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Is Psychiatry the New ‘Opium of the People’?

Picture credits: Atlantic Books/James Davies/Neel Burton

Dr James Davis is a medical anthropologist and trained psychotherapist who is perhaps best known for his book of 2013: Cracked: Why Psychiatry Is Doing More Harm Than Good.

Cracked is a forensic examination of our increasing reliance on psychiatry and psychiatric drugs, in which Davis essentially argues that psychiatry ‘in the name of helping others, has actually been helping itself’.

His latest book, Sedated (March 2021), is broader in scope, looking at the social and political underpinnings that facilitated and enabled this state of affairs.

Since the early 1970s, the number of mental disorders listed in the DSM, the American classification of mental disorders, has risen from 106 to 370. Antidepressant prescribing in the U.K. surged from 25 million prescriptions per year in 2002 to nearly 75 million in 2020. The coronavirus pandemic has only accelerated the trend—while more benign and empowering psychological treatments are ever harder to access.

In Sedated, Davis puts it to us that psychiatric interventions, including superficial psychological interventions principally aimed at returning people to productivity, merely create the illusion of care while leaving the structural causes of distress intact. More than that, by shifting the blame or responsibility onto the sufferer, they serve to obscure these structural causes and, thereby, to preserve and entrench the neoliberal status quo.

The interventions favoured by the government, including even the psychological interventions, are those that involve internal rather than external change, because internal change promises to increase economic productivity and so cost-effectiveness, which is the preferred criterion for endorsing one treatment over another. If we are suffering, we are simply to stiffen ourselves to the social problems created by successive policies aimed solely at the bottom line.

Karl Marx famously said that ‘religion is the opium of the people’. The social institutions responsible for understanding and managing suffering are critical to the preservation of vested interests. With the waning of religion in the West, priests may have been supplanted by psychiatrists. The idea that a pill can make us happy ought to be inherently suspicious but fits perfectly with our materialistic and mechanistic worldview.

Thus, according to the prevailing narrative, suffering is rooted in individual rather than social or existential causes, while well-being is whatever best serves the economic imperative. Behaviours that disrupt economic activity are labelled as mental disorder, and this mental disorder presents yet another money-making opportunity.

If so many of us are ill, if a quarter of us are taking a psychiatric drug, this is because our suffering, having been stripped of its deeper purpose and meaning, is no longer being heeded. It is no longer being interpreted as a vital call to change, or to protest against harmful or inhibiting conditions. 

On the contrary, once we identify as mentally ill, we become disempowered in the belief that the problem lies solely with us, or, more precisely, with misfiring chemicals in our brains. While we are at the clinic, we are not at the barricades.

And while we work to grow the economy, we are not working to grow ourselves.

This is very big picture stuff from James Davies, who weaves our worst fears into a coherent, compelling, and damning narrative.

Neel Burton is author of The Meaning of Madness.

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Orson Welles tells reporters that no one connected with the broadcast had any idea that it would cause panic. (October 31, 1938). Source: Acme News Photos/Wikicommons (public domain)

On October 30, 1938, Orson Welles broadcast an episode of the radio drama Mercury Theatre on the Air. This episode, entitled The War of the Worlds and based on a novel by HG Wells, suggested to listeners that a Martian invasion was taking place. In the charged atmosphere of the days leading up to World War II, many people missed or ignored the opening credits and mistook the radio drama for a news broadcast. Panic ensued and people began to flee, with some even reporting flashes of light and a smell of poison gas. This panic, a form of mass hysteria, is one of the many forms that anxiety can take.

Mass hysteria can befall us at almost any time. In 1989, 150 children took part in a summer programme at a youth centre in Florida. Each day at noon, the children gathered in the dining hall to be served pre-packed lunches. One day, a girl complained that her sandwich did not taste right. She felt nauseated, went to the toilet, and returned saying that she had vomited. Almost immediately, other children began experiencing symptoms such as nausea, abdominal cramps, and tingling in the hands and feet. With that, the supervisor announced that the food may be poisoned and that the children should stop eating. Within 40 minutes, 63 children were sick and more than 25 had vomited.

The children were promptly dispatched to one of three hospitals, but every test performed on them was negative. Meal samples were analyzed but no bacteria or poisons could be found. Food processing and storage standards had been scrupulously maintained and no illness had been reported from any of the other 68 sites at which the pre-packed lunches had been served.

