The magic wand and biological determinism. The two faces of neoliberalism

According to Belgian psychologist Paul Verhaeghe, the psychiatric world is riven by two warring factions. On the one side there is the medical or illness model, which assumes that all mental illness stems from biological or genetic defects. Think of low serotonin levels ‘causing’ depression. Treatment involves taking pills, often indefinitely, to relieve the symptoms. Mental disorders are frequently viewed as lifelong afflictions a person must adjust to. The medical model is the dominant approach, adhered to by the majority of clinicians and doctors.

On the opposite terrain is what is known as the ‘biopsychosocial’ model. Under this way of thinking biology or genetics is relegated to a secondary position. Diagnosis focuses on the broader social context facing the individual and treatment is tailored to a person’s circumstances. This model is also far more open to a person making a recovery from mental illness.

Verhaeghe is resolutely on the minority side of the argument. “The vast majority of mental disorders are not illnesses,” he asserts, “but biopsychosocial manifestations in individuals of broader social problems.”

I believe the biopsychosocial model is essential to understanding how our capitalist, neoliberal society is at the root of many mental and physical illnesses. There is overwhelming evidence of the crucial role factors like childhood poverty, inequality, economic insecurity, loneliness, migration and bullying in increasing the risk of mental illness. According to one UK psychology professor, Richard Bentall, the link between childhood trauma and future psychiatric problems is a strong as that between smoking and lung cancer. In contrast, the medical model of mental illness just presents a closed mind.

But the biopsychosocial model also has a sinister side. It is being used to bully disabled people out of social security benefits by insisting they can make miraculous recoveries from their conditions. Disability, here, is regarded as partially caused by the attitude of the sick or disabled person. Welcome to the world-view of ‘welfare reform’ in the UK.

In defending the government’s transformation of the Disability Living Allowance into Personal Independence Payments, Conservative minister Lord Freud (the same one who believes food banks have mushroomed because they offer a free good) told the House of Lords that ‘we have gone for the biopsychosocial model’.

According to a report from the Centre for Welfare Reform, “the biopsychosocial model has been used to create new obligations for those suffering from common health problems, such as the responsibility to ‘recognise that the sick role is temporary, in the expectation of recovery’”.

In one case, the Department for Work & Pensions funded a medical trial for people with ME which was presented as an exciting success for biopsychosocial intervention. But the standard for ‘recovery’ was lowered after the research began meaning that a person’s condition could have worsened and they were still counted as having ‘recovered’.

Here is 'Biopsychosocial Man' in action: 

The DWP has incrementally re-classified the work related activity group of Employment and Support Allowance claimants (people judged unfit for work) as not really disabled. Before, the government only asserted that people in the WRAG group might be able to work at some point in the future and that full-time work could damage their health. Now, they are subject to a ‘shocking’ level of sanctions and, for new claimants, paid the same in benefits as ordinary JSA claimants, as an incentive, ministers say, to find work.

At the same time the government is trying to re-package unemployment as a personal failing or mental illness, as opposed to a social problem beyond the power of the individual to rectify. There are now psychologists in job centres and job coaches in GP surgeries.

This indicates a fatal flaw in the biopsychosocial model. When it applied to the individual alone and their ‘wrong attitudes’, it becomes coercive, tyrannical and vindictive. Applied to society at large, it is liberating.

Under neoliberalism, an unsuccessful person is either lazy or sick. If they are sick, they need pharmaceutical assistance (which creates a steady stream of profits for pharmaceutical companies). If they are lazy, their misguided attitudes need to be corrected by enlightened experts. Two sides of the same battered coin, which, sadly, is still legal tender. The social and economic organisation of society is taken as a given, and not worthy of consideration.

The medical model strikes me as a dead end, like trying to argue with someone who has their fingers lodged firmly in their ears. But the biopsychosocial model can be both oppressive and illuminating. Perhaps we need to drop the ‘psycho’. A biosocial model of illness has great explanatory power and it can’t be manipulated to scapegoat people and cloak the interests of the powerful.

The strange comfort of symptoms - Intermittent Explosive Disorder and other pseudo-explanations

A curious combination of excitement and annoyance accompanies hitting upon the succinct description of a phenomenon you were only able to skirt around incoherently. Last year, I wrote an article on capitalism and mental health which laboured to make the point that the pathologisation of mental disorders, such as depression or attention deficit, which conveniently enables pharma companies to sell more drugs, does not mean that the social effects themselves are fictions or are not becoming more acute.

