Men are so necessarily mad, that not being mad would be being mad through another trick that madness played.
There is no longer any doubt that serious depression is an organic as well as psychic condition, and that its life-destroying effects can often be controlled by medication. Ironically, it may be precisely this shining success of pharmacology that leads us to extend the concept of depression beyond its proper diagnostic warrant, so that it crowds out older understandings of unhappiness.The semantic shift wherein “unhappiness” is replaced by “depression” has real consequences: Our self-understanding becomes infected by medical categories that may not be appropriate, issuing in a kind of moral inarticulacy. With this comes a different disposition toward one’s own experience. Theodore Dalrymple, a former prison psychiatrist in Britain, suggests that an overly broad concept of depression implies that dissatisfaction with life is itself pathological, a medical condition, which it is the responsibility of the doctor to alleviate by medical means. Everyone has a right to health; depression is unhealthy; therefore everyone has a right to be happy (the opposite of being depressed). This idea in turn implies that one’s state of mind, or one’s mood, is or should be independent of the way that one lives one’s life, a belief that must deprive human existence of all meaning, radically disconnecting reward from conduct.1
Happiness becomes something to be engineered rather than earned; a moral category gives way to a medical one. Since medical engineering is best left to experts, to understand oneself as depressed rather than unhappy is to take a diminished view of one’s own agency. This would seem to be a reasonable view of yourself if you suffer a serious chemical imbalance. But when it becomes the default self-understanding of a whole generation, it signals a major cultural shift toward psychic passivity. In a survey of 23,863 college students conducted in the autumn of 2006, 45 percent of women and 36 percent of men reported being “so depressed that it was difficult to function” at least once in the past 12 months.22.
American College Health Association, National College Health Assessment Web Summary (August 2007).
Campus Mental Health Trends
These numbers are alarming, so I discussed them with Russ Federman, director of Counseling and Psychological Services (CAPS) at the University of Virginia. He told me that when he began eight years ago, CAPS provided twenty hours per week of psychiatric care—one psychiatrist working half-time. Today it is eighty hours per week. About 9 percent of the student body comes in for counseling, on par with universities across the nation. The rate tends to be higher at small colleges. According to Peter LeViness, director of CAPS at the University of Richmond, the number of students visiting the CAPS office has gone from less than 5 percent of the student body in the 1970s to almost 13 percent in 2006–07. At some Ivy League schools, the rate is as high as 20 percent. Of those who come to CAPS at UVA, about a third receive medications. At Richmond, which does not have on-site psychiatrists and therefore must refer students off campus for medication, the rate is about 25 percent. Of the whole student body at Richmond, about 10 percent are on psychiatric medications. The most common problems are anxiety and depression.I asked Federman and LeViness what accounts for these increases, and they both suggested that competitive pressures play a significant role. According to Federman, the average GPA of UVA’s 2007 incoming class was 4.2; LeViness reports that at Richmond about half the students take double majors. The story of early-onset careerism is familiar enough, but LeViness doesn’t think that it’s “evidence based”—meaning it’s not a reflection of the actual competitive job markets they will enter but a mentality already embedded by the time they get to a selective college. It is a form of credential-seeking that floats free of external necessities, and it bespeaks a readiness to assess themselves according to quantitative measures. These are, it seems, the psychic hazards of a narrow sort of meritocracy. When these hazards are understood in mental health terms, it would seem that a set of cultural facts is being interpreted as a medical fact about an individual. For their part, university administrators seem content to accept the medical interpretation. Combine the stresses of college life with an incident like the Virginia Tech shootings, and Federman says that institutional “fear of liability has brought much needed attention to what we do.” Every autumn, UVA students receive an email to “raise awareness” about mental health issues and inform them about CAPS, followed by a second email a week later. This is repeated in the spring. Faculty and teaching assistants received a memo from the