The Political Economy and Etiology of Psychopathology: An Essay
While the condition of a people is prosperous, and uninterrupted by violent and sudden changes, insanity never exceeds. But when the dispensations of Providence fail of their accustomed bounteousness, or man by trouble is afflicted beyond his nature, or by his own wilfulness o’erleaps the bounds which nature and reason define; then insanity is engendered; and an increased number of lunatics indefinitely swells the catalogues of human calamities. -- G. M. Burrows, 18202
Capital is dead labour, that, vampire-like, only lives by sucking living labour, and lives the more, the more labour it sucks…. But in its blind unrestrainable passion, its were-wolf hunger for surplus-labour, capital oversteps not only the moral, but even the merely physical maximum bounds of the working-day.… Capital cares nothing for the length of life of labour-power. All that concerns it is simply and solely the maximum of labour-power that can be rendered fluent in a working-day. It attains this end by shortening the extent of the labourer’s life, as a greedy farmer snatches increased production from the soil by robbing it of its fertility. -- Karl Marx, 18863
What good to us is a long life if it is difficult and barren of joys, and if it is so full of misery that we can only welcome death as a deliverer? -- Sigmund Freud, 19304
Introduction
Political economy is the historical foundation of modern social science, arguably the first discipline to wrest its intellectual independence from the embrace of philosophy. Classical political economy – Ferguson, Smith, Mill, Ricardo, and Malthus – was the first effort to achieve a specifically scientific and materialist understanding of the emerging social structure in the context of the bourgeois and industrial revolutions. Certainly classical political economy failed to provide a consistently thoroughgoing materialist analysis of these great transformations, but its key concepts always pulled us back to the material world. Most importantly the labour theory of value, the concepts of use and exchange value, the proposed laws of population growth and decline, and the positing of the capitalist market as the engine of economic and therefore social development, relentlessly dragged us down from idealist abstractions to concrete materialist considerations.
Marx took the next step by providing us with the analytical and theoretical tools for what can be best described in retrospect as deep political economy. Marx’s critique of political economy sought to understand the emergence of capitalism and to specify the social relations characteristic of the capitalist mode of production, and the transformative struggles involved in their emergence. Marx sought nothing less than to uncover the laws of motion of capitalism – indeed, of history itself through the various modes of production – focussing on human labour power, accumulation, distribution, classes, and the realization, reproduction and transformation of capitalist relations of production.
Following the key injunction of the new scientific method not to be seduced by the surface appearance of things in the world, Marx proceeded to strip away the appearances posing as explanations in classical political economy in order to reach the singular essence of capitalism, the commodity. But then, Marx asked, if the commodity – its production, distribution and exchange – is the essence of capitalism, what is the essence of the commodity? His answer, of course, was that the commodity contained within it the necessary relations of its production, the historical changes necessary to bring them about, and the mechanisms of social and economic control required to sustain and reproduce them. Within the commodity one discovers the full account of capitalism, its emergence and continuity. The key to the creation of capitalist relations of production was the transformation of human labour power itself into a commodity like any other commodity. Human labour power is the commodity which makes the whole capitalist project possible. Yes, he conceded to the bourgeois political economists, labour power is a commodity, and yes, the labour market operates like all markets based on laws of supply and demand, and yes, wages are the price negotiated between the buyers and sellers of this commodity.
Yet, Marx argued, surely it is self-evident that this commodity, human labour power, is not really like any other commodity. On close examination it is clearly a “peculiar commodity” for a number of very obvious reasons.5 Labour power is a capacity, a potential only realized in actual work, not a concrete object like other commodities, and its owner will age and die. For a worker to freely exchange her/his labour power on the market, the worker must have no other products of labour to sell and must therefore be compelled to sell her/himself. This is not a natural condition, it must be brought about. The worker must be separated from access to all means of production. The worker must be reduced to the status of propertyless pauper and thereafter driven by the threat of starvation into the labour market. And the determination of the value of labour power is not simply a market transaction, but contains unique limitations peculiar to labour power and not present in the determination of the value of other commodities.
The wages received for labour power, the money expression of its value, must respond to certain realities which have little to do with pure market mechanisms of supply and demand. Wages must be enough to provide for the day-to-day subsistence of the worker and for the production and reproduction of labour power. Hence, since workers will age and die and must therefore be continuously replaced, wages must account for sustaining the birth and raising of new workers. Labour power often involves skills, and always involves human motivation; hence wages must be sufficient to encourage the development of required skills and the continuing motivation of the worker to work hard and well. As human beings, workers have consciousness of fairness and justice, of what might be, of what should be, and therefore ideas of justice and fairness inevitably intrude. All these elements enter into the negotiation of the wage contract. These are what Marx referred to as the moral and historical aspects of the determination of labour’s value as reflected in wages. Marx’s critical journey through the underbrush of bourgeois political economy’s application of the labour theory of value to capitalism led ultimately to his concept of surplus value, long recognized as Marx’s revolutionary and central contribution to the labour theory of value under conditions of capitalist production. But in that journey he repeatedly shone the spotlight on the existential terrorism encountered by the “peculiar commodity” in capitalist relations of production, and the responses of the working class to that terror.
What, then, was the character of the existential terrorism recounted by Marx and what were the consequences for human beings dominated by capitalist relations of production? Workers had freedom of choice; they could freely choose to sell their labour power or starve to death and watch their children starve to death. This bourgeois freedom included the injunction that the worker must freely compete with others on the labour market as he or she desperately sought to exchange the commodity self for a wage. Hence life was constantly insecure, as workers walked the precipice of disaster should they fail to succeed in this market transaction each day, each week, each month, each year. Wages were so low that often father, mother and children were forced to work to provide for a family’s subsistence. If this were not enough to put an end to any semblance of family life and leisure, the length of the working day and working week made any life but work, food and sleep nearly impossible (the 10 hour day, 6 day week was only achieved in 1850, with some regulation of female and child labour).
