Mr Justice Mostyn vs. vague, rhetorical applications of theory

A court case (GM v Carmarthenshire County Council [2018] EWFC 36) has ruled that a social worker’s “generalised statements, or tropes” based on attachment theory are not admissible evidence.

The full judgement by Mr Justice Mostyn has interesting thoughts on the valid application of theory and balance between theory and observation.

“… the local authority’s evidence in opposition to the mother’s application was contained in an extremely long, 44-page, witness statement made by the social worker […]. This witness statement was very long on rhetoric and generalised criticism but very short indeed on any concrete examples of where and how the mother’s parenting had been deficient. Indeed, it was very hard to pin down within the swathes of text what exactly was being said against the mother. […] [The social worker] was asked to identify her best example of the mother failing to meet L’s emotional needs. Her response was that until prompted by the local authority mother had not spent sufficient one-to-one time with L and had failed on one occasion to take him out for an ice cream. […] A further criticism in this vein was that the mother had failed to arrange for L’s hair to be cut in the way that he liked.”

There is also a detailed section on attachment theory:

“… the theory is only a theory. It might be regarded as a statement of the obvious, namely that primate infants develop attachments to familiar caregivers as a result of evolutionary pressures, since attachment behaviour would facilitate the infant’s survival in the face of dangers such as predation or exposure to the elements. Certainly, this was the view of John Bowlby, the psychologist, psychiatrist, and psychoanalyst and originator of the theory in the 1960s. It might be thought to be obvious that the better the quality of the care given by the primary caregiver the better the chance of the recipient of that care forming stable relationships later in life. However, it must also be recognised that some people who have received highly abusive care in childhood have developed into completely well-adjusted adults. Further, the central premise of the theory – that quality attachments depend on quality care from a primary caregiver – begins to fall down when you consider that plenty of children are brought up collectively (whether in a boarding school, a kibbutz or a village in Africa) and yet develop into perfectly normal and well-adjusted adults.”

Much to discuss!

On evidence in psychological therapy

It sometimes feels that the demand for evidence for psychological therapies is seen as offensive. How dare researchers, commissioners, and policymakers reduce therapeutic relationships to tickbox questionnaires and symptom reduction! Therapy is something larger, broader, more holistic than that.

There are clearly problems with using short questionnaires consisting of a handful of closed-questions, and then summing these to a distress score before and after care. But the other extreme, trusting the professionals who are paid to provide therapy to say how effective their therapy is, doesn’t sound convincing either – especially for therapists in private practice who charge by the session. If a therapist depends on long-term therapy for their income, it might be challenging for them to think through different perspectives on how helpful their brand of therapy actually is.

Improving Access to Psychological Therapy (IAPT) is criticised for being heavily manualised, too brief, and offering only a narrow range of therapeutic approaches. However, perhaps IAPT is helpful for some people; for instance people experiencing panic attacks triggered by certain situations or specific phobia, in the context of an otherwise typically but not unusually bumpy life. The research evidence and testimony seems to lend support to this.

I am particularly suspicious of wealthy “woke” psychoanalysts arguing passionately for their Freudian or Lacanian approach. People can need long-term – in some cases life-long – and frequent support, especially for conditions and predicaments which have complex causes and in the context of brutal cuts to social security (welfare “benefits”). It is not obvious that this support needs to be steeped in psychoanalytic jargon.

Having someone there who is kind, listens, and is trustworthy might make all the difference to someone’s quality of life and ability to survive a harsh world. There is no need to run a multi-million pound clinical study to demonstrate the efficacy of kindness. However, therapeutic relationships need to foreground honesty concerning their limits. A paid professional who is there for us each week is not the same as a friend, and that needs to be clear before a relationship begins.

How to find money to save the NHS

This morning was the launch of the Resolution Foundation report, Healthy finances? Options for funding an NHS spending increase – a response to the rumoured government “birthday present” for the NHS as it turns 70 on 5 July 2018.