office of the vice president and chief student affairs officer at the start of the spring 2008 semester that listed warning signs to look for in possibly troubled students. The fall drive is tied in with National Depression Awareness Week, a festival of solicitude that bears all the hallmarks of a Big Pharma PR campaign. The University of Richmond also employs psych majors as “outreach interns.” Their job is to go about among their peers and “destigmatize” mental health care by putting on various events. At UVA, the CAPS office has a multicultural coordinator to speak to minority and immigrant students. These groups require a special effort of persuasion, since there are “cultural factors” inhibiting many of them from seeking mental health care. One political science professor at UVA points out that deans have far less discretion than they used to in expelling a troubled student. He attributes the change to an overgrown “rights culture.” One has to have air-tight reasons to remove a student, so there is new demand for expert psychiatric opinions that can certify a dean’s judgment and give it solid institutional backing. If the judgment is rendered in medical terms, it becomes less contestable. Agency and Dissent
In the 2006 movie The Departed, there is a powerful scene in which Leonardo DiCaprio’s character lashes out at the psychiatrist he is required to visit “against every instinct of privacy and self-reliance”, as he puts it. Precisely because it strikes the viewer as slightly old-fashioned, the response of DiCaprio’s character to the authority figure of the therapist highlights, by way of contrast, the cultural transformation currently underway. We are becoming more amenable to being therapized in various ways, and less likely to take our bearings from self-reliance.Yet there is a paradox. According to an older perspective, we take a diminished view of ourselves when we accept the psychiatrist’s priestly authority. But a commonly reported effect of antidepressant use is not a diminished view of oneself, but precisely an increase in self-esteem. What sort of bargain is being struck here? Joseph Davis, a sociologist at the University of Virginia’s Institute for Advanced Studies in Culture, has been interviewing college students and others, asking them to talk about their use of psychotropic drugs. Davis says that the way young people usually experience these drugs is that “you’re not giving up agency, you’re getting it.” To put oneself under the care of a doctor has always required taking a crucial mental step, admitting that “I’m the kind of person who needs help.” But this becomes a much easier transition to make if there is a payoff. The availability of drugs changes the calculus compared to past decades. Whether the diagnosis is depression, social anxiety or attention deficit, the perceived payoff of accepting diagnosis and treatment is greater academic and social success. Davis relates that students’ parents loom large in the interviews as a source of pressure to succeed. “The way students feel is that the train is leaving the station, and if you are not on it, you are doomed”, he says. Anxieties arising from academic competition, closely indexed to the economic competition they anticipate after graduation, seem to overwhelm any reluctance about thinking of oneself as having a “condition.” For while drugs are used to get a leg up—especially drugs for Attention Deficit Hyperactivity Disorder (ADHD)—Davis reports that students don’t perceive the use of them cynically, as a way of gaming the system. They really do accept that they have a condition, and the drug is merely restoring them to normal. Indeed, a narrative of reclaiming one’s true self runs through the pamphlets supplied by drug companies. This literature avoids entirely terms such as “mental illness”, and refers instead to an “imbalance.” The problem is with your brain, not your self. Your self stands only to be restored to its true stature—as in Garrison Keillor’s world, here all children are above average. Davis notes that since the problem is located outside the self, there is no perceived loss of agency. This understanding helps those who adopt it to accommodate themselves to their circumstances. From “it’s not my self, it’s my brain”, it follows that “it’s my brain.” All problems become individual. Whereas the self can hardly be understood without reference to a life with its external circumstances running its course through the world, we tend to think of the brain as radically private. So positing the two distinct ontologies of self and brain, and locating the source of one’s unhappiness in the latter, seems to neutralize any impulse to criticize the world. How does any of this square with the “liberal” in liberal education? Arguably, the liberation implicit in the liberal arts is liberation from the present, with its necessarily partial view of human flourishing. Liberal education is an inherently critical enterprise. Students who accept the warmly offered hand of diagnostic solicitude would seem to be less likely to raise their head above the maze and get a critical take on the rat race they evidently feel trapped in. The enhanced self-esteem they feel upon reclaiming their “true self” through psychiatric drugs would seem to be a self whose agency moves in well-defined channels. Taking drugs keeps the engine from breaking down, but what happened to the steering wheel? From Moralism to Medicalism
