Keywords

While the previous chapter defined medicalization and psychologization and provided a detailed description of the similarities and differences between the two concepts, the present chapter draws on these theoretical considerations and links both concepts to the welfare state. Although the disciplines of medicine and psychology have always been discussed as a part of the healthcare system of welfare states, the link between the two disciplines and other areas of the welfare state remains unclear, and an overall theoretical idea of how processes of medicalization and psychologization are embedded in the welfare state remains missing. Hence, the present chapter links medicalization and psychologization theory to theories of the welfare state. We first briefly recapitulate our understanding of the two concepts and then examine how they are connected to welfare state theory. We subsequently examine how medicalization and psychologization have been part of the welfare state restructuring that has been underway in all Western nations since the end of the 1970s. Finally, we present an integrated model of medicalization and psychologization within the welfare state. The categories of this model are illustrated with examples from our research in order to demonstrate how the model can be applied as an analytical tool in empirical research.

3.1 Medicalization and Psychologization as Processes in the Welfare State

As described in the previous chapter, the simple definition of medicalization is “to make something medical” (Conrad, 2007). Medicalization has been analyzed in relation to various processes, including deviant behavior, everyday-life problems (e.g., sadness, loneliness, shyness, fear), and natural life processes (e.g., childbirth, involuntary childlessness, menopause, impotence) (Davis, 2016). However, there has recently been a growing interest in the medicalization of the social problems that are considered central to the welfare state, such as unemployment, poverty, disability, aging, and problems in childhood and youth (Friedli, 2016; Schram, 2000; Stenner & Taylor, 2008). A second line of literature has discussed the growing role that psychology plays in social problems in Western societies (Madsen, 2014). Although medicalization and psychologization have been described for social problems, these problems are not subsumed by either medicine or psychology. Instead, medicalization and psychologization should be considered processes of the growing influence of medicine and psychology. These processes can be analytically assessed on different levels, in different dimensions, and to varying degrees. Halfmann (2012) organized processes of medicalization in a typology that differentiates between three levels (micro, meso, and macro) and three dimensions, which he calls discourses, practices, and identities.Footnote 1 He defines medicalization in these three dimensions, which can be described as (1) the increasing use of medical ideas and concepts, (2) the stronger involvement of medical practices and of medical doctors as actors, and (3) the expanding institutionalization of medicine, for example, through requirements of medical assessments. All three dimensions capture an aspect of medicalization and highlight the different mechanisms through which medicalization can occur. We build on his framework but consider three concepts that are commonly used to differentiate strands of welfare state theory—that is, ideas, actors, and institutions.

In the welfare state, medicine and psychology have an important place in the healthcare system, where their knowledge systems guide services and both medical doctors and psychologists are acknowledged as high-status health professionals (Marshall, 1939; Webster, 2020). However, outside of healthcare, the welfare state literature has taken little interest in the role of these two disciplines in other fields of social policy. Apart from healthcare, the role that medical and psychological professions and categories play in social problems has only recently been established, for example, for dealing with poverty and unemployment (Holmqvist, 2009; Schneider, 2013; Thomas et al., 2018; Wong, 2016) or homelessness (Mathieu, 1993). This body of literature reveals how important medicine and psychology are to defining social problems and social policies in specific fields of the welfare state. However, if there is evidence that medicine and psychology are important in many social policy areas, should we not go further and investigate the role that the two fields play in the welfare state overall? To do this, we first examine welfare state theories and investigate how the processes of medicalization and psychologization can be linked to these ideas.

3.2 The Welfare State and Its Relation to Medicine and Psychology

The welfare state is ubiquitous in the lives of individuals in advanced, industrialized countries and influences these individuals’ life chances from the cradle to the grave. This welfare state is the way in which modern societies acknowledge and act on social problems. What the state does about a social condition or situation becomes the defining feature of whether or not the issue is considered a social problem (Gusfield, 1989). Once a social problem has been acknowledged, it is necessary for the state to act on it in some way. As social policies represent the majority of the activities that are undertaken by modern states, the welfare state is central to the legitimacy of the government and of state bureaucracies in modern democracies.

