A critique of Will Self's August article on psychiatry and "Big Pharma", focussing on the need to conjoin critique of the current practice of psychiatry with an analysis of its place within capitalism.
Psychiatry is undoubtedly experiencing something of a crisis. It is a clean and currently self-contained crisis, one that rarely troubles national headlines or makes it into the everyday conversations of workers in the office or the clothes shop floor, but it is a crisis nonetheless. Whilst the anti-psychiatry movement of the 60s had a libertarian and experimental edge to it that courted controversy and political radicals, the “rational anti-psychiatry” or “critical psychiatry” of today is a lot less exuberant, more level headed and nuanced but, perhaps because of that, grips the imagination of the mass of people much less. This is weird.
It’s weird because when mental health issues do hit the headlines it is to warn us of epidemics of depression, anxiety and dementia; or to warn us of the terrible lunatics that roam the streets whenever “a schizophrenic” kills someone in the street or “psychopath” stalks playgrounds, gunning down children and teachers alike. Even with the publication of the new DSM-V it has only been the readerly classes and the commentariat who have raised furrowed brows and waded into the murky waters of psychiatry’s history. The quiet crisis of psychiatry is weird because 1 in 4 people are supposed to be affected by “psychiatric illness”, although this must be a conservative figure when we include the toll taken on carers, families and friends.
One member of the commentariat, the author and self proclaimed psychogeographer Will Self, has waded in to try to ask the question of whether the current epidemic of depression and hyperactivity has been caused by psychiatry and big pharma themselves. In an online published back in August, Self recounts an anecdote of his own time being treated for heroin addiction under the supervision of an unnamed psychiatrist, before going on to provide a brief synopsis of the noxious collaboration between psychiatry and big pharma. On first read, Self’s is a decent survey of this potent combination of science and industry.
In his view, psychiatry has increasingly tended to attempt to colonise everyday misery and suffering in order to expand its influence and power. As he puts it, the problem lies with
psychiatry’s search for new worlds to conquer, an expedition that has been financed at every step by big pharma.
This partakes of at least two types of narrative that have become incredibly popular. On the one hand, we have the narrative of the pathologisation of everyday life, and on the other hand, clasping the first tightly, is the narrative of imperialism. This story is one that should be familiar to anyone concerned with psychiatry and the experience of mental distress but will be especially familiar to those of us who have trained and work within the psy-disciplines, no less than for those of us who engage with critical theory and radical politics. There is nothing wrong with these stories in and of themselves, but presenting them in such a way as to suppose that this is an inevitable or teleological development of psychiatry would be misleading.
Psychiatry has had a number of minoritatian aspects in its history which have been more or less radical and which could have led to the establishment of a different psychiatry. To list all such missed opportunities would take too long but we could briefly include on such an account RD Laing’s attempt to create new therapies at Kingsley Hall, Felix Guattari’s work at the highly experimental La Borde clinic in France, and Loren Mosher’s similarly radical Soteria Project, the latter of which has demonstrated better efficacy than standard psychiatry in a number of studies in the treatment of psychosis (for instance, see here). We could also include the current work of Romme and Escher with Intervoice and its growth into the Hearing Voices Network, based on the psychiatrist and journalist team’s seminal findings that far more people experience voice hearing than ever receive psychiatric treatment. All of these projects were initiated, led and analysed by psychiatrists and psychiatric survivors against the tendency of biopsychiatry to pathologise distressing or divergent experience and to treat it with neuroleptic medications via coercion or legal compulsion. These projects either failed or remain in suppressed as “alternative” not because psychiatry has some immanent imperialistic drive toward the colonisation of our minds but for historical and material reasons. Some elements of these projects have been filtered into the current trend for person-centred care and use of the recovery model, but people involved in the founding of the recovery model (such as Ron Coleman), and some of those involved in its incorporation into mental health services (like Philip Barker and Poppy Buchanan- Barker, whose essay on “pharmaco-centrism” can be found here) see nothing tokenism destroying a potentially liberatory approach to working with people experiencing distress.