The audience included party advisers (I spotted a Whatsapp group chat for a party’s comms team), people from various think-tanks, academics (including an Emeritus Professor from Imperial who had a lot to say), and a representative from at least one (non-militant, at least in the room) campaigning group.

The line up:

  • Sarah Wollaston MP, Chair of the Health Select Committee and medic who worked as a GP up until 2010. (Given her generally sensible views, I keep having to remind myself that she’s a Tory).
  • Jon Ashworth MP, Shadow Secretary of State for Health, who has a long history as a Labour professional, including as Special Adviser in the Treasury for Gordon Brown.
  • Ben Page, Chief Executive of Ipsos MORI and fellow of the Academy of Social Sciences.
  • Matt Whittaker, Deputy Director at the Resolution Foundation, who previously worked for the House of Commons Library where he provided stats and economics advice.

The event was chaired by Torsten Bell, Director of the Resolution Foundation, former adviser to Ed Miliband (and, incidentally, architect of the Ed Stone).

Interlude: What is the Resolution Foundation?

The launch was set at Resolution HQ in a bright, wide room, with cosy luxurious seats which wouldn’t be out of place in an up-market indie cinema, so I was curious who they are and how it’s all funded.

Resolution Foundation’s website describes it as “a non-partisan and award-winning think-tank that works to improve the living standards of those in Britain on low to middle incomes.” In their most recent annual report, they defined “low to middle” as those in income deciles 2 to 5, whom they say are overlooked in policy debates. Their focus is on working households.

They receive most of their funding via donations from Resolution Trust, founded by Clive Cowdery with a £50m donation, “believed to be one of the largest endowments for public policy research made in the UK”.

Cowdery made his wealth from “sponsoring insurance vehicles” (an FT article says more) and is also founder of financial services investment firm called (again) Resolution.

Resolution Trust backs Prospect Magazine and, intriguingly, WorkerTech, which seems to be about encouraging alternatives to trade unions for the precarious world of Uberified work. (Here are slides from its launch.)

What did they say on health funding?

All agreed that the NHS needs more funding, so the question is how much more funding and where the money is coming from. The issue was framed as a tug-of-war between Treasury and Jeremy Hunt (with Hunt wanting more money, in case not clear – it’s not always obvious), constrained by a complex parliament and a wish to keep voters happy.

Matt Whitaker took us through some headlines from the Resolution report, emphasising that it was a prediction of what the government was likely to announce rather than what it should do. (Though it sounded very much like advice.)

Borrowing was seen as likely necessary, so long as the total was below 2% of the projected GDP in 2020-21 (to meet a Tory fiscal target). But borrowing alone would not suffice, so some sort of tax raise is almost certainly on the cards – the problem is how to keep keep Tory voters and donors on side, whilst getting it through parliament.

One possibility is increasing National Insurance contributions (or NICs, pronounced “nicks”), which Gordon Brown did when he was chancellor. This is a progressive tax for workers; however, increased NICs was seen by the report authors as “unfair from a generational perspective” since older people who rely more on healthcare don’t pay national insurance (this generational perspective might need some analysis). A solution proposed was to extend NICs to include those above state pension age who are still working.

Increasing income tax could be another way to get the money. LibDems and SNP might support this, and Scotland recently introduced a change to its tax bands meaning some pay more and others pay less tax. Labour, the authors argue, would likely oppose increases for anyone earning under £80k and some Tory MPs might oppose too.

Another approach suggested was to adjust thresholds for (i) when income tax is payable and (ii) the higher rate of payment. Threshold changes were Tory manifesto promises, but the authors suggest a fiddle (p. 24):

“An alternative approach would be to lift the Income Tax thresholds to those pledged in the manifesto in 2020-21, but to freeze both them and the NICs thresholds in the final two years of the parliament. This would of course cost money in 2020-21, but by 2022-23 it would raise £3.7 billion relative to the default of uprating in line with inflation every year.”