With its onset of welfare state activity at the end of the nineteenth century, the state assumed increasing responsibility for social security in various areas of social life, thereby leading to the foundation of welfare states across Western nations. In the post-war era, which is commonly called the “golden age of the welfare state,” Western nations expanded their welfare programs both by including more and more parts of the population in existing schemes and by addressing the increasing number of social problems and risks through new programs and policies (Nullmeier & Kaufmann, 2021). While this process can be observed in most advanced, industrialized countries, welfare states look very different across countries. Describing and explaining this wide variation in welfare discourses, practices, and institutions across countries (Verhoest & Mattei, 2010) has been the central interest of comparative welfare state research for decades, with Esping-Andersen’s (1990) typology of the three worlds of welfare capitalism representing a landmark study in the field. In his work, Esping-Andersen argues that there are three distinct welfare state regimes, which are characterized by specific forms of social rights, stratification, and relationships between the state, the market, and the family: (1) Liberal welfare states provide modest benefits that are mainly targeted at the poor and that are subjected to means testing, with market-based solutions to social problems being preferred. (2) Conservative welfare states are based on the male breadwinner model, in which social security is organized through earnings-related contributions to social insurance schemes. Benefits from social insurances are usually related to prior income, with spouses and children enjoying derived rights. (3) The social democratic—often also called the Nordic or Scandinavian—welfare state rests on the principle of equality, provides high levels of benefits, and places a strong emphasis on public social services, such as public childcare.

While Esping-Andersen’s typology of welfare states has been criticized, revised, expanded, and replaced by newer typologies, it remains a central reference point in many debates because it has led to important insights for welfare state research. While a significant amount of research in the 1970s and 1980s aimed to find the common cause as to why welfare states had developed and expanded across Western nations, interest has since shifted to the question of why countries have established such different arrangements of welfare state provision and what these differences mean for welfare outcomes. This line of research is also crucial to determining how we can theorize medicalization and psychologization processes within the welfare state. We can view the issue in quantitative terms, meaning that certain welfare state arrangements enable medicalization and psychologization while others impede these processes (Reibling, 2019). Moreover, the rationales behind and the mechanisms through which medicalization and psychologization might work in different welfare state regimes could look different depending on the respective discourses, actors, and institutions. Finally, the specific medicalization and psychologization process could vary across welfare regimes, for example, across levels and dimensions, as suggested by Halfmann (2012).

3.3 Welfare State Theories and Dimensions of Medicalization and Psychologization

Welfare state theory has aimed to explain why the welfare state has developed as a new historical phenomenon, how and why it varies across nations, and what the consequences of this variation are. Multiple theories and concepts have been suggested to answer these questions and can be subsumed into four strands of theoretical accounts: (1) functions, (2) actors along with their interests and power resources, (3) institutions, and (4) ideas (Lessenich, 2016).

To begin, functionalist approaches were the first theoretical accounts that developed in an effort to explain why the welfare state had developed in Western countries as a new social phenomenon. Their focus lies on economic developments and in particular on the challenges and problems that arise from capitalist economic systems. The rise of the welfare state was thus a “necessary” political reaction to changing socio-economic conditions at the end of the nineteenth and beginning of the twentieth century. Functionalist approaches view welfare state change as a response to (new) social risks that emanated from processes such as industrialization, modernization, and capitalism. For instance, in the development of societies from pre-industrial to industrial, many new social problems arose (e.g., the expansion of cities, unsafe working conditions in factories, miserable living conditions in cities), thereby creating a need for the state to replace the weakened and overburdened traditional safety nets of the family and the community (Wilensky & Lebeaux, 1958). In essence, functionalist accounts argue that the welfare state developed because there was a need for it. This line of reasoning has also been used to explain medicalization and psychologization by arguing that these processes occur as a reaction to the declining role of traditions and religion (e.g., Rieff, 1987). While functionalist accounts are still considered in welfare state theory and new variants have evolved (e.g., globalization theory), these theories are limited since the assumption that the welfare state (or any form of it) fulfills a function is never sufficient to explain its development. Actor-centered approaches thus developed in an attempt to address this limitation.

