Morton, Mark K-Punk and I have been having an interesting discussion on twitter regarding the treatment of mental disorders such as depression, anxiety disorders, ADHD and others through the use of psychotropic drugs. K-Punk contends that psychotropics are over prescribed, that they fail to get at the real cause of these maladies, and points to things like the surprising effectiveness of placebos when treating maladies like depression. Morton contends that these maladies are real material entities, real chemical imbalances, points to the effectiveness of these drugs, and argues that claims that mental illness is “discursively constructed” have been used as apologies for closing down mental clinics. (A post on depressive and anxiety disorders, of course, requires The Scream. Incidentally, my four year old daughter, when recently encountering this painting, asked “what did he do after he screamed?” That’s one smart mini-cat!)
I think they’re both right and they’re both wrong. It seems to me that debates like this are governed by two binaries that both object-oriented ontology and developmental systems theory are designed to complicate, nuance, and displace. Between Tim and Mark we have, on the one hand, an opposition between naive realism (sorry Tim) and discursive constructivism (Mark). Here “maladies of the soul” are either materially real such that they are chemical imbalances in the brain or they are discursively and socially constructed such that they are not real. On the other hand, these maladies of the soul are either inborn and innate (Tim) or they are acquired and constructed (Mark). I am not doing full justice to either Tim or Mark’s position here and I’m certain they are more nuanced than this, but this oppositional grid at least has the virtue of bringing the contours of the public debate to the fore.
What we have here is a prime example of what Latour refers to as the “modernist constitution”. Under modernism there is a strict separation between the cultural world and the natural world. Something is either cultural or natural. The natural world is governed by its own principles based on causality and the cultural world is governed by its own principles based on meaning and signification. Under the modernist constitution the two worlds are never supposed to be mixed or confused. In discussions of mental illness, one is thus either a naturalist (Tim) or a culturalist (Mark). Mental illness either has a naturalistic explanation (Tim) or a culturalist (usually within the framework of the “hermeneutics of suspicion”) explanation (Mark).
The flat ontology of onticology strives to place both culture and nature on equal ontological footing. There are not two worlds governed by entirely different principles, but rather one world where cultural actants and natural actants are entangled with one another. Likewise, the framework of developmental systems theory (Oyama, Griffiths, etc.), contests the model of development in which the qualities an organism will embody in its phenotype are pre-encoded in genes, instead treating genes as one causal, “in-form-ing” factor among others, and where the qualities an entity will embody in its phenotype will be a result of multiple interaction among a variety of different temporal and environmental factors both within and without the organism. Oyama argues for “causal parity” or a “democracy of causes” that refuses to locate all information as already pre-delineated within the genome and where a variety of factors from genes, culture, environment, light, nutrients, etc., all conspire and interact together to generate the phenotype. Insofar as depression is a characteristic of ones phenotype, it follows, from within the framework of developmental systems theory, that it is not simply a product of the genes, but will involve a variety of causal factors ranging from genes, to life experience, to circumstance, to beliefs, to diet, to relations to other people, to frequency of exercise and sunlight, and so on.
In this regard, I find myself deeply sympathetic to Mark’s position on two grounds. First, psychiatry has tended to focus on chemical imbalances and psychotropic solutions, ignoring the life and environmental milieu in which the depressed person exists. In short, psychiatry tends to foreclose analysis of the existential (what the Lacanians call “the dimension of the subject”) and social dimension of these sorts of maladies. Take my own case. When I decided to go on anti-depressants a couple years ago I went to my family doctor, said I was feeling depressed, and he promptly prescribed an anti-depressant for me. While he did suggest the alternative of therapy and observed that it has been shown to be every bit as effective as psychotropics, there was no discussion of my life circumstances, the structure and circumstances of my social world and so on. Rather I was simply prescribed these drugs based on my report that I’m depressed. While I was fortunate in that I eventually found an anti-depressant that seems to render my depression manageable, I also went through a number of drugs first that caused some really horrible side effects and that generated some pretty nasty psychic symptoms of their own (nervousness, irritability, manic activity, etc).
