Wellbeing & Happiness as used by the UK Government

by Julia Evans on May 7, 2007

Introduction

 

Wellbeing and happiness are two words, constructions, or concepts in use by Government in changing the practice of all health professionals. This paper has three sections:

first it considers the context for Government’s use of wellbeing and happiness;

it then comments on its absolute interpretation of these terms;

and finally a different context for wellbeing and happiness is considered.

In exploring wellbeing and happiness, this article brings into question whether the government’s intention is either desirable or achievable.

Wellbeing in the legislation

 

The main objective of The Health Professions Order 2001[footnote 1 ] (HPO2001) is ‘to safeguard the health and wellbeing of persons using or needing the services of registrants or health professionals’ (S3.4). This is enacted through the Privy Council Power and control by the creation of the Health Professions Council Government Agencies. The principal functions of the HPC are indicated in the footnotes below. [footnote 2] It is intriguing that a government, from whose collective lips the words ‘evidence-based practice’ Evaluation & evidence fall so easily, produces no evidence of a link between legislation and the public’s wellbeing. The public’s wellbeing is also assumed rather than defined. The British Psychological Society (BPS), the British Association of Counselling and Psychotherapy (BACP) and the United Kingdom Council of Psychotherapists (UKCP) dominate UK practice and all support the link Government asserts between statutory regulation/ registration and safeguarding users.

Happiness: as used in government-led proposals for the provision of mental health clinics

 

Lord Layard, emeritus professor at the London School of Economics and head of the Mental Health Policy Group, Centre for Economic Performance, LSE, published a book in 2005, ‘Happiness: Lessons From A New Science’.  He asserts that ‘lying across the path of productive happinessD stands mental illness, the common afflictions of depression and anxiety. Society may be more affluent than ever before, but never has it been less at ease with itself’. [footnote 3]

Lord Layard attracted the government’s attention with a public lecture in September 2005 in which he declared mental health to be ʺour biggest social problem – even bigger than unemployment and bigger than povertyʺ. [Footnote 4]

Layard’s four propositions  are footnoted below.[footnote 5] They are:

the scale of suffering and cost;

the existence of known remedies;

treatment centres to provide these therapies;

and the key importance of work.

These propositions link directly into Government’s control of medical clinical practice through the National Institute for Clinical Excellence (NICE) guidelines. From this, Layard proposes a link to the reduction of working time lost and claimants ceasing to receive state sickness benefit. NICE guidelines insist on CBT (cognitive-behaviour-therapy) for all psychically caused conditions as CBT-treatments are short, cost-effective, can be used in evidence-based practice, are easy to evaluate, and practitioners can be trained quickly.

Thus the propositions link Mental Illness to Unemployment or missed working days to cost in State benefits or loss of working-days to provision of CBT – NICE clinical guidelines to happiness. There is no evidence for any of these connections being valid.

The propositions are just that, propositions. There are two treatment centres where these are being tested before going national. The Improving Access to Psychological Therapies (IAPT) programme was launched in May 2006 by the Department of Health and the Care Services Improvement Partnership (CSIP) initiative. IAPT seeks to deliver on the Government’s 2005 General Election manifesto commitment to improve access to psychological therapies (as defined by NICE clinical guidelines) for those who require the help of mental health services. [Footnote 6] The IAPT programme is designed in part to test out Layard’s hypothesis that the provision of stepped improvements in access to psychological therapy for adults of working age with mild to moderate depression and anxiety will improve their wellbeing and in so doing support them to retain their employment or return to work. The LSE group will also test whether a reduction in incapacity benefits and savings in health service costs will largely offset the cost. In addition, this is the first large-scale use of the NICE guidelines on depression [Footnote 7], anxiety [Footnote 8], and other mental health problems. Currently, only half of those with mental health problems on incapacity benefit or income support receive any form of treatment (only nine per cent receive psychological therapies) mainly short-term CBT treatments. [Footnote 9]

There are several interesting assumptions and conjunctions here. It is assumed that the other half with depression as a symptom will respond to CBT to the satisfaction of the evaluation systems and return to productive happiness. So even if it is true that the half, currently evaluated as statistically cured of depression, is returned to productive happiness then there is room to be doubtful that the other half will behave exactly the same.

Layard specifically links happiness to the end-product of CBT [ footnote 10]. It is a treatment that is assumed to work with a machine-like dependability – there are assumed to be no differences between CBT-therapists and CBT-service-users or how, for example, depression manifests itself.