Second, these actor-centered approaches stem from the argument that politics matters. Thus, in these approaches, the expansion of the welfare state is attributed to the power resources of population groups and parties that have an interest in welfare policies in modern democratic systems. Labor unions and social democratic parties have been considered a central force that led to the development of universalistic welfare states, particularly in Scandinavia (Korpi, 1989), whereas conservative parties and churches have contributed to the development of social capitalism in conservative welfare states (van Kersbergen, 1995). These actor- and policy-centered approaches argue that even if there had once been a need for a welfare state, its implementation required political decisions based on majorities in a democratic system. The medical profession has been considered a relevant actor in the development of public healthcare systems; however, the specific role of these medical professionals has been considered controversial, particularly because they had quite often been opposed to public healthcare (Webster, 2020). Nevertheless, actor-centered approaches have been popular in earlier medicalization research, which reveals that the medical profession has at times actively campaigned for or indirectly supported the medicalization of social conditions (Conrad, 2005). As outlined in the previous chapter, psychologists have always had less political power than their colleagues in the medical profession, but psychologists’ practice in various organizations (e.g., hospitals, companies, prisons, schools, etc.) is considered central to psychologization (Rose, 1985, 1996). Thus, actor-centered approaches represent a fruitful perspective for better understanding the role of medicine and psychology in the welfare state. If we expect to find a move toward a biopsychosocial welfare state, we should look for actors who have supported such a development both because it serves their interests and because they have sufficient power to accomplish such a change. Clearly, the medical and psychological profession as well as bio-pharma-tech companies and social movements are likely candidates (Clarke et al., 2003; Conrad, 2005) for pushing medicine and psychology (likely bundled together in the concept of “health”) onto welfare state agendas. Nevertheless, medical and psychological explanations and solutions are also often endorsed by other actors—such as employers, policymakers, teachers, or street-level bureaucrats—when these solutions serve the actors’ interests. For instance, employers have endorsed health-promotion initiatives that medicalize and psychologize experiences of workplace stress through individualized solutions (e.g., counseling, stress trainings) so that they would not have to re-evaluate working conditions (Foster, 2018). Labor market officers support the medicalization of unemployment if an individual’s labor market integration is unlikely (Holmqvist, 2009), or they employ psychologized training measures as solutions to joblessness (Friedli, 2016). Teachers are considered crucial actors in the practice of medicalizing children and young adults because they promote medical and psychological examinations (Rafalovich, 2005). Finally, scientists and the media should be considered important actors in the medicalization and psychologization of social problems because they provide and circulate new evidence on the medical and psychological causes of social problems (Clarke et al., 2003; Harwood et al., 2017; Ross Arguedas, 2020). Science journalism, for instance, has favored medical news in the last few decades over findings from other disciplines (Bauer, 1998).

Third, institutionalist accounts in welfare state theory have argued that what actors want to do, are able to do, and actually do depends on the institutional context in which they act (Immergut, 1998). Thus, social action is always institutionally embedded. Institutions are reproduced or changed through social actions, but even in the case of change, existing institutions remain the reference point for transformation. Institutionalist accounts consider the state to be central to providing the institutions that shape action, as is the case when political institutions shape electoral rules or federalism. Moreover, the welfare state comprises a myriad of institutions through its bureaucratized and professionalized system of welfare financing, provision, and regulation, including social laws, public agencies, bureaucracies, insurance schemes, and professional organizations.

As the institutional setup of the welfare state varies across nations, these setups provide different opportunities to (dis)integrate medical and psychological ideas into welfare state policies. This notion goes hand in hand with institutionalist accounts, which have highlighted the idea that decisions at a certain point in time create path dependencies. Such path dependencies arise because the established institutions produce vested interests and cultural narratives that support the maintenance and expansion of existing institutional solutions (Pierson, 2000). Despite the centrality of institutions, most of the medicalization and psychologization literature has paid scant attention to how these institutions shape the role that medicine and psychology play in a given society (Reibling, 2019). Nevertheless, newer studies have shown that it is important to pay attention to institutions if we want to understand medicalization and psychologization processes. For example, the medical profession can perceive medicalization as an opportunity in one institutional system and as a threat in another system (Halfmann, 2019; Olafsdottir, 2007).

