The inestimable Ben Goldacre worries that doctors might be culpable in “medicalising a social problem”:
There are 2.6 million people on incapacity benefit today, after all, the largest single group of workless people, and every practical aspect of their lives, their housing, their income, their social role, is founded in an ongoing belief in themselves as incapable people, sanctioned by doctors. We haven’t really researched what the consequences of that will be.
Indeed we haven’t (and it would be tricky to get an RCT past the ethics committee). Still, we might hazard a guess that they won’t be too positive. Having a sense of oneself as autonomous and capable is a critical component of experienced well-being; the converse, enduring low self esteem and feelings of worthlessness, are well-established risk factors for mental health difficulties such as depression. Given that around 40% of people on incapacity benefit got there in the first place because of just these kinds of problems, there seems to be every possibility of vicious circles forming.
But Ben might be blaming himself, or at least his profession, a little too much here. The broader thing to notice in the debate about incapacity benefit is how the notions of “capacity” and “being in paid work” have become tacitly synonymous. Because we fail to value unpaid and voluntary activities, the only kind of contribution that the welfare system recognises as worthwhile is having a full-time job. The result is that we end up sorting people into black and white categories: those who can work (the “capable”) and those who can’t. This is deeply unhelpful, not just because of the potential impact on them as individuals but also because of the sheer waste of talent and ability.
A simple change of terminology would be a good start – just because an illness or disability limits your ability to do some kinds of work, this does not render you “incapable”. But in the longer term a smarter system, based on principles of co-production and a much more thoroughgoing concept of “value”, would surely be better for everyone concerned. nef‘s recently launched report on timebanking, a system in which people’s contribution to helping each other or an agency is valued at 1 hour = 1 credit, offers an alternative way of valuing people’s skills and knowledge. Timebanking has been particularly effective in enabling people with mental health problems to contribute to society (not least by helping in each others’ recovery) outside the sphere of the market.