However, there had been in the group an atmosphere of tension, created by the release two days earlier of a newspaper article reporting on management and financial problems at the youth centre. The children had no doubt picked up on the staff’s anxiety, and this had made them particularly suggestible to the first girl’s complaints. Once the figure of authority had announced that the food may be poisoned, the situation simply spiralled out of control. 

Mass hysteria is relatively uncommon, but it does provide an alarming insight into the human mind and the ease with which it might be influenced and even manipulated. It also points to our propensity to somatize, that is, to convert anxiety and distress into more concrete physical symptoms. Somatization, which can be thought of as an ego defence, is an unconscious process, and people who somatize are, almost by definition, unaware of the psychological origins of their physical symptoms.

As I discuss in The Meaning of Madness, psychological stressors can lead to physical symptoms not only by somatization, which is a psychic process, but also by physical processes involving the nervous, endocrine, and immune systems. For example, one study found that the first 24 hours of bereavement are associated with a staggering 21-fold increased risk of heart attack. Since Robert Ader’s early experiments in the 1970s, the field of psychoneuroimmunology has blossomed, uncovering a large body of evidence that has gradually led to the mainstream recognition of the adverse effects of psychological stressors on health, recovery, and ageing, and, inversely, of the protective effects of positive emotions such as happiness, belonging, and a sense of purpose or meaning.

Here, again, modern science has barely caught up with the wisdom of the Ancients, who were well aware of the close relationship between psychological and physical well-being. In Plato’s Charmides, Socrates tells the young Charmides, who has been suffering from headaches, about a charm for headaches that he learnt from one of the mystical physicians to the King of Thrace. However, this great physician cautioned that it is best to cure the soul before curing the body, since health and happiness ultimately depend on the state of the soul: 

He said all things, both good and bad, in the body and in the whole man, originated in the soul and spread from there… One ought, then, to treat the soul first and foremost, if the head and the rest of the body were to be be well. He said the soul was treated with certain charms, my dear Charmides, and that these charms were beautiful words. As a result of such words self-control came into being in souls. When it came into being and was present in them, it was then easy to secure health both for the head and for the rest of the body. 

Mental health is not just mental health. It is also physical health.

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pink glassesThe Norwegian philosopher Peter Wessel Zapffe argued, essentially, that the human capacities for reason and self-awareness break with nature, giving us more than we, as a part of nature, can carry. So as not to go mad, ‘most people learn to save themselves by artificially limiting the content of consciousness.’

People not only limit the content of consciousness, but also fill it with less than the truth. In particular, most people think more highly of themselves than is warranted: they have an inflated sense of their qualities and abilities, an illusion of control over things that are mostly beyond them, and a misplaced optimism about their outcomes and prospects.

For example, most people claim to compare favourably to the average road user, citizen, parent… which is, of course, mathematically impossible, since not everyone can be above average. A couple on the verge of tying the knot is likely to overestimate the odds of having a carefree honeymoon or a gifted child, while underestimating the odds of having a miscarriage, falling ill, or getting divorced.

The concept of positive illusions first appeared in 1988, in a paper by Shelley Taylor and Jonathon Brown entitled, Illusion and well-being: A social psychological perspective on mental health. Still today, it is commonly believed that mental health corresponds to accurate perceptions of the self, the other, and the world, but in their paper Taylor and Brown argued that the evidence suggests otherwise, and that positive illusions are characteristic of normal human thought.

Positive illusions are helpful in so far as they enable us to take risks, invest in the future, and fend off despair and depression. After all, how many people would get married if they had any real sense of what awaited them? But in the longer term, the poor perspective and judgement that come from undue self-regard and false hope are likely to lead to disappointment and failure, to say nothing of the inhibitions and emotional disturbances (such as anger, anxiety, and so on) that can derive or descend from a defended position.

Positive illusions tend to be more common, and more marked, in the West. In East Asian cultures, for example, people are less vested in themselves and more vested in their community and society, and tend, if anything, to self-effacement rather than self-enhancement.

Positive illusions are also more prevalent in unskilled people, possibly because highly skilled people tend to assume, albeit falsely, that those around them enjoy similar levels of insight and competence. This Dunning-Kruger effect, as it has been called, is neatly encapsulated in a short fragment from the introduction to Darwin’s Descent of Man: ‘…ignorance more frequently begets confidence than does knowledge…’ And, of course, it may also be that, compared to highly skilled people, unskilled people are more reliant on positive illusions for their self-esteem and broader mental health.

Depressive realism

Just as it is commonly believed that mental health corresponds to accurate perceptions of the self, the other, and the world, so it is commonly believed that depression results in, or results from, distorted thinking.

