The Happiness Industry (20 page)

One feature of the Kerfauver-Harris amendment was that drugs had to be marketed with a clear identification of the syndrome that they offered to alleviate. Again, this made clarity
around psychiatric classification imperative, although in this case for business reasons. If a drug seemed to have ‘antidepressant properties', for example, this wasn't enough to clear the Kerfauver–Harris regulatory hurdle. It needed a clearly defined disease to target – which in that case would need to be called ‘depression'. As the British psychiatrist David Healy has argued, this legal amendment is arguably the critical moment in the shaping of our contemporary idea of depression as a disease.
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Thanks to Kerfauver–Harris, we've come to believe that we can draw clear lines around ‘depression', and between varieties of it – lines that magically correspond to pharmaceutical products.

By 1973, the APA was facing charges of pseudoscience, homophobia and the peddling of regressive 1950s moral standards of normality. No less critically, they also represented a threat to the long-term profitability of big pharma. Both cultural and economic forces were pitted against the profession, throwing the very purpose of psychiatry into question. Ultimately, the St Louis approach to psychiatry would be the winner in this crisis, and the strict, anti-theoretical diagnostic approach would soon move from the status of nerdish irrelevance to orthodoxy. But it would take a particularly restless figure within the higher ranks of the APA to bring this volte-face about.

Robert Spitzer came from a traditional psychiatric background, joining the New York State Psychiatric Institute in 1966. He fell in with the authors of the DSM-II after hanging out with them at the Columbia University canteen in the late '60s, but was growing somewhat bored of the psychoanalytic theories peddled by his colleagues.
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Spitzer was someone who enjoyed a fight. He'd grown up in a family of New York Jewish communists and spent his youth engaged in lengthy political and intellectual arguments with his father, not least over the latter's Stalinist
sympathies. Today, he is commonly recognized as the most influential American psychiatrist of the late twentieth century. But as much as anything, this was down to his entrepreneurial zeal and imagination as it was to his ideas. What Spitzer had in spades, and which professional associations tended to lack, was an appetite for radical change.

In the late 1960s, Spitzer had a growing interest in diagnostic classification, spotting an alternative to the status quo. But his status within the APA was marginal, until he was given the task of defusing the homosexuality controversy. To achieve this, he mounted an aggressive campaign within the APA, offering an alternative description of the syndrome concerned – ‘sexual orientation disturbance' – which highlighted that
suffering
must be involved before any diagnosis of sexuality disorder could be made. This was a subtle but telling distinction: Spitzer was implying that the relief of unhappiness should replace the pursuit of normality as the psychiatrist's abiding vocation. In 1973, he faced down opposition from senior colleagues within the APA on this issue and won. Thanks to Spitzer's advocacy, the question of sexual ‘normality' was (not-so-quietly) replaced with one of classifiable misery, hinting at how the character of mental illness was changing more broadly.

The following year, Spitzer was given his next political challenge: to deal with the APA's diagnostic reliability. The DSM-II was already looking dated, and in any case needed rewriting to abide by the World Health Organization's own changing diagnostic criteria. Spitzer was appointed as chair of the Task Force on Nomenclature and Statistics, now with a clear mandate to deal with the problems of diagnostic reliability that had been brewing for over a decade. Crucially, he retained complete control over how the task force would be composed. He hand-picked its eight
members with a clear intention to tear up the APA's existing theoretical principles and replace them with a set of methods which were straight out of St Louis.

Four of the eight appointees to Spitzer's task force were from St Louis, whom he described as ‘kindred spirits'. The other four were judged to be sympathetic to the coup that Spitzer was about to stage. In appointing Spitzer, the APA – and certainly the health insurance industry – had hoped that stricter diagnostic categories would actually lead to a reduction in the levels of diagnosis overall. Greater rigor in the criteria attached to a diagnosis, it was assumed, would make it harder for syndromes to be diagnosed. What they hadn't calculated for was the exhaustiveness of the task force's approach to classification, which yielded a progressive multiplication in the varieties of recognized mental illness.