Layard asserts: It is not the poor. You can see this from the National Child Development Study which shows that unhappiness is three times more closely related to mental health (measured 10 years earlier) than it is to poverty (measured today). The cost to the economy in terms of lost output is around 2% of GDP and the cost to the Exchequer is similar – including some £10bn spent on incapacity benefits and some £8bn on mental health services.[Footnote 11]

 

First Conclusion

 

The Government, HPO2001, knots statutory registration and regulation with safeguarding health and wellbeing. Layard knots the prescribed provision of CBT with productive happiness. Both these knottings produce an illusionary certainty or safety of which the Government is the Guarantor. The next section explores other views of happiness and wellbeing.

Comments on Government’s absolute interpretation of Wellbeing and Happiness

 

In both HPO2001 and Layard’s propositions, wellbeing and happiness are assumed to have the one, correct definition and to be sought by the public. The following exploration is based on two articles by the economist, Samuel Brittan.[Footnote 12]

Three definitions are applied to the Government’s promulgation of happiness:

Aristotle identified happiness with virtuous activity;

Jeremy Bentham and his utilitarian followers identified it with pleasure and subjective satisfaction;

John Stuart Mill never wavered in the conviction that happiness was the purpose of life, but he also believed that those who achieve it “have their minds fixed on some other object” such as the wellbeing~~ of others or some art or pursuit.

Happiness (Aristotle) underlies Layard’s proposition that, if the depressed, work-shy population is enabled to work, they will be rewarded with happiness and this will be a very good thing. In guaranteeing to safeguard the public, the Government is also behaving virtuously,[Footnote 13] in the probable expectation of re-election happiness.

In addition, Lord Layard and the Government are using the utilitarian, pleasure-defined happiness where there is no limit to the amount of pleasure an individual or country can have or use: one can’t have too much pleasure. Layard’s proposals are utilitarian[Footnote 14] in a further cost-reduction way. ‘They would make financial sense’, he said, ‘because addressing mental illness would dramatically reduce the number of people claiming incapacity benefit’ (currently just under a million). The economic cost of mental illness is £21bn a year and roughly 91 million working days are lost annually to mental distress.

Happiness (Stuart Mill) ceases to be an individual’s right and becomes associated with their relationships with others. This moves from one-dimensional control of a standard, measured unit of individual happiness to relationships within communities.

On wellbeing, authorities such as Prof Avner Offer [Footnote 15] conclude that neither choice nor economic growth in modern conditions promotes individual and social wellbeing.

Anthony and Charles Kenny [Footnote 16] suggest that only a very limited part of public expenditure contributes to welfare or wellbeing. Income, either absolute or relative, is associated in the US with a maximum of 5 per cent of the reported differences in wellbeing between individuals. So much of the cross-country variation in subjective wellbeing remains unexplained by objective influences that the Kenny camp suggest “a distinct limit to policy or other interventions” in increasing subjective wellbeing scores.

Brittan asserts that collectivists are improving their position in state intervention by calling a new pseudo-subject called happiness studies to their aid. People are asked how happy they are with their lives.

Both HPO2001 and the Layard proposals are state interventions to improve this measure of wellbeing and happiness.

 

In addition to the Governmental functions of internal and external security, providing public goods which the market cannot do, and trying to correct for the worse spill-over effects of our activities upon each other, Brittan argues that individuals rather than the Government ought to be responsible for obesity, respect and so much else on the Blairite agenda.

It appears that the Government’s itch to intervene in ungovernable parts is unstoppable.

It is presumptuous of legislators or social scientists to tell us how to promote our happiness. I agree with Brittan’s statement that the Government’s objective should be to promote conditions in which people have the maximum of options. What they make of these opportunities is their business; and whether they then fill in questionnaires saying that they are happier or not is interesting, but not the final criterion. This follows the John Stuart Mill definition of happiness. It is necessary to go even further back. The bedrock value on which classical liberals traditionally rest is freedom. Someone who attaches importance to freedom is committed to attaching importance to choice, but it does not necessarily work the other way round. You can have a lot of choice, but be fundamentally unfree. What matters is freedom of action and speech among consenting adults.

This can be rewritten in the prevailing Government-defined Mental Health or Wellbeing clinic. It is presumptuous of the Government to tell those with psychically caused distress, how to gain wellbeing or happiness. To limit choice of intervention into such problems to drugs or CBT is disgraceful even on the grounds that the government is acting for your own Good. To use evaluation evidence to promote CBT above the other interventions is to deny these people the right to choose their own treatment. Rigidly defining the outcome of the talking therapies as happiness or wellbeing is a delusion: the certainty that such things can be controlled.