Davis points out that sadness and anxiety, like physical pain, serve a crucial signaling function. They indicate that there is something amiss in the world, or with one’s behavior. By all accounts, the serotonin drugs now prescribed for both depression and “social anxiety” really do dull the user’s affective response to the world, alleviating the kind of psychic discomfort that compels us to pause, ask “what’s going on?”, and perhaps adjust course. So it is not only criticism of the world that gets neutralized by the brain/self dichotomy, but self-criticism as well.Another term for such criticism is moral reflection. Yet the authority of psychiatry rests on a recasting of moral categories in terms of health and sickness. The former come to us through tradition and common sense, whereas the latter are knowable only by psychiatric science, and refer to one’s brain. In the waiting room of the CAPS office at UVA one can find The Freedom from Depression Workbook. The cover lists seven kinds of people for whom the book is intended; the fifth category is those who “feel trapped by a sense of duty.” A self cut off from external moral referents is liberated from duty, guilt, shame, remorse, self doubt and all those social-psychic hooks whereby communal purposes make their claim on the individual. Yet it doesn’t seem quite right to say that the therapeutic self collapses in on itself. Others are there for him, but now as others like himself: isolated individuals who can make no claims on him other than those that withstand the solvent of therapeutic anti-moralism. The therapeutic turn might be understood both as our accommodation to the collapse of inherited moral demands and as a new form of anti-culture that makes its own demands on us—those of radical individualism, the ideology of the market. The rigors of market competition may be internalized as a moral demand system, as the anxiousness of college students seems to confirm. Surely, one might say, a competent clinician can distinguish between depression and normal unhappiness. Indeed, the Diagnostic and Statistical Manual of Mental Disorders, currently in its fourth iteration, is accompanied by the DSM-IV Handbook of Differential Diagnosis. The Handbook lists six steps of differential diagnosis, the last of which is “Establish the Boundary With No Mental Disorder.” But consider that this boundary is no more stable than those that are erected by the discipline, somewhat arbitrarily, between mental disorders—which is to say not stable at all, and subject to forces more social than scientific. For example, in recent years Joseph Biederman, the chief of pediatric psychopharmacology at Massachusetts General Hospital, has pointed out that some of the diagnostic criteria for ADHD fit just as well a diagnosis of bipolar disorder, and has argued for the latter interpretation. Largely as a result of his influence, there are now about a million children being treated for bipolar disorder in the United States, forty times as many as there were ten years ago.33.
See the documentary “The Medicated Child”, Frontline, January 8, 2008.
Most notoriously, the DSM once classified homosexuality as a mental disorder and desisted only as the result of a collective action from outside the discipline. It hardly needs to be pointed out that psychiatrists have a vested interest in taking the narrowest possible view of the sound psyche. Multiplying the varieties of pathology expands the dominion of their discipline. The growing girth of the DSM might serve as a crude index of how dispositions and moral qualities are being recast in health terms. The DSM-II, published in 1968, was spiral bound in a small format and had 150 pages. The DSM-III came out in 1980 at 500 pages. The DSM-IV arrived in 1994 at 900 pages. The DSM tries to sort out the tangle of human experience by reifying it as medical conditions, to which it then attaches labels. But the ad hoc, merely symptomatic grounds on which this is done means that these conditions are easily re-reified, as the ADHD-bipolar re-jiggering illustrates. They are thus subject to shifting cultural norms. Nowadays, we are all encouraged to diagnose ourselves by the direct-to-consumer advertising of psychotropic drugs. The market for antidepressants now exceeds $13 billion annually in the United States.44.
