by K. Wilson
Like coffee and alcohol, prescription psychotropic drugs are becoming a routine part of coping with everyday life. Fifty years ago, when the pharmaceutical industry was still in its infancy and ‘mental health’ newly risen to prominence as a national issue, it must have seemed somewhat remarkable to have a relative or friend undergoing psychiatric treatment. Today it is nearly impossible not to know such a person. 1
The rapid proliferation of medications and mental illness diagnoses has spawned a heated public debate. On one side are the drug defenders, backed by statistics and stories of lives restored to productive normality. On the other side are the doubters, who suspect that ‘attention deficit hyperactivity disorder’ is no more than healthy rambunctiousness and ‘depression’ merely a clinical word for sadness. To the doubters, the defenders of medication are not the hard-headed realists they imagine themselves to be: they are dupes in thrall to (if not directly in the pay of) the drug companies. And to the defenders, the doubters are not savvy skeptics of big pharma: they are anti-science cranks who ignorantly and irresponsibly deny the existence of real, debilitating illnesses.
This debate is interminable in part because both sides deftly skirt around the vital questions, questions about health and sickness and about what our way of life is doing to our human nature. This avoidance is not surprising, since taking seriously the question of why people are so unhappy forces us into a radical criticism of our society. Instead, the unsuspecting observer who takes this debate at face value is safely and inexorably drawn toward a ‘sensible’ and superficial middle ground. We can see this process at work in an article that appeared this week in the New York Times, entitled “Shyness: Evolutionary Tactic?”, by Susan Cain. 2 The article is worth examining, because it gives us an opportunity to subject this whole debate to a radical critique.
The ‘disease’ in question is social anxiety disorder 3, and the drug on offer is Zoloft. Cain begins by acknowledging that some people really do have crippling forms of anxiety for which this medication may be appropriate – but, she says, the company is obviously trying to market their product far more widely. It is able to do so by riding a larger cultural wave that “[encourages] perfectly healthy shy people to see themselves as ill.” Shyness and introversion are “traits our society disfavors” – we live in “a world that prizes extroversion” and “people skills”. This bias shows up in the ubiquitous emphasis on ‘teamwork’ in schools and workplaces, and in 1980 it wormed its way into the third edition of the Diagnostic and Statistical Manual, “the psychiatrist’s bible of mental disorders”, which “inevitably reflects cultural attitudes”: for the first time, ‘social phobia’ was listed as an illness. Thus began the pathologization of shyness. 4
To the critical mind (or to one acquainted with the kind of analysis Marxists like to call ‘materialist’), an obvious question rears its head at this point. So shyness is “disfavored” and “undervalued”. But why? What is the social and material basis for this cultural attitude? And for those of us afflicted with the “careful, sensitive temperament” from which “shyness and introversion…often spring,” a further question arises: what is it about our way of life that is driving us to the desperate point of needing mind-altering drugs just to get through the day? But these are dangerous questions. Better not poke at the ‘base’ of society – stick to the ‘superstructure’! Rather than ask why we have come to disparage shyness, Cain spends the rest of the article telling us that this is a bad thing and that we should stop.
An impressive battery of arguments is deployed to show that shyness and introversion are in fact normal and valuable. History, we are told, is full of shy and introverted greats, from Moses to Einstein. Heck, even fish can be shy, and their shyness can be advantageous in the struggle for survival. (This scientific stamp of approval is central to the argument, since the drug defenders are always claiming hard science for their side. Armed with evolutionary theory, fire can be fought with fire – hence the article’s title.) Sensitive youngsters may be less confident than their peers, but they have their own charms: they are more observant, attentive, and empathetic. And these traits confer real world advantages: such children do better academically, and their predilection for solitude can give them the creative edge – I mean, gosh, Apple co-founder Steve Wozniak is shy! If all this wasn’t enough, a management expert even says that shy people make good leaders: “…it may be extrovert leaders who need to change, to listen more and say less.”
By now the reader has been bowled over by all this good sense and is somewhat in awe of the manifold virtues and achievements of shy and introverted people. They have made seminal contributions to our civilization, they are healthy and normal, they have healthy and normal brethren in the animal kingdom, they thrive in our schools, they are capable leaders of men – so why do we have to give them such a hard time? Why can’t we just live and let live? We retain our prejudice to our own detriment: what if all these shy people “chose to medicate themselves?…If we continue to confuse shyness with sickness, we may find ourselves in a world…of all yang and no yin.”