In order to provide greater clarity, we outline two examples (which are elaborated in the thematic chapters of this book) of how institutions in the conservative welfare state of Germany shape medicalization and psychologization processes. By focusing on unemployment (see Chap. 4), we see how paradigmatic change in Germany in terms of both how unemployment is defined and consequently what is required from the unemployed has opened an institutional space for medicalization and psychologization. Today, illness serves as one of the few reasons as to why strict rules for receiving minimum income benefits do not apply. Another example of how institutions matter for medicalization and psychologization is given in the chapter on children (see Chap. 6). The federalist organization of the educational system has resulted in variation in the treatment of children with learning difficulties. While state laws and lawsuits have resulted in the medicalization and psychologization of children with learning difficulties in certain states, other federal states have created regulations that emphasize educational rather than medical or psychological solutions for the same group of children.

Finally, most recently, welfare state theory has become interested in the central role of culture and ideas in understanding welfare states and social policy. While comparative welfare state research has often referenced the underlying cultural narratives of different welfare state regimes, such as liberalism, conservatism, and socialism, the significance of ideas and the elaboration of welfare culture have only been developed in the last two decades. This new strand of literature argues that welfare culture involves knowledge, values, norms, and narratives that legitimize specific social policies and the welfare state overall (Pfau-Effinger, 2005). This perspective has also paid attention to discourses and to how these discourses contribute both to the development of policies and to the enactment of policies by street-level bureaucrats (Kaufman, 2020; Suavierol, 2015). The central role of ideas and discourses in this strand of literature aligns with arguments put forward in many psychologization or therapeutization accounts that consider the growing role of medicine and psychology to be a cultural narrative that resonates with modern societies. Nolan (1998), for instance, has even argued that the therapeutic narrative has become a new vein of legitimization for the American (welfare) state:

“Because of the strength of the therapeutic consciousness in American culture, and because of the apparent need for alternative sources of state legitimation, I argue that we should find evidence of the therapeutic ethos beginning to institutionalize itself in the American state.” (Nolan, 1998, p. 45)

Although ideas and discourses are analyzed and evaluated as being important to the development both of social policies and of process of medicalization and psychologization, hardly any studies on welfare discourses from non-medical areas (e.g., poverty, unemployment, pensions) that focus on how medical and psychological ideas are implemented and promoted have been conducted (exceptions include the recently published work by Ariaans & Reibling, 2021; Krayter & Reibling, 2020).

We have thus far outlined how welfare state theories have employed functions, actors, institutions, and ideas to explain welfare state development and variation. While functionalist accounts are limited in their explanatory values, the other three theoretical accounts continue to hold prominent places in welfare state research. We have additionally shown how the concepts of actors, institutions, and ideas correspond to thinking in medicalization and psychologization research. Therefore, we propose using these concepts as categories through which we can also analytically understand medicalization and psychologization in the welfare state. Using these established concepts from welfare state research links our framework to existing welfare state theory. Moreover, these categories can be conceived as a more abstract take on Halfmann’s dimensions of medicalization and de-medicalization—namely discourses, practices, and identities (and actors). Before we discuss our analytical framework in greater detail, we need to introduce another important part of welfare state research: research on welfare state change and restructuring. While the welfare state has long been considered a prime example of a durable social institution that has little opportunity for institutional reform, many countries have transformed their welfare states quite substantially over the past three decades. Not only have neo-liberal reforms and the rise of the social investment paradigm changed welfare states in Western nations, but they can also be considered an important reason as to why medicalization and psychologization in the welfare state have grown and taken on new forms.

3.4 Welfare State Restructuring as a Catalyst for Processes of Medicalization and Psychologization

The dominant cultural narrative of the welfare state during its golden age was that of an institution that provided social security against natural life risks (e.g., aging, illness, motherhood) and protection against the drawbacks of capitalism (e.g., unemployment, poverty) (Nullmeier & Kaufmann, 2021). While welfare regimes differed quite substantially in terms of how and to what extent they both provided social security and employed measures of redistribution (Esping-Andersen, 1990), this general narrative was shared. Social security was in many ways what the welfare state stood for (Kaufmann, 2003). Beginning at the end of the 1970s, this narrative—along with the resulting institutional structure—began to be increasingly criticized: In light of declining economic growth and population aging, the financial sustainability of the welfare state was considered problematic and in need of reform (Pierson, 2000). This view was strongly driven by neo-liberal thinking, which argued that the state—primarily through its welfare programs—was inhibiting macro-economic growth as well as individuals’ potential for self-realization and happiness, particularly for individuals who were “stuck” receiving welfare benefits (Banerjee et al., 2017). Beginning in the 1980s in the UK and the US, this view began to lead to neo-liberal welfare reforms, which served as a path toward welfare state restructuring that was followed by all advanced, industrialized nations. While this welfare state restructuring has been moderate in some nations, the period since the 1980s has borne witness to fundamental changes in other countries. In Germany, for instance, Seeleib-Kaiser (2016) has argued that the neo-liberal reforms have transformed the German welfare state from the paradigmatic example of a conservative welfare state to a liberal welfare state.