Workers also faced the fearful insecurity of dangerous conditions of work constantly jeopardizing health and safety. Death was a constant companion even in secure and regular employment, as textile workers and razor grinders lucky enough to work steadily coughed out their lungs in great clots of blood in their twenties and thirties, or as the new machines threatened to sever or crush limbs, or to kill outright. Workers could freely choose to accept work to build and install the new machines which would displace them and deposit them on the streets without work. Workers, even those with regular and secure employment, looked forward to that fateful day as they aged and slowed down and were then jettisoned from work and replaced by younger competitors. Old age, if a worker reached it, was a fearful prospect, one of deep destitution and degradation. Capitalist relations of production contained at their core, then, a sustained sense of terror which followed workers to their graves.
And what were the mechanisms of social control buttressing this terror by offering workers even more terrifying alternatives? Collective actions of self-defence were designated as criminal acts under the law, and state repression was instant and remorseless. At the individual level there was the obvious first compelling choice, work or starve. Economic desperation often led to theft, robbery, vandalism and murder. The punishments were severe: execution; transportation to the colonies; sentences to prisons deliberately designed to break the body and the mind. When Elizabeth I’s poor laws were reformed in the 19th century, workers and their families facing starvation could present themselves at a work house for subsistence and shelter. But work houses were deliberately designed to be brutal and harsh, and work house inspectors were assigned not to ensure that inmates were treated humanely, but to ensure that the treatment met harsh enough standards. Work houses must, the rule went, be so dreadful that no one would voluntarily enter except in the most extreme and dire straits, preferring instead to accept the dirtiest, most difficult, most dangerous, lowest paying jobs available. The fear of being forced into the work house was a constant theme of working class life. For workers who lost their minds under the terrible stress, and retreated into madness and deranged thinking and behaviour, there was the asylum for the insane, even more dreaded than the prison and the work house.6
Collective action by the working class first through trade unions, and then through socialist, communist and social democratic political parties, led to reform and amelioration. But the core economic terrorism necessary to sustain capitalist relations of production was only modulated and abated, not ended. Even today, as we are told of all the great gains making life better for all, including the working class and the poor, we know in our hearts that the economic terror remains. Most wage and salary earners are two or three paycheques away from personal economic disaster. A major recession resulting in widespread factory closures and job losses leads ultimately to evictions from rental accommodations, foreclosures on mortgages, the bankruptcy of many small businesses, dependency on welfare and food banks, and, in the end, potential homelessness and destitution. The collapse of an industrial or financial enterprise can lead to the sudden loss of a pension after decades of service, transforming a comfortable old age into a living hell.
A central purpose of the neoliberal counter-revolution of the last 30 years has been to increase the levels of economic terrorism among wage and salary earners, indeed among the entire population, while diverting more and more of the wealth produced from wages, benefits and social programs to profits earned by capital. The economic terror of capitalist relations of production – both past and present – is not uniquely endured by those who must sell themselves on the labour market, though they bear the brunt. Small business proprietors, dependent on those who work and consume, teeter on the edge of the fearsome fate of being driven onto the wage labour market. The servants and owners of capital also share in the distress and insecurity. As Marx argued, the foundational fact of labour power as a commodity insinuates itself throughout the capitalist system to encompass all human interactions and relationships.7 Human relationships in general, even the most intimate, become commodified as we all succumb to what Marx called commodity fetishism. The capitalist and the highly paid servants of capitalism become enslaved and driven by the relentless demands of capital for growth and expansion. Authentic human relationships become more and more difficult as the sense of alienation and estrangement permeates the society, leading to general dissatisfaction and discontent.
Political economy, particularly with Marx’s improvements, thus provides the key to understanding both the movement of history and the inner psychology of the human being under these specific historical conditions. What are meaning, happiness, and purpose in such a society? What are the causes of despair, anxiety, and discontent? What are the links between the external dynamics of the social system and the inner life and future possibilities of human beings? Such questions dominated early social science, and nowhere more dramatically than in the study of psychopathology – both in the attempt to understand its causes, and in formulating proposals for its prevention, amelioration, and possible cure.
The epidemiology of madness in capitalism
Back in the 19th century the people charged with the care, treatment, and control of “lunatics,” as they were often indelicately labelled in those days, alerted by the widely-read work of the political economists, began to notice repeating social and economic patterns in the occurrence of the afflictions. The various mental illnesses were selectively not randomly distributed among the population. These were the first epidemiological studies of psychopathology and they focussed primarily on the social and economic factors associated with the prevalence of the disorders.8
Epidemiology studies the frequency, distribution and determinants of diseases in groups, noting the selective and unequal distribution of many diseases within a population, and the important associations that exist between the diseases and the circumstances of different groups.9 Epidemiology cautions against quickly assuming a causal relationship between an associated factor and a particular psychological disorder. A demonstrated correlation between a socioeconomic factor or stressor and a psychological disorder does not prove a cause-effect relationship. Rather such correlations define targets for deeper investigation. As research finds repeated correlations between social and economic stressors and particular psychological disorders, a causal relationship can be inferred based on a number of strict rules: the sequence must be causal (i.e., the stressor must precede the disorder); the correlation must be very strong; the correlation must be repeatedly replicated by independent researchers; and multiple stressors exponentially lead to more serious disorders.
