mental health | ukwatch.net

Melancholic Nation

eddie — Sat, 18 Oct 2008 22:57:08 +0000

A distinctive feature of much of the left in Britain, going right back to the early Fabians, is the way in which its view of good and bad has focused upon material goods and conditions rather than on social relations. For the socialist left this found expression in demands for greater equality, and in particular greater access to material goods such as housing, health care and income. For the Labour right, especially in recent years, it has strongly coloured the managerialism of the volume-indicator-obsessed Blair/Brown regime. Here progress has become synonymous with the achievement of a range of measurable targets, largely but not exclusively geared to economic competitiveness. Both left and right have privileged quantity over quality, material progress over the quality of social relations.

This was something that Richard Titmuss, one of the key thinkers behind the post-war welfare state, was careful not to do. For Titmuss, social policy was about what he called ‘social growth’, something that lay precisely in the quality of social relations, whose ‘indicators cannot be measured, cannot be quantified, but relate to the texture of relationships between human beings’.[1] Unfortunately, this relational view of social well-being became eclipsed by generations of public sector economists whose view of the human being was essentially one of the rational, autonomous, interest-maximising individual. In the public sphere nowadays, as the saying goes, what counts is what can be counted. My argument in this essay is that we need to return to positions that place human relationships at the centre of politics.

There has always been a strand in British socialism, from at least the time of Edward Carpenter, that connected social transformation with change in the nature of social relations; this theme was taken up again in the 1960s and 1970s, by feminists, anarchists and libertarian socialists. From this perspective, socialism needs to hold up a picture of a different future, of a society in which human relations are qualitatively transformed for the better: one in which relations between employers and workers, men and women, intimates and strangers, old and young, are based upon a set of values and principles that are radically different to those that pertain today. This strand needs to be reasserted in the face of the current impoverishment of the political and cultural spheres.

Social suffering, CBT and managerialism

In recent years the shortcomings of the conventional economistic approach have become increasingly apparent. First, a growing body of evidence, drawn largely from international survey research, has demonstrated that the massive growth in GDP in western democracies since the Second World War has not been accompanied by any appreciable increase in happiness.[2] The evidence seems to suggest that it is simply not true that the more you have the happier you are. Second, psychiatric morbidity rates indicate that the incidence of mental illnesses such as clinical depression and schizophrenia, and of self-harming behaviours such as alcohol and drug abuse, has increased signifi cantly in recent decades.[3] Moreover there is some evidence to suggest that this may be more pronounced in societies which have embraced neoliberalism.[4]

Richard Layard, an influential contributor to the happiness debate, has recently pointed to the economic costs incurred by the 1 in 5 adults who suffer from mental illness at some time in their lives (perhaps recognising that this is the best way to gain the attention of government ministers).[5] Given the traditionally shameful levels of NHS spending on mental illness, anything which seeks to highlight this suffering, and the absence of even a half-decent set of services and treatment programmes to deal with it, is to be welcomed. However, Layard’s report suffers from some significant weaknesses. First, he ignores decades of accumulated evidence that link the incidence of virtually all forms of mental illness to social causes – social exclusion and marginalisation. Second, he prescribes as a remedy a massive programme of Cognitive Behavioural Therapy, to be delivered from a network of Psychological Treatment Centres: this is likely to serve simply to sustain and reproduce the very social relations that contributed to the lack of well-being in the first place.

The relationship between social inequality, stress and lack of well-being has been documented for over three decades now in journals such as the Journal of Health and Social Behaviour. Not only do poverty and social marginalisation increase the scale and intensity of stress-inducing life events and incidents; they also decrease the social resources – such as the presence of others in whom one can confide – that enable people to cope with such stressful environments. In the last couple of years I have started to use the term ‘social suffering’ – coined by the French sociologist Pierre Bourdieu – as a way of examining how poverty and inequality get inside the soul and eat away at the human spirit. Social suffering draws our attention to the shame, humiliation, despair and frustration that make up the day-to-day experiences of those who are not only poor, but are also made to feel responsible for their own misfortune; to the suffering of those who are made to feel stupid because of their skin colour or accent; of those who feel they are ‘losers’, where being a loser means that you are ‘sad’, inadequate, something to be pitied. Social suffering is not just about lack of respect and lack of recognition; it is about disrespect and misrecognition; it’s about the ways in which one class or cultural group preserves its own (fragile) sense of superior identity by denigrating another group. Social suffering also draws our attention to what happens when those who suffer lack a political explanation for their experience, and thus embody it in stress-related illnesses; project it onto others (for instance through racism and homophobia); or enact it by ‘being hard’, or by demanding recognition through what we now call ‘anti social behaviour’.

