£81 billion is by any reckoning a large number. This is the annual benefits bill according to the Centre for Social Justice; and it’s rising. It is predicted to be over £100 billion by 2030. It’s more than the defence budget and the DWP have estimated that £10 billion is due to fraud. But is it too big a number for a compassionate society?

Rachel Reeves, the Chancellor, thinks so. According to the Daily Express, she is promising a ‘crackdown’ on sickness benefits in a move that threatens civil war in the Labour Party.” The newspaper claims “The Treasury is understood to be specifically targeting benefits for those signed off work for mental health reasons, including anxiety.” Describing it as a ‘crackdown’ is likely to lead to increased anxiety for many current claimants. However, we must wait to hear what a crackdown might look like.

Meanwhile in what appears to be a more compassionate announcement, Wes Streeting, the Health Minister, suggested that the solution to the problem of economic inactivity was to provide greater access to mental health support and treatment. This was partly in response to the Office of National Statistics reporting that the UK economic inactivity rate for people aged 16 and over was 21.6% and that many are economically inactive due to mental health difficulties. There is also concern about the number of school children experiencing difficulties that some regard as mental health problems. It is being suggested that there should be a mental health professional in every school.  

In many areas waiting lists for mental health services are long. But would providing greater access to mental health treatment reduce economic inactivity and the number claiming benefits for mental health issues? Or could there be paradoxical and unintended consequences, as is often the case with top-down policies.

The following offers a broader context in which this problem could be considered. It suggests providing greater access to treatment may well be counterproductive and actually increase the rate of diagnosis of mental health problems and therefore of economic inactivity and school children believing themselves to be suffering from a mental health condition.

1. A historical perspective. The ideas we use to understand ourselves: Possession by demons and possession by mental illness.
2. Diagnostic Inflation.
3. What Is the alternative to diagnosing psychological distress as forms of mental illness, conditions or disorders? The individual as active agent.
4. Conclusion

1. Possession by Mental illness

I have worked as a Clinical Psychologist for nearly 50 years having qualified in 1976. In that time services have expanded exponentially as have the number of people seeking help for psychological difficulties. More fundamentally, the way mental health is spoken about has changed dramatically.

Nowadays, mental health is on everyone’s lips. Even our neighbours, and the guy who delivers our parcels, and the weekly shop has something to say. Why is this? If it’s become so important to talk about it, perhaps it’s even more important to ask questions about what is said. The ideas we use to understand ourselves shape our experience, our ability to understand ourselves and what we feel capable of.

Ideas about mental health have changed dramatically over the years. They may need to change again. From an historical perspective, 200 years ago if we were psychologically distressed, it was time to call in the priest to exorcise our demons. In the 19th century, in tandem with the registration of doctors and the rise of the medical profession the idea of mental illness gained ground. The concept of illness works by suggesting we are the passive victims of something that has happened to us through circumstance. We have illnesses. In effect Possession by demons has been replaced by possession by illness.

Of course, it is not just doctors who manage the mental health services. There are now many professional groups involved. As the gate keepers, GPs have a key role in introducing people to ideas they might use to understand their experiences.

While GPs are an important source of ideas about mental health, long before we think of talking to a GP about our concerns, we have picked up many ideas from friends, family, charities, the media and nowadays more specifically sickfluencers. We use these to make judgements about our feelings, whether they are normal, unusual, unwanted or worrying. If any of the latter apply, our first thought is likely to be; “What is wrong with me? Am I ill? Have I got a condition or disorder?”

If we visit our GP, we will probably be told we HAVE depression or an anxiety disorder. We may be prescribed an antidepressant or tranquiliser or be referred for psychological help. 6.5 million Britons are now using antidepressants. This is up by a million over just the last five years. This is not a small number, and it shows little sign of slowing down.

If we turn to the Internet, we read our sensations and feelings are listed as symptoms of various disorders. We read that the causes of these disorders are not fully understood. We read ‘they could happen to anyone’. If these things ‘happen to anyone’ it seems there’s little we can do for ourselves except seek treatment. Virtually all media messages that mention mental health emphasise the need for treatment.  

This current cultural paradigm comes at us from every direction. It creates the impression that the conditions and disorders we might suffer from are not just descriptions from a particular point of view but are things that unambiguously exist in the real world. This is hard to resist. Most of us will accept we have an illness or disorder that has, in effect, possessed us through no fault of our own. We may conclude there are various things we cannot do. We may feel we have little choice but to become economically inactive and wait patiently for treatment.