Epidemiology had already proven its effectiveness in seeking and finding the causes of various infectious diseases, leading to many early medical triumphs. Its early application to the study of mental disorder focussed simply on patterns of prevalence in identifiable social and economic categories of the population, probing thereby linkages with possible risk factors. The results were dramatic and were replicated repeatedly by many independent researchers. These early prevalence studies clearly proved the following: various forms of economic distress were correlated with elevated rates of admission to mental hospitals; the strongest and most clearly replicated relationship was a direct and inverse correlation between social class or socioeconomic status and mental illness (the poor were at greater risk, while the more affluent appeared to enjoy a form of socioeconomic inoculation); and mental illness was much more elevated among immigrants than among non-immigrants. The correlation between poverty and the risk of mental disorder was so repeatedly strong that the term “pauper lunatic” was coined in the 19th century.
Studies in the 20th century became considerably more sophisticated. Crude measures of poverty and economic impairment were replaced by multi-dimensional measures of social class and socioeconomic status (SES).10 Clear associations between particular psychiatric diagnoses and dimensions of SES were uncovered. Efforts were made to detail the various risk factors which interacted with SES in the occurrence of mental disorders. Since not all poor people, nor all people of low SES developed mental illness – clearly the vast majority did not – researchers began to search for protective factors, i.e., the unique characteristics of those among high risk groups who did not develop disorders and which were absent in those who did. This led to a series of community integration studies which demonstrated that those in disintegrating or dysfunctional communities (and families), in which there was an absence of social, economic, and psychological support systems, tended to be more at risk of mental disorder, particularly in the presence of other identified risk factors, like low SES, extreme poverty, bereavement, divorce, inadequate parenting, and family violence.11
The findings were so overwhelmingly strong and consistent, and so disturbing in their implications – standing as an indictment of the capitalist social and economic system and crying out for remedial interventions – that two challenges were mounted against this growing body of evidence. One was the “drift hypothesis,” arguing that the evidence did not demonstrate a case of “social causation” but rather one of “social selection.”12 Those who were psychologically vulnerable to developing a mental disorder were inadequate, dysfunctional personalities who, upon the appearance of symptoms of mental illness, began to suffer negative social and economic consequences due to increasing functional inadequacy – loss of job, loss of business, loss of friends and family – and thereafter “drifted” down the social class hierarchy, landing at the bottom, living an impoverished existence on the margins of society.
The drift hypothesis was seized upon by the ideologically conservative to dismiss any notion that the evidence demonstrated the social and economic causation of mental disorder. After the proposal of the hypothesis in 1940, researchers went back to the data from earlier studies to test for drift. Further, all research after 1940 tested systematically for drift, and designed research that controlled for the phenomenon. The overwhelming preponderance of the evidence did not support the drift hypothesis, pointing very strongly toward a social causation rather than a social selection explanation. Certainly, in individual cases drift occurred, as people fell mentally ill and suffered disastrous socioeconomic consequences, but this phenomenon is easily controlled for in research designs. The facts were clear: the drift hypothesis failed to explain the repeatedly strong links in very large populations between lower social class/SES and higher rates of mental disorder.
Nevertheless down to the present day ideologically conservative policy makers and planners in governments, and many scientists, have consistently embraced the drift hypothesis contrary to the clear evidence. The reasons for this are pretty easy to understand. Acceptance of the social causation explanation implies a need for costly programs of social and economic intervention for both prevention and treatment. The costs of alleviating the extremes of poverty, of providing decent housing, of ensuring basic economic security, and of community-based, socially oriented treatment programs would be astronomical, and certainly contrary to the spirit of capitalism. The social selection explanation, on the other hand, suggests there are no clear causal social and economic patterns behind the occurrence of mental disorder, and therefore causal factors are rather to be found in the individual psychology, genes, or idiosyncratic predispositions of those afflicted – making it easier to blame the victims for their own conditions and to develop cheaper treatment programs with an individual focus.
The second challenge noted that the controversial studies linking class and mental illness used data on mental illness based on rates of admission to mental hospitals and/or actual diagnoses of mental disorder by psychiatrists in clinics. Since those of higher SES have the means to avoid incarceration in mental hospitals and to pursue remedies to a psychiatric problem privately and confidentially, the data may have missed large numbers of higher SES individuals afflicted by mental disorders. Hence the higher frequency noted among the lower social classes may only signify that the less affluent cannot afford private and confidential care. This was a valid criticism.
In response, some of the larger and more compelling among the studies – the Stirling County study in Nova Scotia (1949-63),13 the Midtown Manhattan study and re-study (1954-74),14 and the Camberwell study of depression in women (1978)15 – avoided the problem by sampling the entire population and carrying out psychiatric assessments of the sample. Another study examined the ups and downs of the larger economy linked to the rises and falls in overall psychiatric hospitalization rates, finding a very strong direct and inverse relationship with socioeconomic status, providing strong confirmation of the social causation model.16
These studies confirmed the earlier epidemiological evidence, while adding considerably to our more precise knowledge of other risk factors which interact with low social class/low SES. More dramatically, of all the major studies only that in Lunby, Sweden (1947-66) failed to confirm the direct and inverse relationship between social class/SES and the risk of psychopathology, leading to the conclusion that Sweden’s superior system of social and economic security sheltered those in the lower social classes. Indeed, the conclusion was that when there is no extreme poverty, the rates of incidence of psychopathology among social classes are similar.17
Perhaps more significantly, studies based on sampling entire community populations, rather than just relying on hospital admission rates and formal psychiatric diagnoses, also found that the overwhelming majority of people suffering from mental afflictions serious enough to warrant clinical intervention do not enter the psychiatric institutional system – the ratio of treated to untreated is estimated at 1 to 14.18 Hence most mental illnesses are never officially diagnosed and treated, suggesting that they are normalized and handled by individuals, families and communities through other coping mechanisms. Many sociological and social psychological studies have documented the negative impact of the stigma of a psychiatric diagnosis and the subsequent surrender of a diagnosed individual to the lifetime role of mental patient, often involving the loss of civil rights and long periods of forced incarceration.19 Clearly we need to know more about such coping strategies outside the psychiatric system, and the extent to which they may be limited to the less serious mental disorders.