By adding the ‘social’ prefix to ‘suffering’ our attention is drawn to the way in which the absence of well-being is linked to structural inequalities (this is not the same thing as identifying happiness with material possessions; rather, it is to recognise the psychical consequences of such inequality). As Richard Titmuss once put it, poverty is the price some people pay for others’ social progress. By ignoring the social patterning of suffering, the Layard Report individualises mental illness: he construes it as the outcome of a generalised social malaise, which then falls haphazardly upon all of society. It follows that Layard’s prescription is necessarily an individualised one. The widening structural inequalities which have accompanied Britain’s neoliberal trajectory over the last three decades are left unquestioned; indeed Layard’s prescription is specifi cally designed to be incorporated within the disciplinary framework of Labour’s ‘welfare to work’ agenda. He makes a direct link between improved access to behavioural therapies and getting people off incapacity benefits and back to work, and argues that, even in the very short term, the costs involved in providing the new services will be more than offset by the savings to be gained by getting people off benefits and back to work. Well-being is now seen as a goal which can be measured, quantified and managed.

Cognitive Behavioural Therapy is a ‘triumph’ of one of the fastest growing and most powerful professions in the world today. Represented, regulated and policed in the UK by the British Psychological Society, modern psychology is dominated by positivist and evidence-based models of human functioning, which are almost tailor-made to fit the managerialist culture of New Labour. This is not a reflexive profession in any way sceptical of its own claims to expertise, or curious about how its practices are situated in the wider power relations of society. Moreover, its positivism has frequently led to a lack of interest in human experience (which is often viewed as an intangible and unmeasurable epiphenomenon); and indeed, when the profession has become interested, it has always resorted to proxies for human experience that can be measured – specifically self-reports. The ‘new science’ of happiness studies that is presently pouring out of psychology departments in North American universities assumes this form. For instance, the Character Strengths and Virtues project of Martin Seligman and his colleagues is creating a battery of selfreport questionnaires designed to assess respondent’s psychological well-being.[6] I’m not saying that such projects have no value – they can and do yield some important insights, and offer an antidote to the preoccupation with pathology, dysfunction and illness that has dominated psychiatry. But the use of these proxy measures inevitably reduces and simplifies human experience.

Cognitive Behavioural Therapy exemplifies this process. When as a therapist I work with someone who is acutely depressed, or who is suffering from panic attacks, I am soon immersed in the incredible complexity of human experience. For example, there may be intricate and subtle connections between the depressed part of the person and a rather triumphant and morally superior part; similarly, many people I see are constantly caught between a desperate desire for closeness and an absolute terror of the same thing. In the wrong hands CBT reduces this complexity of experience to its purely cognitive dimensions, as if depression was simply a matter of being stuck in repeated patterns of maladaptive thoughts which then have self-fulfilling consequences (‘I think I’m a loser, losers don’t pass their exams, therefore it follows that I will fail my exam’). The whole person is reduced to a set of operationalisable ‘problems’, which are sustained by maladaptive personal beliefs; thus, reframing these beliefs and setting measurable positive goals can set in motion more virtuous belief/action/emotion cycles. This kind of ‘quick fix’ can and does make a real difference to the lives of some individuals, but it must not be seen as the only available alternative to psychotropic drugs (the incontrovertible evidence-base for which seems to have evaporated recently).

CBT fits snugly into Labour’s managerialist vision of welfare, which is informed by a phobia about all forms of dependency, and sees human experience as something to be acted upon through prescriptive interventions, rather than something to be listened to, respected and understood. The managerialisation of welfare has led to a situation in which the amount of one-to-one contact between clients/service users and professionals has been systematically reduced – on the ward, in the classroom, between offender and probation officer, client and social worker, troubled adolescent and youth worker. Professionals are consumed by writing up care plans or lesson plans, dreaming up ‘deliverables’ in ever more bids for new contracts or new initiatives, and completing monitoring returns and ticking off ‘outcome measures’. And any time they have left over from this for face-to-face work is itself often governed by targets, tests and treatment programmes that are interposed between them and their ‘welfare subjects’ – who are now recast as the objects of welfare interventions. This is a million miles away from an ethic of care. Care takes time, and time means money; care does not lead to predictable outcomes – because humans are not predictable beings; care is exacting and exhausting. But this is why it is also enriching, both to the giver and receiver. (In our own recent research we came to realise that for many public service workers care is inseparable from social justice: workers care about what they do because they want to make a difference. In particular, those who work with the poorest and most marginalised in society often embody what we called an ‘angry compassion’, in which the ethics of care and justice were fused.[7])