In 2003 the global market for antidepressants was $19.5 billion, with the United States accounting for 68 percent of that, according to the pharmaceutical company H. Lundbeck A/S. The disproportionate size of the market in the United States surely has something to do with the fact that it is one of only two countries that permit direct-to-consumer advertising by pharmaceutical companies. The other is New Zealand. Presumably, every person taking such drugs got a prescription for them. One wonders, then, how seriously to take the pretensions of the DSM to set the standards of clinical practice. The standards come rather from consumer demand. In a July 2007 interview on PBS’s Frontline, Robert Temple, director of the Office of Medical Policy of the Food and Drug Administration’s Center for Drug Evaluation and Research and the acting director of the Office of Drug Evaluation I, says that “the studies we’ve done suggest that doctors can be very heavily influenced, and maybe even influenced to do something they didn’t think was such a great idea.” The result is an explosion of mental illness diagnoses. In the DSM-III, Social Anxiety Disorder (SAD) was called “extremely rare.” But in 1998 the disorder found a champion in GlaxoSmithKline, which applied for FDA approval to market the drug Paxil for SAD. At the time, Paxil lagged behind other brands such as Prozac in the crowded antidepressant market, and SAD was seen as a potential new application. The FDA considers a disorder real if it is listed in the DSM, and the marketing of an existing drug for a new disorder skips straight to Phase Four of the approval process, the Post Marketing Surveillance Trial. Writing in Mother Jones (July/August 2002), Brendan Koerner detailed how GlaxoSmithKline launched a public relations blitz to “raise awareness” about SAD, conducted ostensibly by the “Social Anxiety Disorder Coalition”, which was established for the purpose by GlaxoSmithKline’s public relations firm. The campaign was successful, and it is now commonly repeated that “up to 13.3 percent of the population” suffers from SAD. Sales of Paxil soared. With all these drugs and disorders flying around, it’s no wonder that by the time students arrive on campus, many of them have been on medications for years. But profit-minded PR campaigns are just the tip of a larger cultural iceberg. What sort of “softer” influences might students have encountered prior to college? The Anti-Cultural Predicate
I recently took my infant daughter in for a check-up. There in the waiting room was the November 2007 issue of Contemporary Pediatrics, which had a cover story entitled “Crossing the Invisible Line: Overcoming Resistance to Psychiatric Care Referral.” The article recommended techniques of persuasion for pediatricians to use in overcoming parents’ resistance to sending their kids to a psychiatrist. Now, certainly the authors, psychiatrists themselves, have an interest in drumming up business. And the drug companies whose advertisements provide the revenue for the magazine have a similar interest. But suspicions of interest, allowed to run too single-mindedly, would only lead us to miss the larger point, which is that articles like this one engage in a kind of moral pedagogy. The authors tell pediatricians to encourage parents to “shake off society’s influence”, the sort that shackles us with “social stigma” surrounding mental health care. The pediatrician, then, is to play the role of that stock character of late-modern culture, the therapeutic liberator, who speaks on behalf of the Self and against all forms of social authority (other than his own, of course).The authors include tips for dealing with “cultural” issues, meaning the views of certain sub-populations (immigrants in particular) who retain some religiosity or deference to tradition, among whom social stigma is more likely to attach to psychiatric care. The point is to dissolve such culturally received habits of thought. In The Triumph of the Therapeutic (1966), Philip Rieff wrote, “The systematic hunting down of all settled convictions represents the anti-cultural predicate upon which modern personality is being reorganized.” Paradoxically, in the very section of the article that bears the subheading “Shaking off society’s influence”, the authors enjoin pediatricians to “use positive media images about therapy or use celebrities as positive role models.” Such are the ironies of the authentic Self that shaking off society’s influence becomes indistinguishable from conformity to mass-market forces, and not necessarily even the most benign among them. The Contemporary Pediatrics article includes “Table 1: Techniques for overcoming resistance to psychiatric referral.” In the main text, we are asked to refer to this very table “for more details on empowering reluctant parents.” This is a curious use