Dr James Davies graduated from the University of Oxford in 2006 with a DPhil in social and medical anthropology. He is a Reader in Social Anthropology and Mental Health at the University of Roehampton, London, a psychotherapist (having practiced in the NHS), secretariat to the All-Party Parliamentary Group for Prescribed Drug Dependence and co-founder of the Council for Evidence-based Psychiatry (CEP). He is author of the bestselling book Cracked: why psychiatry is doing more harm than good and his new book Sedated: How Modern Capitalism Created our Mental Health Crisis is out now.
JB: The core theme of your excellent new book, ‘Sedated’, is the progressive medicalisation and individualising of emotional and psychological distress that has moulded all of our lives in the West since the 1980s. This trend, as you illustrate, is deeply and intimately tied to the rise of the neoliberal political project in the US and UK via Reagan and Thatcher. You paint a very powerful picture of the insidious reframing of our often socio-politically derived distress in terms of dysfunctions in the individual, ultimately serving the political status quo but harmful to our wellbeing. I wonder if you could expand on the theme of neoliberalism as it pertains to our ‘mental health’ and give us a taste of the key strands in the book?
JD: Thanks, James, a very good opening question. I’ll give it a go, but let me start by first defining the term neoliberalism, which is generally used to describe the style of capitalism that has dominated most Western economies since the 1980s (in particular the UK and US). Once neoliberalism, under Thatcher and Reagan, began replacing the more ‘socialist’ style of capitalism that prevailed between the 1950s and mid-1970s, it altered society in many significant ways. It did this by greatly expanding the dominance and reach of the market through tax cuts (mostly for the wealthy); by empowering multinationals via wide deregulation (cutting ‘red tape’); and by dramatically reducing the state’s role in the economy through privatisation and cuts to labour, welfare and social protections.
It also introduced a new ideology of individualism, where success was seen as an outcome of exceptional individual qualities (rather than exceptional social privileges and advantages), and failure as rooted in personal deficits (rather than in lack of opportunity, equality or social support). In short, neoliberalism, at its purest, cast the individual as entirely responsible for his or her own destiny – the person you were had little to do with the circumstances in which you were raised, just as the good life was mostly achieved through heroic feats of individual effort, rather than mostly achieved through collective action, togetherness and support.
Now, to understand how our mental health sector colluded with this ideological project, I recruit an idea that’s been central to much sociological thinking over the 20th century —namely, that the main sectors of society (law, education, health care, religion etc) always adapt to what the economic paradigm of the day demands of them. Now, the peculiar thing about our mental health sector is that it’s been more skillful than almost any other sector at adapting to the demands of neoliberalism. This is because the foundations of our mental health are relatively fluid and capricious. Unlike our legal system, for instance, where practice is rooted in long-standing legislative anchors, or our biomedical system, where practice is restrained by the bedrock of biological fact, the mental health sector has found almost no biological markers to anchor its treatment of mental distress, while its ‘evidence base’ is highly amendable to the direction in which powerful vested interests demand it goes.
In ‘Sedated’, then, I explain that the relatively capricious and adaptable nature of our mental sector can help us understand why it’s failed to improve clinical outcomes since the 1980s: its adaptation to neoliberal directives has put the needs of the market above the needs of those seeking mental health care and support. I don’t suggest that this collusion has happened in any kind of conspiratorial or calculated way, but that its been a consequence of the mental health sector struggling to survive under this new set of neoliberal economic arrangements.
So what are the main features of this collusion between neoliberalism and mental health? How has the sector been able to flourish despite its consistently poor results? Well, here are a few mechanisms I discuss in ‘Sedated’:
Firstly, our sector has depoliticised suffering: conceptualising suffering in ways that protect the current economy from criticism – i.e. reframing suffering as rooted in individual rather than social causes, thus favouring self over social and economic reform.
Secondly, it has privatised suffering: redefining individual ‘mental health’ in terms consistent with the goals of the economy. Here ‘health’ is characterised as comprising those feelings, values and behaviours (e.g. personal ambition, industriousness and positivity) that serve economic growth, increased productivity and cultural conformity, irrespective of whether they are actually good for the individual and the community.
