When asked to think about the question of how ‘mental health’ relates to ‘politics’ - clinicians, therapists and, too often, lay people – are prone to view the two fields as largely separate domains. But as I try to show in my book - The Therapy Industry, The Irresistible Rise of the Talking Cure, and Why it Doesn’t Work - this is a fundamental error. In fact, the workings of power within our society, the experience of personal distress, and our response to it: all of them are intertwined; and as thoroughly as mind, brain and body within the same person. Here are five books that reveal this situation with clarity and force, and that will invite many of us to rethink not just our assumptions, but why we hold them, in the first place.
Stuckler, D. and Basu, S. (2013) The Body Economic: Why austerity kills. London: Allen Lane.
For the last six years, the Western world has been in the grip of the longest and most serious economic slump since the 1930s. And yet, as the epidemiologists David Stuckler and Sanjay Basu point out in their new book, The Body Economic: why austerity kills, political leaders and policy makers have committed millions of people in America and Europe, including the citizens of the UK, to ‘austerity’. Presented as a scheme to manage the debts incurred by an under-regulated financial sector, austerity means the evisceration (and usually privatisation) of public services including healthcare, disability and unemployment benefits, and housing support. It also means an attack upon wages and pensions and - for the poor, the sick and the disabled - hardship, the threat of homelessness, and official vilification.
Stuckler and Basu view the flow of economic and (implicitly) political power as the equivalent of the vital signs in a sound or ailing body, an image that is doubly apt, since individual wellbeing is inseparable from that of the healthily democratic and caring state. Comparisons of countries and regions that have adopted either stimulus or austerity programmes in different times and places - from the current Great Recession, to the Russian free market ‘reforms’ of the 1990s, the American New Deal of the 1930s, and on to the post World War II British labour administration (culminating in the welfare state and National Health Service) - show that, for entire populations, the economic choices made by governments shape the patterns of life and death, resilience and risk. Under the harsh treatment of austerity, the most unfortunate, such as the homeless, increasingly fall prey to tuberculosis and other serious infections. For those still clinging to the rungs above, but who suddenly lose their jobs, the resulting collapse of income, purposes, status, routines and social contacts (which help to keep us sane) make it probable that they will sink into the despair that gets diagnosed as depression, and will perhaps seek comfort in alcohol, smoking, or illicit drugs, and in some cases start to neglect themselves, in ways large and small. Life begins to fade sooner than it should, and sometimes ends abruptly through accident or suicide: as recent trends in Europe and the US imply. As public health professionals, Stuckler and Basu suggest reforms that might help us to avoid the disaster of ‘austerity’ in future. They recommend the creation of a watchdog Office of Health Responsibility, tasked with the job of disclosing to the public how various policies affect public health. The poor should be helped to return to work, and with living wages. All nations should maintain or increase their investment in public health, free at the point of delivery.
Healy, D. (2013) Pharmageddon. Berkley: University of California Press.
Of course, it is not just austerity that harms. For all of the benefits that it brings, medical care can itself cause unanticipated problems. In Western countries, complications from medical treatment are the fourth leading cause of death, and within the mental health field they are probably the leading one. Why this should be is a question that has long perplexed David Healy, professor of Psychiatry at Cardiff University and onetime Secretary of the British Association of Psychopharmacology. Over twenty years ago, he was the first to draw attention to the now well-known suicide inducing side effects of the SSRI anti-depressants, like Prozac. In Pharmageddon, he shows that the problems that led to this state of affairs have intensified. Throughout the world, the interests of drug companies, insurers, politicians, academics, doctors, civil servants and even some groups of patients and their relatives have steadily interlocked, to create something near to a charade of clinical medicine. Science should be a public undertaking, but this is not true of the pharmaceutical industry, where the raw data from clinical research trials is locked away from independent scrutiny, and then cherry-picked and homogenized to give results that are sweet, but ultimately lacking in nutritional value. Patients who have suffered harmful side effects of new drugs can be reclassified (and then discounted) as treatment ‘drop outs’; and new, healthier ones can be invented to replace them. Up to half of all pharmaceutical research papers published under the names of leading academics have been written by professional anonymous ‘ghost writers’, paid to make the new drugs seem like breakthroughs when they are no better than their predecessors, and might even be more dangerous. Doctors, ignorant of statistical methods, are easily bamboozled by this shallow research literature, and by the advertising campaigns built upon it.
