Ethan Watters, Crazy Like Us: The Globalization of the American Psyche (Free Press, 2010), £9.99, and Gary Greenberg, Manufacturing Depression: The Secret History of a Modern Disease (Bloomsbury, 2010), £9.99
In May last year the American Psychiatric Association (APA) launched the fifth edition of its diagnostic “bible”, the Diagnostic and Statistical Manual of Mental Disorders. The public controversy surrounding DSM-5 epitomises a major crisis of authority for US psychiatry, with psychiatric and other critics lining up to attack it. It also signals the exhaustion of the project codified in DSM-III in 1980, which laid the groundwork for a distinctly neoliberal psychiatry where pharmaceutical companies, medical elites and governments colluded in the massive expansion of an increasingly commercialised mental health industry.
Neoliberal psychiatry may have become dominant, but increasingly it has also been contested, with a number of recent books exploring its contradictions. By looking at two of the best examples of this new critical trend we can start to answer some key questions: How did the provision of basic mental health services get subjected to commodification and the profit motive? How did an important group of doctors come to provide a pseudo-scientific justification for this process? And why has resistance now started to emerge?
While I concentrate on the theoretical aspects of both books, they are anything but dry accounts. Rich with amusing and disturbing anecdotes, as well as penetrating critiques of mainstream psychiatric ideology, they are written for medical and non-medical audiences alike.
In Crazy Like Us, Ethan Watters examines the global spread of DSM diagnoses through the frame that mental illness is both socially defined and profoundly shaped by social processes. Drawing parallels with US-led corporate globalisation he argues, “Our golden [McDonald’s] arches do not represent our most troubling impact on other cultures; rather, it is how we are flattening the landscape of the human psyche itself. We are engaged in the grand project of Americanising the world’s understanding of the human mind”(p1).
Watters looks at several cases where American psychiatric concepts and practices have been exported to faraway countries, in the process homogenising the meaning of mental distress in the service of big business. Such efforts have been driven by ideologies of individualism and medicalisation, with Western governments and health workers crucial in imposing them. In interventions to “prevent” Post-Traumatic Stress Disorder in Sri Lanka after the 2004 tsunami, and in the stigmatisation of schizophrenia sufferers in rural Zanzibar with US models of biological dysfunction, longstanding local and collective remedies have been undermined.
This has not just happened in the Global South. In Japanese culture before the 1990s melancholy was tied to the belief that personal hardships built resilience and character. Only psychotic depression, where patients were sad as part of having literally lost touch with reality, was seen as a medical issue. Initial Japanese trials of modern antidepressants failed to show benefit. Yet drug companies saw opportunities in the highly publicised case of a finance worker who committed suicide after being overworked by his bosses during the financial crash of the early 1990s. The effects of crisis on workers and then the trauma of the 1995 Kobe earthquake were used by Big Pharma and a willing corporate media to rewrite distress and bereavement not as personal and social forms of coping but as “major depression”—a “cold of the soul” amenable to drug treatment.
In each case Watters describes a similar pattern: medicalisation of distress followed by insistence that socially embedded patterns of coping and healing must be replaced by a more “advanced” and “scientific” individual consumer model of treatment, with the encroachment of corporate interests into previously untapped markets or the treatment of formerly resilient communities as passive victims needing paternalistic intervention. It is hard to imagine a better medical metaphor for the neoliberal and neoconservative eras.
The troubled history of “depression” is the focus of Gary Greenberg’s Manufacturing Depression, an exploration of how US psychiatry mutated into a profession where narrow medical models inform diagnosis and treatment. In the process such shifts robbed sorrow of meaning and even sought to eradicate it altogether. Greenberg writes:
We should wonder whether doctors who urge us to come out against depression aren’t, wittingly or otherwise, also urging us to adjust ourselves to a world that our pessimism shows to be deeply flawed.
To call a reaction to a distressing situation “depression” is therefore more than just a diagnosis; it is a moral and political statement (pp36-37).
Greenberg weaves together the history of psychiatry’s treatment of depression with his own journey to meet the specialty’s current thought leaders and critical voices. Along the road he participates in an antidepressant trial, discovering the gulf between the cold, mechanistic approach of biological psychiatry and the humanism he valued as a working psychotherapist, and which he hopes will guide him through his own fight with depression.
As he explains, biological psychiatry treats mental illness like physical illness. However, because of the lack of biological markers for disorders like those found in general medicine, diagnosis tends to be stuck at the level of describing groups of symptoms, which are then presumed to represent an underlying disease process. Patients are “cases” and not people for whom distress has significance. But even in its post Second World War heyday American psychiatry was dominated by a drive to turn “life problems” into diagnoses requiring the intervention of a doctor. While not as blatant as neoliberal commodification, therapy was sold as something to resolve personal dissatisfaction in the context of capitalism’s greatest ever boom, providing the promise of “psychic security and fulfilment” (pp99-100).
The long boom also saw the emergence of the first really effective psychoactive drugs for major mental illnesses like schizophrenia and bipolar disorder. These were among a series of factors that allowed hundreds of thousands of patients to leave institutions to seek care in the community. Soon pharmaceutical manufacturers sought to expand markets, and state regulation of medications and payment for psychiatric treatments intensified, especially as many former asylum patients found few services available apart from those in psychiatrists’ offices and the pressure to control costs was high.