‘Cognitive distortion’ is a concept from cognitive-behavioral therapy (CBT), developed by psychiatrist Aaron Beck in the 1960s and routinely used in the treatment of depression and other mental disorders. Cognitive distortion involves interpreting events and situations so that they conform to and reinforce our outlook or frame of mind, typically on the basis of very scant or partial evidence, or even no evidence at all.

Common cognitive distortions in depression include selective abstraction, personalization, and catastrophic thinking:

  • Selective abstraction is to focus on a single negative event or condition to the exclusion of other, more positive ones, for example, ‘My partner didn’t call me yesterday. He must hate me.’
  • Personalization is to relate independent events to oneself, for example, ‘The nurse is leaving her job because she’s fed up with me…’
  • Catastrophic thinking is to exaggerate the negative consequences of an event or situation, for example: ‘The pain in my knee is only going to get worse. When I’m reduced to a wheelchair, I won’t be able to go to work and pay the mortgage. So I’ll end up losing my house and dying in the street.’

However, the scientific literature suggests that, despite their propensity for such cognitive distortions, many people with depressed mood can also have more accurate judgement about the outcome of so-called contingent events (events that may or may not occur) and a more realistic perception of their role, abilities, and limitations—a phenomenon that is sometimes, and controversially, referred to as ‘depressive realism’.

The concept of depressive realism originated in 1979, in a paper entitled Judgment of contingency in depressed and nondepressed students: sadder but wiser? On the basis of their findings, the authors, Lauren Alloy and Lyn Abramson, argued that people with depression make more realistic inferences than ‘normal’ people, who are handicapped by their positive illusions. On the face of it, this suggests that people with depression are able to see the world more clearly for what it is, while normal people are only normal in so far as they are deceiving or deluding themselves.

This is a seductive proposition for someone like me, who has long been arguing that depression can be good for us—for example, in my book, The Meaning of Madness. But here’s the rub: people with depression are pessimistic even in situations in which pessimism is unwarranted, suggesting that, rather than being more realistic, their thinking is merely ‘differently biased’, and just as rigid and distorted as that of normal people with their positive illusions.

Wisdom, it seems, consists in being able to shed our positive illusions without also succumbing to depression, although, for many, depression may be a necessary step along the way.

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crown

The hallmark of narcissistic personality disorder is grandiosity. The narcissist harbors a strong sense of entitlement, self-aggrandizing fantasies, and a craving for admiration. In severe cases, she may be envious, lacking in empathy, and ready to exploit others in the pursuit of her lofty ambitions. Although she can be charismatic and charming, she more often seems self-absorbed, controlling, and insensitive. If she feels slighted or ridiculed, she might be provoked into a fit of destructive rage and revenge seeking. Such a paroxysmal reaction is sometimes called ‘narcissistic rage’ and can have disastrous consequences for all those involved, including the narcissist herself.

In the novel The Picture of Dorian Gray, both the characters of Lord Henry Wooton and Dorian Gray are strongly narcissistic. Lord Henry’s narcissism is insightful and often quite charming and no doubt similar to that of his creator and alter ego, Oscar Wilde.

I make a great difference between people. I choose my friends for their good looks, my acquaintances for their good characters, and my enemies for their good intellects. A man cannot be too careful in the choice of his enemies. I have not got one who is a fool. They are all men of some intellectual power, and consequently they all appreciate me.

On the other hand, Dorian Gray’s narcissism is cold and destructive, leading, among other things, to the suicide of actress Sibyl Vane. In Chapter 7, Sibyl tells Dorian that he brought her to “something [higher] of which all art is but a reflection” and made her understand the nature of true love. Instead of feeling flattered or humbled or otherwise moved, Dorian castigates Sibyl for her poor acting, claiming that it has killed off any love that he might ever have had for her.

‘Yes,’ he cried, ‘you have killed my love. You used to stir my imagination. Now you don’t even stir my curiosity. You simply produce no effect. I loved you because you were marvellous, because you had genius and intellect, because you realized the dreams of great poets and gave shape and substance to the shadows of art. You have thrown it all away. You are shallow and stupid. My God! How mad I was to love you! What a fool I have been! You are nothing to me now. I will never see you again. I will never think of you. I will never mention your name. You don’t know what you were to me, once. Why, once… Oh, I can’t bear to think of it! I wish I had never laid eyes upon you! You have spoiled the romance of my life…’

A study carried out by Board and Fritzon at the University of Surrey in England found that narcissistic personality disorder, histrionic personality disorder, and another personality disorder called anankastic personality disorder are actually more common in high-level executives than in mentally disordered criminal offenders at the high-security Broadmoor Hospital.