of “empower”, since what is meant is clearly “prevail over.” Yet if one pays attention to the cultural noise, one notices that this Orwellian use of the word “empower” has become quite conventional: The authors’ confusion enjoys a wider sanction. It is exemplary of what Alasdair Macintyre, in After Virtue (1981), called the tendency of “emotivism”, which “entails the obliteration of any genuine distinction between manipulative and non-manipulative social relations.” To treat someone non-manipulatively is “to offer them what I take to be good reasons for acting in one way rather than another, but to leave it to them to evaluate those reasons. It is to be unwilling to influence another except by reasons which that other he or she judges to be good.” To treat someone manipulatively, on the other hand, is to adduce “whatever influences or considerations will in fact be effective.” It is this distinction that disappears under emotivism. The authors of the Contemporary Pediatrics article write, “Families should be reassured that, no matter what treatment is recommended, the decision about what treatment to proceed with is ultimately up to them.” This sounds very nice, but appearing as it does opposite a table of “techniques for overcoming resistance”, the advice seems a bit conflicted. Immediately after the line about “empowering” parents, the next paragraph begins thus: “Parents who do not respond to the usual interventions by a pediatrician, or those who react with extreme hostility, anger, or simply request their child’s medical records be sent elsewhere, may have a personality disorder.” The authors never entertain the possibility that the parents may have good reasons on their side. According to their argument, failure to be persuaded by “positive media images” and “celebrities as role models” for their children may be indicative of a personality disorder in the parent! Perhaps it is “Oppositional Defiant Disorder”, a catch-all category of the DSM-IV that may be invoked to neutralize any and all dissent. Individuality and Liberal
Universities must find a way to safeguard their institutional interests and the safety of students. But they have no less an obligation to preserve the liberal character of liberal education. They might do this by taking seriously their own rhetoric about diversity, and extending this idea from its established stakeholders to include a due regard for the diversity of dispositions.It seems to be part of the human condition that each of us readily pathologizes his own individuality. You feel your own pain but not that of others, so it is natural to feel that something is wrong with you. Until now, this intuition of brokenness has arguably provided the psychic motor for education. In the best case, a student’s response to a crisis of his own individuality is to seek out the best that has been thought and expressed about the human condition over the centuries in the hope of finding some key to self-understanding. The diversity of intellectual traditions, indeed the diversity within the Western tradition, offers a variety of self-understandings and corresponding models of human excellence. Striving toward one of these, a student’s life may take on the character of a coherent narrative. Properly constituted, the university would support a diversity of human types, some of which find no support in the present. But now we have a one-size-fits-all technology that can alleviate this sense that “there is something wrong with me” by taking pills. Will this short-circuit the psychic motor of liberal education? It might. After all, taking a pill is easy; liberal education is hard. If universities see themselves merely as an adjunct of commercial society, then it is consistent with this view to accept as a given the narrow careerism in which their students feel trapped. It follows that the misery of being an 18-year-old whose future has already been mapped out by others should be interpreted as a medical fact and alleviated accordingly. It also happens to please the risk managers. But the point of college is not to alleviate unhappiness. The point is to exploit it, directing it toward those difficult studies that humanize us.1.
Dalrymple, “The Frivolity of Evil”, City Journal (Autumn 2004).
American College Health Association, National College Health Assessment Web Summary (August 2007).
See the documentary “The Medicated Child”, Frontline, January 8, 2008.
In 2003 the global market for antidepressants was $19.5 billion, with the United States accounting for 68 percent of that, according to the pharmaceutical company H. Lundbeck A/S. The disproportionate size of the market in the United States surely has something to do with the fact that it is one of only two countries that permit direct-to-consumer advertising by pharmaceutical companies. The other is New Zealand.