The results are far reaching. Rates of prescribing have rocketed since the 1990s, and thousands of us are being poisoned by the drugs that we take in hopes of becoming calmer, bolder or happier versions of ourselves, or of escaping the health risks that go with aging. The practice of medicine is changing. Doctors are seen (and increasingly see themselves) as technicians, trained in facile customer satisfaction, and driven by mandatory guidelines that frequently embody this dubious research literature, and that reinforce the apparent reality of questionable diagnoses like ADHD, Bipolar Disorder and Schizophrenia. Patient reports of troubling side effects are discounted or ignored; and health care comes to focus upon the individual as the sole crucible of disease and of its management.
The reasons for this state of affairs are not hard to fathom. Worldwide, approved drug sales exceeded 900 billion dollars in 2010 - easily surpassing the bailout for the US economy after the 2008 financial crisis. Many leading brands are worth more than their weight in gold; and wealth buys influence. Since the 1940s there has been no truly independent American or British agency that examines the effects of new pharmaceuticals, or that investigates when things go wrong; most academics in the field – the ones who should be blowing the whistles - have lost their ability to think critically, along with their lungpower.
Nevertheless, Healy argues that most of these ills could be tackled (if not eliminated) through the introduction of a range of measures, including a drastically shortened time span for all drug patents, new incentives for GPs to more closely monitor patients for signs of adverse reactions to their medicine, the withdrawal of prescription only status for most pharmaceuticals, an end to the practice of ghost writing; and, above all: the posting of all records from clinical trial upon public websites. One laudable consequence is that widespread treatments like the SSRI anti-depressants would have to be sold, more truthfully, as the modern equivalent of 19th century ‘nerve tonics’, rather than as supposed ‘silver bullets for depression.’
William Epstein (2006): The Civil Divine: Psychotherapy as Religion in America: Reno: University of Nevada Press.
If critics of the pharmaceutical industry are in short supply, so it is with the flourishing academic field of research into the talking treatments. But this tradition has its dissidents, too. In the early 1990s, the American social scientist William Epstein examined some of the most cited literature on the effectiveness of psychological therapy, but with rather more care and rigour than is usual. In common with a small but persistent minority of critics down the years, he found that the claimed benefits of psychological treatment were insupportable. Fifteen years later, as described in The Civil Divine, he again scrutinized the best quality clinical trials of psychological treatment, culled from top publications like the American Journal of Psychiatry, many of which endorsed the superiority of leading brands, like Cognitive Behavioural Therapy (or CBT).
The picture was a near mirror image of what David Healy had found for the leading psychiatric drugs. Poor experimental design, lack of long-term post-treatment follow-up, dubious outcome measures and statistical methods which concealed large variations in client outcome – including people who got worse, and clinical trials that were invariably run, evaluated and written up by therapists and academics with an obvious personal and professional stake in the outcome. In fact, the science in support of talking therapies is even worse than that which reigns in the pharmaceutical industry. If there are no ghost-writers, then this is because there has been little need for them: so deeply wedded are the researchers, the clients and nearly everyone else to the myth of personal transformation via psychological techniques. In his summary of the last half-century of this research literature, Epstein is damning: ‘ … there has never been a scientiﬁcally credible study that attests to the effectiveness of any form of psychotherapy for any mental or emotional problem under any condition of treatment.’
Smail, D. (1993) The Origins of Unhappiness: a new understanding of personal distress. London. Harper Collins.
One of the reasons that psychotherapy and counselling continue to prosper in our culture is because they fulfil our latent religious yearning for personal transformation through moral effort. As long as most of us believe in this notion of ‘heroic individualism’, as Epstein calls it, then the poor, the unemployed, and all of us who grapple with inimical circumstances can take the blame for our personal problems, the true sources of which may lie much further afield.
The psychologist who has perhaps done the most to show how all of these processes can operate is the British clinician, David Smail. In The Origins of Unhappiness, he describes his efforts to help some of the demoralised casualties of Thatcherism and of the 1980s ‘business revolution’: an experience that finally persuaded him that it was not - as assumed by most practitioners of psychological therapy - the way people saw things or chose to behave that caused their personal problems, but a malign world. This realization came slowly, as Smail found himself treating more and more middle-class professionals in this first wave of the ‘shock capitalism’ with which the UK has since been repeatedly dosed, by governments of right and ‘left’. As public services and nationalised industries were forced to embrace free market ways and deregulation, endorsed by official commitment to ‘business values’, many of these professionals found themselves struggling within workplaces where long-accepted (often informal) practices, values and ethics were suddenly dropped in favour of a hard nosed commitment to ‘profit making’, ‘efficiency’ and ‘competition’. In a series of composite vignettes, Smail shows that almost every one of his patients attributed their ‘anxiety’ or ‘depression’ to their own weakness, when, more accurately, their sorrows pointed to the imposition of a chillier, harsher social climate, and to the personal unease that it inevitably spawned. For most, this ‘inability to cope’ was the only verdict offered by the psychotherapy and counselling industries, and by the transnational and corporate interests that profited from these unsettling circumstances. Smail’s astute observations were amply confirmed by psychiatric survey data and other health indices, including rising suicide rates for young men; but one of the most remarkable things about this book is that so few of his colleagues seemed to have noticed what was happening.
