The classic liberal position is that stated by John Stuart Mill:
The only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or mental, is not a sufficient warrant. He cannot rightfully be compelled to do or forbear because it will be better for him to do so, because it will make him happier, because, in the opinion of others, to do so would be wise, or even right.
However, in the general interpretation of this principle there is a small problem and a big one. Anti-state libertarians often forget that Mill aimed his injunction not just at Government – as if often imagined – but also at constraints on action imposed by the private sector and by social norms, which complicates things substantially. More fundamentally, it turns out in practice that the distinction between behaviour that only has an impact on the individual and behaviour which has social externalities is rarely clear cut. One example is car seat belts. Of course, it is the person who goes through the windscreen who suffers most from not wearing a belt but there is also a much weaker but much wider impact in terms of the cost to us all from resulting NHS care and higher car insurance.
One of the most fundamental of freedoms is free speech. Here it is generally thought that the right to speak one’s mind is much more important to protect than the right not to be forced to hear things which may be construed as offensive. Nevertheless, there have been many ways in which freedom of expression has been constrained, historically in relation to decency and blasphemy, more recently in relation to attacks on racial and religious groups. Some progressives – among whom I am one – worry that we may have gone too far in protecting the feelings of groups at the expense of individual freedom of speech.
Now, some new and disquieting research adds an extra twist to the debate. The study conducted by two professors at the University of Wisconsin explored the impact of comments made in response to an on-line scientific article about the risks of nanotechnology. Here are their findings in a nutshell:
‘The results were both surprising and disturbing. Uncivil comments not only polarized readers, but they often changed a participant’s interpretation of the news story itself.
In the civil group, those who initially did or did not support the technology — whom we identified with preliminary survey questions — continued to feel the same way after reading the comments. Those exposed to rude comments, however, ended up with a much more polarized understanding of the risks connected with the technology.’
This was as small study and focused on a subject on which the respondents has little prior expertise (although it was also found that scientific knowledge didn’t act as a barrier to what the researchers call ‘the nasty effect’), but the idea that angry and abusive messages are more influential is clearly worrying.
This may be another example of how our actual responses defy what we would like our reactions to be. Writing on the day of Prime Minister’s questions, there is an obvious resonance with political campaigning. I remember years ago as an idealistic and naïve researcher with the Labour Party talking over a proposed campaign with a senior politician. I was about to caution against an approach which focused on attack. I said something like ‘The thing about negative campaigning’, meaning to end with ‘it turns off voters‘, but before I could finish she butted in; ‘the thing about negative campaigning is, Matthew, that it works’.
Our inconsistency is not surprising. Our basic human reactions evolved in a world before advertising and PR. In this world of authentic communication extreme reactions would be an indication of extreme feelings which would often be an accurate warning of danger. Also, parents will socialise children to assume that ‘don’t touch that’ screamed as the infant reaches wet fingers towards a plug socket is more important that ‘don’t do that darling’ soothingly uttered as she tries to dip her fingers in the trifle.
Whilst we might consciously dislike abuse and name calling, emotionally we react on the basis that it is likely to indicate real threats. This chimes with the way the abusive comments about a balanced article about nanotechnology increased people’s perception of the risk of that technology.
But back to freedom of expression; while I am not for a moment calling for any legal constraint on people’s right to express anger and strong opinion perhaps we should encourage stronger social opprobrium on the grounds that such expressions aren’t just the business of the person expressing them but impact on the ability of their rest of us to offer and hear more calmly expressed views. Also, when it comes to structured contexts such as debates, public consultations and on line comment spaces, the research suggests that as well as constraints on things like the time a speaker has, the maximum length of a comment, and prohibitions on slander and obscenity there are grounds in common good for strong guidance on the manner in which people express their views.
I’d be very interested to hear readers’ opinions – politely expressed, of course.