Second Conclusion

 

Is the provision of wellbeing and happiness in any form, including one which is measured and evaluated, a proper matter for government or for government to attempt to supply? Where are the limits for governments in the area of direct provision of wellbeing and happiness and also for individuals? Wellbeing and happiness is embedded in legislation and Government action and they are therefore controlled using agents who deliver the Government’s cure to a satisfactory standard.

A different context for wellbeing and happiness

 

This section compares how the British and Danish social services [Footnote 17] care for looked-after children. The differences between the two cultures are first defined.  The conclusion is that the implementation of HPO2001 and IAPT will result in a similar stark contrast of results.

There are immediate differences with the UK:

Denmark has a high level of staffing;

proudly declares that the residential home has no rules;

each child must be treated as a unique individual;

and the fact that more than 60% of the children go on to higher education – a far cry from the outcomes of looked-after children in the UK.

There are differences in training.

In Denmark, there is attention to the individual,

a huge investment in highly qualified staff,

and the priority of developing strong relationships.

These are all key principles of the Danish tradition of pedagogy.

Differences in training

In the UK, there is emphasis on UK-wide standards for staff who are trained as quickly and cheaply as possible.

A Danish residential home’s staff are all trained as pedagogues in a degree course lasting three-and-a-half years.

The investment in highly trained staff is a dramatic difference from the UK residential care workforce, 80% of which have little or no qualifications.

Differences in attitude to cost are marked in the two countries.

Denmark is well aware that pedagogy doesnʹt come cheap. It represents a huge investment in human resources and in the quality of relationships with service users.

From a Danish perspective there is an aversion to risk in the UK.

Kieran Hatton [Footnote 18] comments that Danes who come to work in our children’s residential homes notice how rigid they are, how often we call in the police to deal with difficulties and how scared of risk we are.

They find how we work with young people very disturbing.

Hatton believes that what has driven the direction of UK policy in the last two decades has been an aversion to risk. ʺThe scandals in the childrenʹs services have permeated all social work,ʺ he says. ʺWeʹve become very risk averse, and residential units have been geared up for health and safety. Yet all the evidence shows that young people gain more from being exposed to some risk. Weʹve been good at the protection of clients, but not their development.”

There is a further difference between the UK’s control-systems, which are run on procedures and have to be fed information and the Danish control systems run on trust. ʺIn the UK, qualified staff spend a lot of their time putting information into a computer database,ʺ Hatton says. ʺThereʹs a lot about paper chasing in the care management approach, which is so widespread now. It involves care packages with measurable outputs, and targets.ʺ A pedagoguesʹ training enables them to be confident about using their personal judgment, rather than the more typical UK approach of relying on procedures, which often cannot accommodate individual circumstances.

These criticisms of the UK’s approach to residential childcare are all implicated in HPO2001’s and Lord Layard’s approach to the treatment of depression and anxiety. They dehumanise both therapist and user.

In safeguarding both the giver and receiver of therapy, development is lost for both.

Human relationships do not register as they are unique and cannot be evaluated.

HPO2001 guarantees that a legalistic approach will be used in recruitment, training, professional development, complaints, and the workings of all clinics.

CBT is used on a cost basis as it is easy to administrate.

The processes the HPO2001 will introduce are rigid and risk-averse (risk is very big in the Donaldson 2006 and Foster Reports 2006).

An insistence on note-taking, keeping records, and constant monitoring of progress does not accommodate individuality and relies on rigid adherence to procedures.

The system aims to remove risk and uncertainty.

The Donaldson report purports to remove the uncertainty of illegal acts and the uncertainty of human error. Donaldson effects this by comparing the ‘health industry’ with other ‘high-risk industries’ such as the nuclear industry, oil production and the aircraft industry.

The question of whether the ‘health industry’ is an industry and whether it is a high-risk industry has not been raised.

The consequences of removing doctors’ ability to use their 10 years worth of training and experiential clinical judgment are just now emerging. When one aims to replace risk with certainty, the consequences are rarely predictable as in the other high-risk industries quoted. This point is emphasised in the case material presented – see footnote 17.

Third Conclusion

 

The governance needed to implement HPO depends on ferocious control systems to produce wellbeing or happiness. Their objective is a risk-free or risk-controlled ‘health industry’.

Dr Shipman et al have caused the government to legislate all who are connected, however slightly, to the ‘health industry’ so that all risks, including human errors are eliminated.

