Talking therapies in a market-based society: Psychology and neoliberalism (part one)

“[…] engagement with neoliberal systems results in characteristic tendencies—including a radical abstraction of self from social and material context, an entrepreneurial understanding of self as an ongoing development project, an imperative for personal growth and fulfillment, and an emphasis on affect management for self-regulation […]”

Adams, G., Estrada, V. S., Sullivan, D., & Markus, H. R. (2019). The psychology of neoliberalism and the neoliberalism of psychology. Journal of Social Issues, 75(1), 189–216 (p.189) https://doi.org/10.1111/josi.12305

In October 2022, the UK government announced that £122 million was being was being ploughed into the stationing of employment advisors in mental health services, specifically in Improving Access to Psychological Therapies (IAPT). This, apparently rooted in “strong evidence that being in work improves mental health.” In my humble opinion, this strong evidence does not exist – there’s evidence that (meaningful) work correlates with good mental health, but that doesn’t guarantee causality. This, along with the problematics of considering work a health outcome, has been repeatedly pointed out by activists and academics over many years (examples here and here), but the UK government selects its ‘expert’ advisors to suit its own agendas.

At any rate, the government’s announcement came as little surprise to many of us in the chronic illness communities. In fact, history seems to be repeating itself: this initiative has an eerie ring of the stationing of employment advisors in UK GP surgeries as part of the ‘pathways to work’ scheme that Mansel Aylward (one of the chief architects of UK welfare demolition) helped develop back in the noughties. It is also similar to other back-to-work schemes, including the ‘Personalisation Pathfinder’ that was introduced in 2015. (The latter scheme was aptly described by journalist Steve Topple at the Canary as “a fucking disaster”). These schemes can be sited within a wider collective of back-to-work policies out of which IAPT was first conceived. Such schemes are thrust upon chronically ill and disabled people with the reasoning that individual ‘recovery’ equals productivity equals economic recovery and thus improved outcomes for all.

At the risk of going off at a tangent, it might be asked whether the long-term costs - of frequently ineffective or even harmful therapies and back-to-work advice, of lost productivity, and of benefit payments in cases where these are actually obtained - may in fact outweigh the economic investment necessary to appropriately address neglected conditions such as those framed as 'medically unexplained' or 'contested'. I’m not aware of anybody ever having done the math, but it would certainly make an interesting project.

Coming back from that tangent, in this 2-part blogpost series, I consider the influence of political and economic ideology on mainstream healthcare within the context of chronic illness and disability. This topic is especially important given the spectre of global recession, constant threat of increasing welfare retrenchment and documented burgeoning of disability and chronic illness owing to long Covid. In the remainder of this post I outline neoliberalism and its relevance to healthcare (in particular, mental health services), and briefly discuss a therapeutic modality that could be argued to encapsulate neoliberal ideals, that of cognitive behavioural therapy (CBT).

Neoliberalism

Neoliberalism (aka neoliberal capitalism) may be understood as a historically specific regime of capitalism and can be defined both as an economic policy model and a bio-political ideology, gaining ascendancy from the 1970s onwards and accelerated by the 2008 global financial crisis through widespread adoption of austerity politics. As an economic policy model, neoliberalism prioritises the interests of private corporations and ‘the market’ over and above respect for human rights, via privatisation, de-regulation, preservation of individual ‘freedoms’ and reduction in state spending. As a bio-political ideology, neoliberalism posits a motivated, autonomous and entrepreneurial subject as the ‘ideal citizen’, holding that hard work and ‘excellence’ pay off and that people get what they deserve (the myth of meritocracy and the just world fallacy combined). The flip side of this is that people who do not live up to the ideal neoliberal subject standard are denigrated and othered.

Neoliberalism is associated with increasing social inequality and has been contended to be highly detrimental to chronically ill and disabled people, since neoliberalism and ableism are inextricably linked, celebrating the same values, with each feeding the other. Again, this is particularly pertinent given the current climate of cut-backs; as I’ve argued in various writings (examples here and here), victim blaming and scapegoating of disabled people is likely to increase, and there is a strong chance that people with long Covid (at least, those sub-groups that can be positioned as ‘medically unexplained’ and thus undeserving) will be part of the collective target.

What can make neoliberalism particularly harmful, in my opinion, is its barely perceptible nature – it has become thoroughly entwined with taken-for-granted ‘truths’ that satisfy the collective psyche in a multitude of ways, whilst depoliticising and naturalising social inequality.

A growing body of literature addresses the potential harms ensuing from the creeping (or perhaps we should say sweeping) neoliberalisation of the healthcare arena. The harms as they impact on patients are implied above: psychologisation of primarily physical conditions positioned as ‘medically unexplained symptoms’, reduction of psychological distress to a putative individualist phenomenon that is recoverable through individual motivation and hard work (implying personal failure), and a withholding or scaling back of appropriate medical care, social security support and other social accommodations. The consequences of this are shocking and profound: whilst some people have died through lack of appropriate biomedical care, others have starved to death, or taken their lives owing to despair (see here, here, here). The ideology that feeds such harms also impacts on healthcare professionals, where the creation of a highly competitive, labour intense, micro-managed, and precarious work environment may result in loss of job satisfaction, alienation and de-moralisation, leading to clinical burnout.