A society’s capacity for providing care (which, as one reader pointed out to me, is not the same as how much it cares) can be seen as a diamond comprising the market, the state, close family and the wider community.
Thinking about how to generate more and better care involves looking at how we might increase the contribution from each source but also thinking about the relationship – sometimes additive sometimes subtractive – between them.
Care funded by the state is perhaps the most straightforward to analyse in the sense that it is fully stretched and it is difficult to see any significant increase in capacity in the foreseeable future. In terms of the overall pattern, the last decade has seen an increase in state support for child care (although under the Coalition it has been a case of swings and roundabouts as the child care element of tax credits has been reduced but the entitlement to nursery provision has increased). In relation to adults and older people, some national care-related entitlements have been tightened while at the local level provision is now limited to the most needy.
The market for care is also very stretched. The private provision of care is expanding in line with need but in all domains of care there is a major affordability gap between what the market can offer – even paying rock bottom wages – and what most people can afford. Austerity is also putting ever greater pressure on the publicly funded aspects for private care. For example, there is a growing gap between the cost the private sector charges self-funding clients of residential care and what it is able to charge increasingly cash strapped local authorities. Coalition ministers had expressed the hope that the implementation of a new long term care funding framework could create an opportunity for a new care insurance market to emerge. But such hopes have been expressed – and dashed – before.
When it comes to families the top line is that informal familial care is the bedrock upon which the whole societal care system rests. On the one hand, nearly all parents enthusiastically provide loving care for their children; on the other, a recent ONS analysis of the 2011 census estimated the total weekly provision of informal adult care in England and Wales at 3.4 million working days (up substantially on ten years ago). In rough terms, valuing an hour of unpaid care at the minimum wage level this means that unpaid care is worth about £170 million per week or about £8.5 billion per year. In fact the value is much greater as those cared for at home are also being housed and fed by their loved ones.
Arguably the problem of informal care by families is oversupply. While parental negligence and ‘granny dumping’ is still very rare, some care, both for children and adults, is not as good as it could be if informal provision was mixed with formal care. Vitally for the economy, levels of employment of mothers and people over fifty are lower in the UK than many other advanced economies. The need to provide care and the costs of buying it are the crucial factor inhibiting mother’s employment and an increasingly important factor keeping older people from full time employment.
This leaves the fourth point of the diamond, the community. We might define this as the contribution voluntarily made by people other than close family to the provision of care. This primarily comprises volunteer time but other contributions include money (in the form of philanthropy), the provision by employers of flexible working and, more generally, the framework of norms and values which shape the status of caring and the degree to which we see it as a collective responsibility.
In relation to this aspect today sees two contrasting contributions. This Guardian piece from Erin Mee http://www.guardian.co.uk/society/2013/feb/26/care-workers-plea-older-people-lonely underlines how much unmet need for even for the simplest forms of care there is lurking in every community. NESTA has today published a new report on a system response to , the Endowment is also calling for new ideas for its website celebrating innovative responses to ageing .
As NESTA says, many innovations can work alone and do not require or benefit from a system wide approach. But, as the report also says, despite lots of activity and concern about ageing social innovation is lagging behind technological innovation and we have a very fuzzy idea of what actually works, which is perhaps why we need to shift our whole orientation. But if we do need to look at the system, what is the system? Is it the system of ageing, the system of care, or more narrowly the system of older care and the system of child care?
My feeling now is that, firstly, there is something essential to the human activity of providing all forms of care, and, secondly, there are common issues and dilemmas in the mixed systems of care which apply to children, adults and elders. This is why it is caring which should be the focus of our system view rather than a particular demographic group.
But, as is always the case when I start thinking in earnest about my annual lecture, I may well change my mind several times before I reach any kind of conclusion.
Did my isolated upbringing stop me becoming Prime Minister? As I traipse from party conference to party conference for (actually rather good) RSA events, I am reminded of how important a skill it is for politicians to be able to remember a good proportion of the hundreds of Party activists who know them.
