from Arena Magazine, No. 29, June-July 1997, pp. 39-41.
A view has developed within Australian government circles that prolonged unemployment can sometimes be caused by the mental condition of unemployed people.[1] Following the publication in May 1994 of Working Nation,[2] the former government's white paper on unemployment, the Department of Employment, Education and Training (DEET) instituted a system of case management[3] for long term unemployed (LTU) people. These are people who have been unemployed for 12 months or more.[4] The number of people categorised as being LTU in Australia stood at 243,100 in June 1995[5] but the aim is to substantially reduce this figure over the next few years.
The term `case management' is commonly used in psychiatry[6] but it has only recently been adapted for use in relation to unemployed people. In order to introduce competitive principles into the practice of case managing unemployed people the operation is being progressively privatised. Private case management is projected to rise to 20% of the total by the end of the 1995-96 financial year[7] and thereafter will increase rapidly as the private sector expands its skills base. The evaluation of case management competitiveness is based on the cost of service delivery as well as the efficacy of case managers in moving people out of long term unemployment.
A case manager can remove people from the status of long term unemployment by obtaining employment for them, directing them into training schemes and labour market programmes, or finding reason to alter their welfare status. When a person is difficult to place the case manager has a device available called the Special Intervention Programme. Special Intervention addresses four main barriers: English as a second language needs, literacy and numeracy problems, outdated work skills and employment-related personal development needs.[8]
Personal development problems are assessed by psychologists employed by DEET.[9] This psychological area is also now being progressively farmed out to private contractors on a competitive basis. Advertisements appeared in the press late last year calling for tenderers who might want to be placed on a DEET Register of Psychological Services for the ACT/Illawarra area. A sample of the psychological assessment form, which a psychologist would use to report on LTU people, was supplied with the tendering documents. The form requires the psychologist to assess the "major barrier" the LTU person might have "to successful participation in employment or vocational training".[10] Clearly, once language, literacy and numeracy problems have been eliminated as the cause of a person's continued unemployment it is the psychologist's job to `scientifically' identify whether there are any attitude problems that need to be dealt with.
The tender documents described the type of people who might require psychological assessment as those,
There was provision in the tendering process for the providers of psychological services to offer "therapeutic intervention" following assessment.[13] The DEET Senior Psychologist for NSW, who was charged with assembling the programme, confirmed that therapeutic intervention sometimes involves psychiatric referral.[14] He was unable to estimate the number of LTU people who are given a psychiatric referral but he did offer that "anecdotal information indicates that a large number of long term unemployed people had psychiatric problems".[15]
A similar inquiry made to the DEET Contact Officer for the Psychological Assessment Programme for the ACT/Illawarra area revealed that no statistics had been assembled regarding the total numbers/percentages of LTU people channelled into psychological assessment or the proportion of these people who are referred on for psychiatric intervention.[16] One of the problems involved with properly assessing the social implications of the DEET psychological intervention programme is that the publicly available documents which discuss the background to the development of case management for LTU people -- like the green paper, Restoring Full Employment [17] and the white paper, Working Nation,[18] as well as the DEET guide to Programs 1995-96 [19] and the DEET Annual Report 1994-95 [20] -- all scrupulously avoid any mention whatsoever of that part of the Special Intervention Programme involving psychological assessment.
It is not clear how much coercion is being imposed on LTU people to enforce their participation in psychological intervention. While the Senior Psychologist claimed it is voluntary the Psychological Assessment Programme Manager for the ACT/Illawarra area said that when psychological intervention was built into a LTU person's case management plan there was no choice for them but to comply. This person described some of the group activities in the psychological programme as being deliberately designed as shock treatment, "to shake them out, test their willingness to work and rearrange their lifestyles".[21]
If LTU people are indeed volunteering for participation in psychological intervention programmes it is obviously because they are under threat of having welfare payments terminated for non-compliance. This hardly amounts to a proper procedure of informed consent and it could raise serious ethical questions for the psychologists involved. With the possibility of onward referral for psychiatric assessment hanging over them there is every reason for LTU people to exercise extreme caution about these programmes. Diagnostic procedures predispose psychiatrists to view unemployment as a symptom of mental disease and even when a person volunteers to be examined by a psychiatrist the consequence of the encounter might be involuntary hospitalisation and treatment.