In fairness, Self doesn’t actually ascribe to a narrative of psychiatric imperialism for its own sake but suggests that the drive towards transforming everyday human misery into pathological disorders comes from biopsychiatry’s failure to cure the psychoses. As he puts it
unable to effect anything like a cure in the severe mental pathologies, at an entirely unconscious and weirdly collective level psychiatry turned its attention to less marked psychic distress as a means of continuing to secure what sociologists term “professional closure”.
As an explanation for why a group of people who ascribe to the hegemonic “medical model” of psychiatric research and practice would attempt to make the sorrow of grief or the tantrums of a toddler into morbid biochemical or behavioural dysfunctions the invocation of a professional collective unconscious does indeed seem weird. It seems weird because it imports an unnecessary combination of Freudian psychological and ontological presupposition onto a turn that can be much more easily explained. To suggest that psychiatrists are attempting to make the misery of unemployment into a brain disorder treatable with antidepressants because it failed to find a cure for psychotic illness is a stretch at the very least.
At most it implies the existence of a symbolic order that only a subset of psychiatrists exist inside of that has structured their desire in such a way as to force them to treat all problems in living as if they were the same a severe and enduring psychotic disorder. While at first it might seem fair to say that feeling wounded by their failure biopsychiatrists expanded their attention to include more “conditions”, it is ludicrous to suppose that this was because the psychiatric unconscious made them do it. Even if Self doesn’t intend to invoke a psychiatric unconscious it remains remarkable that the unconscious drives of the majority of psychiatric researchers and practitioners (recall the two don’t always overlap) across the globe were effected in such a way as to synchronise them into coalescing around a singular trajectory.
Self does note that psychiatry may have wanted to secure its ‘professional closure‘ after it’s legitimacy as a medical science had been called into question by the failure of its curative ambitions.
This seems a reasonable suggestion and is probably closer to the truth, but it does not require an invocation of Freudian psychoanalytic concepts to explain. If psychiatry’s legitimacy as a science was challenged this would also obviously constitute a threat to the status of psychiatry as a medical profession awarded with high status and high salaries. It is thus more likely that psychiatry’s desire to maintain the demarcation of its professional boundaries was driven by directly material and cultural capital concerns. In short, if psychiatry wasn’t a medical profession, if it was nothing but pseudo-science, then consultant psychiatrists would lose their money, their gravitas, their status (recall, in the 1950s psychiatrists were glamorous) and their power as agents of the state. As Self also notes, in the United States insurance companies require that a medical condition be present in order to payout on psychiatric treatment. It is commonly asserted that the DSM-III, published in 1980, was largely produced because of the increase in insurance companies refusing to payout for such claims during the 1970s. In that same period the American NIMH slashed its funding for psychiatric services by 5% in 1976 on the assertion that such funding could not be afforded when mental illness was so vaguely defined and unmeasurable (largely a response to the prior dominance of psychoanalysis in American psychiatry).
In the same moment, clinical psychology was just beginning to find its feet and was looking to launch an offensive on the hegemony of psychiatry in the care and treatment of the “mentally ill”, whilst survivor groups were launching offensives on the inclusion of homosexuality in a diagnostic manual of mental diseases. Threatened from all corners, psychiatry renounced psychoanalysis and renewed its original basis as a biomedical enterprise. There was nothing unconscious about this move, and the collective movement towards rekindling biopsychiarty was far from unanimous. Simply, threatened with the accusation of being a “pseudo-science” that lacked diagnostic validity and reliability, lacking evidence of outcomes for treatment and accountability, psychiatrists had to take measures to protect their relationship with medical cognitive authority and ensure its practitioners private wealth.
Simultaneously with all this, psychiatry also had to be defended as the sole means of dealing with “the mad” because it proved to proved itself as a powerful means of social control. The techniques and drugs employed by biopsychiatry in its past, resurgence and in the present day remain attached to the processes of discipline and normalisation that Michel Foucault elaborated on in a number of texts. As a series of dispotifs aligned to the management of bodies and their conduct psychiatry plays a pivotal role in regulating the distribution of the sensible. What can and can’t be said, what can and can’t be done, what can and can’t be seen or heard, on what is and isn’t to be considered “normal” are part of the preserve of psychiatric institutions. This role is especially important when life under late capital proves itself to be anxiogenic and depressing.