Sadly this is a skill I lack. This was brought home to me when writing Monday’s post about the evolutionary foundations of human motivation. In it I mentioned research on the evolution of leadership and followership undertaken by Professor Mark von Vugt.
It is a great thing nowadays that having identified an interesting academic one can often find lectures by them on the internet. So a few days ago I entered ‘Mark von Vugt’ into Google and pressed the video link. I was delighted to see that the first lecture to appear took place last year here at the RSA. The problem was the identity of the chair of the event – me!
I have always been very bad at remembering faces and names (interesting how these nearly always go together). It seems this affliction is getting worse. I have tended to attribute my failing to three possible explanations: one self serving, one self critical and one neutral. Perhaps it is because I give lots of lectures and perform from time to time in the media that more people know me than I know. This doesn’t however explain why I have forgotten chairing an event and conducting an interview with a fascinating academic only a year ago. Maybe, my frailty is a reflection of my arrogance and self obsession; whoever I meet the most memorable person in the interaction is always me. Or is it a genetic flaw?
My father is just as bad. Indeed one of his former wives (yes, I know) used it as a punishment. Normally, when she saw the telltale signs of non-recognition on Laurie’s face after he had been enthusiastically engaged by someone who seemed to think themselves a good personal friend, the agreed procedure was for her to break into the discussion, look at the interlocutor and say ’Hi, I’m Laurie’s wife, I don’t think we’ve met’. But if Laurie made the mistake of leaving the house in her bad books she would change her approach, looking at her husband and playfully saying ‘Laurie, I don’t think I’ve been introduced to your friend…’
On reflection I have opted for a different explanation. For a variety of reasons I had a pretty isolated childhood. Not only do I have no brothers, sisters or cousins and only one grandparent who was much involved in my upbringing, but my folks moved around the country in my early years and had little scope to build up a close circle of friends. Nurture rather than nature may also explain Laurie’s failing – although he did have siblings they were younger and my father has also told me his parents rarely invited friends into their home.
In our modern service economy a good memory for faces and names can be a vital quality (arguably of much greater value than much of what children are taught at school). And networking skills are important to everything from being a good citizen to – as I say – succeeding in politics. The hypothesis is that children with smaller social circles in their early years (say, between birth and three years old) develop weaker faculties for interpersonal recall.
Here indeed is a neat research project for a student doing a psychology masters: choose a sample and give them a questionnaire and a test, the former covering their childhood and the latter testing their recall. If my theory is right there will be a strong correlation between the size of the infant’s social circle and later aptitude.
If this proves correct there will be a case not only for strongly encouraging parents to bring their infants into regular contact with a group of other people, but also for developing corrective interventions to strengthening the frail memories of the more isolated.
But, much more importantly, it will prove (a) that my failure to become a successful politician was not due to a lack of effort or talent and (b) nor, as it as widely alleged, am I rude, self obsessed and arrogant. Instead, I will be rightly seen as the innocent victim of a deprived childhood who has battled bravely in the face of almost overwhelming odds.
Indeed, this is just what I told an old student colleague of mine who approach me recently in Asda. Now, what was his name?
In my recent annual lecture I made the case (drawn from Cultural Theory) for distinguishing three fundamental sources of social power; hierarchical authority, solidarity and individual aspiration (whilst also recognising fatalism as the expression of a real or perceived absence of social power). It is an idea which raises many questions, one of which is why these drivers of behaviour are paramount. One possible answer lies in evolutionary psychology; the search for the foundations of human thought and motivation in the circumstances of our species’ evolution.
Debates about human evolution can be both technical and controversial, which makes life difficult for the interested lay person. For example, while I instinctively back the group-selection arguments of David Sloan Wilson and EO Wilson over the selfish gene perspective of Richard Dawkins I couldn’t pretend this is a judgment based on understanding the science or maths of either position.
