Tuesday, 14 October 2014

The Shock of the Real: which welfare interventions work for whom?

At the end of last week, I took part in a seminar organized in Durham by Jeremy Clarke and Nancy Cartwright concerning the connection between unemployment and mental illness and the contrast between two governmental approaches. The Department for Work and Pensions sees the cause as a moral problem of worklessness and approaches it punitively. The Department for Health sees the underlying cause as a form of illness and thus approaches it medically. This was set out less crudely in one of the briefing papers thus:

“In recent years the UK has embarked on two policies simultaneously: welfare reform and improving access to talking therapies for depression. It is widely understood that both policy problems are linked – if we are going to reduce welfare dependency we need to support claimants whose primary problem is depression; and – if we are going significantly to increase investment in therapies to treat depression we need to realize cost-savings that will also reduce the burden on welfare spending. What is not known is whether the approach favored by the Department for Work and Pensions – crudely, first get people back to work with benefit sanctions as a stick (Freud, 2007) – or the approach favored by the Department for Health – crudely, first offer them CBT with ‘happiness’ as a carrot (Layard & Clark, 2014) – is the best approach for reversing the trend: rising numbers of people with depression as the single biggest welfare claimant group who become and remain jobless (OECD, 2014).
Both policies are necessary but neither on its own will solve the problem. And if badly combined could exacerbate matters. The Treasury in any case may trump them in its determination to cut welfare spending by £30bn. Thus, the challenge for evidence-based policy making is urgent.”

A background assumption of the seminar was that it was highly likely that there were a number of causal factors interacting. The assumption – ascribed to Richard Layard – that there is a single main factor was unwarranted. Thus practical intervention would have to find some way to deal with this complexity. (Nancy Cartwright outlined some of the difficulties of justifying the application of even good RCT based evidence to particular populations in particular cases and the various ways in which complex causes interact negatively and positively.) An illustration of problems for a single, simple, medical-only approach was that typically there is a 50% fall off of those referred for IAPT services actually reaching them. Typically only 50% who went to the first session went further. And only 50% of people who complete a course of CBT are helped by it. Thus an IAPT / CBT only approach looks likely only to help 12.5%. Surely, therefore, some sort of multi-factorial approach is necessary.

Seminar participants were charged with thinking about an alternative approach which would deploy a range of ‘interventions’, starting with referral routes, the initial judgements or ‘diagnosis’ of key workers, choices for interventions and so on. Jeremy Clarke hoped it would be possible to articulate a kind of decision making model to deal with the causal complexity and thus underpin a rational process without over simplifying it. He gave an example of a model for decision making widely used by the police.

I was completely convinced by the background rationale for the seminar and of the likely complexity of the practical problem but rather less sure of the right response to it. First, as a fan of the situation specific, tacit dimension to good (clinical) judgement, I am not at all sure of the point of a decision making model. As Matthew Ratcliffe pointed out, there is a strong tradition in psychiatric diagnosis of thinking that the modern criteriological approach is only part of the story. I’m reminded of some of the things Mario Maj says about the DSM and schizophrenia (I think it carries over to depression and unemployment related misery).

One could argue that we have come to a critical point in which it is difficult to discern whether the operational approach is disclosing the intrinsic weakness of the concept of schizophrenia (showing that the schizophrenic syndrome does not have a character and can be defined only by exclusion) or whether the case of schizophrenia is bringing to light the intrinsic limitations of the operational approach (showing that this approach is unable to convey the clinical flavour of such a complex syndrome). In other terms, there may be, beyond the individual phenomena, a ‘psychological whole’ (Jaspers, 1963) in schizophrenia, that the operational approach fails to grasp, or such a psychological whole may simply be an illusion, that the operational approach unveils. [Maj 1998: 459-60]

In fact, Maj favours the former hypothesis. He argues that the DSM criteria fail to account for aspects of a proper grasp of schizophrenia: for example, the intuitive ranking of symptoms (which have equal footing in the DSM account). He suggests that there is, nevertheless, no particular danger in the use of DSM criteria by skilled, expert clinicians for whom it serves merely as a reminder of a more complex prior understanding. But there is problem in its use to encode the diagnosis for those without such an additional underlying understanding:

If the few words composing the DSM-IV definition will probably evoke, in the mind of expert clinicians, the complex picture that they have learnt to recognise along the years, the same cannot be expected for students and residents. [ibid: 460]

Maj’s criticism that the DSM criteria do not capture a proper, expert understanding of the diagnosis of schizophrenia raises the question of how or why that could be the case.

So I worry about the development of a model of decision making in this case, too. The police model may work because it lacks substantive codification. ‘Measure three times and cut once’ is good advice - a good warning to be careful - but not a piece of wood/shelf specific substantial guidance of what measuring its length correctly involves.

My sub-group was charged with thinking about a way of dealing with a multi-factorial causes in a diagnosis of the problem for particular clients. But guided by the practical experience of service provision by one of us, it seemed to me that there was a principled way of avoiding the tricky problem of trying to codify a response to complex causes. Why not, instead, take a leaf from the recovery model and ask what would need to be done – what causal intervention - to promote the conception of flourishing of each client. That could start with something like Nussbaum’s Aristotle inspired list of the universal aspects of human flourishing even if each had to be realized in specific ways. The complexity of retrospective causal reasoning could be replaced by still complex but surely clearer prospective causal reasoning. 

JC asked whether we thought one could then go back to look for the historic causes of a client’s state. But although one might be able to, one virtue of a recovery orientated approach is that seems merely of academic interest.

Freud, D. (2007). Reducing dependency, increasing opportunity: options for the future of welfare to work: An independent report to the Department for Work and Pensions.
Layard, R. & Clark, D.M. (2014). Thrive: The Power of Evidence-Based Psychological Therapies London: Allen Lane.
Maj, M. (1998) ‘Critique of the DSM-IV operational diagnostic criteria for schizophrenia’ The British Journal of Psychiatry 172: 458-460
OECD: Singh, S. & Prinz, C. (2014). Mental Health and Work: United Kingdom. OECD Publishing.