• Diagnostic Inflation.

In practice we don’t know what normal is. In fact, it is not a question of knowing; the definition of normality is not something we can discover, we can only agree it amongst ourselves. It is more a question of deciding what we regard as normal. But who should decide and do the rest of us have to agree?  Are we going to concede authority to anyone or more likely to any organisation or institution? Which individuals or organisations would you trust with this responsibility?

Well, we have already tacitly conceded this authority. There has never been any explicit granting of such authority; no process of informed public debate about how this could be undertaken. However, it has happened, and WE have for the most part gone along with it.

Not everyone is happy about this. Dr Allen Frances is one such. He has written a book called ‘Saving Normal’.  The surprising thing is that he had a rather large hand in expanding our ideas about abnormality. He was the ultimate insider since he was the chair of the committee that wrote DSM-1V, (The Diagnostic and Statistical Manual of Mental Disorders). This much-revised manual has become the go-to bible for diagnostic categories and criteria. It has been ‘updated’ many times and not surprisingly it has expanded vastly until in its latest form it comprises over 1000 pages. It is worth repeating that it is generated by a committee.

Dr Frances illustrates with detailed data what he calls diagnostic inflation; the way in which increasing numbers of us now have a psychiatric diagnosis. He recognises that while many people want a diagnosis to ‘explain’ their difficulties this can change the way people feel about themselves in significantly negative ways. He illustrates this for many diagnoses including social phobia which has turned normal shyness into the third most frequent diagnosis.

He is particularly vehement about the way the pharmaceutical industry has taken advantage of the fuzziness of most diagnostic criteria to sell their wares. While pharmaceutical companies justify the high prices they charge due to the cost of researching new drugs, he points out that they spend twice as much on advertising as they do on research. This is especially the case in the US where they can advertise directly to the public.

He saves some ire for the media who like to focus on and dramatise the suffering of individuals and seem uncritically fascinated by the various new diagnostic categories that are being constantly proposed.

Lastly, he is critical of patient lobby groups which push for ‘better recognition’ of particular diagnoses, and the treatment services and benefits that they argue should follow.

He does admit some errors on the part of the DSM-1V committee. These he regards as due to a lack of foresight as to the unintended consequences of how DSM would be abused by big Pharma, time-pressured GPs and lobby groups.

The book may appear to be in part a ‘mea culpa’ but is as much a ‘not-me-guv’. What he really seems to want to do is to Save Psychiatry rather than Save Normal. He wants psychiatry to become what it was, in his terms, a highly specialised group of professionals who alone have the skills to ‘detect true mental disorder’. As such he is claiming which professional group should have the authority to decide who amongst us is normal/abnormal.

In spite of DSM’s many attempts to define different diagnostic categories, the criteria remain essentially fuzzy. This inevitably leaves the door open for diagnostic inflation. But more importantly the criteria always focus on elements of a person’s experience and regards these as symptoms. These symptoms are seen as things we suffer from; things that happen to us. This narrative is so much a part of our cultural landscape that the alternative of understanding the connection between what we are doing and thinking and these ‘symptoms’ is mostly invisible to us.

Dr Frances’ book is an intelligent, data-rich argument about diagnostic inflation and its dangers. While his voice is an important one it is unlikely to be heard against the voices coming from the many vested interests on the other side. Can anything slow the momentum of diagnostic inflation? It seems unstoppable at present.

In effect, as a culture, we have unwittingly conceded authority to definitions of abnormality as exemplified in the DSM. These conditions and disorders that lie in wait for the unwary have been socially constructed. They have been decided by committee, promoted by lobby groups, elaborated by professionals and sustained by the media. 

A long time ago George Bernard Shaw said, “all professions are conspiracies against the laity”. The following is a stunning and blatant example of the professional colonisation he warned us of.

With anxiety reportedly on the rise globally, the US Preventive Services Task Force (USPSTF) has posted draft recommendations for screening adults younger than 65 for anxiety.  The recommendation applies to “adults 19-64 years who do not have a diagnosed mental health disorder or are not showing recognised signs or symptoms of anxiety.”

They say, “To address the critical need for supporting the mental health of adults in primary care, the Task Force reviewed the evidence on screening for anxiety”.  Task Force member Lori Pbert added that “The good news is that screening adults younger than 65 for anxiety can help identify these conditions early so people can be connected to care.”

Based on a review of 64 published articles with 170,000 participants they concluded the pooled prevalence for anxiety Worldwide was 25%. North America had a higher prevalence rate at 43%, compared with 22.1% in Europe, 20.5% in Latin America and 15% in the Asia Pacific region. 

