When help is a four-letter word: Government health/psychology interventions for benefit claimants (part 1)

In an already malign climate for those on benefits, Government interventions which are provided in the guise of “help” for claimants — but which may come with the threat of sanctions attached — deserve close scrutiny.

Firstly I look at a pilot of two ‘Nudge Unit’ psychological interventions for jobseekers. I then look at a DWP (Department of Work and Pensions) pilot which involves mandatory engagement with healthcare professionals for some of those on ESA WRAG. (By ‘mandatory’ I mean schemes which benefit claimants are pressured to engage with under threat of losing some or all of their benefit if they fail to engage. ESA is the replacement for Incapacity Benefit, WRAG refers to the ‘work-related activity’ group of ESA claimants, who may be required to perform ‘work related’ activities.)

These schemes are only two aspects of the current situation regarding “help” for claimants. I’m also waiting for more details in a case of someone being pushed towards a DWP/outsourced psychological intervention, though whether that fits in with the “barriers to work” pilot (discussed in the second half of this post) is unclear. [Update: that particular case seems to have been resolved as non-mandatory, which is good news]. And, in a late addition, at the end of this post I link to a Friedli and Stearn piece which describes more intersections of psychology and benefit claimants.

(1) The BIT personality strengths survey for jobseekers
Earlier this year, it emerged that some jobseekers were being given a truncated version of a Positive Psychology survey, as an intervention, with statements like “Pain and disappointment often get the better of me” to agree or disagree with. Some jobseekers were being told the survey was mandatory to complete. This intervention was the brainchild of the Government’s ‘nudge unit’, aka the Behavioural Insights Team [BIT].

The skwawkbox blog (and commenters on the blog) did a great job of piecing together the story which was picked up by The Guardian. (The skwawkbox blog continues to unearth more problems with the test.) Highlights of the story, which at times borders on farce, include:

Official letters sent to jobseekers by the Department for Work and Pensions (DWP) stated that the test was “scientifically shown to find people’s strengths”

but

In response to questions about whether the test was validated, the Cabinet Office backed away from previous written assurances to jobseekers and said the survey was only “based on a scientifically validated questionnaire”.

And, in what should have been the final nail in the coffin for this intervention, the Guardian reported the education director of the institute that designed the validated survey as saying:

“[The nudge unit] are using the non-validated version … we had tested it a while back and it failed”

(2)The BIT and expressive writing about a traumatic event
In December 2012 The Guardian published a largely uncritical account of a trial of a combination of interventions for jobseekers. One of the interventions is the (failed) survey discussed above:

For those still on jobseeker’s allowance after eight weeks, the centre created a website where claimants could identify their personality strengths. The website then encouraged them to think of ways to apply those strengths to job applications and everyday life.

Then (my emphasis):

The group were also asked to engage on three occasions in expressive writing for 10 to 15 minutes about a traumatic event.

The BIT blog post about this trial (New BIT trial results: helping people back into work) describes the purpose of this as:

“Building psychological resilience and wellbeing for those who are still claiming after 8 weeks through ‘expressive writing’ and strengths identification.”

The expressive writing component of this trial seems to have drawn less comment than the strengths survey, but it seems equally problematic.

In an overview of expressive writing, Baikie and Wilhelm (2005), say:

“it is recommended that patients be told that they can stop writing at any time, should they wish, and appropriate contact numbers should be made available in case of distress.”

I would be very interested to know whether these expressive writing interventions were/are mandatory. If they are mandatory, there is an obvious conflict with the recommendation that people should be told they can stop at any time. I would also be interested in how closely psychologists (rather than employment advisers) were/are involved in supervising an intervention which (as Baikie and Wilhelm say) many participants find initially upsetting.

Responding to someone’s comment on the BIT blog, the BIT team said, in January 2013:

The answers to all your questions will be detailed in a forthcoming report on this work. We can tell you now that the sample size was over 2000.

We are doing further work in this area, expanding the trial across other parts of the country. We will be testing new interventions and focussing on the effects of some individual interventions.

The point about “the effects of some individual interventions” is important — as the original commenter on the blog pointed out, there are two other ‘nudges’ as well as the psychological interventions, and thus it is impossible to tell what effect (if any) the psychological interventions alone are having, as they are part of a package of other measures.

In April 2013 a BIT blog post said:

We are now well into the roll out of a broader trial of these same interventions across the region and except [sic] results at the end of the year

I hope those results include detailed discussion of the methods, and ethics, of jobseeker interventions so far.

