The Lie of the Happy Pill
Text by Maria Clara Schaeffer (Freie Universität Berlin)
Art by Pablo Dohms
“Are we a more stable and productive society as a consequence of all the antidepressants we are consuming? Does the use of these mind-altering chemicals enable people to live more contented and fulfilling lives?” (Moncrieff 2017, 78)
Sky-rocketing diagnostic rates of depression, anxiety disorders and ADHD have caused some to speak of an “epidemic of depression” or an “epidemic of ADHD” (Rose 2003, 52-53). However, what I hope to show with this essay is that one might rather regard this phenomenon in the framework of neoliberal modernity and of what Eva Illouz refers to the “therapeutic discourse” or “therapeutic persuasion” (2008) as an epidemic of over-diagnosing and an ensuing over-prescribing of psychotropic drugs (Illouz 2008).
In this essay, I examine how neoliberalism and the psychopharmaceutical industry are entangled and to what extent the former has enabled the latter to rise to the power it holds today.
Following James Davies, I define neoliberalism as a type of capitalism that aspires to free the market from non-market institutions’ influences and its implied regulations, thus constituting “not just a set of idea, an ideology or an economic movement, but a political commitment […]” (Davies 2017, 190) that promises growth and affluence, “reversing many labour, welfare and social protections […] [by] working explicitly to relocate power from the state to the market and from the domain of labour to that of capital” (ibid, 191). A famous critic of neoliberalism was Michel Foucault who “realised that neoliberalism was not confined to economics and governmental politics in the conventional sense but that it represented a scheme for reordering the social and a design for refashioning the conduct of the self” (McGuigan 2014, 228). It was in this setting that a new ideal of the self emerged, one that was self-reliant, self-interested and competitive, self-salvatory (cf. Davies 2017, 192). This was also due to the shape of modern life and the requirement to compete at any given opportunity. Life was increasingly regulated and monitored by the state, while it simultaneously became more private, resulting in social detachment with individuals being expected to cope on their own while “cultural and moral hierarchies [collapsed]” (Illouz 2008, 1,2) “[This] has been paralleled by an upsurge in feelings of insecurity, anxiety, stress and depression” (Hall, O’Shea 2013, 12).
The establishment of neoliberalism was accompanied by a shift of the concept of productivity within the mental health professions. Until the 1980s a humanistic view dominated, which regarded distress as a sign of impediment of the realization of one’s potentials, emphasizing on “actively facilitating an individual’s productive capacities rather than reactively curing meaningless dysfunction or disease” (cf. Davies 2017, 198). But in the 1980s, productivity started to be aligned solely with occupation. It denoted the beginning of a general change within the field of psychology towards defining mental illness as bodily diseases - “with this the more purposeful humanistic associations were replaced by a view of suffering as a significant obstacle to a ‘previous level of function’ best restored through clinical intervention” (ibid).
This led to a construction of mental illness as a productive threat to companies and corporations which were framed as “potential victims through losses of productivity” (ibid, 200). Individuals were considered to be solely responsible for their success or failures at self-maximization in a society that gradually eroded labourer rights and protections (cf. ibid, 200, 203).
The neoliberalist era has been interacting with what Eva Illouz calls the “therapeutic persuasion” or “- discourse” in her 2008 published book Saving the Modern Soul (cf. p. 1,2). Here, she analyses “the emergence of [this] new cultural structure” (cf. p. 242), which has proven to be a fertile soil for the psychiatric society.
To understand the therapeutic persuasion, we first have to understand how culture “works” in individuals. Illouz argues that one can regard culture as fulfilling the function of a map – one that provides orientation, direction, one that generally helps “to get a sense of the different ‘paths’ available […] and to choose - through calculation or sheer familiarity with the terrain - how to proceed from one point to another” (ibid). She contends that
therapy has become the lingua franca of the new service class in most countries with advanced capitalist economies because it provides the cognitive and emotional ‘tool kit’ for disorganized selves to manage the conduct of their lives in contemporary polities (ibid).
What exactly is the “therapy language” though? Eva Illouz follows a broad definition of “therapy” or “therapeutic” which includes formal as well as informal aspects.
