About the Author
B. J. Brown is a professor of health communication at De Montfort University, Leicester.
Sally Baker is a research fellow in the School of Social Sciences, Bangor University, Wales.
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Individuals, Health and Policy under Neoliberalism
By B. J. Brown, Sally Baker
Wimbledon Publishing CompanyCopyright © 2012 B. J. Brown and Sally Baker
All rights reserved.
Setting the Scene
The individual has never been more important. In politics, education, the workplace, health and social care, leisure and almost every other sphere of public and private life the individual and his or her capacities are sovereign. Yet this importance and apparent power assigned to the individual is not all that it seems. As we shall argue here, it has gone hand in hand with a subtle authoritarianism that has insinuated itself into the government of the population. In this book we will be considering the 'public sphere' as broadly conceived, but we have a particular interest in health and social care. The trend towards individualism has been identified throughout the body politic in many nations, especially in the 'developed world', yet it is perhaps most conspicuous in health and social welfare, such that a kind of 'governance through responsibility' is enjoined upon the population.
This book documents and questions the current prevalence of individualized ways of thinking and healthcare solutions in contemporary policy in Europe and North America. Physical and mental health are conceptualized as never before as being to do with the individual's thoughts and actions. Yet this is certainly not the only way to think about health and leaves us poorly equipped to conceptualize, for example, the relationship between wellbeing and poverty or the strong connections between social cohesion, social capital and health.
Why This Book? Why Now?
The striking feature of individualism in health and social care policy is that it has colonized so much of the social fabric and so many of the ways in which we attempt to take care of ourselves and one another. This process of governance has expanded by leaps and bounds and is instantiated in far more ways than were envisaged in Nikolas Rose's germinal Governing the Soul (1990). It pervades considerably more of the social infrastructure than the anxieties detailed by Frank Furedi in Therapy Culture (2003) and whilst it is not dissimilar to The Culture of Fear (1997) that Furedi also identifies, we will detail instead how the idealized, responsible individual is constructed. In healthcare, responsible patients are exhorted to ensure that their bodies are managed appropriately in order to merit medical intervention. For a growing range of treatments, their weight must be judged to be appropriate, they must have given up smoking, reduced their drinking, moderated their intake of fats and be taking exercise at a level believed to be optimal. In mental healthcare especially, the role of clients and their carers has recently been invested with additional responsibilities. Clients are responsible for maintaining themselves on medication regimes which are often onerous in terms of side effects, carers are apt to be left to manage crises with minimal support and expressions of disorientation or ill temper may be met with criminal sanction. Those on benefits for incapacity or invalidity are subject to inspection and review to ensure that they meet the increasingly stringent criteria in order to receive money. In the UK they are likely to be harangued into readying themselves for employment by means of cognitive behavioural therapy (Z. Williams 2009). Individual solutions based in psychotherapy are increasingly promoted as remedies for sociopolitical disturbances and collective experiences of conflict such as terrorism.
Individualism pervades the realm of public and policy discourse, especially where health and social care are concerned. Clients who may be at their most abject and vulnerable are urged to take responsibility for themselves rather than further burden the health and social care services. In many healthcare organizations, prosecutions are mounted against clients who have lost their temper or who act inappropriately as a result of their disorientation, under the guise of 'making them take responsibility for their actions'. Citizens on the street are likely to have responsibility thrust upon them through mechanisms such as electronic surveillance and the burgeoning new cohorts of community enforcement officers, local authority officials with powers to issue fixed penalty notices and private security guards, as well as the police themselves.
This book therefore aims to explore the topography of responsibility in the early twentieth century. We undertake this task a few months into a new period in British politics, with the book going to press approximately a year after the formation of a Conservative-Liberal Democrat coalition government, following upon the heels of an unbroken 13-year New Labour regime. Meanwhile, parts of the UK such as Wales and Scotland are securing for themselves increasing financial and legislative autonomy. We will be commenting on what all this means for the formulation and exercise of responsibility. Prime minister David Cameron has regularly promoted what he calls the 'Big Society', a notion which is often hard to define but seems to involve volunteering, civic engagement and enhancement of the social fabric. He is quoted as saying, 'I just profoundly believe that in life we have obligations beyond paying taxes and obeying the law. The Big Society is about trying to create a culture where people ask "What more can I do?"' (Winnett 2011, 12). Responsible citizens are proactive paragons of civic engagement, enhancing the social fabric and selflessly crafting themselves, their families and their neighbourhoods to achieve greater economic independence, social capital and wellbeing. The responsibility agenda has therefore been continued and enhanced with the change of government as further exhortations are added to the menu of duties incumbent on the responsible citizen.
