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Modern British History

PIP, Parity, and the Past: why history matters

L0006105 String galvanometer and human electrocardiogram

Few would deny that living with a mental health condition today often means living with stigma, limited support, or access to services. It has also become recognized that these issues do not affect people living with a physical health condition in the same way, thus leading to calls for ‘parity of esteem’ from charities such as Mind. [1]

Parity of esteem is best understood as valuing mental health equally with physical health, and in 2015 a government taskforce was created to achieve this. [2]

Nonetheless, disparity was recently brought into sharp focus by researchers at the University of York, who revealed significant differences in the allocation of Personal Independence Payment (PIP) to people who have a mental health condition, in comparison to people living with physical health conditions such as diabetes.[3]

PIP was introduced as part of the 2012 Welfare Reform Act, and supports people aged 16 to 64 who are living with long term health conditions or disability. [4]

York researchers cited the “informal observation” of appearance and body language in order to make decisions regarding eligibility as a potential cause of this disparity.

Nonetheless, history provides useful insight when attempting to understand how, rather than just why, such disparity between the mental and the physical may emerge in welfare contexts.

This is exemplified by the work of Rhodri Hayward, who traced the emergence and uses of the concept of the ‘unconscious’ in early twentieth century British primary healthcare. [5]

In this comprehensive book, Hayward’s focus on how the unconscious facilitated the interrogation of insurance or compensation claims in the wake of early twentieth-century welfare legislation, is particularly compelling.

Hayward defined the unconscious as the belief that there is “some sort of inner agent which records our experience and organizes its embodiment” which is beyond our control. [6]

In the early twentieth century, the passage of the Workmen’s Compensation Act (1897, 1900, and 1906), and the National Health Insurance Act (1911) offered a new scheme of sick pay and remuneration for the working population of Britain. These welfare policies set in motion significant changes in primary care. In the doctor/patient relationship the interests of the latter changed, as they became a claimant seeking financial compensation or insurance, not just medical treatment.

This legislation thus also stimulated a wave of insurance and compensation claims from the working population. Contemporaries lamented the economic and social implications of this increase, highlighting that a situation had been created where “any experience of sickness was bound up with the possibility of unearned reward.” [7]

The unconscious was vital to navigating and disciplining these complexities, and identifying malingerers. Crucially, the use of this concept allowed claims to be assessed without creating an oppositional relationship between the doctor and the claimant.

Moreover, contemporary medical professionals identified the group of “unconscious malingerers” whose “symptoms may be founded on fact, but are mostly imaginary.” [8] Such claimants continued to seek compensation long since their “real physical disabilities” had disappeared. [9]

Technological developments in electrophysiology facilitated the interrogation of a claim, as by detecting electrical currents produced by the heart, the ‘galvanometer’ was believed to reveal the “unspoken attractions and intentions of an investigative subject.” [10] In becoming quantifiable and measurable, the acceptance and use of the unconscious were solidified.

Hayward also sheds light on the place of the unconscious today, as he suggested that we may now have entered an “age of cosmetic psychiatry”, where psychological health is understood as within our control. [11]

In this new age, we are encouraged to shape our identities through an eclectic package of pharmaceutical and therapeutic treatments such as anti-depressants or mindfulness courses.

If we accept this shift, it is important to question what psychological concepts have or will replace those such as the ‘unconscious’ as a means of understanding the health, characters, and lives of others and ourselves. It is moreover useful to consider how these concepts may operate, discipline, or discriminate in a welfare context, such as a PIP assessment.

In his work, Hayward demonstrated how the unconscious shaped insurance and compensation administration. Married with new language and developing electrophysiological technology, this concept supported the interrogation, investigation, and assessment of claimants, and most importantly, the detection of malingerers. The acceptance and meaning of the unconscious was in turn shaped and reinforced by the language and practice which grew up around it.

By analyzing the use of this concept, Hayward demonstrated that it is possible to grasp why some people were granted insurance or compensation, and why others were not. His contentions and approach are therefore useful when trying to understand the current enduring and damaging disparity between mental and physical health, which has been highlighted by researchers and evidenced in PIP assessments.

Hayward’s work provides us with a useful template to analyse how, and therefore to understand why, people with mental health conditions are currently losing their welfare entitlement to PIP. His contentions should force us to question how current psychological concepts continue to facilitate and shape the decision-making process and outcome for PIP claimants, and whether these concepts have a role to play in disparity.

There are no simple answers to why parity of esteem continues to be so elusive in practice. This blog hopes, however, to have presented some useful tools to begin to ask the right questions.

Kate McAllister is a first year PhD student at the University of Sheffield’s Department of History. Her research is funded by the Wellcome Trust, and aims to contextualise the current parity of esteem agenda, demonstrating that although this concept has shaped policy for over a century, implementing it in practice has recurrently failed. To navigate the complexities of this issue, her thesis focuses on the outbreak of Epidemic Encephalitis in Sheffield during the 1920s and 1930s.

 

[1]https://www.mind.org.uk/information-support/your-stories/valuing-mental-and-physical-health-equally/#.XFVyJS10dQI

[2]https://www.england.nhs.uk/mental-health/taskforce/

[3]https://www.theguardian.com/society/2019/jan/22/mentally-ill-people-more-at-risk-losing-benefits-study-shows

[4] https://www.gov.uk/government/publications/2010-to-2015-government-policy-welfare-reform/2010-to-2015-government-policy-welfare-reform

[5]Rhodri Hayward, The Transformation of the Psyche in British Primary Care, 18701970, (London: 2014)

[6]Hayward, Transformation of the Psyche, xi

[7]Hayward, Transformation of the Psyche, p.37

[8]Hayward, The Transformation of the Psyche, p.36

[9] Hayward, Transformation of the Psyche, p.36

[10]Hayward, Transformation of the Psyche, p.42

[11]Hayward, Transformation of the Psyche, p.130

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Why Study the History of Child Abuse and Infant Death?

