Pills and Interventions: A Business Model.
Text by Katharina Fischer (Universität Greifswald)
© Simina Pătrășcoiu
“How did we become neurochemical selves?” In his article Neurochemical selves Nikolas Rose (2003) begins with a reflection about this question. Here, N. Rose not only talks about the redesign of the self as a neurochemical self, but also about a related business model. According to N. Rose, this mutation has taken place in recent decades to “psychopharmacological societies” (Rose 2003, 46) and also has fundamental implications for health care in general and for mental health in particular. It should be noted that N. Rose’s publication in 2003 is immediately followed by a decade that George W. Bush (Sr.) proclaimed on 17 July 1990 as the “Decade of the Brain” (Gabriel 2017, 328).
The quintessence of this decade was and is the new formulation of human abilities such as thinking, feeling and acting as neurochemical processes. A deviation from healthy thinking, feeling, and acting can therefore only be solved by neurochemical processes. If depression or a generalized anxiety disorder is nothing more than a chemical imbalance in the brain, then the promise of salvation lies ultimately only in the elimination of this chemical imbalance – through medication. Medication which, however, want to be sold by pharmaceutical companies. One condition for this sale is that these drugs – at least in part – must be prescribed by a doctor and accepted or purchased by patients. The reformulation of the self as a neurochemical self is a necessary prerequisite for this. Only when a connection between mental disorders and neurochemical processes appears plausible and is accepted by all sides, both doctors and the neurochemical selves (the patients) are willing to prescribe or buy the healing drugs. “This new style of thought is thus simultaneously pharmacological and commercial. Drugs are developed, promoted, tested, licensed and marketed […]” (Rose 2003, 55). This results in a dependency between health care and commercially produced drugs.
Now, however, there are two major players in the care of mental disorders who divide the field of psychological “disturbances” – psychiatry and psychology. At this point, all psychologists might sit back and relax, as they are not at risk of being tempted to prescribe psychotropic drugs and thus share commercial interests. Aren`t they? Commercial ideas and business models may not only be realized through pills but also through services offered, e.g. a therapeutic conversation.
The aim of this essay is to build a bridge between the prescription of psychopharmacological drugs and an associated business model on the one hand and the interventions offered by the psychological practice on the other.
Reframing of the Self
Similar to N. Rose, Eva Illouz (2008) states a transformation of the self in her book Saving the Modern Soul: Therapy, Emotions, and the Culture of Self-Help. But instead of going through a mutation towards neurochemical selves, Illouz claims that the self finds itself in a therapeutic discourse. It ”helps“ the self to develop a new self-image by providing a new psychological language. The therapeutic discourse overcomes national boundaries and “constitut[es] a transnational” language of selfhood”(Illouz 2008, 6). For the individual, however, this globally acting therapeutic discourse becomes more concrete in the form of a therapeutic narrative about oneself which follows a consistent logic. The narrative informs the way in which individuals set their goals, such as self-realisation, professional success or emancipation. At the same time, it dictates the complications that prevent the self from achieving those goals (be it pathological relationship patterns that prevent the individual from emancipating him/ herself or be it an underdeveloped self-esteem that undermines his/her own desires and needs and thus counteracts self-realisation), which in turn determine on which events of the past the self directs its attention (Illouz 2013, 291). In other words: define a need, realize that this need is not yet satisfied, feel frustration and suffering, and try to relieve suffering by turning to past events.
“The therapeutic culture – whose main mission is to heal – must create a narrative structure in which, strictly speaking, the self is defined by its suffering and victimhood” (ibid.) .
Only when the self feels suffering does it also embark on the search for solutions and offers of help that end its suffering. The therapeutic narrative, from which both suffering and offers of help are derived, now allows suffering and help to work together in a compatible way. The suffering self accepts the psychological help offered to it, precisely because it fits its perceived suffering. The paradox, for which Illouz points out that psychology itself generates the suffering it claims to heal, dissolves into a macabre thought that suffering can only be reduced if people feel suffering in the first place.
While the psychopharmacological society has learned to transfer notions of health and illness to neurochemical processes and has consequently accepted medication as a way out of illness, psychology not only prepares the ground for a currently perceived suffering through therapeutic narration but also provides a suitable range of help in the form of therapy and interventions.