Community psychiatry: the abandoned hope
The early 1970s was a time of considerable optimism about progress in preventing and treating mental disorder. The epidemiological studies provided a solid foundation for evidence-based prevention and treatment programs. Forty-four independent prevalence studies confirmed the strong direct and inverse correlation between social class and psychological disorders.20 Clearly, those in the lower classes face the extreme hardships of poverty and insecurity which lead to relentless exposure to stressful conditions of life in a context of lack of resources for coping. Other stressful life events have been identified as risk factors for psychological disorder: advancing age; divorce/separation; death of spouse; being an immigrant; participation in war; chronic illness; unemployment/loss of business; low levels of community integration; membership in an acculturated and dislocated aboriginal community; non-white ethnicity (which typically disappears when rates are standardized for parental SES). The risk of depression among women was related to certain clearly documented vulnerability factors: low social class; lack of an intimate relationship; three or more children under 14; lack of job outside the home; and loss of a mother before the age of 11.21
Studies of the risk of psychopathologies related to family relationships also provided a wealth of evidence of associations between risk factors, or traumatic life events, and psychological disorders: divorce or separation; bereavement; family violence; emotional, physical and sexual abuse; drug or alcohol abuse; inconsistent, unpredictable and/or bizarre parenting. Clear gender differences were also documented: married women are more at risk of psychological disorder than single women; single men are more at risk of psychological disorder than married men; girls suffer triple the rate of clinical depression compared to boys as well as elevated rates of the eating disorders anorexia nervosa and bulimia nervosa. Though these many stressors or risk factors were very strongly present in clinical data, they proved difficult to systematically describe and clearly link since they involve complex interactions between social, economic, psychological and biological variables. Nevertheless, they provided compelling policy direction. Proposals like the guaranteed annual income to provide basic dignified economic security to all, a series of “well-family” clinics located in schools and staffed by teams of mental health professionals, infant parenting support programs, an expansion of social housing availability, and early intervention programs to support families in crisis, and much more, sought to target the identified risk factors and to provide early assistance and remediation.22
Optimism that we were on the threshold of positive strides in the prevention and treatment of mental disorders was further enhanced by the move to community psychiatry in the 1960s and 1970s, and the closure of many custodial mental hospitals.23 Scandals about the mistreatment of patients, irresponsible and dangerous drug and surgical research on incarcerated patients without the informed consent of either patient or family, court cases confronting the stripping of psychiatric patients of their rights as members of civil society, and the poor treatment outcomes made custodial mental hospitals increasingly indefensible. The clinical evidence was clear – such facilities had little success in treatment and cure, and had become dumping grounds for individuals abandoned by their families and by society, serving what often amounted to life sentences of incarceration without the right of appeal.
The move to community psychiatry looked good on paper – it still does.24 Patients would be discharged to community-based programs staffed by social workers, psychiatric nurses, psychologists, psychiatrists, and varieties of counsellors. Rather than simple custodial care and the management of symptoms, so typical of mental hospital treatment regimes, the afflicted would be involved in ongoing and aggressive therapeutic programs in the community, where they would remain rooted. The future seemed promising.
But only the first and easiest step was taken. Governments closed mental hospitals and discharged patients, but the necessary investment in community psychiatry never occurred. The discharged patients were simply dumped from institutional custodial care onto the welfare rolls. The treatment received remained the simple management of symptoms through psychoactive drugs buttressed by the odd, underfunded drop-in centre.
Those patients who remained difficult to manage often ended up incarcerated in provincial jails and federal penitentiaries rather than mental hospitals.25 Today’s asylum for many among the seriously mentally disordered is the prison. And the psychiatric waiting room for the treatment of serious psychiatric illness among thousands has become the streets of large urban centres, hidden among the homeless and indigent. Sadly, the most common psychiatric social worker routinely available to the psychiatrically afflicted is the street cop on the beat. This has led to a growing number of avoidable tragedies, including the use of lethal force against those in agitated psychiatric episodes, and the premature release of the afflicted from hurried psychiatric treatment leading to horrendous events.
Those incarcerated are often placed in solitary confinement due to agitated and/or bizarre behaviour and flagrant rule-breaking. The most infamous outcome of the treatment received by the mentally ill in prison was the case of Ashley Smith in Canada, a 15-year-old with serious psychiatric problems, who was sentenced to six years in prison in 2003 for a number of bizarre criminal acts. She was transferred from prison to prison 17 times, finally hanging herself on October 19, 2007 after almost 12 consecutive months in solitary confinement in brutal conditions. Seven guards watched her die and did not intervene. She was 19 years old.26 The case of Ashley Smith is clearly an extreme example of the neglect and abuse of the mentally ill confined to the prison system. Nevertheless the treatment accorded the mentally ill in prisons is routinely far worse than that characteristic of most custodial mental hospitals in the past.