Thirdly, it has widely pathologised suffering: turning behaviours and feelings deemed inconvenient from the standpoint of certain authorities (i.e. things that perturb and disrupt the established order), into pathologies that require medical framing and intervention.
Fourthly, it has commodified suffering: transfiguring suffering into a vibrant market opportunity; making it highly lucrative to big business as it manufactures its so-called solutions from which increased tax revenues, profits and higher share value can be extracted.
Finally, it has decollectivised suffering: dispersing our socially caused suffering into different self-residing dysfunctions, thereby diminishing the shared and collective experiences that have so often in the past been a vital spur for social change.
JB: What I found eye opening in ‘Sedated’, was just how entrenched and pervasive this ideology is in our society. The ways you illustrate how the neoliberal ethos — competition for resources, productivity over wellbeing and ‘survival of the fittest’ thinking — is at play in schools and hospitals, for example, makes this quite clear. It is not just the habitual stress and anxiety that results from this, but a whole experience of others and the world in terms of “us vs them, haves vs have nots.” Our value under this rubric is earned — by what have and do — rather being to do with intrinsic human qualities. This ethos has become so embedded in our society that for many it can simply seem to be a given. How do you think it became so powerful?
JD: Neoliberalism is not just an economic paradigm but, like all such paradigms, it also entails a theory of human nature — a concept of what is healthy and unhealthy, what is moral and functional; what motivates us and what constitutes the good life. In this sense, neoliberalism is a ‘totalising system’ to use a sociological phrase — it does not solely advance a suite of economic directives, but also a set of guiding principles for living (principles that, by the way, mostly serve those very economic directives). Margaret Thatcher intuitively understood this vital link between economics and human psychology. She understood how economic policy (in her case, neoliberal economic policy) had the power to radically transform how people feel, act and behave. As she said two years into her term as UK Prime Minister, her aim was to use economic policy to change the mentality and character of the nation: ‘Economics are the method’, she confessed to the journalist Ronald Butt, ‘the objective is to change the heart and soul’.
The kind of hearts and souls she wanted to fashion via her policies were entrepreneurial, self-reliant, hard working and economically productive. In fact, the kind of personality type she revered most of all, seemed to most closely match the contours of her own: she wasn’t that much interested in introspection, introversion and self-cultivation, but in extraversion, ambition and constant activity. She admired the battling sort, and believed that perpetual striving and busyness indicated a kind of higher species of living – something her economy would both encourage and reward. She had less imagination for the happy minutiae of everyday life, for more local ambitions, hobbies and affiliations – for the multitudes of little kindnesses upon which communities and societies are built. She was impressed by success, self-reliance and striving – by people who sacrificed everything to ‘better themselves’ (which for her mostly meant ascending the economic ladder).
During the 80s and 90s, then, displaying the outward signs of such self-betterment grew in cultural salience. The things we consumed became the outward markers of our success. More and more of us came to derive our identity and self-esteem from our possessions, believing that we principally defined and created ourselves through the objects we consumed, and that by acquiring more high-status possessions and accolades we somehow increased our value and worth as persons. As the more we possessed the more we believed we were, a dominant cultural aim became ‘to have much’ rather than ‘to be much’ — to put it in Erich Fromm’s terms — to make material acquisition a central fulcrum of living.
So to answer your question as to why the neoliberal ethos has become so powerful in society, well, economic policy has the power to affect the direction in which we all come to strive, shaping our identities, goals, personalities and experience in the process. This idea has been embraced by those on the economic left and right, from left wing thinkers like Karl Marx and Erich Fromm to the great architects of late capitalism itself — Fredrick Hayek and Milton Friedman. And this is why economics is so eminently psychological; economic systems have the power to shape psychological systems, and sometimes in insidious ways.