Another promising source of funding would come from reversing George Osborne’s 2016 pledge to cut corporation tax by 2020. This tax uncut could provide £5.2 billion in 2020-21 and £5.7 billion by 2022-23. Other political parties would likely support the move and the authors argue (p. 27):

“The Chancellor might also feel emboldened to act given the way in which the estimated costings of the move from 19 per cent to 17 per cent have shifted since George Osborne first announced it.”

Remarkably little was said about Brexit. Will it torpedo all the projections and render the suggestions (sorry, predictions?) unimplementable? The exception was Sarah Wollaston, who noted that she never believed the infamous £350m bus claim; she expressed reasonable worries about the effects Brexit would have.

What might more money mean for mental health?

Although the focus was very much top-level – where’s the money? – speakers did say a little about how it should be spent. For instance, Jon Ashworth quoted numbers on additional doctors and nurses required (it’s thousands), citing a report from IFS – also cited by Sarah Wollaston.

Reassuringly, mental healthcare was mentioned a few times as being important and in need of improvement (though note the history of “warm words”). Ben Page cited public support for increased spending, with mental health being second on the list in an April Ipsos MORI survey of priorities, after Accident and Emergency. Jon Ashworth mentioned improving support for addictions, in particular.

Sarah Wollaston cited the Health and Social Care Committee’s report into integrated care, published yesterday, which discusses detailed contractual changes needed to improve how, e.g., mental healthcare integrates with other services, including discussion of accountable care organisations (ACOs). (Perusing this report just now highlights how difficult it is to have public debates on these issues – it’s technical stuff.)

The coming weeks as we approach July 5th would be a good time to campaign for key specifics on how much money mental healthcare should receive and what it should be spent on. If the NHS received £20 billion more in 2022-23, how much should go to mental health and where?

Vote Labour… but…

I am writing to tender my resignation from the Labour Party and to inform you that I have cancelled my direct debit.

I will continue to vote Labour and support many of its policies and its much-needed shift Left. However, I am opposed to Labour’s approach to Brexit – and I have been patient. I have gradually but now completely lost faith in the leadership.

  1. The Brexit ballot was only advisory – even Farage accepts that.
  2. Leave misused official statistics to lie about £350/week for the NHS.
  3. Leave.eu broke electoral law.
  4. All convincing estimates point to Brexit being a disaster for the economy.
  5. There’s a high risk the Northern Ireland peace process will be harmed too.

Corbyn was too quick to call for triggering article 50. Since then Labour’s approach to Brexit has been confused, putting it mildly.

There is enough evidence now to consider the “will of the people” to be uninformed at best and deliberately manipulated through lies and cheating at worst. Brexit could and should be stopped.

I initially joined Labour in 2010. After a brief spell away, rejoined to vote for Corbyn in 2015. I voted again for Corbyn in 2016. For what it’s worth, I wrote a non-resignation letter nearly two years ago in support of Corbyn. I was hopeful for the party and supported Corbyn despite numerous criticisms.

It’s great to see the membership grow and surely Corbyn deserves praise for enabling this. I’m just not convinced that the Corbyn, McDonnell, and Abbott leadership are electable, and mainstream media bias – though partly responsible – is only a partial explanation.

The problems are too many to enumerate. Salient and illustrative examples include Corbyn refusing to condemn the IRA for its bombing campaign which killed civilians; sharing a platform with SWP members despite being asked and promising not to (given the “Comrade Delta” affair); appearing on a platform alongside a CPGB flag fluttering merrily in the wind; employing a former Sinn Féin staffer. The last straw for me was Corbyn publicly expressing sadness that Ken Livingstone resigned – after all the harm Livingstone has caused recently to Labour.

Given the targets Corbyn’s critics choose, these are clearly misguided decisions, and harm the chances of a democratic socialist government taking power from the Tories.

As I said I will vote Labour and encourage others to do so, to try to get the Tories out so there’s a chance the welfare state can be restored with sanctions and other conditionality stopped; to undo marketisation of the NHS; improve mental health care; and for a range of other important issues. I continue to be an active trade unionist in higher education. But I don’t feel I can be a member of Labour under the current leadership and with its current approach to Brexit.

