Jeremy Bentham’s “greatest good of the greatest number”, has been critiqued before. For Marx, a productive inquiry had to investigate what sorts of things are good for people — that is, what are our true natures, alienated under capitalism. Second, Marx argues that human nature is dynamic, so the concept of a single utility for all humans is one-dimensional and not useful [8
]. Interestingly Pope John Paul 2 had a similar view "Utilitarianism is a civilization of production and of use, a civilization of things and not of persons, a civilization in which persons are used in the same way as things are used” [9
]. We also have concerns over Layard’s adoption of Benthamite principles. A major feature of his proposals has been to encourage the availability of psychological therapies as a way of resolving unhappiness and improving economic efficiency. As a result, largely of his influence, considerable NHS investment has been committed to providing an unprecedented increase in available, publically funded therapists in the form of the Improving Access to Psychological Therapies (IAPTs) programme. The initiative has been based upon a pair of related assumptions: first, that unhappiness and disability is associated with mental health problems and can be viewed as the result of one or other of a set of discrete conditions and second, that appropriate psychological therapy can be an effective way of treating such conditions, and therefore reversing unhappiness and alleviating related disability.
The IAPTs programme began in 2006 with demonstration sites in Doncaster and Newham, focusing on improving access to psychological therapies services for adults of working age. In 2007, the Department of Health published an implementation plan which committed the government to £33 million in 2008/09, a further £70 million in 2009/10 and a further £70 million in 2010/11 [9
]. This money was to be used by NHS commissioning authorities to fund distinct provider organisations offering unprecedented access to psychological treatments. By 31 March 2011, 142 of the 151 Primary Care Trusts in England had a service from this programme in at least part of their area and just over 50 per cent of the adult population had access. 3,660 new cognitive behavioural therapy workers had been trained, and over 600,000 people started treatment. Over 350,000 completed it, over 120,000 moved to recovery and over 23,000 came off sick pay or benefits (between October 2008 and 31 March 2011 [10
]. This final claim reflects an important feature of the rhetoric encouraging the Exchequer to make such a commitment. In 2004 Layard had been able to claim that “there are now more mentally ill people drawing incapacity benefits than there are unemployed people on Jobseeker’s Allowance” [1
]. In 2007 Oxford Economics reported that “in 2006 there were nearly one million recipients of Incapacity Benefit due to mental and behavioural disorders. This is 40% of total Incapacity Benefit recipients. This is similar to the total number of unemployment benefits claims in the UK [11
]. On the basis of such figures and results from the IAPT Demonstration sites, it was estimated that the programme could save the NHS up to £272million and the wider public sector would benefit by more than £700 million: a good return on an initial investment of £173 million. The proposal suggested that a programme of improved access to psychological therapies would result in considerable savings on welfare benefits costs and, given the reasonable assumption that unresolved mental health difficulties are a significant source of unhappiness, it would also make a considerable contribution to the “greatest good of the greatest number”.
Unfortunately this promise is not being realised. Five years after initiation of the IAPT programme, mental health difficulties remain one of the most common reasons for sickness-related welfare benefits [12
] and the rate at which NHS practitioners are prescribing anti-depressants has continued its inexorable rise. In England, some 25 million prescriptions for a course of antidepressants were issued in 2000. That figure had risen to nearly 40 million by 2009 [13
], and it has continued to rise at a rate of some 10% per annum [14
]. What is more the percentage of incapacity Benefit claimants with mental health problems has not decreased either [15
]. At these levels of analysis, making therapy widely available does not appear to be making a significant impact upon wellbeing. Therefore, it could be argued that Layard’s assumptions: that unhappiness and disability associated with mental health problems can be viewed as the result of one or other set of discrete conditions, and that appropriate psychological therapy can be an effective way of treating the condition and therefore reversing unhappiness and alleviating related disability, are flawed. We believe that they are based upon a mistaken oversimplification of the relationships between mental health difficulties, therapy, disability and happiness which deserves clarification.