Structure of the Book
Our exploration of individualism and responsibility falls into a further eight chapters. Chapter Two lays out the conceptual tools that we will use. Definitions of individualism and neoliberalism are attempted and their relevance to contemporary political life in Europe and North America are established. We will expound the view proposed by Michel Foucault and popularized by Nikolas Rose that there are specific 'technologies of the self' at work to make up the modern individual, complete with the sense of 'choice' and 'self-determination' that is at the heart of neoliberal politics (Foucault 1980, 1985; Martin, Gutman et al. 1988; Rose 1990). Most discussions of neoliberalism have focused on the economic and political domain, with emphasis on the importance of free trade and the deregulation of markets in favour of corporate interests. Yet equally interesting are the implications for the citizen in terms of what is expected of them under such regimes and more interestingly citizens' images of themselves, as the anchors of state-stabilized institutions are gradually released. The concept of the person as someone who can be self-reliant, flexible and who can cope with the instabilities of the market by continually investing themselves with skills, abilities and preventative measures is one which has a specific genealogy. We shall explore this in Chapter Two in readiness for more extensive treatments later.
In Chapter Three, we explore some of the implications of this new age of responsibility in healthcare. Whilst the state has undertaken a withdrawal from many of the postwar consensus technologies for ensuring the health of its citizenry, this has been supplanted by a growth in discourse which places the responsibility for welfare squarely in the hands of citizens themselves. This has operated not so much through coercion but through exhorting citizens to undertake a variety of personal disciplines to manage themselves, arranging their bodies, minds and lives around the expert advice dispensed by public health bodies and government agencies. Especially for those citizens deemed to be vulnerable or 'socially excluded', notions of choice and responsibility are often accompanied by legislative frameworks through which their conduct can be regulated or normalized, and it is frequently supposed that a person's vulnerabilities arise as a result of poor personal decisions or bad habits. It is these that are often the focus of epidemiological investigation and government concern in the contemporary era.
Chapter Four delves deeper into the processes of responsibilization in healthcare, where patients and clients are being seen increasingly as rational consumers of healthcare services who are also charged with managing themselves as a potential source of risk. The risks we face are increasingly seen as personally embodied and susceptible to our participation in screening programmes, despite limited epidemiological evidence of their effectiveness. The subjective space inside the patient's or consumer's head is carved out as a realm for intervention and as a driver of the healthcare enterprise itself. Within this kind of regime, individual cognitive capacity is theorized as a key factor in wellbeing, compliance with expert advice and responsibility itself. The reach of responsibilization extends also to individuals who might, in earlier times, have been looked after entirely by statutory services, but are now being encouraged into a new brand of entrepreneurship as contemporary welfare regimes 'empower' them to organize and pay for their own care services.
In Chapter Five we will explore the notion of responsibility as it is manifested in mental healthcare. Frequently we have found that distressed people are urged to take responsibility, even when they are in hospital involuntarily. This highlights with particular acuity some of the tensions within the concept of responsibility. On the one hand, the individual is not responsible, which is why they were hospitalized, yet on the other they have responsibility thrust upon them. This is also to be seen in cases where people with mental health problems find their way into the criminal justice system, such that their disorientation, distress or disability is met with criminal sanction. Increasingly, therapeutic regimes in mental healthcare are impressing on clients that it is their responsibility to want to get better and their responsibility to do so under their own steam. The discourse of self-determination has grown strong in mental healthcare at the same time as the scale and variety of services available has, arguably, grown smaller.
Chapter Six pursues the notion of responsibility as it has been manifested in psychotherapy. A great many leading figures in twentieth-century psychotherapy have extolled the process of taking responsibility as an essential accompaniment to change. In some psychotherapeutic systems, any perceived limitation imposed by the outside world is reconfigured as the responsibility of the individual who perceives it. The individualism and preoccupation with personal wellbeing in contemporary policy is not imbibed directly from mid-twentieth-century American psychotherapy of course, but it has become part of the conceptual fabric which is readily drawn upon in the formulation of the citizen's duty to be well.
Chapter Seven explores an additional aspect of the process of responsibilization, namely what Garland (2001) has called the 'new punitiveness' and the novel ways in which recent governments have formulated and implemented a powerful range of civil and criminal sanctions which may be applied to the populace in the quest to encourage and enforce responsibility. Not only is there an impulse towards incarceration itself, but a variety of measures are activated to manage 'anti-social behaviour' in communities, residential areas and public spaces. These do not always spring from a strong democratic mandate, but in many cases it appears that the impulse to management and regulation has a momentum all of its own.
Chapter Eight delves further into what all this means for the conception of the self that is encouraged by the proliferation of responsibilities that are urged upon the individual. Whilst Giddens (1991) and Beck (1992) characterized the present era as one of reflexive individualism, it is clear that this has arisen as a result of a variety of processes with a much longer pedigree. The individualism of Protestant theology allied to the movement towards detraditionalization are believed by many authors to have prompted the present day preoccupation with crafting a lifestyle and identity. Telling one's story and confessing come to the fore in a variety of secular contexts, including the process of presenting oneself as an individual, as a kind of 'research' in academic contexts and as a source of continuity between fragmented experiences of work and transient relationships. Moreover, the individual is urged by a variety of media — self-help literature, popular advice from experts and even talk show hosts — that 'opening up' is somehow beneficial. Moreover, a good deal of popular advice is directed towards lowering expectations of material advancement and instead focusing on the inner rearrangement of values to secure 'fulfilment' or 'resilience' for the individual.