And so the problem, it turns out, is all in our heads. For some inscrutable reason shyness gets a bum rap. But not to worry, the solution is near to hand, and not surprisingly it is also in our heads: “Ridding people of social unease need not involve pathologizing their fundamental nature, but rather urging them to use its gifts.” This is what we are left with: a lame plea for inclusion, diversity, and understanding. We don’t actually need to change our society, we just need to change our minds.
So much for liberal wishful thinking. Let’s descend from the airy canopy and dig a little among the roots. We begin with the article’s single skeptical voice, a mother informed by Ms. Cain that her young daughter’s shyness is in fact natural and healthy: “’That is all very nice,’ she said, ‘but how will it help her in the tough real world?’” The author’s response: “But sensitivity, if it is not excessive and is properly nurtured, can be a catalyst for empathy and even leadership.” Look at Eleanor Roosevelt – she was “painfully shy and serious as a child,” and yet she became “a courageous leader” in part because she “could not look away from other people’s suffering.”
Here we have two possible career paths for the little girl with the “careful, sensitive temperament.” She might blossom into a strong and compassionate leader (even marrying a future President!); or, overwhelmed by the blows of the “tough real world,” she might end up with a crippling anxiety that eventually leaves her unable to function without medication. Cain wants us to believe that the former path can be paved with just a little bit of cultural tolerance and parental encouragement. Unfortunately, the girl’s fate is not a simple matter of “cultural attitudes”. It is, first of all, a matter of real social relationships.
Social anxiety disorder is apparently a malignant form of a certain kind of sensitivity: sensitivity to scrutiny and judgment by other people. This leads us to the question: what type of relationship makes it possible for this kind of sensitivity to develop in a benign direction, and what type makes it liable to sharpen into a debilitating fear? The crucial difference, I submit, lies in the character and function of negative judgment. In the former case, negative judgment takes the form of rational criticism that is motivated by love; it opens up genuine possibilities for learning and growth, and its function is to safeguard and further the common endeavors that are pursued through the relationship. In the latter case, negative judgment is arbitrary or selfish; it is an insult or an ultimatum, and it functions to cement relations of control or to cut off ties altogether.
The social relationships in question are not only or primarily those between parents and children. To understand the character of our experience (and indeed, to understand family relationships in our society) we must examine those relationships embodied in the dominant economic institutions of capitalist society – the ‘social relations of production’, for those who prefer the Marxist jargon. These are the relations of market exchange between buyer and seller; exploitation of the worker by the capitalist; and competition among capitalists and among workers. We obtain our means of life, not by producing for ourselves or by working together, but through exchange: we get what we want out of others and then we go our own way. As workers, we compete for the privilege of selling our labor. In the process of production we are means to an end, judged by our usefulness to capital: those who don’t make the grade, or who have already been squeezed dry, are cast off into oblivion. These relations are, it hardly needs to be said, anxiety-inducting in the highest degree. It should not surprise us that social anxiety disorder exploded onto the scene three decades ago, just as welfare state capitalism was giving way to neoliberalism.
These capitalist relations do not modestly confine themselves to some narrow region of our existence. Rather, social relationships in every sphere of life have been ever more thoroughly refashioned in their image. As capital seized upon new areas of productive activity, it displaced or corrupted the institutions that previously presided there, while turning others into mere adjuncts of its profit-making process. The family, the professions, the school, the university, the church – all once embodied social relationships that were (at least to some extent) supportive and enduring, conducive to learning and growth. As these institutions have been emaciated or transformed, that realm in which we needn’t be continually on our guard, performing and competing just to be sure of our very existence, has correspondingly dwindled.
The more we lack the experience of any other way of doing, of relating, of being, the more our personal relationships too take on a callous and instrumental character. We package, market, and sell ourselves not only to employers, but to each other. Personal relationships are conceived in terms of an exchange of services, a mutual satisfaction of needs: we anxiously strive to acquire or to simulate qualities we believe are desirable, and we judge others according to how well they measure up to our preferences. Difficulties and conflicts are not opportunities for personal development; they are impediments to the smooth and efficient functioning of a relationship, and if they persist then it is time to move on. 5
However much we may want to conduct our personal relations in a more caring and healthy manner, this is only partly a matter of individual will. Eleanor Roosevelt’s inability to “look away from other people’s suffering” may have served her well, but empathy is increasingly a luxury none of us can afford. The disintegration of community and the family, exacerbated by economic decline and the destruction of the welfare state, has left in its wake an ocean of unmet needs, both material and emotional. In these conditions, sensitivity to the suffering of others is a downright liability. Psychic survival demands that we become emotionally stingy, ruthless, ready to cut people off when they threaten to drag us down with them.