Donaldson extrapolates the need for a risk-free ‘health industry’ from studying five reports (covering possibly 10 to 15 doctors).

The models for producing wellbeing and happiness are taken from disasters in three industries: oil production, nuclear electricity generation and air transportation.

Evaluation is evidence and cost based and can be criticised for not measuring that which it purports to measure and for excluding that which makes the treatment successful. Thus much time is given to inputting information into systems to produce meaningless evaluations. This information is also used in the legalistic complaints system. However, what is being evaluated is the production of happiness and wellbeing for users at low cost. Any form of individual development is not recognised.

The contrast between the government’s vision (an industry-inspired control system) and those based on relationships and individuality is huge.

The government’s system is perverse: it excludes relationships and treats people as objects not individuals capable of thought. It is also an attempt to control that which should be left to individual choice.

Julia Evans

Note: Originally published in ‘Psychoanalytical Notebooks: A review of the London Society of the New Lacanian School, Issue No 16 – Regulation and Evaluation, London, May 2007 Page 143 to 153

References & Notes

1. Statutory Instrument 2002 No. 254 The Health Professions Order 2001 © Crown Copyright 2002 Statutory Instruments 2002 No. 254 Health Care and Associated Professions Health Professions: The Health Professions Order 2001 Made 12th February 2002 Coming into force articles 1 and 48(4) 12th February 2002 remainder in accordance with article1(2)

2. Section 3 of the Health Professions Order 2001 (HPO2001):

(1) There shall be a body corporate known as the Health Professions Council (referred to in this Order as ʺthe Councilʺ).

(2) The principal functions of the Council shall be to establish from time to time standards of education, training, conduct and performance for members of the relevant professions and to ensure the maintenance of those standards.

(3) The Council shall have such other functions as are conferred on it by this Order or as may be provided by the Privy Council by order.

(4) The main objective of the Council in exercising its functions shall be to safeguard the health and wellbeing of persons using or needing the services of registrants

3. These points are made in the following article: Mary O’Hara, “Walking the happy talkGuardian, Wednesday November 20 2005.

4. ʹMental illness is now our biggest social problem On Wednesday September 14, 2005 Richard Layard calls for a network of 250 treatment centres to offer psychological therapy to the public. Lecture is available from the web. · This lecture draws heavily on Richard Layard – ‘Mental Health: Britainʹs Biggest Social Problem’, which is available at: www.strategy.gov.uk/downloads/files/mh_layard.pdf . (This seems no longer available and may be the same as:   The Case for Psychological Treatment Centres February 2006) and on Richard Layard’s book – Happiness: lessons from a new science

5. From Richard Layard’s speech. See footnote 4. “So tonight I would like to persuade you of four propositions.

Firstly, there is a mass of suffering which is untreated and which imposes severe burdens on the economy.

Secondly, we have effective means of treating it, which are enshrined in Nice [National Institute for Clinical Excellence] guidelines. But those guidelines cannot be implemented with the current resources of people and money. In particular evidence-based psychological therapies like CBT [cognitive behavioural therapy], which are in heavy demand, are not adequately available.

Thirdly, we could meet reasonable demand within five to 10 years by a major programme to train more therapists. But this will not be cost-effective unless we maintain the quality of training and of provision. This means that provision should be through psychological treatment centres, working on a hub-and-spoke basis.

Fourthly, for many people, work is a vital part of therapy and of the recovery process but at present there are more mentally ill people on invalidity benefit than the total number of unemployed people. The governmentʹs Pathways to Work pilots show that many of these people can be helped back to work, and these programmes should become available throughout the country.

So those are my themes: the scale of suffering and cost; the existence of known remedies; treatment centres to provide these therapies; and the key importance of work. Let me start with the scale of suffering and cost.”

6. For an update on progress see Penny Gray’s “Improving access to psychological therapies – the story so far.” Therapy Today March 2007 page 18 to 21

7. National Institute of Clinical Excellence: Clinical guideline reference CG23 ‘Depression: management of depression in primary and secondary care.’ Summary: The NICE clinical guideline on depression covers:

1) the care people with depression can expect to receive from their GP or other healthcare professionals, whether they receive treatment in or out of hospital

2) the information they can expect to receive about their problem and its treatment

3) what they can expect from treatment, including psychological therapies, drug treatment and electroconvulsive therapy

4) the kind of services that help people with depression, including your GP, specialist mental health series and hospital care .