Every known psychiatric symptom was being listed, alongside a diagnosis. To do this, they drew heavily on a 1972 paper on diagnostic classification authored by the St Louis group, but adding further classifications and criteria.
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Typing away in his office in Manhattan's West 168th Street, urging on his task force to recite symptoms and diagnoses like some endless psychiatric shopping list, Spitzer was unperturbed. ‘I never saw a diagnosis that I didn't like', he was rumoured to have joked.
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A new dictionary of mental and behavioural terminology was drafted.

Relatively unhappy

The resulting document that Spitzer and his team produced in 1978 provided the basis of the DSM-III, arguably the most revolutionary and controversial text in the history of American
psychiatry. Finalized over the course of 1979 and published the following year, this handbook bore scarce resemblance to its 1968 predecessor. The DSM-II outlined 180 categories over 134 pages. The DSM-III contained 292 categories over 597 pages. The St Louis School's earlier diagnostic toolkit had specified (somewhat arbitrarily) that a symptom needed to be present for one month before a diagnosis was possible. Without any further justification, the DSM-III reduced this to two weeks.

Henceforth, a mental illness was something detectable by observation and classification, which didn't require any explanation of why it had arisen. Psychiatric insight into the recesses and conflicts of the human self was replaced by a dispassionate, scientific guide for naming symptoms. And in scrapping the possibility that a mental syndrome might be an understandable and proportionate response to a set of external circumstances, psychiatry lost the capacity to identify problems in the fabric of society or economy.
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Proponents described the new position as ‘theory neutral'. Critics saw it as an abandoning of the deeper vocation of psychiatry to heal, listen and understand. Even one of the task force members, Henry Pinsker (not from St Louis), started to get cold feet: ‘I believe that what we now call disorders are really but symptoms'.
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The DSM-III came about because the APA had found itself on the wrong side of too many cultural and political arguments at once. The forms of truth that psychiatrists were seeking could not survive the turbulent atmosphere of 1968 and its aftermath: they were too metaphysical, too politically loaded and too difficult to prove. But amidst this is a story about how happiness – and its opposite – appeared as a preoccupation of mental health professionals, medical doctors, pharmaceutical companies and individuals themselves. To get to this point, the mainstream
psychiatric establishment had to be virtually cut out of the loop. A landmark legal case in 1982, in which a psychiatrist was successfully sued for prescribing long-term psychodynamic therapy to a depressed patient, and not an antidepressant drug, offered a rousing demonstration of the new state of affairs.
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Today, 80 per cent of the prescriptions that are written for antidepressants in the United States are by medical doctors and primary care practitioners, and not by psychiatrists at all.

In a post-1960s era of ‘self-anchored striving', what can people possibly hold in common other than a desire for more happiness? And what higher purpose could a psychological expert pursue than the reduction of unhappiness? These simple, seemingly indisputable principles were what emerged from the cultural and political conflicts which came to a head in 1968. The growing problem of depression, experienced as a non-specific lack of energy and desire, combined with the emergence of a drug that seemed selectively to alleviate this, and the need of drug companies, regulators and health insurers to find clarity amidst such murkiness, meant that psychoanalytic expertise was heading for a fall.

A host of new techniques, measures and scales would be needed to track positive and negative moods in this new cultural and political landscape. Aaron Beck was well ahead of his time with his 1961 Beck Depression Inventory. In respect of physical pain, the influential McGill Pain Questionnaire was introduced in 1971. Various additional questionnaires and scales were introduced during the 1980s and 1990s to identify and quantify levels of depression, such as the Hospital Anxiety and Depression Scale (1983) and Depression Anxiety Stress Scales (1995). With the growing influence of positive psychology, which offered to mitigate the ‘risk' of depression occurring, scales of ‘positive affect'
and ‘flourishing' were added to these. Each of these represented a further manifestation of the Benthamite ambition to know how another person was feeling, through force of scientific measurement alone. Underlying them was the familiar monistic hope, that diverse forms of sadness, worry, frustration, neurosis and pain might be placed on simple scales, between the least up to the most.