The biological detour
The collapse of the commitment to community psychiatry, and to the social model of explanation and intervention, occurred in the context of the triumph of a biological determinist model of mental illness starting in the 1970s.27 This model asserted that social and psychological factors play a secondary role in the development of mental disorders, and that the fundamental and primary cause and cure were to be found in the realm of biology. Diagnosis, treatment and cure, therefore, required a biomedical approach. Through the conflation of diverse events and social forces, the biomedical model became the dominant paradigm and has remained so for the past 30 years. The great advances in psychoactive drugs, which made it possible to manage even the most extreme symptoms of psychiatric illness, and which had made the closure of mental hospitals feasible, contributed to a conviction that perhaps the secrets of cause and cure would be the next great breakthrough of biomedical science.
A powerful coalition therefore emerged, pushing a biomedical consensus. Pharmaceutical companies, already fattened by huge profits from the sale of psychoactive drugs, aggressively pushed the biomedical approach – here was the last great medical frontier and success lay with the more rigorous application of the biological model. As governments reduced their commitment to funding independent medical research, pharmaceutical companies moved in to become the primary source of research funding and focussed resources on the biological causes and cures of psychiatric illness. Governments were delighted to avoid the huge costs involved in social models of prevention and treatment, and enthusiastically joined the biological chorus. Many of those suffering from psychiatric disorders desperately wanted to believe they were suffering from a biomedical condition which could someday be cured like any infectious disease. Not only did this shift give hope to the often hopeless, but the stigma of mental illness was significantly reduced when it was viewed as a biological phenomenon rather than some inadequacy in personality or will power. Families of psychiatric patients leapt on the bandwagon, now free of the burden of guilt implied by social and psychological explanations and now hopeful that a medical cure was just one biomedical breakthrough away. Advances in genetic research, including the mapping of the human genome, according to many prominent scientists, would finally solve the mysteries of mental illness and lead us to more successful interventions. For the past 30 years biopsychiatry enjoyed hegemony in psychiatric research, treatment and programming. The consensus was so widespread in society that individuals increasingly medicalized all their problems of living, seeking the correct biomedical diagnosis and the proper drug to provide instant alleviation of conditions ranging from anxiety to loneliness to job stress. The research documenting the social and economic sources of madness disappeared down the memory hole, and those who persisted in such views were ignored and swept aside.
The decline of the biological model
Today serious cracks are forming in the previously impenetrable biopsychiatric edifice. Quite simply biopsychiatry, and the biological determinist model generally, have failed to deliver on the great promises made. There is still no psychiatric consensus on diagnosis of many mental disorders except the most common and most serious. No genetic cause of a major mental disorder has been found and independently replicated. Although psychoactive drugs have become more numerous and more powerful, they still simply control symptoms and, when successful, allow the sufferer to function reasonably adequately. This is a tremendous contribution, but the early promise of cure has largely disappeared. And the many successes of such drugs must be weighed against the many negative impacts and risks.
Many clinical trials have documented that most psychoactive drugs are only marginally more effective than a placebo. Many anti-psychotic drugs have serious long-term side effects, including a higher risk of strokes and sudden cardiac death. Anti-depressants often exacerbate apathy and indifference, suicidal thoughts, or flattening of affect and intellectual functioning. Some experts argue that withdrawal from anti-depressants has been associated in some studies with increased risk of psychosis and suicide. A leading medication routinely used for the treatment of ADHD among children has been associated with an increased risk of suicide attempts. Some psychoactive drugs contribute to marked obesity and embarrassing physical peculiarities like tics and spasms. As a result, many of those afflicted with mental disorders go off their medication in despair and desperation, and consequently suffer serious relapses.
The widespread use of psychoactive drugs has created considerable controversy. Swayed by the biomedical model, patients and families, parents and teachers, tend to reject psychological and social explanations of behavioural or mood problems and demand drug treatment. Increasingly, psychoactive drugs are routinely used to manage troublesome, vulnerable and powerless populations, like overactive and delinquent children, the elderly, and those in prison. And years of research by feminist scholars have already documented the overuse of psychoactive drugs to manage the problems many women face in unhappy marriages, dysfunctional families, and a patriarchal society.
It appears, then, that the greatest contribution of biopsychiatry has been to provide effective chemical rather than canvas straitjackets for the mentally afflicted. Indeed, this was a great step forward. Clearly drugs that control symptoms and manage a mental disorder so the sufferer can function even marginally adequately are to be preferred over the asylum, the canvas straitjacket, the restraint chair, the padded cell and the polishing block. But the promise of finding the biomedical cause and then the cure of mental disorders has not been fulfilled, while efforts to address the social and economic causes of these disorders have been all but abandoned.
The biological evidence is murky at best.28 Studies have documented significant biochemical changes in those with many mental disorders, including neurotransmitter abnormalities. Some post-mortem studies have also noted abnormalities in the brains of sufferers of some mental disorders. But are these the cause or the consequence of mental disorder? Studies have shown that environmental stress leads to biochemical changes involving neurotransmitters. But what is the causal sequence? Does environmental stress lead to biological events that in turn lead to negative psychological and behavioural consequences? Or is it simply a biological phenomenon? Further, many studies over the years have announced to headline publicity the discovery of the “gene” for schizophrenia. Yet none of these studies enjoyed sufficient independent scientific replication, and the claims have withered on the vine. More recent genetic studies have concluded that schizophrenia is actually a grab-bag of many distinct disorders (hardly a new insight, since it is referred to by many in clinical psychiatry as a diagnostic garbage can), entailing multiple genetic mutations involving perhaps thousands of interacting genes.