Development of Drugs and Interventions
The previous example points to a parallel between psychological and pharmacological practice. This parallel can be seen when one focuses on the question: Whether psychology and pharmacology are to be understood as acting or reacting in relation to mental disorders? In other words, the question is: Do psychology and pharmacology react to mental disorders that already exist, or do they play an active role in causing these disorders to develop? In his article, Rose ascribes an active role to pharmacological practice of which the development of new drugs is always the ultimate goal. Everything else is derived from this goal.
Pharmacological practice and research, for example, have an influence on the development of scientific theories in other disciplines, as in the case of the serotonin hypothesis, i.e. the attribution of depression to a serotonin deficiency. Depression is therefore seen as the result of a neurochemical imbalance. Another example shows up in clinical practice, e.g. there seems to be a connection between the availability of a drug and the preference for a certain diagnosis. Only the diagnosis then justifies the use of a certain medication.
“The best researched case is that of depression. Of course, the simplest explanation for the remarkable rise in diagnosis of depression […] is, first, that that depression is more common than has previously been realized” or […] “that we now have powerful and effective new drug therapies to treat it.” (Rose 2003, 53).
In psychology, however, this active role is somewhat different. Although the focus here is not on developing a concrete intervention, it may be on developing new ideas and assumptions. Assumptions that secretly turn into interventions. To stick with the already quoted Illouz, this thought is illustrated here by one of her examples.
“The Rise of Emotional Competence” (Illouz 2008, 200 ff.)
For Illouz, the concept of emotional competence initially presents itself as an idea developed by psychologists. Emotional competence means “a type of social intelligence […] that includes the ability to observe one’s own feelings and those of others, to differentiate between them, and to use the knowledge gained to guide one’s own thinking and actions” (Illouz 2013, 339). To believe in this idea of emotional competence, psychologists rely on their very own understanding of emotions, i.e. to understand emotions as “substance” or “true” emotions “caught in the self and just waiting to be appropriately named and recognized by a conscious and knowing subject” (ibid., 343). The conscious and knowing subject can be the therapist as well as the trained average Joe. This results in two interesting consequences for the practice. On the one hand, people can now be described by this competence, so there are people who are emotionally competent by themselves and people who are less emotionally competent. The second group falls behind the first and thus develops a need to make up for their lack. Psychology will then provide a series of interventions, workshops, trainings, and readings to address this shortcoming. All of course not for nothing.
The second consequence of this is the association between mental disorders and emotional competence. The absence or failure of an emotionally competent behavior can be seen as a consequence of a mental disorder or can reinforce or maintain it. Only a series of interventions and trainings can counteract this. Of course, not for nothing here either.
In both cases, whether disturbed or not, the average consumer must, therefore, consult experts for the expansion or recovery of his competence, who in return would like to be paid for their help and support. This example shows that, in addition to pharmacology, psychology plays an active and formative role as well. By developing new ideas and assumptions, or more precisely by reformulating general human abilities as competence, psychology opens a space for the development and offering of interventions. Interventions designed to help people to promote their poorly developed competence or to regain this competence if it was lost by mental disorders. In the case of psychology, “too little” of an idea developed by psychology itself becomes a justification for therapeutic interventions. If emotional competence is underdeveloped or fails, only emotional competence training can help:
Impairments of this competence represent a significant risk for the development and chronification of various psychological problems and disorders. […] Against this background, we have developed the Training of Emotional Competences (TEK). It is intended to expand and strengthen the emotional competencies of the participants and thus reduce deficits in the area of general emotional regulation. (Berking 2015, V)
According to Rose, the principle of “disease mongering” (Rose 2003, 54) has developed into a significant marketing tactic among pharmaceutical companies. This creates powerful alliances of pharmaceutical companies, physicians and communities of suffering, eager to diagnose underdiagnosed problems.
Disease awareness campaigns, directly or indirectly funded by the pharmaceutical company that has the patent for the treatment, point to the misery caused by the apparent symptoms of this undiagnosed or untreated condition, and they interpret available data so as to maximize beliefs about prevalence (ibid.).