Let me give you a concrete example if you are unconvinced. Why does current data show that undergraduate students today are more depressed and despondent than were undergraduates of 15-20 years ago? Well, undergraduates today generally perceive the world they are entering as more hostile than did undergraduates of the past, which is understandable. Unlike in the past, graduates now have huge student debts to repay; their prospects of owing a home are ever more elusive, while the job market is more competitive. Additionally, wages are flat–lining, careers for life are disappearing, and levels of worker dissatisfaction are escalating. Despite the obvious economic reasons for higher despondency in present day undergraduates, the narrative around worsening student mental health is still mostly depoliticised – the social context is even actively denied. The cry is for ‘more psych-services’ and ‘mental health consultancies’, not for serious reflection on, and reform of, the harmful policies weighing on student life. This latter domain feels too big, too immovable to even entertain, so we instead focus on ‘mental health away days,’ relaxation hours, and better access to GPs.
JB: In ‘Sedated’, you powerfully argue that we need to focus on the social roots of distress — such as unfair taxation, poor social welfare, inequality and social exclusion — which have been historically denied by psychiatry (and also, it must be said, by academic psychology). The evidence mounts that this is indeed vital in understanding such distress and to the ongoing wellbeing of our societies as a whole. It is also true that psychiatry has increasingly acknowledged the role of these factors. They will be framed, however, in terms of ‘triggers’ of what then becomes an individual disorder that should be medicalised, something which you obviously disagree with. This is, to me, the very tricky thing about the psychiatric model: it can fit almost anything into its narrative. I wonder how you make sense of the differences?
JD: Psychiatry is not a science, even though, of course, it aspires to make use of scientific findings to guide its practices (as to who often produces those ‘findings’ we’ll leave for another day…). If psychiatry is not a science, then what it is? Well, many social scientists may call it a set of cultural practices and ideas or what the Harvard anthropologist and psychiatrist, Arthur Kleinmann, has called an ‘explanatory model’. The term ‘explanatory model’ I believe fits psychiatry very well, insofar as it is defined as a system of interlinked ideas and practices that frame and respond to suffering in ways that, in my view, mostly serve powerful social, political and professional interests.
One of the most obvious ways in which ‘explanatory models’ serve interested parties, is through their use of language (or, in the case of psychiatry, through its use or misuse of medical symbolism). Psychiatry uses medical symbolism to endow its pronouncements and practices with an aura of authority that they would otherwise lack, and to reframe human experiences in ways that make the model itself appear altruistic and indispensable. By using medical symbols like ‘disease’, ‘illness’, ‘disorder’, ‘pathology’, ‘diagnosis’ etc, the explanatory model drags diverse experiences of human suffering under the authoritative purview of its own jurisdiction; recasting suffering as an essentially medical problem that its own specialist knowledge and proficiency is uniquely positioned to treat.
The explanatory model therefore deploys symbolism to bolster its credence and power in the world, hence the huge resistance the model has to de–medicalising its ideas, concepts and practices (and its almost structural hostility towards non-medical symbolic alternatives). So even though the symbols don’t capture the realities of our emotional worlds (you could even say that they distort these realities) they still serve the function of endowing the model with the authority it needs to dominate and thrive.
To provide an example of how this misuse of symbolism works in a day-to-day practice, let’s consider the following sentence that includes a word you mentioned a moment ago, James: ‘poverty triggers mental illness’. As you suggested in your question, rather than saying ‘poverty generates multiple forms of human suffering and distress’ the word trigger invokes the powerful cultural symbol of ‘mental illness’ to denote something that poverty supposedly provokes and that the model can supposedly ‘treat’. This move does a couple of things. It ensures that the model remains relevant in the face of the social determinants of distress, protecting or even expanding the model’s jurisdiction over us, but it also allows the model to claim sophisticated ‘bio-psycho-social’ credentials, despite relegating social causes to mere ‘triggers’ and widely privileging biological/drug interventions in the management of what has been triggered – namely – the ‘mental illness’.
But let’s now also look at the phase ‘mental illness’ in this sentence. Some time ago I asked a group of medical students at Imperial College, London, to make sense of the following fact: why in the UK are the highest rates of psychiatric drug prescribing found in the areas of highest socio-economic disadvantage, poverty and unemployment? Is this coincidence? Or is there something causal behind the correlation? One student responded, to wide approval of the others, that it was no coincidence at all, as these are precisely the kind of social circumstances (high deprivation, poverty, etc.) that generate higher rates of mental illness.