Basinet

Content Note: death of infant children, child abuse, wrongful imprisonment.

Fifteen years ago today (December 10th 2003), Angela Cannings walked free from court, after over a year and a half in prison. She had initially been convicted of murdering two of her own children. Jason died in 1991 (aged seven weeks) and Matthew in 1999 (aged 19 weeks). The prosecution alleged that she had smothered them to death. Cannings consistently maintained that their deaths were from natural, but medically unexplained causes. Both convictions were quashed on appeal. The key issue was whether the deaths of the children were simply two instances of what is known colloquially as ‘cot death’ (Sudden Infant Death Syndrome (SIDS)), or of deliberate smothering.

The case was bound up in many ways with questions of expert evidence in court, especially that of (then) eminent paediatrician Professor Sir Roy Meadow. He had described a rare form of child abuse that he named Munchausen Syndrome by Proxy (MSbP) in 1977. In MSbP children have illnesses faked or induced in them by one of their parents or caregivers, who are supposed to be doing it for attention, or some form of recognition. It is now known as Fabricated or Induced Illness (FII) by Proxy. Meadow became an authority on child abuse and infant deaths and his testimony was used in legal cases for the prosecution in the 1980s and 1990s. His shift from looking at prolonged fabrication of illness to SIDS has been covered elsewhere.

The quashing of Cannings’ convictions followed the quashing of a similar conviction for baby murder of Sally Clark in January 2003, and the acquittal of Trupti Patel in June of the same year. All three cases had featured Meadow’s evidence.

One of the interesting things here for historians of childhood and child abuse is how different explanations for child death, illness or maltreatment emerge in historically specific ways. Meadow’s 1977 naming of MSbP emerged from hospitals, and many of his cases were based upon repeated presentations of unexplained severe illness episodes. Cases would present and re-present over months or years, with huge numbers of tests being ordered to no avail. Eventually suspicion fell upon the mother, who normally in these cases ‘lived in’ hospital with her sick child, rarely leaving their side. Typically, in the early literature, when the mother was excluded from the hospital, symptoms subsided, and the child became well again. The inference was then drawn that it was the mother causing the symptoms.

In the aftermath of the Clark, Patel and Cannings cases the tide of public opinion turned against the very idea that mothers might harm or kill their children in this way. In January 2004, Government Children’s minister Margaret Hodge questioned “whether this is a proper diagnosis”; opposition health spokesman Lord Howe was more forthright, calling it “one of the most pernicious and ill-founded theories to have gained currency in childcare and social services… It is a theory without science.” The public tide had clearly turned. Meadow was struck off the medical register in 2005 for misleading statistical evidence given in Sally Clark’s trial, but reinstated a year later.

Awareness of different kinds of child abuse ebbs and flows in distinctive, historical ways. Explicit awareness of child (physical) abuse in hospitals emerged in the early 1960s through the practice of routine paediatric X-rays. (Child sexual abuse, which is now the most common meaning of the term ‘child abuse’ in British and North American paediatrics, does not take on this meaning until the 1970s, according to Ian Hacking). In Denver, Colorado, in the early 1960s, healing fractures in small babies were discovered, without being accounted for by histories given by the parents. Doctors concluded that these babies had been beaten. This issue of physical abuse, which bubbled along largely under the radar in Britain – despite some NSPCC reports in the late 1960s – exploded into national significance in England in 1973. Nine-year-old Maria Colwell was beaten to death by her stepfather while supposedly under local authority supervision. In the investigations into her death, guidelines were established to promote cooperation and information-sharing between the police, hospitals and social services.

This is the initial context for Meadow’s theory of MSbP: in a hospital environment, and one of heightened suspicion and concern. There was scope for extended contact between various agencies that could provide evidence that maltreatment might be occurring. As mentioned above, during the 1990s Meadow’s concerns shifted from prolonged fabricated illness to SIDS or ‘cot death’. Meadow was interested because he thought some of these latter cases were actually instances of baby murder by smothering, for the same psychological reasons he thought were behind MSbP.

However, the context had changed: from huge amounts of evidence in hospitals, Meadow was then called in to give evidence in court where there had simply been more than one SIDS death in the same family. He repeated at Sally Clark’s trial a statistic from a study that proposed the chance of two cot-deaths in the same (affluent, non-smoking) family were of the order of 73million to one. This calculation excluded the possibility of genetic or many environmental factors from consideration. Other paediatricians calculated that if hypothesised genetic and environmental factors did indeed play a role, the chance of two SIDS deaths in the same family can be as low as 200 to 1. (This is the statistical error for which Meadow was initially struck off, but it is not the reason that the first baby murder conviction – for Sally Clark – was quashed.)

In any case, the context has changed between the late 1970s to the late 1990s (hospital presentations to infant mortality statistics). The environment that brought a particular kind of child abuse to light in the 1970s is far removed from the court cases being tried in the early 2000s. The broader social history of these cases and conditions matters. It may well be that child abuse has regrettably always existed. But these are human definitions, human problems, and they are managed within historically specific contexts, ideas and institutions. These are subject to sweeping changes in relatively short periods of time. The Clark, Cannings and Patel cases are so controversial because they straddle a period of rapid change in understandings of infant death, and the credibility of various theories around child abuse.

Chris Millard is Lecturer in the History of Medicine and Medical Humanities at the University of Sheffield. He is interested in British approaches to mental health, broadly conceived, and has written about self harm, child abuse and the philosophy of diagnosis.

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