This suggests that people commonly benefit from strongly ingrained and potentially maladaptive personality traits. For example, people with narcissistic personality disorder may be highly ambitious, confident, driven, and able to exploit people and situations to maximum advantage. People with histrionic personality disorder may be adept at charming and manipulating others, and thus adept at building and exercising business relationships.

In their study, Board and Fritzon described the executives with a personality disorder as ‘successful psychopaths’ and the criminal offenders as ‘unsuccessful psychopaths,’ and it may be that highly successful people and disturbed psychopaths have more in common than first meets the eye. As the psychologist and philosopher William James put it more than a hundred years ago, ‘When a superior intellect and a psychopathic temperament coalesce… in the same individual, we have the best possible condition for the kind of effective genius that gets into the biographical dictionaries.’

Over in the United States, Mullins-Sweatt and her colleagues investigated how successful psychopaths might differ from unsuccessful ones. They asked several members of the psychology and law division of the American Psychological Association, professors of clinical psychology, and criminal attorneys to first identify and then to rate and describe one of their acquaintances (if any) who could be counted as successful and also conformed to psychologist Robert Hare’s definition of a psychopath:

…social predators who charm, manipulate and ruthlessly plow their way through life… Completely lacking in conscience and feeling for others, they selfishly take what they want and do as they please, violating social norms and expectations without the slightest sense of guilt or regret.

From the responses that they collated, the researchers found that successful psychopaths matched unsuccessful ones in all respects but one: conscientiousness. So, it seems that the key difference between unsuccessful and successful psychopaths is that the former behave impulsively and irresponsibly, whereas the latter are able to inhibit or at least restrain destructive tendencies and build on their achievements.

Narcissistic personality disorder is, of course, named for the Greek myth of Narcissus, of which there are several versions. In Ovid’s version, which is the most commonly related, the nymph Echo falls in love with Narcissus, a youth of extraordinary beauty. As a child, Narcissus was prophesized by Teiresias, the blind prophet of Thebes, to ‘live to a ripe old age, as long as he never knows himself’.

One day, Echo followed Narcissus through the woods as he hunted for stags. She longed to speak to him but dared not utter the first word. Overhearing her footsteps, the youth cried out, “Who’s there?” to which she responded, “Who’s there?” When at last she revealed herself, she rushed to embrace Narcissus, but he scorned her and pushed her away—just, in fact, as Dorian did Sibyl. Echo spent the rest of her life pining for Narcissus and slowly withered away until there was nothing left of her but her voice.

Some time after his encounter with Echo, Narcissus went to quench his thirst at a pool of water. Seeing his own image in the water, he fell in love with it. But each time he bent down to kiss it, it seemed to disappear. Narcissus grew ever more thirsty, but would not leave or disturb the pool of water for fear of losing sight of his reflection. In the end, he died of thirst, and there, on that very spot, appeared the narcissus flower, with its bright face and bowed neck.

What does this myth mean? On one level, it is an admonition to treat others as we would ourselves be treated, and in particular to be considerate in responding to the affections of others, which, as with Echo, are often so raw and visceral as to be existential. After being rejected by him, poor Echo had no self and no being outside of Narcissus, and ‘slowly withered away until there was nothing left of her but her voice’.

On another level, the myth is a warning against vanity and self-love. Sometimes we get so caught up in ourselves, in our own little egos, that we lose sight of the bigger picture and, as a result, pass over the beauty and bounty that is life. Paradoxically, by being too wrapped up in ourselves, we actually restrict our range of perception and action and, ultimately, our potential as human beings. And so, in some sense, we kill ourselves, like so many ambitious or self-centered people. Treating other people badly is a sure sign that we are still trapped in ourselves.

Teiresias prophesized that Narcissus would ‘live to a ripe old age, as long as he never knows himself’, because to truly know oneself is also to know that there is nothing to know. Our self, our ego, is nothing but an illusion, nothing more substantial than the ever-receding reflection that Narcissus was unable to grasp. Ultimately, Narcissus’s ego’s boundaries dissolved in death and he merged back into the world in the form of a flower. In Greek myth, the hero—Theseus, Hercules, Odysseus—has to die and travel through the underworld (the unconscious) before re-emerging as a hero. He has to conquer himself, to die to himself, to become more than merely human.

