The Happiness Industry Read online

  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.

  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 classif
ication 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.26 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.27 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.28 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.29 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.30 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’.31

  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.32 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 poli
tical 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.