Tuesday, 13 August 2013

A plague of depression or sadness rebranded - what's the truth about capitalism and mental illness?

An essay, published a couple of weeks ago by the novelist Will Self, caught my eye because it embodies an interesting conflict between two differing left-wing critiques of corporate capitalism. They appear to be making diametrically opposite points yet both stem from an anti-capitalist viewpoint, or at least display a healthy scepticism towards the “truths” of our corporate society.

Self, who has previously been a psychiatric patient, was concerned to take on the psychiatric profession and  (as the stand-first puts it) its “disease mongering”. Unable to cure severe mental pathologies, Self argues, psychiatry has instead turned to treating “less marked psychic distress”. Aided and abetted at every stage by pharmaceutical companies, doctors now create diseases to fit the drugs available. What used to be ordinary sadness has been rebranded as depression, an illness that can conveniently be combated by the prescribing of anti-depressants  - a dispensing of billions of pills to correct an alleged chemical imbalance in the brain that coincidentally makes fantastic profits for big pharma.

“The sad are becoming oddly co-morbid (afflicted with the same sorts of diseases) with the mad,” writes Self.

Selfish capitalism and it discontents

Contrast this with the claim by Mark Fisher, author of Capitalist Realism, that neo-liberal capitalism is generating a “mental health plague”. Depression is now the condition most treated by the National Health Service in Britain, says Fisher. According to clinical psychologist Oliver James the “selfish capitalism” of Anglo-Saxon societies is causing an acute intensification of emotional distress ; an epidemic of depression, anxiety, substance abuse and personality disorder. James cites World Health Organization surveys: 26% of Americans experience an episode of “mental distress” every year. In Britain, the number is one person in five.

Here is James speaking:

So one side identifies a contagion of mental illness, while the other says it’s all a plot to uphold the prestige of psychiatry and supply pharma corporations with a steady profit stream. Who’s right?

At the risk of being diagnosed with an incurable case of fence sitting, it seems to me that both of these positions, on the surface utterly incompatible, may be true.

Depression x 1000

There is undoubted evidence for the veracity of what Self is saying. The arrival of Prozac and other SSRIs in the late 1980s coincided with a thousand-fold increase in the diagnosis of depression. It would be extremely difficult to honestly argue this had nothing to do with efforts of drug companies to market anti-depressants. And this initial anti-depressant spurt has since become a biblical flood. In 2011, 46.7 million prescriptions were written for anti-depressants by the National Health Service in England, an increase of 9.1% on the previous year, and an avalanche of pills compared to the 9 million prescriptions signed off in 1991.  But though “psychic distress” - to use Self’s term - has clearly been turned into chemically treatable depression, that doesn’t mean the distress was a fiction, or that the distress hasn’t increased, or that it was simply sadness given a medical name. There is, it seems to me, a large space between sadness and full blown mental illness. And a lot has been happening, in the last twenty or thirty years, in that space.

Ordinary and extraordinary sadness

Self himself makes the distinction. “But what has made it possible for someone recently bereaved or unemployed,” he asserts, “to have a prescription written by their doctor to alleviate their ‘depression’ is, I would argue, very much to do with psychiatry’s search for new worlds to conquer, an expedition that has been financed at every step by big pharma.”

Bereavement and unemployment are, I would argue, two completely different states. Bereavement is ordinary, though it doesn’t feel ordinary, sadness. It’s impossible to go through life and not be bereaved and feel its emotional effects. Unemployment is, by contrast, very much a socially constructed state. In the first place, unemployment has only been around for 200 years or so. Secondly, it’s much more acute now than it was forty years ago (from 1950 to 1973, UK unemployment averaged 1.6%). Lastly, its effects on an individual depend very much on how society treats it. Post-capitalist economists such as Richard Wolff and David Schweickart have argued that, in a more humane society, people that have to be laid off by enterprises would automatically be offered jobs or training elsewhere. This is everyday practice now in the Mondragon federation of worker co-operatives, comprising 256 companies employing 83,000 people, located in Northern Spain.

By contrast, what British society does is to make unemployment the personal responsibility of the person who is unemployed. Unemployment – a social problem if ever there was one - becomes an individual problem. The result is self-blame and, in a society that is intensely comparative, all the ingredients for mental distress, not just sadness, are laid. It is interesting that the root causes of the emotional distress identified by Oliver James in 2008’s The Selfish Capitalist (a book written before the financial crisis) – stagnating real wages, the growth of short-term, service industry jobs (see the rise of zero-hours contracts) and an exaltation of the consumer habits of the rich – have only become more prevalent. So why shouldn’t mental anguish have got worse?