The symptoms of melancholia

Care, respect and solidarity are not just about the principles which should underline public welfare, as Fiona Williams argued in her article in Soundings 30. They are also about how each of us leads our lives, about the kind of society we want. The evidence that economic growth does not produce more human happiness should be seen as providing excellent ammunition for those who argue that global warming can only be tackled effectively by some kind of limit on economic growth. But for many, a green future seems austere and unattractive – something people would only turn to if pushed by fear of catastrophe. It follows that the task for the green left is to put forward a convincing vision of a future that combines lower economic growth and increased human happiness – that is, one which decouples human flourishing from material abundance.

A starting point is to understand that, beyond a certain level of economic scarcity, there is a direct relationship between deterioration in the quality of a society’s social relations and an increase in its preoccupation with materialistic sources of happiness. The less we invest in each other, the more we invest in material goods and services. Studies of autistic children indicate that they often cling to material objects, often hard and shiny ones. It’s as if the object becomes a substitute for the sense of human relatedness that would otherwise hold them together. Perhaps consumer objects increasingly function in this way, not so much as sublimations of desire but as items essential to our going-on-being, any threat to which produces a sense of panic. I have come to believe that anxiety saturates the pores of wealthy post-scarcity societies such as ours, constituting a particular ‘structure of feeling’, to use a term from Raymond Williams.

This is an anxiety with many sources. In post-scarcity societies citizens are no longer consumed by the struggle for physical survival, and questions of identity and recognition become more central. The individualisation of these struggles becomes manifest in the ‘problems of being’ – of the borderline personality, of self-harmers, of the millions now stuck in various addictions (including addictive consumerism), or persecuted by fears about their masculinity, body-image, and so on. These problems of ‘psychical survival’ (as Christopher Lasch once put it) are ripe for exploitation by advertising, marketing and the lifestyle media, and consumption becomes more about the alleviation of anxiety than the pursuit of pleasure. Then there are the disrupting effects of the constantly accelerating pace of economic and social change, made worse under neoliberal governments such as those in Britain and the USA, which dismantle secure labour markets and welfare safety nets and seek to strip away the regulation which might otherwise offer citizens some protection. There are also anxieties generated by the proliferation of new forms of risk, including those, like genetic engineering, consequential to technological and scientific innovations, and those that emanate from the panarchy of global security and financial systems, with their constant threat of chaos and catastrophe.

Some anxieties are global, some are more specific to particular forms of governance such as neoliberalism, and yet others may be unique to the particular historical circumstances of a nation. What might be the particular set of historical circumstances that have contributed to our own uniquely intense social malaise? My belief is that it may have something to do with the slow but seemingly inexorable economic decline of Britain, a decline concealed during the last decade by the credit bubble and turbo-capitalism. We are a country haunted by loss and decline – the loss of empire that Paul Gilroy has commented on, and the loss of our status as a world power both militarily and economically. Britain is also haunted by the loss of community and class solidarity, the loss of ‘proper jobs’ and manufacture, and the loss of respect and decency. Of course many of these things exist in other countries too, but Britain was once a hegemonic world power, the first of the modern era. I wonder if we need a new development term that could be applied to a country whose development has now been arrested. Under Labour, there seemed to be one last throw to pretend things were otherwise, as Blair strode the world stage and Brown presided over an apparent economic miracle. But in cities and towns throughout the country, particularly beyond the mania of the capital, people have been sensing this loss for some time, without being able to give words to it.

Long ago Freud gave us a word for this – a loss which cannot be thought about. He called it melancholia. A melancholic is stuck in an endless cycle of grievance and self-reproach, irritability and despair. Perhaps this is what it means to be British today. According to Madeleine Bunting, ‘there is an increasing perception that we have become a nasty country – aggressive, quick to judge or humiliate, and profoundly competitive’ (_Guardian_ commentisfree, 19.2.07). The UNICEF Report found that little more than 40 per cent of our 11 to 15 year olds found their peers ‘kind and helpful’, the lowest score of all the richer countries.