I then asked the students to pay attention to the use of the phrase ‘mental illness’. While it is true, I said, that people in deprived situations are likely to suffer a great deal more than those who are more affluent, on what grounds are we correct to use medical symbolism to describe that suffering? Do we use it because we have simply been taught to use it, or because we have objective evidence that it is somehow better to medicalise such suffering than it is to view it, as many social scientists might, as a non-medical, non-pathological, yet understandable human response to harmful social, relational, political and environmental conditions? Perhaps the reason why inequality, poverty, and social disadvantage are good news for the antidepressant market, I continued, is because our response to socially induced suffering is now so medicalised. This preserves the domain of psych-authority and prescribing, subtly distracts attention from the centrality of bad social policy and so helps exonerate bad circumstances. If these mechanisms greatly improved patient outcomes then perhaps any criticism would seem churlish. But the fact is, ever since this explanatory model has widely dominated our services, clinical outcomes have at best flat lined while according to some measures they have got worse, which is the opposite of what you’d expect to find if the model were working.
So yes, psychiatry’s explanatory model is slippery and adaptable. It endows poor interventions with status and power, and misleads as to the real origins of the ‘illness’ it purports to remedy. In this sense, its power, status and authority is more derived from the symbols it wields than from the actual social good it generates. This explains, of course, its deep attachment to the symbols.
JB: Clearly, much of the individualising of distress/ideology of persons with ‘disorders’ goes directly back to the 1980s — neoliberalism & the DSM-III — as you illustrate and unpack. Reading your book, I couldn’t help but also think about the conditions that made these possible. It seems to me that the individualising/disorder-ising of distress is almost written into what we might call the broad Western ‘project of the individual self’ (for example, the more experience is conceptualised as an internal, subjective phenomenon in some way reducible to the brain or body, the easier it is to say that that something ‘wrong’ is in the person). Though we might call the manufacturing of minds and lives a la neoliberalism the most modern and extreme version or outcome of this, its roots, it seems to me, go back to the very inception of capitalism and the scientific world view. I wonder what your take on this is?
JD: I am an anthropologist by training, and so have read countless ethnographies of how human communities and relations operate outside the domain of neoliberal arrangements. This has taught me many things, but in particular, it’s taught me how the kinds of emotions and subjective states that any society honours, normalises and rewards are those kinds that best serve the smooth functioning of its social system. The anthropologist Emily Martin looked at this in the context of the modern US, where ‘manic states’ are far less stigmatised than ‘depressive states’. Why? Manic states are more active, productive, consistent with frenetic demands of modern life, while ‘depressive states’ are counter to extraversion and productivity, they slow people down and make them introspective. In this sense ‘anti-depression’ does not just refer to a kind of intervention, but to a pervasive cultural prejudice towards suffering itself – as a society we have a very hostile relationship to any emotion that brings us down and that threatens the social order. Our communities have consequently developed a deep intolerance of suffering, which has in turn bred a certain amount of fear among us. The professionalisation of ‘mental health management’ has deskilled and intimidated us – and our communities no longer trust they have the wisdom or resources to respond effectively (pretty much contrary to any indigenous group I have ever studied). And so we exile sufferers to ‘experts’ in consulting rooms sitting far outside the community walls, who in turn end up, often with good intentions, transfiguring suffering into a mere commodity from which revenue can be accrued (let’s not forget that the global psychotropic market is now worth around $70 billion a year). And our idea of care, once they return, often amounts to: ‘please don’t forget to take your meds’ – there is no community, no shared cosmology, no ritual coming-together around the person’s pain. There is isolation, fear, pathologisation and much too much medication.