Diseases, disorders and effects

The key to understanding what has happened, I think, is to separate social effects from their pathologisation, the turning of states of mind and behaviour into a “disease” which can then be treated by drugs. This pathologisation may be entirely unjustified, just suiting the need of pharma companies to make lots of money from selling pills, and indeed the pills may not actually work (Self says that the chemical imbalance theory of depression, on which SSRIs are based, is “essentially bunk” – he may be right, I don’t know) But all that doesn’t mean the social effects are not real. “The vast number of ‘hyperactive’ children in the US prescribed Ritalin is so well attested that it’s become a trope in popular culture,” writes Self. True, but I’m not convinced that labeling trends as a medical disorder, means that the trends themselves – difficulty in concentrating and impulsive behaviour in this case – are not genuine. Likewise, I don’t believe that the rise in mental distress is a myth.

Valium nation

To take a historical example, millions of prescriptions were written for the tranquilizer, Valium, a predecessor of anti-depressants, in the 1960s and 1970s. The drug quickly gained a reputation for being “the housewives’ choice”. It provided a release from the psychic consequences of an extremely restricted life. The problems for these women were pathologised and the symptoms they suffered from chemically anesthetized. But that didn’t imply that the underlying issues – a life limited to motherhood and caring and confined to the home – didn’t exist, or that doctors somehow created them, as most people, now the vast majority of women go out to work, would recognise. Why can’t the same be said for anti-depressants?

The book, The Spirit Level, provides persuasive evidence that Anglo-American societies have become more anxious, if not more depressed. The authors cite the work of American psychologist, Jean Twenge, who looked at 269 studies measuring anxiety in the US from 1952 to 1993. She found a continuous upward trend. By the late 1980s, the average American child was more anxious than child psychiatric patients in the 1950s. Anxiety, as far as I understand, is related to depression, though not as extreme. You can’t explain away these findings by saying it’s all down to doctors, egged on by pharma companies, discovering anxiety where previously it didn’t exist. Prozac was first released in 1988, just five years before the period of study ended.

I’ve little doubt that Self is right and psychiatry and big pharma, have, for different reasons, created diseases and pathologised distress. But that is only half the story.

Friday, 2 August 2013

In praise of idleness, part 3. Democracy and the question of time

In July a college lecturers’ union in Britain released a survey of so-called ‘NEETS’- young people, aged 16 to 24 who are not in employment, education or training. There are estimated to be 900,000 NEETS in the UK. One third of the 1,000-strong sample said they had suffered from depression, 37% said they rarely left their home and 39% were beset by stress. One jobless 23 year old told the BBC: “I rarely go out and feel so down about myself. I’ve tried so hard to find a job but I feel no-one wants me.”

According to David Stuckler, co-author of The Body Economic: Why Austerity Kills, Britain is “one of the clearest expressions of how austerity kills”. Suicides were falling before the recession, Stuckler relates in an interview. Then they spiked in 2008 and 2009 as unemployment shot up, only to fall again when jobless levels declined.

Unemployment, it is clear, is terrible for your mental health; provoking feelings of isolation, unwantedness and a corrosive sense of not contributing to society. But unemployment – and underemployment - is a perennial blight in virtually all advanced capitalist countries. With onset of the ‘Global Financial Crisis’, the blight of joblessness has become chronic, reaching an eye-watering rate of 27% in Spain and Greece.

Sinister consensus

So a consensus has formed, in Britain, as elsewhere, that sees joblessness as the enemy and employment as salvation. Trade unions in the UK want stable and rewarding jobs, the British Labour party now brands itself as “the party of work” while the ruling Conservative party, in a move of cynical callousness, justifies the withdrawal of state benefits from the disabled on the grounds of offering “tough love” to people stranded at home, doing nothing, in order to “help them into work”.