It is not uncommon for this “maximize prevalence estimate” campaigns to include well-placed stories of victims reporting on their ordeal as well as the provision of experts who are able to explain this suffering scientifically and to relieve these victims from their distress. According to Rose, this type of “awareness campaigns” is used to market specific clinical pictures in a targeted manner. In this way, they focus attention on a specific disease and the associated suffering and offer the right medication in the same breath. If this strategy is not enough, there will still be one last trump – the “autobiographical accounts by well-known public figures” (ibid., 53) or public victims. In Rose’s article William Styron and Andrew Salomon’s autobiographies, the reader is made aware that depression as an organic disease, often inherited in the form of increased susceptibility, often goes untreated, and that medication is the first line of treatment (ibid, 53). In E. Illouz’s work, Oprah Winfrey, Brook Shields, and Jane Fonda report on their suffering or their therapeutic narrative through autobiographies. E. Illouz points out that the autobiographies of these three famous women do not deal with their success, but with the suffering, they themselves have experienced. “All three autobiographies of powerful, successful and glamorous women are thus told as the history of past wounds, and the protagonists are still busy solving their emotional problems” (Illouz 2013, 306).
But also the less well-known people are offered a stage to tell about their life story and their suffering. Thus these people can disclose their therapeutic narrative e.g. in groups of self-helps and articulate at the same time as “community of fate” their requirement on the public acknowledgment of this suffering. By appearing as, a “community of fate”, the sheer scale of this suffering becomes visible to the public – and the prevalence is promoted. With the public recognition of this suffering, psychologists are the natural candidates to provide urgently needed guidance.
Again, pharmacology and psychology seem to rely on similar strategies. If for one side (pharmacology) mental disorders as organic diseases must necessarily be treated with medication, for the other side (psychology) mental suffering can primarily be alleviated with therapies and interventions.
At the moment the pharmacology becomes a mental health expert, where it has managed to redesign the self as a neurochemical self. At the same time, psychology – with the design of a therapeutic self as an expert – becomes indispensable. As sought-after experts, psychology and pharmacology can now offer solution approaches, in forms of interventions or psychotropic drugs, to the victims. For example, psychological interventions are used, to help one’s own career or one’s own desire for a relationship by perfecting one’s own emotional competence or compensate for a deficit caused by a disorder. Both psychology and pharmacology rely on ingenious campaigns that market the disease (or disorder), the illness and, most importantly, the associated suffering. Only those who suffer also seek help. Thus, both pharmacology and psychology are able to skillfully market their products, either as indicated therapy after a given diagnosis or over the counter as a workshop & Co. or as “Aspirin for the soul”.
Berking, Matthias (2015): Training emotionaler Kompetenzen. 3., vollst. überarb. Auflage. Berlin: Springer (Psychotherapie).
Gabriel, Markus (2017): Ich ist nicht Gehirn. Philosophie des Geistes für das 21. Jahrhundert. Ungekürzte Ausgabe, 1. Auflage. Berlin: Ullstein.
Illouz, Eva (2008): Saving the modern soul. Therapy, emotions, and the culture of self-help. Berkeley: University of California Press.
Illouz, Eva; Adrian, Michael (2013): Die Errettung der modernen Seele. Therapien, Gefühle und die Kultur der Selbsthilfe. 3. Aufl. Frankfurt am Main: Suhrkamp (Suhrkamp Taschenbuch Wissenschaft, 1997).
Pfingsten, Ulrich (2009): Training sozialer Kompetenz. In: Jürgen Margraf und Silvia Schneider (Hrsg.) (Hg.): Lehrbuch der Verhaltenstherapie. Heidelberg: Springer Medizin Verlag, S. 587–596.
Rose, Nikolas (2003): Neurochemical selves. In: Soc 41 (1), S. 46–59.
 „Now, Therefore, I, George Bush, President of the United States of America, do hereby proclaim the decade beginning January 1, 1990, as the Decade of the Brain. I call upon all public officials and the people of the United States to observe that decade with appropriate programs, ceremonies and activities.“ (Gabriel 2017, 328)