Genetic studies are increasingly recognizing both the interaction and the interpenetration which occurs between organisms and environments, noting that social factors often appear to trump genetic predisposition and that social factors are likely involved in the mutation process. Recent studies which claim to have discovered “bad behaviour” genes concluded that the behaviour only seems to occur when one or more social stressors are present, and that positive social environments often prevent the expression of the genetically anticipated bad behaviour. Even more dramatically, the much heralded discovery of the single “depression gene” back in 2003 (the serotonin transporter gene, 5-HTTLPR), which was widely accepted as the final word and became the most cited evidence in support of the biopsychiatric model, was discredited in 2009. The data from 14 independent studies including a combined sample of over 12,000 subjects failed to support the claim, noting rather that a major life stressor dramatically elevated the risk of depression while no association was found between the serotonin gene and susceptibility to depression.29
Mental illness, in all its frightening and immensely diverse manifestations, results from the complex interaction of social, economic, psychological and biological factors. Research must focus on that interaction, perhaps guided by the notion that we need to distinguish between precipitating events, like economic, social and psychological stressors, and predisposing factors, like genetic/biological vulnerability and early inadequate socialization. We were on the threshold of such an approach in the 1970s, but it was shut down by the totalized, one-dimensional approach of biopsychiatry, supported by the general hegemony of biological determinist ideology.
Since the turn of the century there are indications in well-established medical journals that faith in biopsychiatry is collapsing among some professional leaders of psychiatry and medicine in general.30 Such articles constitute a dramatic break with the biological model. The May 2007 issue of The Canadian Journal of Psychiatry published three articles revealing a crack in the consensus: “Rethinking Social Causes in Psychosis,” “The Contribution of Social Factors to the Development of Schizophrenia,” and “The Social Causes of Psychosis in North American Psychiatry: A Review of a Disappearing Literature.”31 Collectively these articles call for a “fresh theoretical approach…not limited to the narrow biological framework of disease etiology,”32 while providing up-to-date empirical confirmation in research since 1996 of many earlier epidemiological findings: a higher risk for schizophrenia among second-generation immigrants, among those who suffered “social adversity” in childhood, and among those with a background of birth and/or upbringing in an urban setting. The articles also noted and regretted the virtual disappearance of social causation studies of psychopathology in North America at the same time has there has been a dramatic increase in such studies in Europe. The October 2008 issue of The Journal of the American Medical Association included an article urging the reconsideration and further study of traditional psychodynamic therapeutic interventions, a clear break with the biomedical model. Based on a review of 23 studies, researchers reported superior effectiveness of this longer term approach compared to today’s short-term, drug oriented therapies.33
Taken together, these articles may be merely a case of re-discovering and re-stating already long-established and well-documented scientific truths, but it is a decisive step if we are to move beyond the intellectual desert of biopsychiatry and biological determinism. Most importantly the publication of such articles in established and respected psychiatric and medical journals begins to fracture the hegemony enjoyed by biological determinism for the past 30 years and more.
Conclusion: A Return to Science?
Over the past two or three decades, North American social science was seriously deflected from its core project – to achieve a specifically scientific understanding of the social and economic world. Two necessary detours were taken to defend and renew this core project, and these consumed much time and energy.
One detour was the challenge posed by varieties of postmodern theory which repudiated the validity of this core project, insisting that comparative textual analyses by different subjectivities must replace efforts at approximation of the truths to be uncovered in the actually existing social and economic world using the scientific method, with its methodological disciplines of “objectivity” (intersubjective testability) and rigorous requirements for critical assessment and replication of truth claims. Postmodernists argued there were so such truths to be approximated, and the scientific paradigm itself was merely another subjective fabrication. Only an analysis of language and its use was possible. Indeed, postmodernism claimed as one of its core projects the unmasking of science, and its false promises of seeking and finding approximations of external truths and thereby providing the means for enhancing human freedom and building a better life. Science, rather, was directly implicated, as were all so-called meta-narratives, in the totalitarian horrors of the 20th century.34
Such a view radically challenged social science’s founding premise that the essence of the human species was its social character and that this essence resulted in the construction of an external social reality, independent of individual subjectivities, that could be known. From the dawn of human consciousness all forms of human thought, from animism to magic to religion to science, sought urgently to understand and know the natural and social world. Human consciousness was always purposeful, and its project was and remains to describe, to explain and to predict the world for two very urgently pragmatic purposes: to prevent bad things from happening and to make good things happen. In fact, at the core of human consciousness is a need to know and understand, and the scientific method developed by the philosophy of science has been the most successful in fulfilling this need to know, to understand, and, as far as possible, to predict and control the natural and social worlds. Postmodernists largely rejected this position when they happened to consider such “trivial” matters as any defining trait of the human species beyond individual subjectivity and the use of language.
Recently postmodernism has been in decline as a useful paradigm in the social sciences, and now even faces considerable ridicule. But much effort and time were spent by those committed to social science as science, most importantly the political economists, in answering the challenges posed by postmodern thought. As a result the social sciences have lost much credibility among the public and students, and many students have abandoned them since neither postmodernism, nor the debate to settle scores with postmodernism, seemed particularly relevant to the pressing issues of our times. The public no longer seems particularly interested in advice from the social sciences, dominated recently by increasingly esoteric and often apparently silly debates. It is perhaps time we all got back to work, having swatted this annoying intellectual gnat.