The evolutionary corollary of my argument is that individualism, solidarity and hierarchical authority reflect the importance, respectively, of self-interest, reciprocity and leadership/followership as necessities for the survival and development of the human race.
On the one hand, this implies support for the view that the interests of the group may have been as important and fundamental to our evolution as individual (or genetic) survival (thus the innate capacity for solidaristic feeling). On the other hand, it introduces a third dimension. Backing for the latter is offered by the work of Mark van Vugt who makes the case for leadership and followership being distinct traits and essential to the evolution not just of humans but of all species which require some kind of collective organisation.
Supporters of reciprocity as an independent and essential trait (ie not just a by-product of individual survival strategies) point to evidence such as the ultimatum game, or surveys finding apparently universal ethical instincts, to make their case. Similarly, von Vugt highlights studies showing how we follow leadership even when there is little or no obvious benefit from so doing.
So it seems there may be evolutionary grounds for giving a special explanatory status to the typology; hierarchy, solidarity, individualism (and fatalism). Choosing this framework invites us to reject or seek to amend other typologies. For example, last week David Priestland spoke at the RSA about his typology of soldier, merchant, sage and worker. While there are clearly overlaps between the two frameworks (individualism/merchant, sage/solidarity, soldier/hierarchy) the ambiguity over the idea of caste (which David himself recognised at the event) left me preferring to focus on shifting ways of thinking and acting rather than fixed social status or role.
One interesting parallel with Cultural Theory lies in Freud’s structural view of the psyche in which the id is equated with individual survival/appetite, the ego with hierarchical rationality and the super-ego with solidaristic duty. Fatalism could also be linked to the Freud’s idea of the death drive.
But even if the case is made for my preferred typology, questions remain over its explanatory and practical value. The universe is made from a small number of basic particles, but not only is this knowledge of limited everyday value but to talk about objects in terms of their sub-atomic make-up would be deeply unhelpful in almost all practical circumstances.
One of the subtleties of Cultural Theory (or at least my interpretation of it) is its fractal nature. So, for example, in an organisation which is dominated by hierarchical models of change there might be a group of people articulating a solidaristic critique, but within this group there may be someone arguing for an individualistic form of resistance. Yet all the people involved in this social drama are themselves capable of favouring any of the four predispositions depending on the circumstances in which they find themselves (thus the most hierarchically minded person at work may be a champion of solidarism in their community).
But this subtlety also adds to complexity and makes it more difficult to apply the framework formulaically in any setting. At this point the theory feels to be less a set of rules and more a form of sensitivity towards, and favouring of, a particular pattern (of motivations and drivers). At this point the boundary between reasoned analysis and aesthetic appreciation starts to blur, something which was I guess implied in my lecture when I described using a design rather than a policy making mind set to explore social problems and solutions.
As a panellist on Moral Maze tonight (Radio 4, 20.00) I will be discussing some of the implications of a recent LSE report on mental illness and treatment in the UK. I am looking forward to the programme, but with some trepidation, as I find myself ambivalent about both the report and the issue in general.
There is good evidence of high rates of untreated mental illness in the UK. The LSE report suggests six million adult sufferers from depression and anxiety conditions, plus 700,000 children with these conditions or other problem behaviours, but that only a quarter of each group is being treated. The links between mental illness and both physical impairment and low life satisfaction also seems strong. And the Cognitive and Behavioural Therapy (CBT) intervention promoted in the LSE report has three strong benefits: apparently impressive success rates, relatively low costs and (unlike drug therapies) few potential adverse side effects.
My interest in the science of brains and behaviour also inclines me to believe all of us need to be aware of our cognitive frailties and to recognise how easy it is to fall into ways of thinking and acting which are bad for us (and for those around us).
So, why the ambivalence? One concern is the flip side of the LSE’s evidence about prevalence. If getting on for one in five adults and one in ten children suffer from mental illness, what does this mean for the divide between normal and ill, and what does it tell us about wider society?