Although Thomas Szasz is a long-time campaigner against psychiatric coercion,[22] in a recent book, Cruel Compassion, while detailing the typical profile of a candidate for psychiatric diagnosis, he is influenced by an unconcealed political bias to supply an argument that might prove very useful for those intending to use psychiatry to deal with LTU people.
"The young person who fails to engage in some activity others value, and for which they show admiration and appreciation, in effect opts to become a dependent, exploitative, or predatory person. As the reality of his uselessness dawns on him the young adult begins to feel inferior to siblings and friends and to envy their competence and success. To avert the painful realisation of his justified lack of self-esteem, he protects himself by means of a dangerous psychological defence. He tells himself he is better than others .... (psychiatrists call it `narcissistic'), and embraces the logic of hostile entitlement: "I am not a useless person. Others have more than I do and ought to feel guilty and help me .... Everything the producers have, they have gained by exploiting others. I have a right to rob them of their possessions".* Somewhere down this path, he commits or threatens to commit a violent act, against himself or others .... he is then brought into the presence of a psychiatrist who is likely to diagnose him schizophrenic and launch him into a career of the chronic mental patient.[23]
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*Herein lie the similarities between the unproductive mentality of the chronic mental patient and the anticapital mentality of the socialist/communist.. [Szasz's footnote]."
It is not difficult to find confirmation of Szasz's argument. The psychiatric diagnostic manual most commonly used in Australia, DSM IV, specifies that a mental disorder is a condition that "causes clinically significant distress or impairment in social, occupational, or other important areas of functioning".[24] This suggests that a psychologist or psychiatrist who has been charged with making an assessment of a person manifesting `occupational impairment', i.e. long-term unemployment, might begin with the assumption that there is a mental disorder present requiring diagnosis.
DSM IV groups the criteria for diagnosing schizophrenia, for instance, into several categories and sets them out in a box. The first group, Criterion A, are concerned with unusual thinking patterns -- like delusions and hallucinations -- and it is necessary to correlate a symptom from this group with one of the indicators from the second group. Criterion B is headed:
"Social/occupational dysfunction.
For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic or occupational achievement)."[25]
In an effort to clarify these indicators the manual declares elsewhere that, "Many individuals [schizophrenics] are unable to hold a job for sustained periods of time and are employed at a lower level than their parents (downward drift)."[26]
While it is evident that it would be incorrect for a person to be diagnosed with schizophrenia for no other reason than being unemployed, at the same time it appears as if participation in the productive/social system, at the expected level, generally offers protection against the diagnosis. A person is allowed to have unusual thoughts and beliefs so long as there is no interference with their ability to function productively. The corollary, which seems to be a growing perception in government circles, is that there is a need to assess LTU people who are not functioning productively, and who are difficult to place in training programmes, in order to determine whether mental illness might be the cause.
The vulnerability of these people to allegations of having schizophrenia is quite real. A LTU person, for instance, who told a psychiatrist that he/she had adapted to his/her circumstances with the assistance of a personal philosophy which justified living on the dole, could quite conceivably be judged to have a delusory belief system. This would almost certainly happen if the person claimed that the ideas had been developed through the agency of an inner voice or a personal deity.[27]
Youth unemployment in Australia has stabilised at a little under 30%. This means that at any given time about 30% of the youth workforce might be said to suffer from the psychiatric symptom of `occupational dysfunction'. The assumed link between mental illness and unemployment is now so deeply entrenched in Australian thinking that the report of the Inquiry into Human Rights and Mental Illness has even promoted the view:
"Unemployment is a particular stressor, both for the mentally ill and those who are at risk of mental illness. It may lead to, or exacerbate depression, anxiety and other mental disorders. The most recent research has indicated very adverse effects on health generally -- and mental health in particular. Recent studies have indicated that more than 50% of unemployed young people suffer from depression."[28]
A recent response to the problem of youth unemployment by the former Minister for Employment was to argue that "the issue isn't whether or not there will be sufficient jobs in the future for young people but whether they have received the right education to allow them to compete for those jobs that are available".[29] This indicates that the former Labor government had given up on the ideal of full employment and was instead deliberately dividing youth into winners and losers. There are no indications that the new Liberal government has any intention of deviating from this particular policy. Within this context it seems that psychological and psychiatric labelling, along with educational shortcomings, are set to become convenient political tools for explaining the `inadequacies' of the long-term losers in the scramble for jobs.