So, if Britain were on the couch today what would follow from this diagnosis? Well, perhaps the first task would be to get the patient to face the loss, and abandon manic attempts to assert the opposite (further military adventures, the idea that we can go it alone by balancing precariously somewhere in between the USA and Europe, perhaps even the idea that we can host the Olympic Games). Second, we 115 would try and help the patient understand that what it imagines to be progress is in fact largely an illusion. This means coming to terms with the idea that, except in a very few areas, such as the cultural industries, we have ceased to be economically creative; that areas of intelligent production and manufacture in Britain are few; that we invest significantly less in R&D than nearly all of our competitors; and that the one area – banking and financial services – where there seemed to be growth and innovation was, appropriately enough, a form of parasitic rather than productive capital. Thirdly, applying a bit of CBT, we would show the patient how some of its habits of mind contribute to its own self destruction. Only recently, for example, Robin Alexander, who leads the inquiry into Britain’s primary education, bemoaned the way in which adult society rams the cult of celebrity down our children’s throats. There are also the impossible norms we impose on ourselves of masculine hardness and feminine thinness – and the whole cultural denigration of losers, chavs, feral kids, etc. Fourth, and more positively, we would indicate to the patient that their belief that they lack the internal resources to overcome the loss is one of the characteristics of depressive anxiety, and that they in fact have plenty of resources even though in phantasy they believe that they are running on empty. Britain has potentially more renewable resources (particularly wave, wind and tide) than almost any country of comparable size in the world. It is also a mongrel nation, the result of successive invasions and migrations stretching back nearly two thousand years, and, as we all know, mongrels happen to be far more resilient than pedigrees. Britain has been reasonably good at adapting to change: reactionary forms of populism and fascism have been minority responses, and whilst we complain and moan we also embrace strangers and imitate them – the vitality of British creative industries today is in no small part a result of this. Fifth, but by no means last, we would encourage the patient to rage at the source of their loss, even if the source, as in bereavement, was nature itself. For us, at this particular point in time, I think this means we must get back in touch with our anger, particularly anger at our parasitic and spineless ruling elites – which now, tragically, include much of the party that once stood for labour. The problem is that melancholics turn their anger upon themselves – hence Madeleine Bunting’s comment about the ‘nasty country’.

To speak of some kind of national psyche in this way is of course to engage in a gross over-simplification. What I am offering here is no more than a way of thinking, a thought experiment if you like. To pursue the experiment a little further, we can see how melancholics have a particular ‘problem of being’, the problem being an inability to live in the present. Unable to think realistically about and accept their loss, distorted fragments of the past continuously return to haunt them. Like a melancholic, Britain is stuck in a process of arrested development. What we need now is a new vision. A vision, like that of Richard Titmuss, of social development, concerned with the texture of relationships between human beings, and between human beings and the natural world.

Notes

1. R. Titmuss, Social Policy: An Introduction, George Allen & Unwin 1974.

2. R. Layard, Happiness: Lessons from a New Science, Penguin 2005.

3. M. Rutter & D. Smith (eds), Psychosocial Disorders in Young People: Time Trends and their Causes, Russell Sage Foundation 1995.

4. See for example Unicef’s 2007 Child Poverty in Perspective: An Overview of Child Well-being in Rich Countries, in which Britain and the US scored worst.

5. The Centre for Economic Performance, The Depression Report: A New Deal for Depression and Anxiety Disorders, London School of Economics and Political Science 2006.
6. M. Seligman & T. Steen, ‘Positive Psychology Progress’, American Psychologist, July-August 2005.

7. P. Hoggett, M. Mayo & C. Miller, The Dilemmas of Development Work, Policy Press, 2008 forthcoming.

NHS Whistleblower speaks out

tim — Tue, 27 May 2008 12:35:59 +0000

Senior mental health nurse Karen Reissmann was sacked last year after being found guilty of gross misconduct by Manchester Mental Health and Social Care Trust for speaking out against NHS cuts. Tom Haines-Doran catches up with her to ask about the latest in the campaign to have her reinstated.

Where are you at with the campaign to get you reinstated?