The other detour was the growing hegemony of the biological determinist paradigm among increasing numbers of social scientists, particularly in psychology and sociology. This hegemony spilled over into the helping professions with their intellectual foundations in the social sciences, like social work and clinical psychology. Surprisingly, even growing numbers of political scientists, economists and historians were swayed by the intellectual temptations of the biological paradigm, giving us such sub-disciplines as evolutionary history, evolutionary political science, and with some economists adding a biological/evolutionary dimension justifying the free market. Varieties of biological determinist doctrines – most typically those rooted in the doctrine of the gene as the key to all aspects of the human species – dovetailed nicely with postmodernism. Once you have jettisoned the scientific project insofar as social and economic structures are concerned, and accepted the view that the search for laws of socioeconomic development and for the social causation of human behaviour is not possible, what then is left? The biological organism remains, which contains the subjective essence of each individual member of the species. Like a new version of the old behaviourism, biological determinism provided simplistic and enticing explanations of human behaviour, especially its problematic varieties. The advantage here is the entire edifice of the social and economic world becomes a largely irrelevant externality for the purposes of understanding human behaviour. Individual human subjectivity and the individual functioning biological organism become the focus of all we can study and understand, insofar as understanding is even possible and capable of being successfully shared.
The emerging return to seeking social and economic patterns in the distribution of the risk and occurrence of psychopathology suggests these intellectual detours are nearing completion, signalling perhaps a return to an unapologetic use of the scientific method. Historical and cross-cultural studies confirm that the afflictions of psychopathology among the human species are ubiquitous. But each mode of production – slavery, feudalism, and capitalism in all its varieties from the state capitalism of the former USSR and today’s China to the late transnational capitalism of the US and Europe – with its characteristic relations of production presented humans with different forms of economic terror and distress. Psychopathology, from the perspective of political economy, is an interacting social structural and idiosyncratic phenomenon. Each epoch’s psychopathological afflictions differ in form, content and epidemiological patterns from the others. The task of political economy is to uncover which aspects of these afflictions are unique to the socioeconomic realities people endure, and the differential structural distribution of risks among the population. This opens the door to successful interventions to prevent and alleviate much of psychopathology rooted in identifiable social and economic patterns, while recognizing that individual existential circumstances leading to mental anguish will forever remain part of the human experience.
Notes
1. This essay is rooted in conclusions reached after many years teaching in the area and keeping abreast of the literature, including the development of a selected bibliography. Electronic copies of the bibliography are available upon request at John.Conway@uregina.ca.
2. G.M. Burrows. An inquiry into certain errors relative to insanity. London: Underwood, 1820, 64. Cited in J.J. Schwab and M.E. Schwab. Sociocultural Roots of Mental Illness: An Epidemiologic Survey. New York: Plenum, 1978, 307-8.
3. Karl Marx. Capital, Volume I. Moscow: Progress Publishers, 1965 (1886), 233, 264-5.
4. Sigmund Freud. Civilization and Its Discontents. London: Hogarth Press, 1930, 25.
5. Marx. Capital, Volume I, 170.
6. Michel Foucault. Madness and Civilization: A History of Insanity in the Age of Reason. trans. David Cooper. London: Tavistock, 1967; Michel Foucault. Discipline and Punish: The Birth of the Prison. trans. Alan Sheridan. New York: Pantheon, 1977.
7. Karl Marx. Economic and Philosophical Manuscripts of 1844. Progress Publishers: Moscow, 1967 (1844), and Marx, Capital, Volume I, 71-86.
8. See for example: Burrows, An inquiry into certain errors relative to insanity; E. Jarvis. Report on Insanity and Idiocy in Massachusetts by the Commission on Lunacy Under Resolve of the Legislature of 1854. Boston: White, 1855. A good overview of these early studies is provided in Schwab & Schwab, Sociocultural Roots of Mental Illness , 98-157.
9. R. Plunkett and J. Gordon. Epidemiology and Mental Illness. New York: Behavioural Publications, 1971, and Schwab & Schwab, Chapters 3, 4, and 6, 28-51, 88-97.
10. R.E.L. Faris and H.W. Dunham. Mental Disorders in Urban Areas. Chicago: University of Chicago, 1939, and A.B. Hollingshead and R.C. Redlich. Social Class and Mental Illness: A Community Study. New York: Wiley, 1958.
11. See for example: A.H. Leighton. My Name is Legion, Vol. I. New York: Basic, 1959; and L. Strole et. al. Mental Health in the Metropolis: The Midtown Manhattan Study, Vol. I. New York: McGraw-Hill, 1962.
12. A. Myerson, “Review of Faris and Dunham’s Mental Disorders in Urban Areas,” American Journal of Psychiatry, 96, 1940, 995-97.
13. Leighton, My Name is Legion; C.C. Hughes et. al. People of Cove and Woodlot, Vol. II. New York: Basic, 1960; A. H. Leighton et. al. The Character of Danger, Vol. III. New York: Basic, 1963.
14. L. Strole et. al. Mental Health in the Metropolis: The Mid-town Manhattan Study, Vol. I. rev. ed. New York: Harper, 1975; T.S. Langer and S.T. Michael. Life Stresses and Mental Health: The Mid-town Manhattan Study Vol. II. London: Collier-Macmillan, 1963; L. Strole, “Measurements and classifications in socio-psychiatric epidemiology: mid-town Manhattan study (1954) and mid-town Manhattan restudy (1974),” Journal of Health and Social Behaviour, 16(4), 1975, 347-64.
15. G.W. Brown and T. Harris. Social Origins of Depression: A Study of Psychiatric Disorder in Women. London: Tavistock, 1978.
16. M.H. Brenner. Mental Illness and the Economy. Cambridge, Mass.: Harvard University, 1973.
17. O. Hagnell. A Prospective Study of the Incidence of Mental Disorder. Lund: Scandinavian University, 1966; and D.C. Leighton et. al., “Psychiatric disorder in a Swedish and a Canadian community: an exploratory study,” Social Science and Medicine, 5, 1971, 189-209.
