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Are we spending too much on welfare by classifying people who could work as mentally ill? Politicians may think we are over-diagnosing mental illness but psychiatrists suggest we need to hire more psychiatrists to cure it. The history of welfare shows it has always been contested, but also that we do not need to give people medical labels to provide financial or social support.

There is a heated debate raging in the UK about the benefits bill, which has been rising rapidly, especially among the young. Mental health problems account for the majority of sickness benefit claims, with 80% of young people on benefits claiming for a mental or neurodevelopmental disorder. Politicians worry there is ‘overdiagnosis’ of mental health problems. Alan Milburn, who is leading the government’s review into Young People and Work, warns of a ‘social catastrophe’ and of a ‘generation destined for the scrapheap’.

Outgoing president of the Royal College of Psychiatrists, Lade Smith, responded to this situation on BBC radio by calling for more funding for psychiatry and mental health services.

Smith claimed there is a ‘pandemic’ of mental illness that affects one in eight people, is clearly distinguishable from the mental health challenges we all experience and requires medical treatment. People don’t just get better on their own, she said, as they might with an infectious disease. ‘If you don’t get treated, things get worse’.

Thankfully, she concludes, effective psychiatric treatments are available that can prevent the chronicity that leads to people going on benefits. So people just need more treatment earlier on.

But Smith’s claims may be a pipe dream. At best, psychiatric treatments reduce symptoms by a few points on dubious measurement scales in the short-term. There is no evidence that treatment effects translate into better real-world outcomes or long-term benefits. And rising prescriptions of antidepressants over the last few decades have been accompanied by rising rates of sickness and disability benefit claims for mental health problems.

Moreover, telling people they can’t get better through their own efforts, as Smith does explicitly, and as medical labels and treatments do implicitly, is hardly conducive to lasting recovery. Indeed, research shows that people who are signed up to the medical model have worse outcomes, are more pessimistic about their chances of recovery and more likely to end up on long-term treatment.

As long as there has been welfare, people have worried about the possibility that it will be abused. When the original Poor Laws were introduced into England in the 16th and 17th centuries, they distinguished between the able-bodied and ‘impotent’ poor and the ‘deserving’ and ‘undeserving’ poor.

The impotent poor, that is the sick and disabled, including those with what we would recognise as severe mental disorders, were given unconditional ‘relief,’ consisting mostly of the provision of food and clothes. ‘Relief’ was usually granted on a temporary basis, with the expectation that the mentally afflicted would recover. The able-bodied, 'deserving' poor (those willing to work) were also granted ‘relief’ and were provided with materials for work. The underserving poor — the ‘vagrants’ and ‘vagabonds’ who were unwilling to work — were supposed to be punished.

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Over the succeeding centuries, members of the community who paid for this system through a local tax (the Poor Rate) worried they were being exploited by idlers and shirkers and various attempts were made to tighten the eligibility for ‘relief’. These culminated in the Victorian Poor Law of 1834, which required people to enter the dreaded Workhouse to obtain food and shelter, where they were set to work in a system of harsh discipline. Those who were sick or confused (the impotent poor) were excused from this regime and housed in the Workhouse hospital or the asylum, which, despite its fearsome reputation, was intended to be a therapeutic space where people were treated kindly.

Modern welfare benefits are a bit like the old Poor Laws, providing subsistence for people in the community. Although the system is now funded through national taxation, the same tensions exist.

I agree with left-wing, critical commentators who highlight how modern social and economic conditions drive anxiety, stress and demoralisation and constantly raise the bar for performance and productivity, making it more difficult for people to work. Yet people’s reactions to these conditions are not illnesses (in the usual sense of that term). Conceiving of them as such undermines people’s self-belief and exposes people to unhelpful and sometimes positively harmful medical interventions.

We can afford to be and should be generous and caring in our welfare system, but that doesn’t mean the current situation is OK.

Work can be demanding, exploitative, insecure and stressful, but it also brings financial independence, or a degree of it (many people in low-paid jobs are still reliant on benefit subsidies), which can boost self-esteem and widen people’s options in life. It gives people a role in society and provides structure and social interaction. It is difficult to sustain good mental health when there is no reason to get up in the morning and nothing to stop you spending the day in your bedroom.

We need a framework for welfare and support during times when people are struggling or in crisis that, like the early Poor Laws, does not require them to be labelled as having a medical disorder, with the implications of limitation, chronicity and dependency this confers. As with all such systems, there will need to be a system of gatekeeping to decide who is in need and who is not, something that is never easy. Alternatively, a proper system of universal basic income would do away with the need for selective welfare benefits altogether, and is being tested in the UK.

Most importantly, perhaps, we need to prioritise decent jobs that provide a living wage and accommodate people with varying strengths and abilities. Everyone deserves a chance to contribute and to receive recognition and a fair reward for doing so.

© Psychology Today