The campaign started when I was first suspended [June 2007] for bringing the Trust into disrepute. We had 700 people on strike for 14 days of action, followed by further action in November. My appeal was turned down and is now going to an employment tribunal. MPs will be asked to sign Early Day Motion 443 which calls for my reinstatement and there may be further days of strike action. We’re trying to persuade Alan Johnson to sign the motion. It’s ironic that I am being supported by Stephen O’Brien the Shadow Minister for Health, and not his opposite in the Labour government.

Is the return to work something that can keep the campaign alive?

The campaign is not going to fizzle out. I have received an incredible amount support from my colleagues and many others. People are worried about the Health Service; there is a fear of speaking out and a number of health workers are saying they’re glad that I did. One of the questions I was asked by the management was ‘what loyalty do you have to our organisation?’ I said I have plenty of loyalty to the patients, but what they wanted to know was what corporate loyalty I had to the individual trust. The aim of my suspension was to break our union, but now we have seven more Unison stewards than at the start. The fight to stop staff cuts in our service, the campaign that led to my suspension in the first place, has been won – the managers have conceded they will keep the original staffing levels.

During the campaign you brought in many activists from the Trade Union movement and the left. How was this achieved?

One of the first things we recognised was that we needed to mobilise political pressure from the outside. There was a deliberate strategy of including trade unionists and service user groups and networks. We have fought to get users heard. They overcame the stigma of mental illness and have been articulate in their defence of the service. We made an effort to write to every Unison branch to pass information on and particularly helpful were the CWU and RMT unions who made donations to the campaign and invited us to speak at their meetings.

Regarding the NHS in general what would you say are the key issues?

One of the key problems is the tendering process. It identifies areas of work, for example, hip replacement operations and parcels them off. The idea is to create a competitive market within the Health Service. South Manchester Psychiatric Unit is run by a Private Finance Initiative that uses a private contractor to clean the ward and it costs the NHS four times what it did when the work was in-house. Also more of the work is target-driven.

As an NHS employee how would you say working conditions have changed during your career?

When I started 25 years ago we provided a service to patients. Now targets are the be all and end all and we can no longer prioritise in terms of need. On the other hand 25 years ago nurses’ wages were worse because they were less unionised. But with this slight improvement in wages has come a greater workload. The pace is unrelenting. For example occupancy rates are much higher. Now there are 20 beds for 24 or 25 patients with occupancy rates at 120 per cent to 130 per cent. This leads to stress amongst the staff and patients.

Would you recommend a job in the Health Service to people?

I love the work and the people I work with are fantastic. If you do a job that is helpful to others it is generally more satisfying. But more time is spent filling out forms and battling bureaucracy. I would say ‘do it’ but you’ll have to fight your corner.

Michael Moore’s documentary Sicko gave an overview of what a privatised health system looks like in the US, is that something that could happen here?

Nothing is automatic about the NHS. People who fought in the Second World War weren’t prepared to go back to the provisions available in the 1930s. Unlike the Tories, this government dresses up privatisation in complicated proposals. They don’t say they will privatise it but they are in effect creating a market – they’re saying that 15 per cent of the Health Service should be outside the NHS. Not only has the NHS management chosen private operators to run aspects of the service but now private companies are set up to do this on their behalf.

Selfish capitalism is bad for our mental health

Tim Holmes — Fri, 04 Jan 2008 11:32:06 +0000

By far the most significant consequence of “selfish capitalism” (Thatch/Blatcherism) has been a startling increase in the incidence of mental illness in both children and adults since the 1970s. As I report in my book, The Selfish Capitalist – Origins of Affluenza, World Health Organisation and nationally representative studies in the United States, Britain and Australia, reveal that it almost doubled between the early 80s and the turn of the century. These increases are very unlikely to be due to greater preparedness to acknowledge distress – the psychobabbling therapy culture was already established.

Add to this the astonishing fact that citizens of Selfish Capitalist, English-speaking nations (which tend to be one and the same) are twice as likely to suffer mental illness as those from mainland western Europe, which is largely Unselfish Capitalist in its political economy. An average 23% of Americans, Britons, Australians, New Zealanders and Canadians suffered in the last 12 months, but only 11.5% of Germans, Italians, French, Belgians, Spaniards and Dutch. The message could not be clearer. Selfish Capitalism, much more than genes, is extremely bad for your mental health. But why is it so toxic?

Readers of this newspaper will need little reminding that Selfish Capitalism has massively increased the wealth of the wealthy, robbing the average earner to give to the rich. There was no “trickle-down effect” after all.