A distinctly different field illustrates this complexity. More than a century has passed since first publication of The Secret Garden by Frances Burnett in 1911 [16
]. The novel illustrates the consequences of assumptions of disability and its limitations, and only indirect associations between rigid medical and therapeutic conventions and expectations, and personal outcome. Colin had been assumed a cripple and consigned to a life of dependency and unhappiness. Relationship, care, curiosity and a certain amount of ingenuity enable his redemption, or in contemporary language, recovery. The intervening century has seen great strides in change towards those with significant physical disability, culminating in the celebration of triumph over disability which was the theme of the London Para-Olympics of 2012. Although many of those who took part, and those many more who live fulfilled, happy and flourishing lives despite significant physical disability may welcome and benefit from professional healthcare support; none have achieved their recovery exclusively because of it. Most importantly, their ability to achieve and flourish has not been dependent upon, or waited for, effective “treatment” of their “illness”. They have achieved autonomy and a measure of happiness in spite of their disability. The New Economics Foundation have identified 5 alternative pathways to wellbeing – which are, `Connect; Be Active; Take Notice; Keep Learning and Give’ which seem far more relevant to improving people’s lives than the actions of therapists [17
]. These pathways are also used in the mental health recovery process by use of music, dance and art as forms of therapy.
The journey taken by the Disability Rights Movement across the twentieth century is one that could be usefully mirrored by a similar approach to psychological difficulties. Important stages on that journey have been normalisation, dissociation of the assumption that one form of disability implies global disability, and assimilation of the fact that recovery of autonomy and a measure of happiness are not entirely dependent upon professional input. All of these are poorly developed in the mental health field, and as result there is a large and steadily growing number of unnecessarily disabled and unhappy individuals who are trapped by their assumed status, in the same way as Burnett’s Colin is trapped at the beginning of the story.
Mental health difficulties are troubling, not only to those suffering but also to those around them. Distress, despair, fear, confusion or anxiety provoking behaviour all evoke strong feelings amongst those witnessing them, and sometimes people in such a state do behave in a dangerous or reprehensible way. Therefore, it is not surprising, that there is a long and continuous history of social distancing and institutional sanction in response [18
]. Indeed one of Jesus’ earlier miracles was to cast out demons from a socially marginalised madman. Confinement in one context or another was standard practice until the middle of the twentieth century, and the power of a label intimating a mental health difficulty remains considerable. Stigma and other forms of social exclusion are commonplace. Amongst these are adverse experiences in the workplace, social settings, relationships, health-care facilities and at the hands of the police and judiciary, in ways that would now be considered unthinkable if directed towards someone with paraplegia, or, perhaps even more strikingly, towards someone from a racial minority [20
]. Normalisation and an assumption of wider capability remain a distant aspiration for many who have become identified as one with a “mental health problem”, even though other previously marginalised groupings now expect to enjoy them.
The anxiety provoked by a particularly distressing, threatening or seemingly self-destructive person also leads to a search for expert help. Most who come into contact with mental health professionals and acquire the identity of someone with a mental health difficulty will have done so via a route which began with troubling behaviour that had caused others sufficient concern to seek professional help on their behalf, or oblige them to seek it [21
]. The point at which understandable emotional distress, such as bereavement or romantic disappointment becomes “mental illness” is commonly determined not so much by the form it has taken, but by the extent to which the sufferer’s immediate support network is able to accommodate the resulting difficulties. Once health care professionals are engaged in assisting with a distressed or confused individual it is but a short step for them to take before being conferred the identity of one with a mental health problem, and the labelling that goes with it. As happened in response to Colin’s assumed spinal disability, the experience of a troubled person who has sought or who has felt obliged to seek professional help is frequently one of becoming unjustifiably identified as incompetent, untrustworthy, a source of shame and dependent upon patronising support. This commonly occurs quite independently of the nature of their difficulties. Instead it is a direct reflection of common, prevailing discourse concerning strong emotional or psychological reactions.