CBT is often combined with drug therapies and the view that a sustained feeling of sadness, anxiety, inadequacy or over-stimulation should be seen as a medical condition requiring treatment is one which has been pushed long, hard and very successfully by the pharmaceutical industry. Yet, remarkably, the theory on which most drug treatments are based – that moderate mental illness is caused by a chemical imbalance in the brain – remains unproven. The drug industry uses the fact that some people get better after being given brain altering chemicals as evidence, but this is like saying a headache is caused by an absence of aspirin. Furthermore in relation to the major growth areas for diagnosis and treatment, there continues to be an absence of evidence for drug interventions being more successful than placebo with side-effects.
As the LSE report does not discuss drugs I don’t know its authors’ views about this kind of treatment. But its medical model suggests that if the chemicals did work, the authors would be reconciled to nearly one in five of us taking them.
On occasion, the LSE report seems closer to advocacy than objective research. A core argument is that mental illness is more curable than long term physical conditions. To an extent this depends on what we mean by curable and whether the aim of an intervention is to cure or to enable the patients to manage their illness, but the claims made in the report for CBT also rely on some hiden assumptions.
The summary (and press release) state:
‘…..the costs of psychological therapy are low and recovery rates are high. A half of all patients with anxiety conditions will recover, mostly permanently, after ten sessions of treatment on average. And a half of those with depression will recover, with a much diminished risk of relapse. Doctors normally measure the effectiveness of a treatment by the number of people who have to be treated in order to achieve one successful outcome. For depression and anxiety the Number Needed to Treat is under 3. In the government’s Improved Access to Psychological Therapy programme, outcomes are measured more carefully than in most of the NHS, and success rates are much higher than with very many physical conditions’
By definition chronic diseases cannot be cured so it hardly surprising that mental health interventions achieve a better rate or recovery. But when assessing the long term cure rate for CBT (about 30%) we have to include two factors which much less often apply to long term physical illness: over-diagnosis and the scope for recovery without treatment.
In relation to the former, while most chronic conditions are diagnosed through objective physiological or chemical tests, mental illness is based more on subjective reporting. Also, there are various work and benefit-related incentives for people to seek a medical diagnosis. Furthermore, while few people want an unnecessary physical treatment many people (whether or not they are ‘ill’) might welcome the structured advice offered by CBT.
In relation to recovery, one of the many continuing imponderables about mental illness – including quite acute problems – is the course of illness. Unlike chronic physical conditions, many people seem to get better naturally (or find an effective way of coping without treatment), and avoid future episodes.
If we were to assume that one in five diagnoses of mental illness was inaccurate and that, say, one in ten treated patients would have got better anyway (a conservative estimate), and if we assume that these two groups are likely to be over-represented in the 30% for whom CBT ‘works’, then the implied level of efficacy falls dramatically.
The slightly clumsy use of statistics in the report stirs my other concern. I am currently reading Robert and Edward Skidelsky’s book ‘How much is enough – the love of money and the case for the good life’ (I am chairing father and son here at the RSA tomorrow). As the book makes clear, millions of us work longer hours than we need to primarily to buy goods which we then consume in a compressed leisure time which is much less satisfying than it could be if we had a different outlook on life. Such behaviour could be portrayed as a form of collective madness (particularly when – notwithstanding the ‘lump of labour’ fallacy – a better distribution of work would be good for economy and society). How many of the six million adults and 700,000 children are ‘mentally ill’ directly or indirectly as a consequence of these dysfunctional social norms and patterns?
We don’t respond to obesity primarily by demanding mass liposuction but by focusing on the social and economic factors which seem most likely to be fostering over-eating. Although Richard Layard – the driving force behind the LSE report – has a distinguished record in promoting debate about the wider social conditions for happiness and wellbeing, the publicity attached to his report directs attention to an individual medical answer rather than a wider inquiry into why modern living makes so many people so sad and worried.