The real wage of the average English-speaking person has remained the same – or, in the case of the US, decreased – since the 1970s. By more than halving the taxes of the richest and transferring the burden to the general population, Margaret Thatcher reinstated the rich’s capital wealth after three postwar decades in which they had steadily become poorer.

Although I risk you glazing over at these statistics, it’s worth remembering that the top 1% of British earners have doubled their share of the national income since 1982, from 6.5% to 13%, FTSE 100 chief executives now earning 133 times more than the average wage (against 20 times in 1980); and under Brown’s chancellorship the richest 0.3% nobbled over half of all liquid assets (cash, instantly accessible income), increasing their share by 79% during the last five years.

In itself, this economic inequality does not cause mental illness. WHO studies show that some very inequitable developing nations, like Nigeria and China, also have the lowest prevalence of mental illness. Furthermore, inequity may be much greater in the English-speaking world today, but it is far less than it was at the end of the 19th century. While we have no way of knowing for sure, it is very possible that mental illness was nowhere near as widespread in, for instance, the US or Britain of that time.

What does the damage is the combination of inequality with the widespread relative materialism of Affluenza – placing a high value on money, possessions, appearances and fame when you already have enough income to meet your fundamental psychological needs. Survival materialism is healthy. If you need money for medicine or to buy a house, becoming very concerned about getting them does not make you mentally ill.

But Selfish Capitalism stokes up relative materialism: unrealistic aspirations and the expectation that they can be fulfilled. It does so to stimulate consumerism in order to increase profits and promote short-term economic growth. Indeed, I maintain that high levels of mental illness are essential to Selfish Capitalism, because needy, miserable people make greedy consumers and can be more easily suckered into perfectionist, competitive workaholism.

With overstimulated aspirations and expectations, the entrepreneurial fantasy society fosters the delusion that anyone can be Alan Sugar or Bill Gates, never mind that the actual likelihood of this occurring has diminished since the 1970s. A Briton turning 20 in 1978 was more likely than one doing so in 1990 to achieve upward mobility through education. Nonetheless, in the Big Brother/ It Could Be You society, great swaths of the population believe they can become rich and famous, and that it is highly desirable. This is most damaging of all – the ideology that material affluence is the key to fulfilment and open to anyone willing to work hard enough. If you don’t succeed, there is only one person to blame – never mind that it couldn’t be clearer that it’s the system’s fault, not yours.

Depressed or anxious, you work ever harder. Or maybe you collapse and join the sickness benefit queue, leaving it to people shipped in to do the low-paid jobs that society has taught you are too demeaning – let alone the unpaid ones, like looking after children or elderly parents, which are beneath contempt in the Nouveau Labour liturgy.

There is much tearing of hair across the media and advocacy of nose-pegging on these pages of the “grin and bear it” variety. In fact, there is an alternative. We desperately need – and before long, I predict we will get – a passionate, charismatic, probably female leader who advocates the Unselfish Capitalism of our neighbours. The pitch is simple. Not only would reduced consumerism and greater equality make us more ecologically sustainable, it would halve the prevalence of mental illness within a generation.

· Oliver James is discussing Selfish Capitalism with Will Self, Madeleine Bunting and Stewart Wallis in three London seminars this month www.selfishcapitalist.com

The Hidden Costs of Going Back to Work

Tim Holmes — Sat, 22 Dec 2007 09:04:01 +0000

So once again the Government has announced plans to overhaul the benefits system to get people on Incapacity Benefit (IB) back to work, this time through a move to “employment and support allowance” which positively focuses on “what people can do rather than what they can’t”. But despite all the recent hoo haa about the 50 people with acne and those with nail disorders and the 400 people “too fat” to work, the group the Department of Work and Pensions really want to get off their books is people with mental health problems.

A glance at those books tells you why: mental health problems are costing the Government £2 billion a year in Incapacity Benefit, a hefty proportion of the total £12.5 billion they pay out.

It’s not that those with mental health problems are shirking, campaigners insist. “People who have experienced severe mental illness have the highest want-to-work rate of any disability group, but have the lowest in-work rate,” says Jane Harris, head of campaigns at Rethink. She points out there are two likely hurdles: the unwillingness of employers to take on people with mental health problems; and the hidden costs of going back to work.

