect between this apparent willingness to recognise some of the painful realities of British society, and the models of therapy offered on training courses and in clinical consulting rooms across the country. The dominance of IAPT and of 'quick-fix' CBT and 'mindfulness' based therapies within mental health services in general, suggests that social materialist psychology is largely ignored.
For the most part, academic and of applied psychology remain focused on the mythical concept of an individual, artificially separated from their context. The few attempts that have been made to incorporate social and material influences endure at the margins – as tokens. They serve to deflect criticism, allowing the relentless focus on supposed individual cognitive processes to continue.
In the end, we are faced with the question of whether the role of the psychologist is to adapt people to a sick society or rather to use the evidence of our clinics and our socially informed research to bear witness to and speak out against the multiple ills inflicted by the neoliberal order. There is a long way to go, and desperately little time – but in our view, a social-materialist psychology would offer a better touchstone and guide in the troubled times that lie ahead.
- The Midlands Psychology Group are clinical, counselling and academic psychologists. See midpsy.org for more information.
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