 

Samaritans

Today Samaritans announced that Esther McVey has left its advisory board.

This is great news, thanks to hard work by groups like Disabled People Against Cuts, Recovery in the Bin, and Black Triangle — groups led by disabled people, mental health service users and survivors. Their investigations revealed McVey’s membership on the board.

These groups should be confident Samaritans is on their side and should be more involved in informing policy.

This episode reveals a need for a review of advisory board membership. Samaritans must win back the trust of disabled people and others who have been harmed by disability (re)assessment policies, “sanctioning”, and cuts to welfare payments.

Additionally, there should be an urgent review of Samaritans’ communications policy. It is not acceptable for the same message to be copied and pasted to multiple people who are concerned about serious conflicts of interest which harm Samaritans’ reputation, potentially affecting donations and most worryingly putting people off calling.

Mental healthcare funding: Letter to Jeremy Corbyn 22 September 2017

Dear Jeremy,

I submitted a series of Freedom of Information (FOI) requests to Treasury, Department of Health, and NHS England, asking:

  1. Who is responsible for decisions made in relation to mental health care budgets?
  2. How are budgetary decisions made, including evidence of how, in calculating the total health budget, mental health needs have been taken into consideration?

Treasury and DH both replied citing s35 of the FOI act. Releasing discussion of options available, Treasury argued, might inhibit future “rigorous and candid assessments of options available” [1]. DH replied similarly: “Premature disclosure of information protected under sec tion 35 could prejudice good working relationships, the neutrality of civil servants” [2].

NHS England did reveal something of their decision making processes, naming Paul Baumann, Chief Financial Officer for NHS England, as responsible for budgets, and citing a technical document [3], the technical annex of which [4] sketches an estimate of likely growth in mental health costs over the coming years.

But Treasury and DH’s responses indicate that other factors have been taken into consideration that are not currently in the public domain. A rigorous debate about options, involving the people who need mental health services as well as those who provide them, requires transparency.

I am therefore writing to ask for more information concerning the reasoning behind decisions made. In particular, what discussion has there been of the following?

  1. The effectiveness of mental healthcare treatments and support, e.g., in comparison to physical health care;
  2. The costs of the various treatments; and
  3. The potential for reducing costs, e.g., by employing lower band staff or increasing involvement of voluntary services.

It is important that reasoning on these issues is made public so they can be openly debated.

Thanks,

Andy

[1] https://www.whatdotheyknow.com/request/293922/response/723453/attach/html/3/DOC231015%2023102015120744.pdf.html

[2] https://www.whatdotheyknow.com/request/299123/response/734036/attach/html/2/966789%20Fugard.pdf.html

[3] https://www.whatdotheyknow.com/request/mental_health_budgets_2#incoming-736647

[4] https://www.england.nhs.uk/wp-content/uploads/2013/12/cta-tech-Annex.pdf

The social model of disability as a case study of social ontology

Ontology is the study of what kinds of entities there are in the world and how they relate to each other. As Effingham (2013, p.1) explains, “You will not find ontologists rummaging around your wardrobe” cataloguing everything they find. Rather, the idea is to conceptualise more broadly the kinds of things there are, including material and abstract “things” like numbers and colours. Social ontology concentrates on entities relevant to social theorising at various levels of explanation from the sub-personal (including unconscious processes like those controlling finger tips on keyboards) to people, their interactions, institutions and beyond.

Debates in social ontology, such as on ontological individualism or emergentism, can be abstract and their relevance hard to grasp. There has even been a case to “rid social sciences of ontology altogether – of all philosophized metaphysics of how the social world is” (Kivinen and Piiroinen, 2007, p.99). This short post tries to make it clearer why it’s important to think about ontology, using an example from disability activism.