Late addition: As I was writing this post, a long article about the nudge unit appeared in the New York Times. It describes how the expressive writing component came about:

A 24-year-old psychologist working for the British government […] was supposed to come up with new ways to help people find work. He was intrigued by an obscure 1994 study that tracked a group of unemployed engineers in Texas. One group of engineers, who wrote about how it felt to lose their jobs, were twice as likely to find work as the ones who didn’t. [The psychologist] took the study to a job center in Essex, northeast of London, where he was assigned for several months. Sure, it seemed crazy, but would it hurt to give it a shot?

The article links to the 1994 study. It’s pertinent to note that the trauma the experimental group were asked to write about was specifically the trauma of their recent layoff from a job.

It will be interesting to see what comment the NY Times article attracts. Even allowing for a bit of journalistic spin, the narrative is not one that inspires confidence in this particular intervention.

The DWP “barriers to work” health pilot
November 2013 saw the start of a pilot scheme (for some in the ESA WRAG group) in some parts of the country, about which a November DWP press-release said:

People on sickness benefits will be required to have regular meetings with healthcare professionals to help them address their barriers to work – or face losing their benefits – in a two-year pilot scheme in central England which begins in November.

Further details include:

“The regular discussions with healthcare professionals – which will be provided by Ingeus UK – will not replace someone’s GP, but can promote health support and help a claimant to re-engage with their GP if they are struggling to adapt to their condition. They will also signpost claimants to activities and information to help them manage their condition to improve their readiness for getting a job, and work with local services to provide a holistic approach to health interventions.”

A previous press release from July listed the sorts of healthcare professionals involved:

“People on sickness benefits will be required to have regular meetings with doctors, occupational health nurses and therapists to help them address their barriers to work”

It’s unclear whether mental health problems are being targetted in the pilot.

(There is an ambiguity in the wording re: “therapists”, though the Latent Existence blog spotted that Ingeus were recruiting Occupational Therapists for this scheme. So it may be occupational therapists that are being referred to in the above press release.)

The disability news service site quotes Mind on this pilot:

Mind said that “compelled health support” would cause “further distress for many people with mental health problems” and could also be “very disruptive and confusing”.

Paul Farmer, Mind’s chief executive, said: “The DWP continues to fundamentally misunderstand the barriers faced by people with mental health problems in returning to work – resorting time and time again to threatening people with sanctions instead of supporting them into sustainable employment.”

About one third of those in the WRAG have a mental health condition, according to Mind.

Farmer said: “Whilst additional health support might help someone in their progression to work, this must always be a decision taken freely by the individual and they must not be sanctioned for failing to carry it out.”

Some problems with this scheme
The current regime of sanctions (loss of some or all benefit) casts a shadow over “discussions with healthcare professionals”.

Whether for physical or mental health, this pilot raises lots of issues, some already raised by the Latent Existence blog, for example:

(i) Will claimants face sanctions for failing to attend meetings with healthcare professionals? According to the November press release, this sounds likely.

(ii) Will claimants be sanctioned for failing to perform “activities” that a healthcare professional suggests?

(iii) How will advice/guidance from an outsourced healthcare professional mesh with the advice and treatment from the claimant’s own GP or specialist?

And if it does turn out that mental health is being targetted, then:

(iv) Where is the line between providing advice/guidance and providing an actual intervention?

I hope that the BPS (British Psychological Society) and other bodies would agree that there are ethical issues around providing psychological interventions to service users who may be sanctioned for failing to engage with the intervention.

If it becomes apparent that there are cases of service users being pushed into psychological interventions they may not want then I hope the BPS and other bodies will protest.

Summary
It was good to see the half-baked version of a Positive Psychology intervention being picked up by the national press, though in my view a similar spotlight needs to fall on the expressive writing/trauma intervention too. Most of all we need the BIT to put out a detailed report about what is going on.

The pilot of meetings with outsourced healthcare professionals to address health “barriers to work”, for WRAG claimants, also needs much greater scrutiny. Whether for physical health, mental health, or both, this scheme raises several red flags.

Late addition In another development, the Centre for Medical Humanities blog has just published a post called “Whistle While You Work (For Nothing): Positive Affect as Coercive Strategy – The Case of Workfare” by Friedli and Stearn, which includes further intersections of psychology and benefit claimants. The Centre for Medical Humanities say, in an introduction to the post:

There has been little or no debate about the recruitment of psychology/psychologists into monitoring, modifying and/or punishing people who claim social security benefits.

I hope that Friedli and Stearn post marks the start of an overdue debate.

Other links and commentary:
An interesting paper here on “Nudging into subjectification: Governmentality and psychomettrics” by Cromby and Willis.

A good analysis here of “‘Illness as ‘Deviance’, Work as Glittering Salvation and the ‘Psyching-up’ of the Medical Model: Strategies for Getting The Sick ‘Back To Work’.”

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