Johnstone, L. (2000): Users and Abusers of Psychiatry. London: Routledge.
David Smail remains in a tiny minority of critically minded psychologists, but one who shares much of his outlook is Lucy Johnstone. In her classic study, Users and Abusers of Psychiatry, she takes aim at the medical establishment and its fondness for trying to cram tangled (often abusive) personal histories and complex situations, into narrow mental health diagnoses: imposed upon each patient via a tick-box style interview, which can be as short as 20 minutes. Johnstone shows that these labels tell us little about the causes or experience of distress, about how it is understood by the sufferer, and still less about how anyone might attempt to ease it – other than by prescribing psychiatric drugs that are less useful than anyone can bear to recognize.
It is both the mental health professionals themselves and the patient’s significant others who are often the true users of psychiatry and of the wider mental health treatment system over which it presides. The professionals gain kudos, salaries, and confirmation of the value and scientific basis of their work. Relatives and friends can be comforted in the belief that the problem hides inside of the sufferer, in the form of a mythical biochemical imbalance. And the abusers? They are the very same groups of people. The doctors and nurses who, too often with blithe confidence in their own scientific and humanitarian credentials, apply powerful tranquilising drugs to silence those who have been driven crazy by impoverishment, by their families, friends and colleagues, or by the erosive racism or sexism of their own communities. The sufferers are then returned, in the guise of ‘the mentally ill’, to the inimical circumstances that forged their problems in the first place; many of them now burdened with the chronic side-effects of the psychiatric drugs that have been prescribed to them. These effects can extend from disfiguring facial tics, to massive weight gain, drowsiness (to a degree that is socially and occupationally crippling), and lost libido. Too often, Johnstone suggests, the supposed cure is worse than the supposed illness.
Nevertheless, she shows how things might have been different, had alternative approaches pioneered by psychiatrists like Richard Scott, during the 1960s, been given their due. In common with R.D. Laing, and others, Scott saw that the acutely disturbed person had already been diagnosed by their family or associates as ‘mad’: in the expectation that the doctors would officially sanction their verdict and allow the underlying issues to be ignored. Scott’s response was to reject this judgment as premature. Instead, he would meet with the family and the troubled patient with the aim of helping everyone to behave more compassionately, and thereby removing the need for the patient to display ‘symptoms’, as the only conduit for their anguish. Needless to say, his labour-intensive and low drug approach never caught on, though its underlying ethos persists in some sections of the service user led recovery movement; and especially amongst those who argue that personal progress depends, most of all, upon the chance to live in a more benign and encouraging world.
If Johnstone is sometimes over optimistic about the potency of the psychological treatments that she endorses as the superior alternative to biomedical psychiatry, then she is nonetheless correct to argue that it is often more helpful to forgo the prescription pad; and to instead try to listen to what so many patients are saying about their distress and how it reflects what others have done to - or withheld - from them.
What then, should we do?
The work of these authors presents a profound critique of the practice and politics of the mental health system. They suggest that it is not faulty biochemistry, lack of insight, or want of personal grit but a noxious world that is the main root of madness and despair. In a society built around wealth and power, some of us have a more precarious existence than others, and in times of economic turbulence will face even greater turmoil; as governments start to cut away the public services and protections upon which we depend for employment, and shelter. For those of us who belong to this group – which is no small minority – distress is all but inevitable. The mental health professions have been slow to communicate this reality to the wider public. They have in the main endorsed simplistic, quick-repair treatments, which conceal the environmental origins of our personal ills, just as they foster a state of anxious self-absorption. In David Healy’s words, we are left, not with a desire for societal change, but with ‘reduced life expectancies, a growing discontent with who we are, and an atrophied ability to care for others’ (237). The books discussed here come close to being antidotes for this kind of error. If they do not provide (or claim to provide) all of the answers, they at least help us to ask the right questions which, so often, turn out to be political ones.
Paul Moloney is a Counselling Psychologist based in the UK. He has written widely in the fields of mental health, community psychology, and learning disability, and is a founder member of the Midlands Psychology Group. His recent book, The Therapy Industry, The Irresistible Rise of the Talking Cure and Why it Doesn’t Work, is published by Pluto Press.