There is something inherently wrong, indeed sinister, with this myopic consensus, as I hope parts one and two made apparent. Yet it derives its potency from a pervasive and genuine fear, that of the destructive effects of non-activity. This fear becomes all-consuming so that it is immaterial what work is for or what it entails, only that it exists. Zero-hour contracts – where an employee does not know how many hours they will be contracted to work in a given week – are mushrooming in Britain, while close to 80% of new jobs pay below £7.95 an hour (the minimum wage rate is £6.19). The overwhelming need is to be wanted by an employer, to avoid the predations of unemployment, to not be excluded from mainstream society. This consensus is both conservative and desperate.

Alternatives to exhaustion

There are innumerable advantages to the “organised diminution of work”, that Bertrand Russell advocated in In Praise of Idleness. Genuine choices would arise if your life was not dominated by the need to serve the interests of another. More time to spend on caring, child-rearing, studying or artistic endeavours, for example. It is not hard to compile such a list. A healthier, more relaxed and more interesting society would result. Russell himself estimated that at least one percent of the population – if not distracted by the requirement to spend most of their useful hours on activities designated by an employer – would produce works of public importance and “since”, he argued, “they will not depend on these pursuits for their livelihood, their originality will be unhampered”. It is, I feel, partly to block the emergence of such original thinking, a bubbling and multi-pronged challenge to mainstream explanations in economics and politics, that the boot remains firmly planted on the neck, as far as working hours are concerned.

But there is one activity which is both enabled by a radical reduction in working hours and also has the potential to substitute for the cohesive side effects of paid employment. I am speaking of democratic self-management. The English economist, Harry Shutt, has said that “in the absence of productive work opportunities … potentially the human race could rediscover the opportunity to practise direct democracy somewhat in the manner of the ancient Athenians – but without their need to depend on slaves to do all the menial work.”

Time for democracy

There are many modern forms of direct democracy – participatory budgeting, worker self-directed enterprises, citizen assemblies, random selection. They are all based on the idea that ordinary citizens have the competence to run their own affairs and that an outsourcing of power to representatives is not necessary for good governance. But what they require to thrive is an abundance of time. Genuine democracy is not possible in a time-pressed, hurried society. Democracy, to work, has to be learnt by experience, by practising it.

A famous ancient Athenian, Aristotle, remarked that excellence was a habit, not an act. You become good at something, he said, by doing it repeatedly. Democracy, in its classical sense, is not a habit for people in modern societies. When it does appear, sporadically, its practices have to be learnt all over again and fitted in with all the other demands of life. Work, by contrast, is a habit and one we are loath to shake off. Management is a habit, careers are a habit, consumption is a habit. The modern capitalist economy has been described as a “gigantic school” doting on and encouraging some skills and allowing others to atrophy.

Contrasting the practices of Athenian democracy with modern notions of politics, the social ecologist Murray Bookchin, wrote: “The ‘political process’, to use a modern cliché, was not strictly institutional and administrative; it was intensely processual in the sense that politics was an inexhaustible, everyday ‘curriculum’ for intellectual, ethical and personal growth – paidea that fostered the ability of citizens to creatively participate in public affairs.”

The promise of idleness

Some people may find the word “curriculum” vaguely threatening but I think it is very apt. If work is to fade in significance, as it is doing and will surely continue to do, then its associated blessings – a sense of belonging, validation and of making a contribution to society – will have to be replaced by something. The fear of a void of non-activity needs to be assuaged. We need a society attuned to post-scarcity, in contrast to this one which is in flagrant denial. John Maynard Keynes, writing in 1930, said the abiding problem for people once the economic problem had been solved, would be what to do with their freedom, how exactly to occupy their abundant leisure. Keynes, who was irredeemably elitist, could not answer his own question.

We, however, can. Democratic self-management, in my opinion, is both enabled by a post-scarcity society and vital to such a future society’s inner strength. The UK government, backed by the opposition Labour party, wants to create a “nation of entrepreneurs”. A genuine Left movement should have the opposite endeavour, to create a “nation of self-managers”, even if the phrase sounds horribly clunky. Once that commitment is made, through forms such as participating budgeting, citizen assemblies, participatory commissioning or worker co-ops, then the process, as Bookchin recognised, becomes as important as the end point. Skills such as public speaking, formulating positions, dissensus, disagreeing with the opinions of others whilst respecting them, need to be learnt and, as objectively as possible, taught. What passes for the Left nowadays seems only to know what it is against and cannot encapsulate what it is for. Economic stagnation and austerity has only further exposed this deficiency. The promise of idleness should be recognised as an opportunity to fill the vacuum.