The Food and Drug Administration began to demand randomised, placebo-controlled trials to prove drug effectiveness, and insurers insisted on reliable diagnoses rather than fuzzy “life problems”. Lay therapists were taking business from doctors by providing talking cures more cheaply. At the same time patient movements and anti-psychiatric ideas arose in the context of civil rights, anti-war and liberation struggles of the 1960s and 70s. In short, psychiatry’s place within the political economy of American capitalism was threatened from numerous directions, leading to a profound crisis of legitimacy.
The impasse was resolved with DSM-III, a diagnostic system that gave a veneer of “scientificity” that satisfied critics, regulators, insurers and drug companies, and reinforced psychiatrists’ role as medical gatekeepers within a fast-growing mental health industry. However, the victory of the DSM-III committee was the result of a political struggle within the APA, not any substantive scientific advance. The result was the categorisation of hundreds of discrete “disorders” psychiatrists could treat.
Two key problems accompanied this massive expansion of possible diagnoses. The first was that psychiatrists, psychologists and drug companies could expand the bounds of what was “abnormality” or “illness” so long as they could fit their patient into a diagnosis. Because many different problems can lead to symptoms of depression, the newly created and broadly inclusive category of major depression underpinned the astronomical expansion of antidepressant prescriptions from the first appearance of Prozac in the 1980s. Media stories claimed that antidepressants could have almost magical effects on people’s lives, just as neoliberalism was producing greater pools of misery across society. Big Pharma sold its wares not only as a solution to “pathological” unhappiness caused by the harsh reality of the American Dream, but as something that would decrease sick leave and increase productivity for employers, more cheaply than social reforms or long-term psychotherapies.
This encouraged greater ties between clinicians, researchers and the pharmaceutical industry, leading to a series of corruption scandals that shook the integrity of the biomedical model. This was accelerated by growing evidence that antidepressants might be no more effective in treating most cases of depression than placebos.
The second problem was the promotion of biological explanations of every kind of mental problem, in effect making psychiatrists ideologists who whitewashed the origins of unhappiness in social relations. To take an important example that Greenberg doesn’t discuss, the idea that suicide is usually the result of a “chemical imbalance” causing a depressive illness that is curable with medications is a recent phenomenon. The French sociologist Émile Durkheim argued in Suicide: a Study in Sociology in 1897 that, while there were individual factors in most suicides, they could only be properly understood as a social phenomenon. Decades before Durkheim, Marx wrote powerfully on suicide as a product of intolerable social conditions driven by the contradictions of the capitalist system (see Plaut and Anderson, 1999, Marx on Suicide). Neoliberal psychiatry instead downplayed social causation and was more interested in helping to shape the ideal capitalist subject, an impossible person who Terry Eagleton suggests is “prudently restrained in the office and wildly anarchic in the shopping mall”.
The crisis of the current psychiatric paradigm has provoked widespread anger at the even more radical moves towards diagnostic inflation, biological reductionism and blatant commercialism in DSM-5. The revulsion felt by millions of ordinary Americans at the actions of corporate elites in the wake of the global recession has undoubtedly fed cynicism and exacerbated the profession’s credibility problems. But what alternative is there to this state of affairs?
Both Watters and Greenberg manage to provide more thoroughgoing criticism of the problems than detailed solutions to address them. At times Watters seems to simply accept cultural relativism. Greenberg comes closer by trying to construct alternative ways of conceptualising depression in a social context where meaning is key. In doing so he refers briefly to Peter Sedgwick, a psychologist and writer associated with International Socialism journal, who tragically died 30 years ago. Sedgwick developed a double critique in the 1970s—of psychiatry and of the “anti-psychiatry” ideas of thinkers like Goffman, Szasz, Laing and Foucault. The anti-psychiatrists had correctly rejected psychiatry’s narrow “scientific positivism”, the idea that science can proceed without the intrusion of human values. But their attack on mental illness as a social construction was one-sided because they didn’t examine the social construction of health and illness in general.
Sedgwick’s approach highlighted social conflicts over what are and aren’t illnesses—and over what should be done about them—refusing to rob them of their social meaning by forcing them into some “value-free” realm of science. This spoke to the necessity of overcoming false divisions between patients and health workers in a political struggle for better care. In Psychopolitics, he argued that: “Without the concept of illness—including that of mental illness since to exclude it would constitute the crudest dualism—we shall be unable to make demands on the health service facilities of the society we live in” (p40).
Sedgwick therefore opposed widespread calls on the British left for the destruction of the mental health system (fed into by films like Ken Loach’s Family Life) and instead argued for “more and better mental hospitals, more and better doctors and nurses—at the expense of armaments and the profits of the rich”. Watters’s and Greenberg’s books, while not completing the political challenge set out by Sedgwick, nevertheless provide indispensable insights into psychiatry’s neoliberal phase that can be used in the service of a project Sedgwick would have endorsed—the battle to reshape mental health care as part of wider class struggles for social transformation.