[…] The therapeutic discourse is a set of linguistic practices with a strong institutional base […]; it emanates from the professional class of psychologists […]; but it is also an anonymous, authorless, and pervasive worldview, scattered in a dazzling array of social and cultural locations. (Illouz 2008, 10)
By the 1960s – owing to the legacy of Freud’s psychoanalysis which transformed the conceptualization of the self and the manner of relating to others (cf. ibid, 241) – the discourse had saturated the whole of society, pervading all pivotal institutions, being legitimized by the (alleged) scientific nature of psychology – especially thanks to the media disseminating the therapy language and the image of the therapeutic self, they mediate between a group of professional experts on the one hand, and the public on the other hand, a public which is simultaneously constructed as patients and consumers (ibid, 162). The modern state, too, was eager to embrace this conceptualization of the relationship of the self to itself and to others which was (seemingly) designed to mitigate human suffering since its authority was/is inferred by its ability to guard and protect its citizens and their wellbeing (cf. ibid, 242). However, many critics of modernity have reasoned that advanced capitalist societies have made the therapeutic narrative soar because it alleviates grievances and deficiencies that the very capitalist ideals have produced through the ideal of “atomistic individualism”, “[…] while psychology supposedly addresses and helps resolve our increasing difficulty in entering or remaining in social relations, it actually encourages us to put our needs and preferences above our commitments to others” (Illouz 2008, 2).
In 1952, the first Diagnostic and Statistical Manual of Mental Disorders (DSM) was published by the American Psychiatric Association (APA). It was meant to categorize mental illnesses and help psychiatrists diagnose their patients. The first DSMs were considered highly unreliable, “The likelihood that two psychiatrists, when presented with the same patient, would make the same diagnosis was little better than chance” (Whitaker 2017, 165). By 1970 the APA had pleaded to create a more valid and dependable version, their intentions not being selfless as since the 1960s “psychiatry was facing societal challenges to its legitimacy on so many fronts that leaders in the APA spoke about how their field was under ‘siege’” (ibid). sychiatry began to be heavily criticized among academics who accused it of being more of a tool of social control than aiding those in pain. These allegations were fortified by former patients opening up about the horrors of psychiatric hospitals (going as far as calling themselves ‘survivors of psychiatry’). “At the same time, psychiatry increasingly found itself in competition with an array of therapists - psychologists, social workers, counselors and others […]” (Whitaker 2017, 165).
In need of a new image, the APA had the objective of rebranding psychiatry as a branch of medicine, one with clear cut disorders and concurring symptoms and thus distinctive possible diagnoses (cf. ibid, 166), purporting its neutrality.
Above all, this made drugs the go-to treatment for mental health disorders thus promoting psychiatry since it was (is) the only field with “prescribing privileges” (Whitaker 2017, 166). Simultaneously one could observe processes of medicalisation and accompanying ‘cost containment techniques’ (Rose 2003, 51),
[…] placing strict limits on periods of hospitalization, refusing to authorize requests by medical staff for extended stay, controlling the drug budget by monitoring prescribing practices in the interests of cost saving and insisting on generic alternatives where available. […]. In this context, drug treatment outside hospital becomes the treatment of choice […].
It is indispensable to stress that the DSM was not created on the basis of any new ground breaking scientific discoveries. Its approval was highly subjective, voted for by consensus by the APA committee and was (and continues to be) based on a white male individual from the middle class (cf. Markus 2017, 855; Davies 2017, 194). Additionally, the DSM was largely influenced by the financial ties of its members to the pharmaceutical industry (cf. Davies 2017, 212- 213).
Mental illnesses were reinvented as illnesses of the brain, ones that were usually explained by a chemical imbalance – which could be restored through certain, specialized drugs (cf. Rose 2003, 47) – an approach Moncrieff has called “disease centred” and which dominated all of US psychiatry by the 1980s as opposed to the “drug centred approach” (Moncrieff 2017, 89) which was mainly prevalent until the 1950s, when “drugs […] were understood to work through the characteristic mental and physical alterations they produced” (ibid).
As a matter of fact, the shift to the disease-centred model was only possible through a large-scale misinformation campaign. Regarding the alleged chemical imbalance of the brain Ronald Pies, editor-in-chief emeritus of Psychiatric Times wrote in 2012 “ […] the chemical imbalance notion was always a kind of urban legend […]” (Whitaker 2017, 173).
Trials for licensing new drugs were biased and their results distorted or even falsified (cf. Davies 2017, 1; Whitaker 2017, 176-178), the public not truthfully informed of side effects and/or withdrawal symptoms and the efficacy of the drugs often overplayed (cf. Davies 2017, 1; Gotzsche 2017, 26-27; Timimi 2017, 52; Whitaker 2017, 174-175).