Taken together, these processes encourage the citizen to be self-fulfilling and self-developing almost as if this were a social obligation, as we argue in Chapter Nine. The obligation to self-development as part of citizenship has been underscored by David Cameron in his 2010 party conference speech. Equally, the coalition government has embraced the notion of 'nudging' people toward expert-approved, politically expedient modes of conduct, following Thaler and Sunstein's (2008) book of the same name. The responsible citizen is not one who can genuinely claim autonomy, but rather one who conducts himself or herself as directed or nudged by a variety of experts and government agencies. As Hunter (1996) presciently claimed over a decade and a half ago, this is the era of the 'pedagogical state' and our task as citizens is to manage ourselves according to this instruction. In tandem with this, there has been a withdrawal on the part of public agencies from fields which might, under the old welfarist model, have been collective, rather than individual responsibilities. Rather than heal us when we become sick, health services are likely to see their role as dispensing 'healthy living' advice. In the event of tragedies in child protection or social care, subtle shifts in accountability are undertaken so that it is the clients themselves who bear the responsibility. Practices of audit, inspection and review, ostensibly to enhance accountability and value for money across a variety of public services, have gone hand in hand with a shrinkage in the range and variety of problems which public services can tackle. Accompanying this is a sense of what Hirschorn (1997) has called 'market risk', such that practitioners no longer feel confident in their own capabilities in the face of the liabilities involved in their practice.
Thus, a picture emerges of contemporary citizens who are urged to be responsible yet at the same time to rely on expert guidance, education and nudges, governed by legislative frameworks that are apt to be punitive and who are encouraged to think of themselves as vulnerable and in need of assistance. This brings the citizen into a new kind of relationship with him or herself — a relationship that is mediated by expertise or by the state itself.
Of course, the citizen is not always compliant in the face of the sheer minatory power of the state or of expert advice. Educators and policymakers are almost always disappointed by the uptake of advice, whether this be to do with eating fruit and vegetables, participating in health screening programmes, becoming volunteers, taking exercise or clearing up after their dogs. The penetration of these practices is always incomplete. Yet the significance is in the new ways that they afford of conceptualizing citizens, or of thinking about ourselves in relation to assemblages of expertise, processes of governance and society itself.
Nor should we see an authoritarian conspiracy at work every time a doctor advises a patient to give up smoking, a housing officer tries to get tenants to keep the noise down, exasperated neighbours call the police about rowdy teenagers or politicians, frustrated at the intractability of economic problems, urge us to concentrate on self-fulfilment instead. Taken separately, these are relatively banal everyday incidents. Yet collectively, across a variety of sites and a myriad of occasions, we would argue that they add up to something more. Rather than an authoritarian conspiracy, this perhaps reflects what Nikolas Rose (1999) and before him Michel Foucault (1990) would see as the 'capillary' nature of power. The practices are locally implemented and are true in a much more particular sense than if they resulted from the imposition of some wide ranging ulterior fiat. As Rose's collaborator Peter Miller describes in his work on what he calls the 'calculating self', the continual process of evaluation, economic reckoning and self-measurement peculiar to the modern age goes hand in hand with the shaping of subjectivity or forms of personhood (Miller and Rose 2008). This provides new possibilities for acting on oneself and on the actions of others.
Excerpted from Responsible Citizens by B. J. Brown, Sally Baker. Copyright © 2012 B. J. Brown and Sally Baker. Excerpted by permission of Wimbledon Publishing Company.
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Table of Contents
Acknowledgements; Preface; 1. Introduction; 2. Individualism, Neoliberalism and the Imperatives of Personal Governance; 3. Individualism in Healthcare; 4. Enlisting, Measuring and Shaping the Individual in Healthcare Policy and Practice; 5. Mental Health and Personal Responsibility; 6. Responsibility in Therapy and the Therapeutic State; 7. The Punitive Turn in Public Services: Coercing Responsibility; 8. Thinking about Ourselves; 9. Talking Citizenship into Being; References; Index
What People are Saying About This
‘Brown and Baker have produced a vital study of the central place of the responsible individual in the contemporary remaking of public services. They brilliantly demonstrate how the idea of responsibility is the link that connects the image of the wisely choosing citizen-consumer, the coercive enforcement of responsible behaviour, and the punitive sanctioning of those who fail to act responsibly. In these austere times, their work illuminates how the championing of responsibility licenses the turn to authoritarian measures.’ Professor John Clarke, The Open University