Overall, neo-liberal reforms have included cutbacks to and privatization of parts of the welfare state (Nullmeier & Kaufmann, 2021). These reforms have also led to an increase in welfare conditionality, which means that the conditions that must be met in order to access benefits have been substantially tightened (Watts & Fitzpatrick, 2018). An important aspect of these conditions is that behavioral expectations must be met in order to access benefits and services. Not only has this neo-liberal transformation changed Western welfare states, but it has also created a context that encourages the medicalization (Barbee et al., 2018) and psychologization of social problems (Madsen, 2018). On the one hand, a number of studies have shown that because many individuals have not been able to either find a job or meet other behavioral expectations, there has been an increase in claims or the actual receipt of health- and disability-related benefits, such as sick leave and disability pensions (Hansen et al., 2014; Holmqvist, 2009; Wong, 2016). Thus, the medicalization of unemployment and poverty has been a paradoxical effect of neo-liberal cutbacks in the welfare state (see Chap. 7). On the other hand, neo-liberal governmentality includes an increasing reliance on psychology in order to enable individuals to act as rational, motivated subjects, as is intended by the neo-liberal agenda. This reliance on psychology can be seen in the use of psychometric testing (International Labour Organization, 2017), in the rise of psychological ideas such as resilience in welfare discourses (Michael Garrett, 2016), in the use of psychological techniques such as nudging in social policies (Peeters, 2019), and in the role of psychotherapy in (re-)producing neo-liberal subjects (LaMarre et al., 2019).

In recent years, the limitations of neo-liberal reforms have been discussed intensively, with international organizations, the EU, and many nations having come to consider the social investment paradigm to be a remedy for neo-liberal thinking (Jane Jenson, 2012). While social investment also considers traditional social security to be unsustainable and potentially detrimental, the concept acknowledges that the state must provide a context in which individuals can develop human capital that helps them avoid risks and the need for social protection (Hemerijck, 2015). Thus, the state needs to strategically invest in areas of human capital formation that strengthen labor force participation and productivity. While the original development of the paradigm strongly focused on education and family policies, the significance of health as a resource for a productive life has been substantially highlighted in recent years (European Commission, 2013b; Goijaerts et al., 2022; Kvist, 2015). The social investment paradigm has opened new routes for the medicalization and psychologization of the welfare state and has resulted in the expansion of medical and psychological ideas, practices, and actors in welfare institutions. Examples of the medicalization and psychologization of the welfare state can be found in initiatives on active aging, in the orientation of early childhood education toward health and the development of personal and social skills, in health promotion and rehabilitation for unemployed people and individuals who receive disability pensions, in the evolution of parenting initiatives, in health promotion in the workplace, and in the increased attention paid to mental health and illness across all areas (European Commission, 2013a, b).

The transformation of the welfare state can thus be divided into three phases: (1) the traditional welfare state, (2) neo-liberalism, and (3) social investment. Using this division enables us to demonstrate the varying potential for medicalization and psychologization within the welfare state. While these models developed in the suggested sequence, no one paradigm has yet fully replaced another. Thus, in reality, today’s welfare states are hybrid institutional arrangements; this means that traditional social security, neo-liberal welfare, and social investment policies co-exist. How these institutional complementarities shape medicalization and psychologization processes is illustrated in detail in the following chapters on empirical social issues. However, first, we summarize how medicalization and psychologization can be empirically investigated by outlining our analytical model.