18. T.J. Scheff. Being Mentally Ill: A Sociological Theory. 3rd ed. NY: Aldine, 1998, 64.
19. E. Goffman. Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. New York: Anchor, 1961; Scheff, Being Mentally Ill.
20. B. Dohrenwend and B.S. Dohrenwend. Social Status and Psychological Disorder: A Causal Inquiry. New York: Wiley, 1969; B. Dohrenwend, “Socioeconomic status (SES) and psychiatric disorders: Are the issues still compelling?” Psychiatric Epidemiology, 23, 1990, 41-47; and B. Dohrenwend et. al., “Socioeconomic status and psychiatric disorders: The causation-selection issue,” Science, 255, 946-52.
21. Brown and Harris, Social Origins of Depression, Chapter 17, 270-293.
22. J.F. Conway, The Canadian Family in Crisis. 5th ed. Toronto: Lorimer, 2003.
23. G. Caplan. Support Systems and Community Mental Health. New York: Behavioral Publications, 1974; D. Ralph. Work and Madness: The Rise of Community Psychiatry. Montreal: Black Rose, 1996.
24. Community-based interventions for prevention and treatment are clearly more humane than either the asylum or the current nightmare for the mentally afflicted. Such an approach would be costly in the short term but quite efficient and cost-saving in the longer term. While it is self-evident that the dominant players in any of the current capitalist systems would resist such interventions, history records that class struggles and popular agitations can fight for and win concessions to alleviate human suffering and to achieve higher degrees of social and economic justice. In North America we were on the cusp of winning many humanitarian improvements for the mentally afflicted in the 1970s. But like so much else fought for and won from capitalist systems since the 1920s, these reforms were killed by the turn to neoliberalism. Though the capitalist system is deeply irrational as a social system, glimmers of reason and compassion sometimes triumph through evidence and political struggle. There is a large scientific literature in social psychology and social work which clearly demonstrates that early interventions in community-based programs targeted to populations identified as at risk not only alleviate vast amounts of human suffering, but prove efficient and cost-saving to society in the long run. The best known of these studies is the Perry Preschool Study, which followed comparable samples of children living in poverty, one sample receiving the benefits of an inexpensive early intervention program while the other sample did not. At age 40, the most recent report on the cohorts, $17.07 was returned in savings for every dollar initially invested in the program -- $12.90 of these savings were enjoyed by the public sector: savings on policing, crime oversight and processing, and incarceration in juvenile detention centres and prisons; education savings; taxes paid on increased earnings of those in the program; and foregone welfare payments. See L.J. Schweinhart. The High/Scope Perry Preschool Study Through Age 40. Ypsilanti, MI: High Scope Press (www.highscope.org). The other seven monographs reporting on the cohorts through 40 years can be obtained from High Scope Press.
25. R. Issac and V. Armat. Madness in the Streets: How Psychiatry and the Law Abandoned the Mentally Ill. New York: Free Press, 1990; E.F. Torrey. Out of the Shadow: Confronting America’s Mental Illness Crisis. New York: Wiley, 1996.
26. The Globe and Mail, 21 November and 8 December, 2007; 3, 4, 5, 10, and 11 March, 2009.
27. A. Kerr and T. Shakespeare. Genetic Politics: From Eugenics to Genome. Cheltenham, UK: New Clarion, 2000; R.C. Lewontin, “The Fallacy of Biological Determinism,” The Sciences, March/April 1976, 6-11; and S. Rose et. al. Not In Our Genes: Biology, Ideology and Human Nature. London: Penguin, 1990.
28. R. Lewontin and R. Levins. Biology Under the Influence: Dialectical Essays on Ecology, Agriculture, and Health. New York: Monthly Review, 2007; S. Rose. The 21st Century Brain: Explaining, Mending and Manipulating the Mind. London: Vintage, 2006.
29. N. Risch et. al., “Interactions Between the Serontonin Transporter Gene (5-HTTLRR), Stressful Life Events, and Risk of Depression: A Meta-analysis,” Journal of the American Medical Association, 301:23, 2462-71.
30. Here are just three examples from a growing literature: E. Bebbington et. al., “Psychosis, victimization and childhood disadvantage,” British Journal of Psychiatry, 185, 2004, 220-26; E. Cantor-Graae, “Schizophrenia and migration: a meta analysis and review,” American Journal of Psychiatry, 162, 2005, 12-24; and G. Harrison et.al., “Association between schizophrenia and social inequality at birth: Case-control study,” British Journal of Psychiatry, 179, 2001, 346-50.
31. E. Cantor-Graae, “The contribution of social factors to the development of schizophrenia: A review of recent findings,” Canadian Journal of Psychiatry, 52:5, 2007, 277-86; G.E. Jarvis, “Rethinking the causes of psychosis,” Canadian Journal of Psychiatry, 52:5, 2007, 275-7; G.E. Jarvis, “The social causes of psychosis in North American psychiatry: A review of a disappearing literature,” Canadian Journal of Psychiatry, 52:5, 2007, 287-93.
32. Jarvis, “Rethinking the causes of psychosis” (note 31), 275.
33. F. Leichsenring and S. Rabung, “Effectiveness of long-term psychodynamic psychotherapy: A meta-analysis,” Journal of the American Medical Association, 300:13, 2008, 1551-65.
34. For a selection of assessments and critiques of the impacts of postmodernism on social scientific inquiry, see: D. Harvey. The Condition of Postmodernity. Oxford: Basil Blackwell, 1990; D. Hind. The Threat to Reason: How the Enlightenment was hijacked and how we can reclaim it. London: Verso, 2007; and E.M. Wood and J.B. Foster (eds.). In defense of history: Marxism and the postmodern agenda. New York: Monthly Review, 1997.