In 1975, the Union of the Physically Impaired Against Segregation, a group of disability activists, published a series of fundamental principles which challenged the ontology of disability:

“In our view, it is society which disables physically impaired people. Disability is something imposed on top of our impairments, by the way we are unnecessarily isolated and excluded from full participation in society. Disabled people are therefore an oppressed group in society. […] For us as disabled people it is absolutely vital that we get this question of the cause of disability quite straight, because on the answer depends the crucial matter of where we direct our main energies in the struggle for change. We shall clearly get nowhere if our efforts are chiefly directed not at the cause of our oppression, but instead at one of the symptoms.”

Here a distinction is made between impairment and disability. From this perspective, it doesn’t make sense to say that someone “has a disability”; individual people can have impairments, but it is society which determines whether someone is disabled. Note how the conceptualisation is used to unite people behind one social struggle.

This guide from the activist group Disabled People Against Cuts explains how social barriers cause disability:

“… we live in a society that’s designed by, built for, and used by non disabled people. Because of poor historic attitudes to disabled people […] disabled people were effectively locked away in hospitals, sanatoriums, in care homes or other kinds of institution.

“And that meant that we were excluded from the development of the way our society works, the way our buildings are designed, transport systems, education systems, machines and appliances, leisure activities and the world of work anything really that you care to think about was designed at a time when disabled people weren’t included in the process.

“And that means that all these things don’t work in a way that enables us to use them.

“And the upshot of all that is that in hundreds of different ways, some big, some seemingly small, its difficult for us to take a full part in all kinds of activities that non-disabled people take for granted.

“So we believe that its not our impairments that disable us, it is the social barriers that disable us. Our own impairments we can adapt and/or use aids to overcome, but social barriers are out of our control.”

Whether someone with a particular impairment becomes disabled is also affected by scientific and technological advances. For instance, many people who have a visual impairment wear glasses or contact lenses and wouldn’t consider themselves disabled (see Slorach 2016, p. 37).

A related example is illustrated in this piece on the difference between deaf and Deaf identity:

“To be ‘deaf’ (small d) is to fit into the medical definition of deafness as something to be cured and eradicated. Being deaf means you have a hearing loss, but you choose or don’t feel able to function within the Deaf Community. […] Deaf – with a capital “D” (and occasionally with capital E, A and F too) – is used to refer to people who are culturally Deaf. These people actively use British Sign Language; they see themselves as being culturally Deaf and part of the Deaf community. […] I consider myself to be culturally Deaf; this is my Deaf Identity. […] I don’t see it as a disability – there is nothing I feel I cannot do – rather, I see it as an important aspect of my character that makes and shapes me.”

These conceptualisations of impairment and disability, social barriers, adjustments, aids, deaf and Deaf identity, concern ontology. The debates on these topics occur naturally in social struggles and discussions of social policy, whether or not explicitly articulated as being about ontology. They also have clear implication for how social research is carried out and understood.

References

Effingham, N. (2013). An introduction to ontology. Cambridge: Polity Press.

Kivinen, O., & Piiroinen, T. (2007). Sociologizing Metaphysics and Mind: A Pragmatist Point of View on the Methodology of the Social Science. Human Studies, 30, 97–114.

Slorach, R. (2016). A very capitalist condition: a history and politics of disability. London: Bookmarks Publications.

Disease vs. drug-centred model of psychiatric medication

“The disease-centred model suggests that psychiatric drugs work because they reverse, or partially reverse, the disease or abnormality that gives rise to the symptoms of a particular psychiatric disorder. Thus ‘antipsychotics’ are thought to help to counteract the biological abnormalities that produce the symptoms of psychosis or schizophrenia… the ‘drug-centred’ model suggests that far from correcting an abnormal state, as the disease model suggests, psychiatric drugs induce an abnormal or altered state. Psychiatric drugs are psychoactive substances, like alcohol and heroin… The drug-centred model suggests that the psychoactive effects produced by some drugs can be useful therapeutically in some situations. They don’t do this in the way the disease-centred model suggests by normalising brain function. They do it by creating an abnormal or altered brain state that suppresses or replaces the manifestations of mental and behavioural problems.” 

Blog post by Joanna Moncreiff