3.5 The Model of the Biopsychosocial Welfare State

Figure 3.1 presents our conceptual model, which we employ throughout this book. With this model, we map changes in the welfare state from the theoretical angles that can be found in the theory of both the welfare state and medicalization—namely the perspectives of actors, institutions, and ideas. Our goal is to capture the processes both within and between these three dimensions, which have thus far been primarily situated and analyzed in “the social realm” (capital–labor conflicts, economic and social inequalities, social rights and services) but have increasingly also been used to address the biological and the psychological realm. In addition to these different dimensions (i.e., actors, institutions, ideas), changes can occur on different levels of the welfare state: (1) on national and international levels of politics and policy = macro, (2) on the level of organizations and bureaucratic procedures = meso, and (3) in individual interactions, such as between clients and street-level bureaucrats or in doctor–patient interactions = micro.

Fig. 3.1
A framework depicts the biopsychosocial welfare state. It has text in 3 rows and 3 columns. The levels are micro, meso, and macro. The dimensions are ideas, institutions, and actors.

The biopsychosocial welfare state framework

Full size image

We theorize how medicalization and psychologization processes and thus the move from the welfare state to a biopsychosocial welfare state may unfold by explaining how dimensions and levels interact. We outline how such processes can materialize when medical and psychological actors play a different role within the welfare state. Medicalization and psychologization, can also mean that institutions increasingly rely on medical and psychological categories or technologies. Finally, these processes may take place against the background of the changing importance of medical and psychological ideas and bodies of knowledge in welfare discourses. Our model should be considered an ideal-typical model that developed from the theoretical considerations in both this and the previous chapter and with contributions from the empirical case studies that are presented in the following chapters. Furthermore, our analytical distinction between dimensions and levels (boxes in Fig. 3.1) aims to illustrate and operationalize the multiplicity and complexity with which processes of medicalization and psychologization unfold. In reality, there are many overlaps and interrelations that are not represented in the model. Finally, we interpret the model in a way that shows how the welfare state has developed into a biopsychosocial welfare state and thus also in a way that reveals how medicine and psychology enter or increase their scope in the different dimensions and levels. However, the model can also be used to label and analyze developments in the opposite direction—that is, de-medicalization and de-psychologization processes. As our main argument in this book is that the welfare state has developed into a biopsychosocial welfare state, we interpret and describe each category with the terms “more” or “increasing.” However, each category can also be described with the terms “less” or “decreasing,” which we do not elaborate on here but consider empirically in the thematic chapters and the conclusion of this book.

3.5.1 Transforming the Welfare State Through the Increasing Use of Medical and Psychological Ideas

Ideas point to the importance of language, theoretical concepts, and narratives in justifying or criticizing existing welfare state arrangements. Medicalization and psychologization within the welfare state can thus be traced by tracking changes in the importance of medical and psychological terms and concepts in welfare discourses. Such terms could include “illness,” “symptom,” “treatment,” and “biological” for medical issues and “competences,” “cognitive,” “emotions,” and “self-efficacy” for psychological issues. Moreover, there are concepts shared by both disciplines, such as “diagnosis,” “therapy,” and “health.” On the macro-level, the development toward a biopsychosocial welfare state could be visible through the increased role of medical and psychological ideas in national discourses, which can be assessed, for instance, through (supra-)national policy documents, debates, court rulings, and media documents. This changing language can spur process on the meso-level and enable administrations of welfare state programs to legitimize their practices by referring to medical and psychological concepts in internal documents. Furthermore, organizations that act within the welfare state,—such as companies, unions, professional associations, foundations, and non-governmental associations—may influence discourses by using medical and psychological terms and concepts in external presentations (e.g., press releases, speeches). In the end, medicalization and psychologization can also take place on the micro-level, for example, when medical or psychological ideas (e.g., diagnoses, self-regulation skills) are used in interactions (e.g., between teachers and parents) or by individuals in the construction of their identities (e.g., the identity of being disabled).

3.5.2 Transforming the Welfare State by Incorporating Medicine and Psychology in Welfare Institutions

The stability of the welfare state is based on the institutionalization of welfare programs as social rights, including the development of public organizations that are responsible for the funding, organization, and regulation of welfare provision. Thus, medicalization and psychologization occur on the institutional level if medical and psychological knowledge and practices have become incorporated in terms of the way that welfare benefits and services are distributed. On the macro-level, medicalization and psychologization mean that medicine and psychology have become incorporated into legislation and policies, for example, through the use of medical and psychological categories and technologies. On the meso-level, medicalization and psychologization unfold by applying these categories and technologies in order to determine access to benefits and services (e.g., health questions that must be filled in on administrative forms) in welfare state agencies. Moreover, medicalization and psychologization do not necessarily mean that the medical or psychological profession is involved. For instance, in benefit assessments and the provision of services, medical and psychological concepts and technologies could be used by other professionals, such as teachers, social workers, and street-level bureaucrats. Finally, the institutionalization of medical and psychological categories shapes how individuals interact with the welfare state, how and for what benefits and services these individuals (can) apply, and how these individuals are categorized and treated by the system.