Many of these consequences can be viewed as a result of applying or assuming the classic sick role framework [22
]. The “patient” is incapacitated in a way that may benefit from expert attention, they are relieved of responsibility but lose autonomy, they are obliged to submit to treatment, and the situation is considered to be short term. Williams [23
] has provided a useful commentary upon the strengths and weaknesses of this classic description when applied to conditions that do not conform to this stereotype and Middleton [24
] a comment upon the weaknesses of applying it to mental health difficulties. Central to both of these is the expectation that professional input may be productive and has something to offer that other sources of support do not. The authority to engage the constraints of the sick role framework is only legitimate if doing so will lead to the beneficial application of specialised knowledge and skills. When this does not apply, the constraints of the sick role framework can bring more harm than good, particularly, as we have argued, in the case of mental health difficulties. What might be learned from the journey taken by the Disability Rights Movement through the twentieth century is that many with conditions that were not going to alter significantly as a result of specialised, professional intervention, had more to gain by eschewing the sick role than they had by embracing it. What is also becoming apparent is that the same is true in relation to mental health difficulties. Despite half a century of intensive biomedical research, contemporary medical treatments for depression and psychosis are no more effective than their 1950s predecessors. There is still no understanding of why they work when they do, and many now attribute much of their efficacy to an enhanced placebo effect [25
]. Put under the spotlight of extensive review and meta-analysis, the efficacy of psychological treatments appears to reflect more the ability of the therapist to form a supportive alliance with their client, than it does any specific technical skill they might bring to the consulting room [26
]. When someone with mental health difficulties does respond to treatment it is probably more as a result of a healing relationship, (which may have included the administration of a medicine they had faith in), than because the health care professional did something “expert”.
Layard’s therapeutic approach fails to take this complexity into account, and as a result could be causing unintended harm. By conceptualising unhappiness as something that a therapist can alleviate; he frames it as something amenable to professional intervention, and in so doing (perhaps unwittingly) consigns the client to certain aspects of the sick role, which, as we have outlined, can have particularly adverse consequences in a mental health setting. There is no known data that might link this proposition to the lack of impact IAPT has had upon sickness benefit claims and antidepressant prescription rates, but the presence of this facility, framed as it is, does confirm the view that emotional difficulties, and therefore by association, unhappiness, are an illness to be treated by professionals. That is not a position that would generate many successful para-athletes.
Finally, Layard’s position, that happiness is something that can be achieved by instrumental professional intervention is emphasised by his choice of psychotherapeutic technique. IAPT provider organisations have been explicitly instructed to focus upon making the available therapy Cognitive Behavioural Therapy (CBT). This is a form of psychotherapy pioneered by Aaron Beck in the 1960s and could be (crudely) described as a form of internal monologue. By teaching people to identify their negative thoughts and replace them with positive ones, cognitive therapists try to enable people to master their emotions. The basic concept is not new. Aristotle first pointed out that emotions both influence and are influenced by the thoughts we have. By eliminating thoughts that promote bad moods and to encourage thoughts that foster pleasant emotions, people gain a measure of control over their emotional state and lift themselves out of depression or anxiety by will power. Cognitive therapy teaches specific techniques for identifying and removing negative thoughts. When used by a trained therapist it can be as effective in treating depression as drugs such as Prozac. However we wonder whether most of the efficacy attributed to CBT is not due to the advice of the therapist, but more the expression of empathy that the sufferer experiences. Historically there may have been political reasons for Layard’s expressing an interest in CBT. By virtue of the very fact that it is a particularly instrumental approach to psychological therapy, it is also particularly amenable to evaluation by conventional medical-style, clinical trials. An idealised CBT therapist addresses identifiable difficulties the client is suffering using an identifiable technique, and so it is notionally possible to measure the extent to which application of the technique has led to desirable change. Although, as we will argue, this is commonly a gross oversimplification of processes associated with psychological change, it is a seductive framework which appeals to those seeking cost-effectiveness from public services and those wedded to the ideology of evidence based medicine. These financial and bureaucratic considerations have undoubtedly influenced the form IAPT has been obliged to take, and as a result obscured the notion that empathic relationships are more important to the promotion of happiness than technological interventions. This is something we will develop in the following section.