[1] Although this view was developed under the Labor government it seems unlikely to change under the new Liberal government.
[2] Department of Employment, Education, and Training, Working Nation, Australian Government Publishing Service, Canberra, May 1994.
[3] Department of Employment, Education and Training, Annual Report 1994-95, Australian Government Printing Service, Canberra, 1995, pp. 203-206.
[4] Ibid., p. 16.
[5] Ibid., p. 16.
[6] See for example, William H. Sledge, Boris Astrachan, Ken Thompson, Jaak Rakfeldt and Philip Leaf, `Case Management in Psychiatry: An Analysis of Tasks', American Journal of Psychiatry, Vol. 152, Number 9, September, 1995, pp. 1259-1265.
[7] Ibid., p. 211.
[8] Ibid., p. 177.
[9] Department of Employment, Education and Training, Special Intervention Program (SIP) Tender Specification -- Psychological Assessment & Intervention Services, DEET ACT/Illawarra Office, Programs Business Unit , 10 November 1995, p. 1.
[10] Attachment F, Special Intervention Assessment Report, ibid., p. 3.
[11] `General Information About Special Intervention-Employment Related Personal Development Needs (SIP ERPD), ibid., p. 3.
[12] Ibid., p. 2.
[13] Ibid., p. 1.
[14] Frank Wilkinson, Senior Psychologist, Department of Employment, Education and Training, Personal telephone communication, November 28, 1995.
[15] Ibid., December 6, 1995.
[16] Ian Wilson, Programme Manager, Psychological Assessment Programme, ACT/Illawarra Area, Department of Employment, Education and Training, Personal telephone communication, December 15, 1995.
[17] Committee on Employment Opportunities, Restoring Full Employment, Australian Government Publishing Service, Canberra, 1993.
[18] Department of Employment, Education, and Training, Working Nation, op. cit.
[19] Department of Employment, Education and Training, Programs 1995-96, Australian Government Publishing Service, Canberra, 1995.
[20] Department of Employment, Education and Training, Annual Report 1994-95, op. cit.
[21] Ian Wilson, op. cit.
[22] See for example, Thomas Szasz, The Myth of Mental Illness, Hoeber-Harper, New York, 1961. and Schizophrenia: The Sacred Symbol of Psychiatry, Basic Books, New York, 1976.
[23] Thomas Szasz, Cruel Compassion: Psychiatric Control of Society's Unwanted, John Wiley and Sons, New York, 1994, p. 145.
[24] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, American Psychiatric Association, Washington DC, 1994, p. 7.
[25] Ibid., p. 285.
[26] Ibid., pp. 277-278.
[27] The history of ideas is replete with stories of inspiration from inner voices and personal deities. Socrates relied on an inner voice to guide him and the Christian religion was founded on advice and commands emanating from the deity which were received by various individuals. Generally speaking, the modern medical view of a person's relationship with a deity is that it is quite all right for a person to talk to their God in prayer so long as it is confined to a one-way communication of wishful thinking. But if belief is raised to the level where the God is perceived to respond it becomes a symptom of mental disease.
[28] Human Rights and Equal Opportunity Commission, Human Rights and Equal Opportunity Commission, Report of the National Inquiry into the Human Rights of People with Mental Illness, Australian Government Publishing Service, Canberra, 1993, p. 846.
[29] Simon Crean, Minister for Employment, Education and Training, ABC Radio News, 1PM, December 8, 1995.