In trying to gain support for the new changes to IB, government has been briefing that getting off benefits and back to work will swell your bank account as well as increase your sense of wellbeing. But we are unable to look at government profiling to see how they have worked these figures out and for whom it applies.

Other government figures are freely available to look at.

Harris says that though government publishes annual tax benefit model tables that show the relationship between incremental wage increases for lone parents, for example, they don’t do this for people with disabilities.

We spoke to the Department of Work and Pensions (DWP). They told us that to publish model tables for people on disability benefits would be too complicated because of the number of scenarios that would need plotting.

The published tax benefit model illustrates the effect on net income of gross income, rent, marital status, number of children, tax credits, tax and National Insurance Contributions, they explained. “A model that looked at disability benefits would be a very complex table as there are so many factors involved in working out an individuals’ entitlement. For example, not only would it have to take into account the information that is contained in the current model but it would also need additional information such as: type of disability, length of time on benefit, type of disability benefits customers are in receipt of, what rate of benefit they are in receipt of i.e. higher or lower.”

While the DWP have pledged long-term Incapacity Benefit claimants will be at least £25 a week better off in work, this figure may cover little more than the travel costs that they will now incur through being off IB and in employment. But employment brings more costs than that, costs that could ultimately prove dangerous to people with mental health problems.

We spoke to people with mental health problems who have gone back to work. They told us that they had been taken aback by some of the expenses they now had to pay as a working person such as exercise costs, school meals, talking therapies and prescriptions.

Kay

“When I came out of hospital I was on four different meds,” says Kay, a woman with bipolar disorder. “Because I was seriously depressed, I was only given two days of some medications at a time. Everyone assumed that I would be on benefits, but I wasn’t so I was paying a fortune for prescriptions.”

Those in the know can buy a pre-paid prescription card for just under £100 a year or about £27 for three months, which covers unlimited prescriptions. But most people aren’t aware of this, and continue to shell out £6.85 an item when they start paying for medication.

“Nobody told me that I could pay a set amount up front – not my psychiatrist, not the pharmacist,” Kay told us. “I don’t think the doctor knew. No one in the mental health system expects you to be paying, they blithely make the assumption that you can afford to keep taking the pills.” She points out two ironies. If she hadn’t taken the medication she would have been back in hospital where it would have been free, and if she had epilepsy, the other condition treated by the same medication, she wouldn’t have paid for the pills.

Sara

This woman of 35 who also has bipolar and works full time despite a number of episodes in hospital, also paid for her prescriptions until she was diagnosed with a thyroid disorder. When the pharmacist told her she no longer had to pay for medication she was pleased but also furious. “Why should people pay for prescriptions for mental illness when you don’t have to pay for other conditions? Why is something physical worth paying for, but mental health isn’t?”

Sara is still doing the sums over what medication has cost her in the decade since she was diagnosed.

It is not surprising then, that some people throw the prescriptions away. Research carried out by the Citizens Advice Bureau in 2001 found that 50 of their clients paying prescription charges had difficulty affording them and 28% failed to get all or part of a prescription dispensed because of the cost.

Increasingly the Government will offer short-term talking therapies for people with minor mental health problems to enable a swift return to work. But those with ongoing mental health problems will often need longer-term therapy, and while this might be available on the NHS, it is almost exclusively within normal working hours. As it is difficult to take time out of the working day for ongoing talking therapy, people either quit or find themselves paying for private therapy out of hours at a ballpark £30-40 a session.

Julian

This was the case for Julian who was discharged by his Community Psychiatric Nurse when he returned to work. Once back, he found himself more vulnerable and in need of someone to talk to, so now pays £30 a week for counselling sessions. “I find I need more support now than ever before, but I’m more likely to skip appointments with my shrink as well, because if there’s an important meeting at work it’s easier to cancel the doctor than make an excuse to my boss about a therapy session,” he says.

Julian swims and works out at a local leisure centre as he finds exercise helps to keep his depression at bay, but no longer gets a discount. “I pay about £30 a month more than when I was on benefits,” he says. “It might have been less if I could use the gym off peak, but that’s the thing about going back to work – every bit of help or discount is geared towards people who don’t work.”

he has a prescription card but calculates the price of going back to work will be around £2000 this year.

Andy Bell, head of public affairs at the Sainsbury Centre for Mental Health, says that services must stop being “predicated on the notion that you are out of work”. “If you support someone when they are out of work and forget about them when they get back to work there’s a chance they will fall out of work again,” he warns.