It is on the role that psychiatry plays in the medicalisation of everyday misery as the medicalisation of the destructive effects of post-Fordist capitalism that Will Self’s article veers firmly away from. In the analysis of psychologists like David Smail and political theorists like Mark Fisher, the production of distress is seen to be accelerated by the effects of capitalist recomposition. As the psychiatrist Joanna Moncrieff giving someone a psychiatric diagnosis
allows behavioural control to be presented as treatment and it sanctions the release of state funds for support that may not be desirable.
Since Richard Warner’s Recovery from schizophrenia: psychiatry and political economy, psychiatry has been aware that long term unemployment and a precarious/casualised labour market produces all the signs and symptoms of depression, and I have written time and again on how life under capitalism produces anxiety, panic, and other “new symptoms”, such as self-harm and eating disorders. I have no doubt that depression and anxiety are on the increase, and that hyperactivity is increasingly being diagnosed, but to suggest that this is the fault of psychiatry and the pharmaceutical industry is to confuse a cause with a symptom and means of managing disastrous psychological effects. That people work shit jobs at low pay, that are increasingly precarious, and that there appears on the temporal horizon a choice between more of the same or some catastrophic moment (ecological, industrial, whatever) within austerity conditions, the corrosion of public services and support networks such as the NHS, unemployment and disability welfare, under increasingly totalitarian state power means that everyday life is increasingly leading to mental distress. People feel impotent and unable to control their lives. They are taunted with empty consumerist visions of a happiness that is denied to them. As Self points out, their traditional coping networks are fragmented and, as Smail and Fisher both point out, their suffering is rendered as a personal failure or a biological disorder.
Why would psychiatry need to pathologise depression and hyperactivity? Its obvious why dubious diagnoses like borderline or anti-social personality disorder exist, but less so why unhappiness should become depression? Self openly states that ’I don’t think it helps anyone to see the current imbroglio as simply a function of late capitalism’, and yet this would help immensely. The pharmaceutical industry (not “big pharma”) is an industry, which is to say no more or less than that it is a section of capital. For pharmaceutical capitalism to continue accumulating profit it must have an audience to sell its products to and it has that in the form of psychiatry, itself a wing of state power that has a captive market who can be legally compelled to take their medication. Psychopharmacology and psychiatry have been entwined since psychiatry’s birth, and even in the heydays of psychoanalytic psychiatry in the USA benzodiazapines were still regularly prescribed.
What is new in recent years is the transition from a Fordist to a post-Fordist economy, and to the revolution in social life that this has entailed. David Healey, a psychiatrist and psychopharmacologist, has discussed how SSRIs were marketed through pathologisation (ie. transforming unhappiness into a market). Its worth noting that Selective Serotonin Reuptake Inhibitors have nothing “selective” about them, and that the RCTs that prove their effectiveness are- as Self notes- funded by pharmaceutical companies, with significant reporting bias known to plague publication. SSRIs were marketed precisely at the time when the possibility of collective response to capitalism broke down and when capitalism entered a faze in which everything was submitted to economic reason, including human emotions and affectivity. Thus, capital effects a double stroke: a new market and a chemically constrained population. This chemically constrained labour force, who might otherwise slide into despair given the new reality in which real subsumption appears to have swallowed everyone and everything whole, individualises the causes of its distress, never looking to the conditions of its subjectification, and never being capable of summoning the energy to fight back. Of course, this is capitalism’s dream, rather than an accomplished fact. Yet even those people who riot or refuse to work, those who enact a kind of psychic withdrawal from the harshness, uncertainty and emptiness of the work-consume world, can now be medically treated to ensure no further loss ofworking hours. Economically, the biopower of psychiatry ensures that labour-power can be regulated more or less efficiently whilst as Moncrieff suggests,
concealing the political nature of the responses to the situations that are labelled as ‘mental illness’, psychiatric diagnosis prevents these responses from being questioned and scrutinized. It allows the state to delegate a difficult area of social policy to supposed technical experts, and thus to remove it from the political and democratic arena.