Having worked in IAPT, I can’t help but think the clinical climate created in part by neoliberal policies locks patients and practitioners into a vicious cycle of conflict and mutual disregard. That is, healthcare professionals have their hands tied in many ways when it comes to patient care but are also frequently poorly informed of the socio-political context that constrains them. This can lead to all manner of defensive clinical behaviours which patients understandably pick up on and seek to defend themselves against. This inevitably leads to further clinical defensiveness, and so it continues. As I’ve previously argued, these tensions might be mitigated to some degree if clinicians were more aware of how policies and politics both constrain their practice and impact detrimentally on patients (some patient groups more than others).

Of particular relevance to the marginalisation of conditions such as ME/CFS and, increasingly it seems, long Covid, the rise of (bio)psychosocial discourse and practice – particularly as it applies to health conditions that can be shoehorned into the category of MUS and conceptualised as psychosocial - can be also theorised through a lens of neoliberalism. Not only does such discourse appeal to the collective clinical and social imagination, but it also justifies neoliberal policies of cut-backs across health and welfare sectors, which (bio)psychosocial theorising facilitates and has been used to justify. Why neoliberalism may appeal so strongly to many people is discussed here. In the psychotherapy arena, this appeal perhaps goes some way to explaining the clear preference of the state, and many therapy training providers, for CBT over and above other therapeutic modalities.

Cognitive behavioural therapy

The influence of neoliberal ideology in CBT can be observed in how the ‘problem’ is located squarely within the individual: individual thoughts (cognitions) and behaviours, underlying assumptions and core beliefs are the focus of CBT, but therapists are not trained to consider and work with what might have shaped this psychology. That is, there is little to no recognition in mainstream CBT that patients, like all human beings, exist within a matrix of social structures, some of which systematically disempower certain patient groups. Undue focus on individual psychology, alongside ignoring contextual factors, can easily tip over into victim-blaming.

The cognitive-behavioural emphasis on effort and motivation in ‘overcoming’ putatively unhelpful cognitions and maladaptive behaviours – which in the field of MUS and mental health allegedly equals recovery - is also highly consistent with neoliberal assumptions. Neoliberalism celebrates a de-contextualised, autonomous subject which, as Adams et al. (2019) point out, is tied to “an entrepreneurial understanding of self as an ongoing development project.” This fits very comfortably with the ethos of CBT, and also with positive psychology as we shall see: both approaches assume that individual effort and motivation lead to ‘success’, which again easily leads to victim-blaming when people do not ‘succeed’ as per neoliberal exigencies. Adams et al. (2019) also highlight how neoliberalism promotes “affect management for self-regulation”, that is, encourages subjects to ‘control’ their emotions. This type of regulation, consonant with notions of rationality and self-mastery prized in WEIRD societies, is central to CBT.

Pertinent to CBT’s affinity with WEIRD cultures, the ’fathers’ of CBT and closely related Rational Emotional Behavioural Therapy (REBT) - Aaron Beck and Albert Ellis respectively – were both relatively privileged individuals. Whilst they were both concerned with the worldviews and self-concepts of their patients, it is interesting to consider to what degree their own ‘schemata’ shaped these therapeutic modalities. CBT (like neoliberalism) might be argued to celebrate values that are largely consistent with a white, abled, male, socio-economically advantaged standpoint.

Relatedly, some academics have noted that mainstream notions of recovery – notably in the arena of MUS - are highly gendered, drawing upon stereotypically masculine perspectives of ‘pulling oneself together’ that likely harm all people, but perhaps disproportionately harm disabled women. (As a disabled woman myself, I have often wondered how to describe the space at the intersection of ableism and androcentrism or sexism - does such a term exist? I tend to think in terms of 'andro-ableism' but I'd be interested to hear from other people on this question). In any case, given the highly situated assumptions of mainstream therapies, it should be asked whether they can truly help anybody who does not fit the ‘gold standard’ social mould of the multiply privileged subject.

Whilst some researchers and practitioners have responded to this bias issue through developing various permutations of culturally sensitive CBT, it has been contended that CBT proponents may in fact be colonising or co-opting values, and treatment philosophies from other modalities to stay relevant (where relevance includes securing funding, increasing professional status etc). Accordingly, Dr Jay Watts has argued that CBT does not exist except as a ‘political convenience’.

CBT is not the only therapeutic modality that sits comfortably with a neoliberal outlook. In fact, it has been argued that many therapeutic modalities, emerging against an increasingly neoliberal backdrop, have unwittingly embraced the ideals and assumptions of neoliberalism. That said, some therapeutic modalities, and broader frameworks, sit more comfortably with neoliberal values than others, and some openly celebrate such values. This will be discussed in the second part of this two-part blogpost series.