While general medicine has certainly advanced over the last few decades, clinical psychology has travelled a deeply distressing trajectory. As Marx thought of religion, the role of the mental health sector is now to sedate, to distract from distress and to prevent political action, all in the interests of our neo-liberal economy. Following the publication of his book, Sedated, How Modern Capitalism Created our Mental Health Crisis, James Davies explains.
Since the 1980s, clinical outcomes in general medicine have been on a positive trajectory upward, due to impressive advancements in biomedical research, technology and treatment. While progress has been rapid throughout general medicine, one area of health care has nevertheless bucked the trend – the area of psychiatry and mental health.
Not only have clinical outcomes broadly flat-lined in this area, but according to some measures they have declined. In recent decades, mental health disability rates have almost trebled; the prevalence of mental health problems has risen fourfold, while for people diagnosed with serious mental health issues the gap between their life expectancy and everyone else’s has widened (from 10 years to 20). These and other dire statistics exist despite our having invested over quarter a trillion pounds in UK over quarter a trillion pounds in UK mental health research and services since the 1980s, and despite nearly a quarter of our adult population receiving some kind of mental health intervention each year.
To understand what has gone wrong I want to first take a seemingly unconventional route, by invoking an idea that the political economist, Karl Marx, once used to explain the impact that organised religion exerted upon a health crisis of his own day – one caused by wide economic exploitation.
Marx argued that religion, by teaching that our suffering in this life would be rewarded in the next, was instructing people, and usually the most disadvantaged people, to accept and endure rather than to fight and reform the harmful social realities oppressing them. As religion numbed the distress that would otherwise motivate political action, he referred to it as ‘the opium of the people’ – a cultural sedative powerful enough to disable the impulse for social reform.
While progress has been rapid throughout general medicine, one area of health care has nevertheless bucked the trend – the area of psychiatry and mental health.
What Marx articulated through his analysis of religion was that those social institutions responsible for understanding and managing suffering were critically important to the aims of any economy. By adapting to the needs of the wider economic system, these institutions had the power to defuse politically dangerous emotions that could otherwise disrupt the economic interests of the established order.
While Marx’s argument targeted religion during industrial capitalism, its analytical thrust over the 20th century would influence social scientists across the political spectrum. They would use his ideas to explain how social institutions (e.g. religion, education, health care) all adapted to the aims of the wider economy, mostly to ensure their own survival and success. In what follows, I want to explore how this enduring idea can help explain the failure of our mental health sector to improve its outcomes since the 1980s.
As a starter, it is important to acknowledge that the mental health sector, when compared to other social institutions, has been exceedingly responsive to the economic currents of our time. Unlike our legal system, where practice is rooted in long-standing legislative anchors, or our medical system, where practice revolves around the bedrock of biological fact, the foundations of our mental health sector are relatively capricious. The sector has found almost no biological markers to anchor its treatment of mental distress, while its theories and practices are mostly rooted in the preferences of those who have the money and power to shape the evidence-base. Our mental health sector, a bit like our education sector, then, has had little protection against what more powerful politico/economic interests have demanded of it. The result has been the sector’s growing servitude to its spontaneous adaptation to the economic dictates of the last 30 years.
Our mental health sector has had little protection against what more powerful politico/economic interests have demanded.
To understand this dynamic, let’s look at the ways in which our mental health sector has broadly adapted to the needs of our economy, but at the expense of generating the good clinical outcomes we all want and deserve. There have been four main trends.
The first, and perhaps the most significant, is the trend of over-medicalisation. Since the 1980s, under the control of the psychiatric profession, the sector has progressively renamed more and more of our natural and normal (albeit painful) human responses to the difficulties of living as ‘mental disorders’ requiring medical intervention. It has achieved this by inflating the number of mental disorders believed to exist (from 106 in the early 1970s to around 370 today) and by progressively lowering the bar for what constitutes having a psychiatric disorder (making it easier for any of us to be classed as ‘mentally ill’).