In separating actually existing psychiatry from “big pharma”, and in separating “big pharma” from capitalism and the interests of a particular class protected by state power, Will Self’s analysis effectively decouples his critique from any economic or political implications. What we are left with is a weak moralism that he himself even calls ‘ lily-livered liberal’, that also misrepresents certain aspects of the history of the two disciplines. This moralism is born out in Self’s comparison of psychiatrists as “drug-pushers” where it is clear that we’re supposed to read “drug-pusher” as a good go-to caricature of a bad person. This moralism of the psychiatrist as unscrupulous bastard getting kids hooked on downers is conjoined to the weak assertion that ‘we are all to blame’. Our responsibility, according to Self, comes from the fact that we are
‘absolutely bloody miserable, we can’t get up in the morning, we are dirty and unkempt, and we go along to our GP and are prescribed an antidepressant and lo and behold we recover.
For Self, the bad dealer-man gives us misery guts a pill and we feel better and therefore “we” are to blame for having been miserable and/or for the ‘chemical repression of the psychotic’ (it isn’t clear which). This complete obliteration of a perspective willing to recognise, analyse and critique the structural causes and consequences of psychopharmacological psychiatric treatment completely mirrors the prevailing ideology under which that structure justified itself (the same problem is found in the second half of Soderbergh’s recent film, Side Effects). Presumably this morality also extends to the parents of children, or the children themselves, who are desperate to find some way to ameliorate the incredibly stressful situation that hyperactivity can cause. It is also telling that people who experience psychotic phenomena are given only fleeting mentions in the article, as if concern over psychiatric power is really only important when it concerns the middle class readership of the Guardian. People diagnosed with psychotic illness tend to be either live in poverty at onset or to drift into poverty as a result and Self only real reflection on economic position seems is his correct reference to ‘socio-medical discrimination: no sick note – and no social benefits’, although he leaves out any reference to the fact that today many people who should not be working are having their welfare revoked and forced back to work.
Self does include reference to ‘autonomously organised self-help groups’, suggesting that these might provide adequate compensation for the loss of traditional family networks. While this might be true, Self’s example is the 12 step program that is used in alcohol and substance misuse, groups that require members swap a pathological identity (“ill”) for a deviant one (“addict”). While 12 step programs might prove useful to some people they do not challenge the causes of people’s problems but further privatise them as individual failures- “My name is John and I am an alcoholic”, as the well-known admission of responsibility goes. I have no qualms with self-help groups. They are shown to be efficacious, to foster recovery, to aid in the production of destigmatising communities of support, and may even lead to the ability for people to become politically active. I don’t want to suggest that the answer for all mental distress- as one insurrectionary anarchist text has it- is ‘revolt, not therapy’, but therapy without an understanding of the material conditions in which distress develops often does more harm than good. Examples like the Hearing Voices Network and the Soteria Project are far closer to how I understand the term ‘autonomously organised self-help groups’. In time, members of such groups might even drop the “self-help” reference, and engage in the organisation of autonomy.
I like Will Self’s novels and short-stories. They are full of a dark humour and Ballardian insights. If I am critiquing his understanding of psychiatry, psychopharmacology and the pharmaceutical industry it is not because he is part some nefarious cabal attempting to mystify us but because his view is symptomatic of a mystification that is already in place. Self’s brief overview partakes of a fiction that he didn’t write, but when he write that ‘I don’t think it helps anyone to see the current imbroglio as simply a function of late capitalism’ he becomes a supporting character inside of it. After all, what else but capitalism is helped by refusing to see capitalism’s role in the production of “mental illness”, and accusations that psychiatry is a pseudo-science is precisely what lead to a resurgent biopsychiatry. My fear is that similar accusations, regardless of their truth, will only drive the current trend towards an applied neuropsychiatry into becoming the conditions for the possibility of a neurototalitarianism.