Another reason for the branding of certain drugs as treating psychiatric conditions was considered necessary […] to distance [them] from recreational drug[s] […] and present [psychiatric] practice as commensurate with the increasingly sophisticated use of drugs in other parts of medicine. (Moncrieff 2017, 88-89)
By the 1970s the trust in psychiatric drugs had declined significantly. It was known that some, like Valium, could be addictive and “there was also an increasing awareness that antipsychotics could cause permanent damage to the basal ganglia, which led to the motor dysfunction known as tardive dyskinesia” (ibid, 174) – so new drugs had to be promoted as better, safer and more effective.
The APA prepared fact sheets for distribution to the press, which told of remarkable new advances in psychiatry, and it formed a ‘Public Affairs Network,’ composed of ‘expert’ psychiatrists who were trained in telling psychiatry’s new story to ‘radio and television media’. […].
As new classes of drugs came to market, the APA conducted national educational campaigns that told of how psychiatric disorders were brain illnesses that often went ‘underrecognized and undertreated,’ and how there were new and very effective drugs available to treat those illnesses. (Whitaker 2017, 167)
In her case study of India, China Mills analyses how the disease-centred model of US psychiatry has shaped not only the conception of mental health in the ‘Global North’ but as well in countries with so-called ‘emerging economies’, who often are under heavy influence of and dependence on the World Health Organization (WHO) regarding the medical field.
The WHO has recommended the use of psychiatric drugs based on the DSM for decades, “framing […] mental health as a global priority […] centre[d] on the construction of ‘mental disorder’ as a global burden” (Mills 2017, 232), with the explanation that understanding diseases with a physical foundation in the brain (the neurochemical imbalance) mental illness is beyond culture-bound conceptualizations but “can affect everyone, everywhere” (WHO 2010 in Mills 2017, 232). This implies that “diagnostic categories that originate from specific countries of the Global North [have been transposed] onto countries that may have very different knowledge systems and worldviews” (Mills 2017, 232) – a troublesome phenomenon considering how even in the Global North these disorders have only recently, within the last 150 years (the beginning of industrialization and the spread of capitalism), begun to be regarded as such – indicating that they may not be considered as pathological everywhere and are thus indeed “products of specific social, cultural, economic and historical trajectories” (Mills 2017, 232-233).
Since their 2013 report however, the WHO has slowly distanced itself from promoting pharmaceuticals as the priority treatment method after critique of the new generation drugs have become louder and the severity of side effects become more well-known – especially since pharmaceutical companies have not been able to manufacture innovative drugs to lend a clean image to and their financial influence on psychology has not gone unnoticed (cf. Whitaker 2017, 182; Ecks 2017, 258).
The fact remains however, that the impact of the disease-centred approach coupled with the DSMs has had a lasting effect on global diagnostic and treatment strategies and the psychopharmaceutical era is still ongoing, since most countries have based their mental health care on the DSM (cf. Whitaker 2017, 174).
Although the WHO has recently called for more non-medication-based support, pharmaceuticals continue to be prescribed in large numbers in the Global South, which stands in contrast to the number of psychiatrists – meaning prescriptions are often filled out by non-professionals working in the private sector (cf. Davies 2017, 16).
A viable step towards the exit of the psychopharmaceutical era could be to work against ongoing privatisation of the whole medical sector and the resulting cost-containment methods. Counselling therapy might be covered more sustainably through the low-threshold provision of insurance with therapy spots made more easily available and accessible. In order to neutralize the pharmaceutical influence, to be able to objectively inform about potential side and/or withdrawal effects, “policies [should| reward academic researchers who eschew all [financial] ties to pharmaceutical companies (Whitaker 2017, 182).
 In the United States, the number of adults on government disability due to mental illness rose from 1.25 million in 1987 to more than 4.5 million in 2013 (Social Security Administration, 1987–2013 in Whitaker 2017, 181).  “the army, the corporation, the family, the state, the mass media, and civil society” (Illouz 2008, 242). ‘[…] these errors led to published reports that totally misled readers about the actual results.’ […]. The public was told of care that produced a 70 % cure rate. The study told of a stay-well rate of 3 % (Pigott 2011 in Whitaker 2017, 180).
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