The Happiness Industry (19 page)

People felt
better
as a result of these pharmaceuticals, not in
any specifically medical or psychiatric sense, but more in terms of their capacity for fulfilment and hope. As Kuhn observed, his new substance appeared to have ‘antidepressant properties'. The extraordinary implication, which has since become our society's common sense, was that sadness and deflation, and hence their opposites, could be viewed in neurochemical terms.

For a while, psychiatrists struggled to know how to describe the new drugs. Kline chose to refer to his as a ‘psychic energizer', which remains a decent description of many of the drugs currently marketed as ‘antidepressants', but which are used to treat anything from eating disorders to premature ejaculation. The subtlety of their effects was perplexing, but this very property – this
selectivity
– has since come to be the main promise of those who seek to transform and improve us via our neurochemistry. Unlike barbiturates, the new drugs did not alter physical metabolism or overall levels of psychic activity. They appeared to boost those parts of the patient that had been deflated or damaged but to leave mind and body otherwise unaffected. This wasn't just the discovery of a new drug, but of a whole new notion of personhood.
¹⁸

In the decades since Kuhn and Kline first experimented with their new drugs, antidepressants have become celebrated for this alleged selectivity and their non-specificity. The supposed genius of the selective serotonin reuptake inhibitor (SSRI) is to seek out the precise part of the self that requires energizing and give it a boost. In the years following the launch of Prozac in 1988, enthusiasm for the potential of SSRIs reached unprecedented heights. Claims were made by psychiatrists such as Peter Kramer that Prozac didn't simply boost mood, but reconnected individuals with their real selves.
¹⁹
The notion of illness, not to mention that of sadness, has been transformed in the process.

It would take twenty-five years before Kuhn and Kline's new ‘psychic energizers' would attain mass market appeal; indeed they were initially marketed as anti-schizophrenia drugs. But culturally, their discovery was perfectly timed. Psychiatrists and psychologists had shown virtually no interest in the notion of happiness or flourishing up until this time. The influence of psychoanalysis meant that psychiatric problems were typically viewed through the lens of neurosis, that is, as conflict with oneself and one's past. Depression was a recognized psychiatric disorder that could be treated with electric shock therapy if severe enough, but it received comparatively little attention from the psychiatry profession, let alone the medical profession. The Freudian category of ‘melancholia', as the inability to accept some past loss, continued to shape how chronic unhappiness was understood within much of the psychiatry profession.

But these psychoanalytic ideas were relatively useless when it came to dealing with a more diffuse form of depression, manifest as a generalized deflation of desire and capability. It was this that psychiatrists and psychoanalysts were increasingly confronted by as the 1960s wore on, forcing them to question certain core aspects of their theoretical training.
²⁰
Depressed individuals were not speaking in terms of shame or repressed desires any longer, but merely in terms of their own weakness and inadequacy. If anything, it was an
absence
of desire that afflicted them, more than a bottling up. Admittedly, drug companies were content to assist with the relinquishing of traditional psychoanalytic theory, as the pharmaceutical company Merck demonstrated in 1961 when it distributed fifty thousand copies of Frank Ayd's
Recognizing the Depressed Patient
to doctors around the United States, immediately after winning a patent battle over the antidepressant amitriptyline.
²¹
But the drugs were entangled in a broader cultural and moral transformation.

The question of how to boost general energy and positivity was an entirely new one for psychologists at the close of the 1950s. But it was slowly emerging as a distinctive field of research in its own right, with a number of new questionnaires, surveys and psychiatric scales through which to compare individuals in terms of their positivity. The year 1958 saw the launch of the Jourard Self-Disclosure Scale and then in 1961 the Beck Depression Inventory, the work of Aaron Beck, the father of cognitive behavioural therapy. Mental health surveys conducted in the United States during the 1950s, aimed partly at assessing the psychological state of war veterans, discovered that generalized depression was a far more common complaint than psychiatrists had assumed. This psychic deflation was coming to appear as a risk that could afflict anyone at any time, whether or not there was psychoanalytic material to back that assessment up.