Does the USPSTF recommendation matter? How much higher would rates go if their screening recommendation were implemented? If the UK ever match the rates for anxiety in the US, the NHS and the benefit system would surely be overwhelmed.

What the USPSTF is recommending is more like advertising than promoting mental health. Would it put the prevalence rates in North America up to 50% or perhaps even 60%? In time will anyone without a diagnosis of one mental condition or another feel they are missing out?

The full report of the USPSTF is very long. It might be hard to believe but buried deep within its many pages is the following statement. “But the direct evidence for screening for anxiety was extremely limited and did not suggest a benefit. Further the evidence on the diagnostic accuracy of screening tools had minimal replication for anxiety disorders other than generalised anxiety disorder.”

Recently in the UK there has been more talk of the importance of prevention. In practice, prevention often turns into screening or early intervention and, like the USPSTF recommendations, simply leads to more professionalisation of ordinary experience and the expansion of services.

When any activity is professionalised and turned into a service, it erodes the confidence of the non-professional. Parents, family members and friends of those in distress feel less able to offer their wisdom: they feel it should be left to those that are qualified. Diagnostic inflation has deskilled the person on the Clapham omnibus.

• Is there an alternative

The ideas we use to understand ourselves matter. As Anthony Ryle has made clear, they act as both frames and cages; they allow us to operate within a framework but, at the same time, prevent us from seeing alternatives. Thomas Kuhn, in his seminal The Structure of Scientific Revolutions discussed how science progresses not simply by the accretion of new knowledge but through paradigm shifts, ie, changes in the fundamental framework of ideas. Paradigm shifts occur when our old framework of ideas increasingly fails to solve the problems we face. Could this be the case with our current ideas about mental health?

William James, the famous psychologist and brother of novelist Henry James said, “the greatest weapon against stress is our ability to choose one thought over another.”

This captures the essence of the simple but radical alternative to the illness model. It suggests we see ourselves as active agents who through the way in which we think about the world are shaping our experiences. We plan, anticipate, predict, want, hope, dread. We are constantly and actively trying to work out how things will be for ourselves and anyone we care about. We never stop doing this thinking. What we choose to focus on, how we judge it and how much we make it matter makes a difference. This is how we animate ourselves and colour our world.

As for our specific experience of anxiety, we are always interested in what might happen next. When we predict something we want, we feel good. When we predict something we don’t want, we will feel anxious. This is what anxiety is; simply something we are doing in the way we are thinking. It is us seeing the world in a particular way. It is not something we have or suffer from.

The current relentless messaging about anxiety and other psychological experiences insidiously shapes our consciousness. It changes our minds. It keeps us focused on problems and what might be wrong with us. It is hard to overstate how this negatively affects our quality of life and expectations.  If the current messaging continues, more and more of us will regard our ordinary and often useful apprehension as anxiety that we suffer from. We will expect, and even demand, the services or products of the mental health services; their advertising will have worked for them, but not for us.

Nowadays, almost nothing and no one tells us that thinking matters. But it does. The power of thought is vastly underrated. How you think makes a difference. It matters more than anything. It determines how you feel and what you do next. “Our ability to choose one thought over another” is vital to living well.

• Conclusion

Ordinary people regard themselves as having psychological problems partly because they have tried to understand their feelings using the current culturally dominant ideas. These ideas are being promoted by various interest groups in a form of colonisation of ordinary experience.

A policy to ‘crackdown’ on benefit claims is likely to create a great deal of anxiety. In effect it will be criticising people for accepting the dominant cultural paradigm and believing what they have been told about their experiences.

A policy to continue the present ubiquitous messaging within the current mental health paradigm with its focus on feelings as symptoms and the provision of more treatment services is very likely to lead to more people coming to believe they suffer from conditions they need treatment for. More will become economically inactive because they will naturally believe what they are being told.

To Save Normal we need to take our thinking more seriously. We will then see ourselves as active agents with the power and responsibility to manage our lives more effectively. We will always need support from those around us, but we will no longer see ourselves as simply possessed by some illness or condition.

To understand our experiences better we need to see our thinking as front and centre of the way we feel. We need to deepen our understanding of the very ordinary but powerful psychology that lies behind the nature and quality of our experiences. We already know much of this psychology at least implicitly. We use it in some spheres but not necessarily when it is most important. If we can recognise what we are doing when we think, and the power in our thoughts, we will regain “Our ability to choose one thought over another”