Echo had not enough ego, and Narcissus far too much. The key is to find the right and dynamic equilibrium, to be secure in oneself and yet to be able to dissociate from the envelope that we happen to have been born into.

References

  • Board BJ and Fritzon KF (2005): Disordered personalities at work. Psychology, Crime and Law 11:17-23.
  • James W (1902): The Varieties of Religious Experience, Lecture 1 ‘Religion and Neurology’, Footnote 6.
  • Mullins-Sweat S et al. (2010): The Search for the Successful Psychopath. Journal of Research in Personality 44:554-558.

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Is the medicalization of human suffering doing more harm than good?

‘Mental disorder’ is difficult to define.

Generally speaking, mental disorders are conditions that involve either loss of contact with reality or distress and impairment. These experiences lie on a continuum of normal human experience, and so it is impossible to define the precise point at which they become pathological.

What’s more, concepts such as borderline personality disorder, schizophrenia, and depression listed in classifications of mental disorders may not map onto any real or distinct disease entities. Even if they do, the symptoms and clinical manifestations that define them are open to subjective judgement and interpretation.

In an attempt to address these problems, classifications of mental disorders such as DSM-5 and ICD-10 adopt a ‘menu of symptoms’ approach, and rigidly define each symptom in technical terms that are often far removed from a person’s felt experience. This encourages mental health professionals to focus too narrowly on validating and treating an abstract diagnosis, and not enough on the person’s distress, its context, and its significance or meaning.

Despite using complex aetiological models, mental health professionals tend to overlook that a person’s felt experience often has a meaning in and of itself, even if it is broad, complex, or hard to fathom. By being helped to discover this meaning, the person may be able to identify and address the source of his distress, and so to make a faster, more complete, and more durable recovery. Beyond even this, he may gain important insights into himself, and a more refined and nuanced perspective over his life and life in general. These are rare and precious opportunities, and not to be squandered.

A more fundamental problem with labelling human distress and deviance as mental disorder is that it reduces a complex, important, and distinct part of human life to nothing more than a biological illness or defect, not to be processed or understood, or in some cases even embraced, but to be ‘treated’ and ‘cured’ by any means possible—often with drugs that may be doing much more harm than good. This biological reductiveness, along with the stigma that it attracts, shapes the person’s interpretation and experience of his distress or deviance, and, ultimately, his relation to himself, to others, and to the world.

Moreover, to call out every difference and deviance as mental disorder is also to circumscribe normality and define sanity, not as tranquillity or possibility, which are the products of the wisdom that is being denied, but as conformity, placidity, and a kind of mediocrity.

The evolution of the status of homosexuality in the classifications of mental disorders highlights that concepts of mental disorder can be little more than social constructs that change as society changes. PTSD, anorexia nervosa, bulimia nervosa, depression, and deliberate self-harm (non-suicidal self-injury) can all be understood as cultural syndromes. Yet, for being in the DSM and ICD, they are usually seen, and largely legitimized, as biological and therefore universal expressions of human distress.

Other pressing problems with the prevalent medical model is that it encourages false epidemics, most glaringly in depression, bipolar disorder, and ADHD. Data from the US National Health Interview Survey indicate that, in 2012, 13.5% (about 1 in 7) of boys aged 3-17 had been diagnosed with ADHD, up from 8.3% in 1997. It also encourages the wholesale exportation of Western mental disorders and Western accounts of mental disorder. Taken together, this is leading to a pandemic of Western disease categories and treatments, while undermining the variety and richness of the human experience.

For example, in her recent book, Depression in Japan, anthropologist Junko Kitanaka writes that, until relatively recently, depression (utsubyō) had remained largely unknown to the lay population of Japan. Between 1999 and 2008, the number of people diagnosed with depression more than doubled as psychiatrists and pharmaceutical companies urged people to re-interpret their distress in terms of depression. Depression, says Kitanaka, is now one of the most frequently cited reasons for taking sick leave, and has been ‘transformed from a rare disease to one of the most talked about illnesses in recent Japanese history’.

Many critics question the scientific evidence underpinning such a robust biological paradigm and call for a radical rethink of mental disorders, not as detached disease processes that can be cut up into diagnostic labels, but as subjective and meaningful experiences grounded in personal and larger sociocultural narratives.

Unlike ‘mere’ medical or physical disorders, mental disorders are not just problems. If successfully navigated, they can also present opportunities. Simply acknowledging this can empower people to heal themselves and, much more than that, to grow from their experiences.