The reconfigured DSM, together with the various newly designed scales, made it very clear what should be classified as depression and to what extent. A sufficient number of symptoms, such as loss of sleep, loss of appetite, loss of sexual appetite, in combination for two weeks or more could now be called ‘depression'. But what it actually meant to be depressed, or what caused it, had disappeared from view, for many of the new league of psychological experts who emerged on the tails of Spitzer and the St Louis team. The voice of the sufferer was not quite silenced in the new diagnostic era, but it was regulated by the construction and imposition of strict questionnaires and indices. The neurosciences potentially now enable psychiatry to move away from even those restricted questions and answers.

So what really is this so-called disease that now afflicts around a third of people at some point in their lifetime, and around 8 per cent of American and European adults at any one time? It is often said that depression is the inability to construct a viable future for oneself. What goes wrong, when people suffer our contemporary form of depression, is not simply that they cease to experience pleasure or happiness, but that they lose the will or ability to seek pleasure or happiness. It is not that they become unhappy per se, but that they lose the mental – and often the physical – resources to pursue things that might make them happy. In becoming masters of their own lifestyles
and values, they discover that they lack the energy to act upon them.

It is only in a society that makes generalized, personalized growth the ultimate virtue that a disorder of generalized, personalized collapse will become inevitable. And so a culture which values only optimism will produce pathologies of pessimism; an economy built around competitiveness will turn defeatism into a disease. Once the Benthamite project of psychic optimization loses any sense of agreed limits, promising only more and more, the troubling discovery is made that utilitarian measurement can go desperately negative as well as positive.

Depressive-competitive disorder

‘Just do it'. ‘Enjoy more'. Slogans such as these, belonging to Nike and McDonald's respectively, offer the ethical injunctions of the post-1960s neoliberal era. They are the last transcendent moral principles for a society which rejects moral authority. As Slavoj Žižek has argued, enjoyment has become an even greater duty than to obey the rules. Thanks to the influence of the Chicago School over government regulators, the same is true for corporate profitability.

The entanglement of psychic maximization and profit maximization has grown more explicit over the course of the neoliberal era. This is partly due to the infiltration of corporate interests into the APA. In the run up to the DSM-V, published in 2013, it was reported that the pharmaceutical industry was responsible for half of the APA's $50 million budget, and that eight of the eleven-strong committee which advised on diagnostic criteria had links to pharmaceutical firms.
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The ways in which we
describe ourselves and our mental afflictions are now shaped partly by the financial interests of big pharma.

One of the last remaining checks on the neurochemical understanding of depression was the exemption attached to people who were grieving: this, at the very least, was still considered a not unhealthy reason to be unhappy. But in the face of a new drug, Wellbutrin, promising to alleviate ‘major depressive symptoms occurring shortly after the loss of a loved one', the APA caved in and removed this exemption from the DSM-V.
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To be unhappy for more than two weeks after the death of another human being can now be considered a medical illness. Psychiatrists now study bereavement in terms of its possible mental health ‘risks', without any psychoanalytic or common sense of
why
loss might be a painful experience.
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Corporations are also increasingly aware of the economic inefficiency of depression in an economy that trades on enthusiasm in the workplace and desire in the shopping mall.
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Finding ways to lift people out of this illness, or reduce the risks of encountering it in the first place (through tailored diet, exercise or even brain scans to assess the risk early in children), is viewed as essential to the survival of corporate profitability. One report on the topic, sponsored by a number of UK corporations including Barclays Bank, stated with a peculiar absence of compassion, ‘Today's brain-based economy puts a premium on cerebral skills, in which cognition is the ignition of productivity and innovation. Depression attacks that vital asset.'
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