This deep intolerance of distress (which is linked to bias against any economically inconvenient emotion) was even explicitly enshrined in the DSM. In 1980, the same year that Reagan came to power, the DSM for the first time reclassified occupational underperformance as a key index of mental disorder, at the very same time as neoliberal states began to grapple with the need to improve worker productivity – i.e. the output of each worker per hour of their labour. While governments would aspire to improve productivity from the outside, via new social policy, psychiatrists and drugs companies would claim to improve it from the inside, via new drug interventions that claimed to alter the very dynamics of the unproductive self. The mid-century preoccupation among the psych-professions with cultivating productivity in the more humanistic sense (working to realise and make productive use of our full human powers) was now supplanted by the professional obsession with the need to cultivate productivity in the economic sense (rendering people better able to satisfy abstract economic measures, like returning to work rapidly). Those forms of subjectivity that threatened the optimum functioning of the market thus became those most readily pathologised and discredited, as did other ways of being deemed antithetical to the grander neoliberal project.
To give just one example of another way, the eminent sociologist Richard Sennett once wrote an excellent book on late capitalism, called New Capitalism. This book addressed how close and enduring social networks and relationships can actually impede the designs of late capitalism. The modern economy needs to have a highly mobile workforce (e.g. the average time we spend in any given job is now around 5 years). But having deep social ties and strong community affiliations actually inhibits the high mobility, and rapid staff turnover keep wages low, corporations nimble, and anxiety in the workforce at a productive high. Thus neoliberalism subtly benefits from the loosening of community ties, as detached people are better able to up-and-move, and are more able when they settle in a job to make the workplace itself their primary community. While this may be excellent news for employment markets, it’s very bad news for our emotional health.
So what I argue in ‘Sedated’, to come to your question, James, is that our mental health sector, broadly speaking, does nothing to problematise the social conditions of distress. It’s conservative, uncritical and deferential to dominant structure. It’s neoliberal by default. It seeks to appeal servilely to late capitalist aims and directives (often to secure government funding) more than to offer any radical programme for reform. To use an analogy, our sector is like the good boy in the class who brings gifts and praise each day for the tyrannical teacher and becomes compromised as a result. Our system thus fails because it colludes with social structures that themselves generate harmful ways of being in the world. The sector at best sedates these states while at the same time exonerates harmful social arrangements by over-emphasising the so-called internal and disordered causes of structural distress.
JB: Finally, your overall conclusion was that things need to change from the top down — from politics and the politicians. I know you do lobbying at that level, so your money is where your mouth is! I wonder, though, how you see the role of service user movements on the one hand, and the critical discourse in the mental health professions on the other in that process? In other words, what can we do to help shift the dominant political narrative?
JD: There are two things I believe must happen if the mental health sector is to work. Firstly, reform has to start with ourselves, with identifying where we collude with the very causes of the suffering we purport to alleviate, by disseminating ideas and interventions that exonerate these causes. When I say ‘ourselves’ I refer to both professionals and services users (or to the very many who straddle both categories). And we are making excellent strides – I need not repeat for MITUK or MIA readers a list of the many people and organisations now engaged in pushing against the status quo. And by the way, we are no longer a small and symbolically inconsequential minority – we are a growing and ever more powerful majority, with organisations like the World Health Organisation and the UN gradually aligning with this potent call for change.
But I am also a realist, and believe that until we have more accommodating political arrangements in our economy, reform will be significantly hobbled. You see, our sector fits so neatly with neoliberal arrangements that until there is wider structural change, I think the style of our current sector will continue to dominate, despite poor outcomes. I really grappled with accepting this conclusion while researching ‘Sedated’, because it’s not particularly uplifting now it is, as it implies such a major prerequisite for change. On the other hand, it is also true that socio-economic reform looks far less implausible than it did even in early 2020, given the economic effects that Covid will doubtless continue to exert in the coming years (an area I expand on in the book). So, and to finish by paraphrasing something I say in ‘Sedated’: when change arrives, and it will arrive as no economic paradigm has ever existed in perpetuity, alternative ideas in the realm of mental health will only be poised for implementation if we keep putting in the effort right now; if we work to defy the neo-liberal pressures and enticements, and if we develop interventions that put the needs of people and communities above our failing and now fading economic ideology.
JB: Wonderful. Thanks for taking the time to share your wisdom, James!
JD: Thanks so much for talking with me, James.