By the late 1960s, psychologists were studying depression far more closely, without the assumption that there must be an underlying neurosis. Martin Seligman's experiments on ‘learned helplessness', in which he showed that if you electrocuted a dog enough it would eventually cease to resist, helped to map out a new understanding of depression. This sowed the seeds of the positive psychology movement, dedicated to the programmatic ‘unlearning' of helplessness, of which Seligman is the figurehead.

A drug that is itself
selective
immediately weakens the responsibility of the physician or psychiatrist to identify precisely what is wrong with a patient. It can therefore be prescribed in a non-specific way, as if to say, ‘Try this, and see if whatever is ailing you starts to fade'. Misery itself becomes the phenomenon
to be dealt with, rather than any particular manifestation or symptom. In the early 1960s, this was an affront to the authority of psychiatrists and doctors, whose professional role involved specifying
exactly
what was causing a problem and offering a solution to it. The idea that individuals may be suffering from some general collapse of their psychic capabilities, manifest in any number of symptoms, challenged core notions of medical or psychiatric expertise.

Over half a century after the discovery of antidepressants, it remains the case that nobody has ever discovered precisely how or why they work, to the extent that they do.
²²
Nor could anybody ever make this discovery, because what it means for an SSRI to ‘work' will differ from one patient to the next. A great deal of attention has been paid to how SSRIs alter our understanding of unhappiness, relocating it in our brain neurons; but they also fundamentally alter the meaning of a medical diagnosis and the nature of medical and psychiatric authority.

A society organized around the boosting of personal satisfaction and fulfilment – ‘self-anchored striving' – would need to reconceive the nature of authority, when it came to tending and treating the pleasures and pains of the mind. Either that authority would need to become more fluid, counter-cultural and relativist itself, accepting the lack of any clear truth in this arena, or it would need to acquire a new type of scientific expertise, more numerical and dispassionate, whose function is to
construct
classifications, diagnoses, hierarchies and distinctions, to suit the needs of governments, managers and risk profilers, whose job would otherwise be impossible.

Psychiatric authority reinvented

The Chicago School ultimately benefited from the ostracism that it was long shown by the American economics and policy establishment. It offered a lengthy gestation period, during which alternative ideas and policy proposals could mature and be ready for application by the time the governing orthodoxy had been engulfed in crisis. That crisis began brewing in 1968, as US productivity growth began to falter and the cost of the Vietnam War ate into the government's finances. The crisis mounted from 1972 onwards, with sharp rises in oil prices and the breakdown of the global monetary system that had been put in place after World War Two.

The American psychiatry profession experienced its own crisis, with an almost identical chronology. In 1968, the American Psychiatric Association (APA) published the second edition of its handbook, the
Diagnostic and Statistical Manual of Mental Disorders
(DSM). Compared to later versions of the manual, this publication initially elicited very little debate. Even psychiatrists had little interest in the book's somewhat nerdish question of how to attach names to different symptoms. But within five years, this book was the focus of political controversies that threatened to sink the APA altogether.

One problem with the DSM-II was that it seemed to fail in its supposed goal. After all, what was the use of having an officially recognized list of diagnostic classifications if it didn't appear to constrain how psychiatrists and mental health professionals actually worked? The same year that the DSM-II was published, the World Health Organization published a study showing that even major psychiatric disorders, such as schizophrenia, were being diagnosed at wildly different rates around the world. Psychiatrists
seemed to have a great deal of discretion available to them, being led by theories as to what was underlying the symptoms, which were rarely amenable to scientific testing in any strict sense. They shared a single terminology but lacked any strict rules for how it should be applied.