Then comes along Belgian psychoanalyst Paul Verhaeghe, who says in this latest book What About Me? that, as far as mental distress is concerned, symptoms are being reclassified as diseases. I can see now what I was trying to say. Cheers. Kind of.

Here is Verhaeghe speaking:

One example is attention deficit and hyperactivity disorder. Because a child is hyperactive and has difficulty concentrating, they obviously have ADHD. A person who periodically explodes in uncontrollable rage suffers from Intermittent Explosive Disorder (IED). It’s rather like saying that someone who endures painful headaches every other day, has headache disease.

Verhaeghe says we are trapped inside circular arguments and pseudo-explanations. Breaking out involves accepting, in common with the British Psychological Society and the World Health Organization, that mental disorders are primarily caused by social factors.

Contemporary blindness

Every society generates mental illness as well as mental health, says Verhaeghe. The Victorian age, with its strict moral codes and repressive sexual morality, produced hysteria in some women and obsessive-compulsive disorder in some men. Our current society generates “disorders” such as depression and anxiety among adults and ADHD and autism in children. While we are quite able to look back with clarity on the deficiencies of past epochs, says Verhaeghe, “we are blind to what goes on in our own day and age.”

This is compounded by the neo-liberal insistence on the effects of mental distress, never the reasons behind it. “Sociological research has shown a clear link between the current socio-economic system and severe psychological and social problems,” writes Verhaeghe. “The dominant neo-liberal mindset ignores this fact and, instead of tackling the causes, focuses entirely on the consequences: namely, the deviant, disturbed, and dangerous others – psychiatric patients, junkies, young people, the unemployed and ethnic minorities.”

The reason why western politics seems so immovably stuck on this and other issues, is that even enlightened critics who want to change society’s attitude towards mental illness cannot extricate themselves from this “dominant neo-liberal mindset”.

For “better mental health”

Consider the UK charity, Mind, which has as its tagline “for better mental health”. The charity aims to ensure everyone experiencing a mental health problem gets help and support and is a member of Time for Change, a coalition of charities that campaigns against mental health discrimination and stigma.

There is nothing wrong with any of this and Mind does important work trying to make sure people with mental health problems are not unfairly affected by the Work Capability Assessment and other benefit horrors. But if you really want to achieve “better mental health” you have to extend your gaze immeasurably. You have to examine how the current organisation of work generates mental distress rather than mental health, how lack of control over your work is a cause of both mental and physical illness, how inequality generates distress, and how the erratic quality of early childhood relationships incubates mental problems that emerge later in life.

You would have to delve -  as the twentieth century German psychoanalyst Erich Fromm did – into what brings about a ‘sane society’ and what causes its opposite. This would inevitably take you into controversial and difficult issues, such as how success in contemporary society is dependent upon the fostering of certain characteristics, such as (in Verhaehge’s words) “flexibility, speed, efficiency, result-orientedness and articulateness in the sense of being able to sell yourself.” And how the lack of these skills leads to failure and self-blame.

But Mind and other mental health charities wouldn’t dare approach any of these issues. Apart from the fact that they are sternly warned off by politicians (a short-lived UK “minister for civil society” told charities to “stick to their knitting”), to do so would take you away from symptoms, which can always be ameliorated or looked upon in a different way, into the dangerously “political” waters of root causes. But because they are controversial and political is precisely the reason we need to go there.

As Verhaeghe readily admits, “finding evidence for the connection between a particular type of society and mental disorders is no simple matter”. He suggests that the spectacular rise of ADHD is connected to constant exposure to “information nuggets” such as text messages, tweets and keywords. There is no time to practice the art of concentration. This sounds plausible. But accepting this hypothesis then begs the question of why our work and free time is filled with so many distractions, why we are, in the words of David Harvey, “totally absorbed either in the pseudo busy-work of much of contemporary production or in the pursuit of alien consumerism.”

“Always connect”, said the early twentieth century novelist EM Forster. But, exceptions like the Equality Trust and the New Economics Foundation aside, most of the organisations that surround us are myopic when what is required is 20:20 vision. This narrow focus on symptoms is not limited to mental illness. When our political culture can bear to accept the reality of global warming, it becomes fixated on technological fixes that will give a spurt to economic growth. The root cause of the financial crisis becomes lost in attempts to eradicate symptoms such as unemployment or government debt.

Possibly, a compulsive need to always be occupied partly explains the compulsive attention on symptoms, because the symptoms will never go away unless you address the underlying disease. Maybe we want to permanently exhaust ourselves in trying to solve never-ending symptoms. I think Erich Fromm called it the fear of freedom.