The guideline looks at depression in people aged 18 years and older, and covers mild to severe depression . It does not specifically look at: 1) depression in children 2) dysthymia 3) postnatal depression 4) seasonal affective disorder 5) people with depression who have a separate physical or mental illness. December 2004

8. NICE (see note 7) clinical guideline CG22: Anxiety: management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care. Summary: The NICE anxiety clinical guideline covers the care of adults who have panic disorder (with or without agoraphobia) or generalised anxiety disorder. The recommendations address:

1)diagnosis 2) medication 3) psychological treatments 4) self-care.

The guideline does not cover the care of people with other anxiety disorders such as post-traumatic stress disorder or obsessive compulsive disorder, which will be addressed in separate guidelines. The guideline does not cover the care of people who have both anxiety and depression. NICE has also issued a guideline on depression. December 2004

9. Quote from: Walking the happy talk Therapy for all who need it on the NHS. A network of counselling centres for the depressed and anxious. Could the government be about to take mental health seriously? Mary OʹHara reports Wednesday November 30, 2005 The Guardian (See Footnote 3): “The first concern is the question of how effective therapy is. Evidence from the National Institute for Clinical Excellence (NICE) suggests that some therapies – notably cognitive behavioural therapy (CBT), the treatment highlighted by Layard – can help reduce reliance on medication and increase long-term recovery prospects. It is one of a number of therapies available already on the NHS. It is also easier to measure the outcomes of CBT – something attractive, no doubt, to Whitehall.

10. From Richard Layard’s 2005 lecture op. cit. section on “Treatments that Work”: ‘You do not need to be lectured on that. We have drugs that will end a depressive episode within four months for 60% of sufferers. And we have therapies (and especially CBT) which will do the same as a result of a weekly session. Once the episode is over, relapse is less likely if the sufferer received CBT, unless drug therapy is continued. Thus cost arguments are not decisive as between drugs and psychotherapy, and as I have said, many people do not want drugs for the best possible reason – they want to feel in conscious control of their mood. For all these reasons the Nice guidelines on depression say that ʺcognitive-behavioural therapy should be offered, as it is of equal effectiveness to antidepressantsʺ. The Nice guidelines also cite clear evidence that even in purely economic terms these treatments would pay for themselves – ignoring altogether the gain in happiness to the patient. Yet as things are the Nice guidelines cannot be implemented, because the therapists are not available to meet the demand. So the next phase of improving our mental health services has to be based on a simple offer: ʺMentally ill people should have the choice of evidence-based psychological therapy.ʺ The Labour partyʹs last election manifesto does not say quite that but it says enough for it to be worth discussing in concrete terms how such an expansion could be achieved.’ From lecture given by Lord Layard in September 2005

11. Quoted from Lord Layard’s September 2005 lecture op.cit.

12. Samuel Brittan’s ‘On J. S. Mill, liberty and choice’ Financial Times: April 6 2006 and ‘Happiness is a fortunate by-product’ Financial Times: December 14 2006

13. For comments on the complicity of the Health Professions Council in the task of safeguarding the population, see Julia Evans ‘Comments on the Health Professions’ Council’s ‘In Focus’ issue 8, December 2006’ and published at eIpnosis the magazine for the Independent Practitioners’ Network.

14. Point made by Mary O’Hara op.cit.

15. Avner Offer, professor of economic history at Oxford University quoted by Sam Brittan op.cit.

16. Quoted in Sam Brittan op.cit. Anthony and Charles Kenny, a father and son team of philosopher and economist. ‘Life, liberty and the Pursuit of Utility’ Imprint Academic.

17. The source for this contrast is Madeleine Bunting’s ‘A word to the wise. The Danish approach to caring for children is about nurturing relationships, individuality and creativity. It’s costly, but it gets results. Can it work in Britain?’ The Guardian: Wednesday March 8 2006

18. Kieran Hatton, Head of the Centre for Social Work, Portsmouth University quoted by Madeleine Bunting op.cit.

 

Note : If links to any required text do not work, check www.LacanianWorksExchange.net. If a particular text or book remains absent, contact Julia Evans.

 

 

Julia Evans

Practicing Lacanian Psychoanalyst in Earl’s Court, London

 

Further posts:

Some Lacanian history here

Lacanian Transmission here

Of the clinic here

Translation Working Group here

Use of power here

By Sigmund Freud here

Notes on texts by Sigmund Freud here

By Jacques Lacan here

Notes on texts by Jacques Lacan here

By Julia Evans here

One comment

A far-sighted analysis of what has come to be.

by Jo Rostron on 05/06/2011 at 6:53 pm. Reply #