The ‘anti-psychiatry movement', as it was known, included some who viewed the entire profession as a political project aimed at social control. But it also included others, such as Thomas Szasz, who believed that psychiatry's main problem was that it was incapable of making testable, scientific propositions.
²³
In a famous experiment conducted in 1973, nineteen ‘pseudopatients' managed to get themselves admitted into psychiatric institutions, by turning up and falsely reporting that they were hearing a voice saying ‘empty', ‘hollow' and ‘thud'. This was later written up in the journal
Science
under the title ‘On Being Sane in Insane Places', adding fuel to the anti-psychiatry movement.
²⁴

Most controversially, the DSM-II included homosexuality in its list of disorders, provoking an outcry that gathered momentum from 1970 onwards, with the support of leading anti-psychiatry spokespersons. The APA was relatively untroubled by the problem of unreliable diagnoses, seeing as few of its members or governing body were especially interested in reliability in the first place. But the political storm generated by the homosexuality classification was far harder to ignore. Whereas the problem of diagnostic reliability was largely containable within the profession itself, the controversy over the DSM classification of homosexuality had spilled out into the public sphere.

Just as the Chicago School waited patiently in the cold until the economic policy crisis of the 1970s had run its course, there was one school of psychiatry which was blissfully untroubled by
the turmoil sweeping the APA. This small group, based at Washington University in St Louis, had long felt alienated from the psychoanalytic style of American psychiatry. Far more indebted to the Swiss psychiatrist Emil Kraepelin than to Freud (or to Adolf Meyer, whose adaptation of Freud's ideas dominated much APA thinking through the 1950s and '60s), they treated classification of psychiatric symptoms as of the foremost importance. Mental illness was to be viewed in the identical way as physiological illness, an event in the body – more specifically, the brain – which required objective scientific observation and minimal social interpretation.

Through the 1950s and 1960s, the St Louis group, led by Eli Robins, Samuel Guze and George Winokur, was left to operate in its own intellectual and social bubble. They were repeatedly refused funding by the National Institute of Mental Health, who preferred instead to fund studies within the Meyerian tradition, which focused on the relationship between mental illness and the social environment. The St Louis school were outcasts from the establishment, relying on networks with European sympathizers and throwing some rollicking parties among themselves, but peripheral to American psychiatry.

For these ‘neo-Kraepelinians', psychiatry's claims to the status of science depended on diagnostic reliability: two different psychiatrists, faced with the same set of symptoms, had to be capable of reaching the same diagnostic conclusion independently from one another. Whether a psychiatrist truly understood what was troubling someone, what had caused it, or how to relieve it, was of secondary importance to whether they could confidently identify the syndrome by name. The job of the psychiatrist, by this scientific standard, was simply to observe, classify and name, not to interpret or explain. Within this vision, the moral and political
vocation of psychiatry, which in its more utopian traditions had aimed at healing civilization at large, was drastically shrunk. In its place was a set of tools for categorizing maladies as they happened to present themselves. To many psychiatrists of the 1960s, this seemed like a banally academic preoccupation. But it was about to become a lot more than that.

While they were rejected by the psychiatry profession itself, the St Louis school were not the only voices arguing for greater diagnostic reliability at the time. Health insurance companies in the United States were growing alarmed by the escalating rates of mental health problems, with diagnoses doubling between 1952 and 1967.
²⁵
Meanwhile, the pharmaceutical industry had a clear interest in tightening up diagnostic practices in psychiatry, thanks to a landmark piece of government regulation. There was an increasingly powerful business case for establishing a new consensus on the names that were attached to symptoms.

In 1962, Senator Estes Kerfauver of Tennessee and Representative Oren Harris from Arkansas had tabled an amendment to the 1938 Federal Drug, Food and Cosmetic Act, aimed at significantly tightening the rules surrounding regulatory approval of pharmaceuticals. This was a direct response to the thalidomide tragedy, which led to around ten thousand children around the world being born with physical deformities between 1960 and 1962 as a result of a new anti-anxiety drug that had begun to be prescribed for morning sickness. The United States was relatively unaffected, due to the prudence (later viewed as heroism) of one FDA official who blocked the drug on grounds that it wasn't adequately tested.