In short, we are all of us – not only the temperamentally sensitive – in an impossible bind. We withdraw into ourselves for self-protection, only to find ourselves bereft of real human ties. We risk reaching out, only to be burned by rejection or pulled into the abyss of another’s pain. And so we cordially agree to get by on the surface, becoming emotional contortionists adept at repression and denial. Most of us remain ‘normal’, as certified by our ability to keep churning out our daily eight or ten hours of labor. Others, unlucky by temperament or by circumstance, find their ‘functioning’ impaired. It is not surprising that some should be driven past a point of no return, damaged so that a semblance of normality can be maintained only with the aid of mind-altering drugs.
The beautiful woman in the Zoloft ad does not need to “rediscover her allure” – she is not sick and in need of professional help, but neither is she simply shy and mysterious. She is suffering, as in one way or another all of us are suffering. She is suffering from a way of life that punishes sensitivity, punishes empathy, punishes sincerity and vulnerability. No doubt the clever simulation of these qualities may still be an asset, a selling point in the personality market – but the genuine articles are not to be wished for. No amount of argument, no amount of proclaiming the virtues of the sensitive soul, is going to help us create a world in which it is rewarding to be sensitive.
- According to the National Institute of Mental Health, “in a given year approximately one quarter of adults are diagnosable for one or more [mental] disorders”. The National Survey on Drug Use and Health reports that “in 2008, 11.3 percent of adults in the United States received prescription medication for a mental health problem.” (2008 is the most recent year for which NSDUH mental health statistics are available.) This figure may be far too low. According to a different study: “The rate of antidepressant treatment increased from 5.84% in 1996 to 10.12% in 2005, or from 13.3 to 27.0 million persons.” (“National Patterns in Antidepressant Medication Treatment”, Mark Olfson and Steven Marcus.) The NSDUH, by contrast, reports a 10.7% prescription treatment rate in 2005 for all mental illnesses, not just depression, and moreover excludes children, whose medication rate is lower than adults. ↩
- All quotations are taken from this article. ↩
- Here, from the most recent edition of the Diagnostic and Statistical Manual (DSM-IV), is the official symptomatic definition of social anxiety disorder (also called “social phobia”):
A. A persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be embarrassing and humiliating.
B. Exposure to the feared situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally pre-disposed Panic Attack.
C. The person recognizes that this fear is unreasonable or excessive.
D. The feared situations are avoided or else are endured with intense anxiety and distress.
E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person’s normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
F. In individuals under age 18 years, the duration is at least 6 months.
G. The fear or avoidance is not due to direct physiological effects of a substance (e.g., drugs, medications) or a general medical condition not better accounted for by another mental disorder.
- In fact, something more than a reflection of cultural attitudes is involved in the compilation of the DSM: “Of the 170 DSM panel members 95 (56%) had one or more financial associations with companies in the pharmaceutical industry. One hundred percent of the members of the panels on ‘Mood Disorders’ and ‘Schizophrenia and Other Psychotic Disorders’ had financial ties to drug companies.” (“Financial Ties between DSM-IV Panel Members and the Pharmaceutical Industry”, Lisa Cosgrove, Sheldon Krimsky, Manisha Vijayaraghavan, and Lisa Schneider.) The number of disorders listed in the DSM has more than tripled from 106 in the first edition of 1952 (DSM-I) to 365 in the revised fourth edition of 2000 (DSM-IV-TR). ↩
- This “marketing” character of personal and social relationships under capitalism is analyzed by Erich Fromm, e.g. in The Sane Society. Another important point is that personal relationships have been emptied of their content – in the sense of losing their productive and to some extent their reproductive functions, as the household and the family have broken down – at the same time as they have become more and more the sole focus of strivings for meaning and fulfillment, as these become less and less obtainable in other, more ‘public’ spheres of life. We have great expectations – and yet there is really nothing for us to do together anymore except consume things. This goes some way toward accounting for the frustrating and disappointing character of personal relationships in declining capitalist society. The cultural and psychological ramifications of this process, which accelerated greatly in the second half of the twentieth century, have been variously described and analyzed. See, for instance, Christopher Lasch, Haven in a Heartless World: The Family Besieged and The Minimal Self: Psychic Survival in Troubled Times. ↩