3.5.3 Transforming the Welfare State by Involving Medical Doctors and Psychologists

Finally, welfare states are reproduced and changed through actors; therefore, another important dimension of medicalization and psychologization in the welfare state is the involvement of medical doctors and psychologists. On the macro-level, the development toward a biopsychosocial welfare state can manifest in the growing influence of the professions and bio-medical companies that are involved in social-policy-reform processes. This growing influence might also be evident in the increased presence of representatives from these professions in the media or in political discourses. On the meso-level, medicalization and psychologization are visible when members of the two professions are involved in decision-making processes (e.g., as experts) or in service provision (e.g., by offering specialized medical or psychological services to students, unemployed people, families, etc.). At the micro-level, the role of the professions can be identified, for example, in the rising number of individuals who (have to) utilize medical or psychological services or who are assessed by these professions.

As defined and described above, the categories in which a move toward a biopsychosocial welfare state should be evident are not separate; rather, they overlap and are interrelated. For example, changing ideas on the macro-level shape whether and how medical definitions and categories become engrained in social law (institutions on the meso-level). These medical definitions have consequences for individuals when medicalized and psychologized categories and technologies are utilized and institutionalized within welfare organizations (institutions on the meso-level). Hence, the categories help us to disentangle certain aspects of a move toward a biopsychosocial welfare state and to pinpoint changes to certain levels and dimensions of the welfare state. The categories also facilitate the empirical measurement of medicalization and psychologization in the welfare state. However, it is important to stress that the interrelated view (i.e., evaluating all developments together) is most important when providing an overall assessment of the development toward a biopsychosocial welfare state.

3.6 An Integrated Model of Medicalization and Psychologization in the Welfare State

In this chapter, we revealed that it is useful and fruitful to analyze medicalization and psychologization within the welfare state. Despite empirical studies on medicalization and psychologization in specific welfare state programs, the different entries from the theoretical literature on medicalization and psychologization and on the welfare state have rarely been brought together. Thus, a theoretical model of how medicalization and psychologization unfold in the welfare state is missing. This issue is surprising because theoretical research angles and categories display similarities and complement one another. Furthermore, developments of and reforms to welfare states after their “golden age” have both intentionally and unintentionally paved the way for medicalized and psychologized welfare.

We developed an ideal-typical model of how welfare states evolve into biopsychosocial welfare states. Our model indicates that this transformation can occur on different levels (i.e., macro, meso, micro) and in different dimensions (i.e., ideas, institutions, and actors) of the welfare state. Hence, the model reveals the complexity of the change toward a biopsychosocial welfare state. As the examples indicate, medicine and psychology are added to and integrated with existing ideas, institutions, and actors of the welfare state. Thus, the welfare state is not fully taken over by medicine or psychology. Indeed, most social problems are neither completely defined by medicine or psychology nor completely transferred into their jurisdiction; however, these social problems are increasingly woven into the fabric of the “social” welfare state.

In the following chapters, we apply this model to three groups of welfare state recipients: the poor, the unemployed, and disadvantaged children. We focus on these groups because they have no direct lobby that stands up for their rights, and only advocates such as social welfare organizations and teachers defend them in welfare state arenas. Furthermore, as these groups have no direct lobby, medical professionals, in particular, might step in as advocates and add medical and psychological ideas to these discourses through the back door. Moreover, these groups are in many ways dependent on the state (i.e., through welfare benefits) and are regulated by it. Thus, they can hardly refuse or resist medicalized or psychologized access to welfare benefits because they depend on these benefits. In this context, processes of medicalization and psychologization are linked with the state monopoly of power. While technologies of the self may have become more important, they are tied to a system of force, rewards, and sanctions in the welfare state. Most importantly, they are also tied to resources and life chances.