By expanding the definition of mental illness to encompass ever more domains of human experience, the sector has not only reconfigured how we respond to distress in health care settings, but to how we respond to distress in the wider world: grief at a significant loss, struggling to reach orgasm, experiencing lack of concentration at school, undergoing trauma, feeling anxious about public events or simply underperforming at work are just some of the manifold painful human experiences now liable to psychiatric framing and intervention.
With the spread of medicalisation, we’ve also opened the door to unrestrained commodification – that is, we’ve transformed mental suffering into a vibrant market opportunity. The main benefactors of this market have been the drug companies and the mental health professionals and organisations they’ve bankrolled. With psychiatry’s help, nearly a quarter of the UK adult population received a psychiatric drug prescription last year, with the total global market for psychiatric drugs now worth in excess of $70 billion dollars annually.
This market has thrived on good marketing concealing bad science, on close and often corrupting financial ties between industry and psychiatry, on a deregulated pharmaceutical sector that has lowered regulatory standards, and on the chronic underfunding of psycho-social alternatives. While 7.4 million adults were prescribed antidepressants last year in England’s NHS, for instance, only 1.3 million received psychological therapy. This imbalance does not reflect what most people want, but the staggering impact of commodification.
As medicalisation and commodification have occurred apace, they have also hastened the widespread depoliticisation of distress. Although we all live in a sea of social determinants that inextricably shape our experience, our mental health sector has only played theoretical lip service to the fundamentally social nature of distress. Instead, hypothesised dysfunctions that purportedly reside between our ears have become the principle target of its interventions. And this privatisation of woe has generated a culture highly advantageous to current corporate, economic and governmental arrangements.
As medicalisation and commodification have occurred apace, they have also hastened the widespread depoliticisation of distress
First off, the depoliticisation of suffering has helped exonerate bad policies, environments and powerful institutions from crucial scrutiny. A most telling example has been the rapid proliferation of mental health workplace consultancies over the last 10 years. These semi-private/public companies train selected employees to identify and ‘help’ work colleagues who may be distressed and underproductive at work. What this means in practice is referring underperforming colleagues to services, that reframe worker dissatisfaction and disengagement (themselves rooted organisational and social arrangements) as mental health conditions requiring individualised interventions.
There is no evidence that these consultancies improve employee mental health. Even so, they are very popular with employers, mostly as they help control the narrative on workplace distress. By interpreting suffering as a commentary on self rather than system, they banish difficult work experiences from the domain of public discussion, placing them into the private, depoliticised domains, which effectively help shield bad environments from liability. We have seen similar dynamics occurring in job-centers, where outsourced mental health consultancies are used to ‘re-educate’ the unemployed to view unemployment as a psychological problem. Personal rather the structural change becomes the remedy, and if personal change doesn’t work, well, then it’s your fault.
By sedating people to the causes and solutions for their socially rooted distress our mental health sector has stilled the impulse for social reform
By sweeping the social causes of distress into the private corners of self, our mental health sector has helped stifle collective and community action. Collective suffering, after all, when fully owned and properly channelled, has always been a vital spur for social change. This was true for the civil rights movement, the women’s liberation movement, and will be true for any successful movement to come. But by dispersing our socially caused and shared distress into different, self-residing dysfunctions, medicalisation refracts and diminishes collective experience. In this way, diagnostic tribes replace political tribes, as we identify with a given ‘mentally ill’ social grouping rather than with a particular social cause (or the interests demands of the diagnostic grouping become the one and only social cause). Once suffering has been politically defused in this way, individualised and profitable treatments then follow, emphasising on self over social reform.
Just as religion served industrial capitalism in the mid-1800s, our mental health sector now performs a similar function. Through the medicalisation, privatisation, depoliticisation, dehumanisation and commodification of distress, it has aligned ideologically with aims of the neoliberal economy, with its emphasis on individualism, political quietism, marketisation, deregulation and corporatisation success. By sedating people to the causes and solutions for their socially rooted distress – both literally and ideologically – our mental health sector has stilled the impulse for social reform, has distracted people from the real origins of their despair, has favoured results that are primarily economic, while presiding over the worst outcomes in our health care system. It is due to this our mental health sector has now surely become the new opium of the people.
Order your copy of James' book, Sedated, How Modern Capitalism Created our Mental Health Crisis here.
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