The problem here is in “medicalizing” psychic maladies in this way, the broader existential and social context in which we suffer from these maladies is occluded, foreclosed, covered over and therefore not addressed. We end up, as Lacanians say, treating the symptom and not the cause of the symptom. Not only do we not investigate our own life, our own desire, and how it might contribute to the formation of these maladies, but also we ignore the social conditions that might contribute to the formation of these maladies. In texts like an Introduction to Marcel Mauss Levi-Strauss taught us that “schizophrenics” in contemporary society and “schizophrenics” in “primitive” tribal societies are very different entities, that they experience very different affects, modes of cognition, forms of social relationships, and so on. In the latter, the “schizophrenic” might live as a highly respected and valued spiritual leader, guide, and healer. In our society, a “schizophrenic” is a sad and excluded figure, often living in squalor and misery. What accounts for this difference? How are we to explain it? Clearly, these differences can’t simply be reduced to nature but have something to do with the nature of the societies in which these persons develop and are individuated. Likewise, in our society we have seen a massive rise in depression and anxiety disorders. Is it just that we didn’t know about these disorders until the twentieth century and therefore didn’t recognize instances of people suffering from these disorders, or is it that something about this form of society is toxic to us? A wide variety of evidence suggests that people living under capitalism suffer a wide variety of negative psychological and physical health effects.
The problem with the medicalization of psychic maladies is that it forecloses our ability to even recognize and address these sorts of existential and political issues that might be crucially related to our psychic maladies. Here our psychological suffering is de-politicized and we’re separated from being existentially engaged in what our symptom might mean for us and our life. Rather than trying to change our social world and our lives, we instead just take a drug and allow these conditions to persist. Similarly, both our governments and the pharmaceutical industry have a vested interest in this medicalization of maladies of the soul. The pharmaceutical industry, of course, has a vested interest insofar as this is how it can make its money. If it can convince us that such and such things (Restless Leg Syndrome anyone?) are, in fact, disorders and that they are merely physiological disorders than it can render us dependent on their product. Psychotropics become the new cigarettes as they are drugs that we become dependent on (withdrawal from them is often horrible and debilitating) and must therefore take them for life. Likewise, if it is true that there is a social and political dimension to our psychic maladies, it’s likely that both our governments and the powers that be would prefer that we see our maladies as purely physiological such that any social explanation is foreclosed. Where the social dimension of our maladies taken seriously this could lead to political activism that threatens these forms of power. In this respect, the medicalization of psychic maladies is a way of “liberalizing” social conflicts, antagonisms, and inequalities. Rather than treating these things as social, rather than treating them as political, we instead treat them as a personal affair separate from society and politics.
Nonetheless, with Tim, I agree that these maladies are real, material things. We know that human ways of living, human practices, etc., can produce substantial differences in the brain. The brains of people who meditate regularly are markedly different electrically and chemically from the brains of people who don’t. They aren’t born this way, but how they have lived produces real material differences in their brain. Likewise, it’s likely that the brains of pianists, academics in the humanities, aquatic engineers, dancers, etc., are materially and physically different as well. Again, we aren’t born with these types of brains, but we do, through our form of life, develop these kinds of brains. Just as the chronic methamphetamine user develops, over time, the inability to produce dopamine even after they quit using meth, our brains undergo vectors of development that render us capable of certain affects and incapable of others. This is one lesson we should draw from the plasticity of body thesis formulated by thinkers such as Catherin Malabou and Tom Sparrow.
And if this is the case, then it follows that the culture we live in can produce real material changes in our brains. In this regard, it can be entirely appropriate, as Tim points out, to take something like SSRI’s. The SSRI is treating a real phenomenon within the brain. It just so happens that these phenomena like depression are what Latour and Serres call “quasi-objects“. They are both entirely real and social.
I might never had had depression if I had lived my life in another way or if I had grown up as a slave in ancient Greece or Rome. Yet the life I have led, coupled with the society in which I live, have had a real impact on my biology (perhaps in tandem with genetic predispositions), leading to the formation of this mild form of bipolar depression from which I suffer. Perhaps the manner in which my anti-depressant affects my nervous system is merely a placebo. At this point I don’t think we’re in a position to know. I do know, however, that prior to my anti-depressant I was barely able to get out of bed, function, or think and that I was constantly prone to conflict (yes, yes, I know, I still get in a lot of disputes but it was far worse). In my case, that anti-depressant provided me with that minimal distance from these crushing symptoms, rendering available a space in which I could reflect on these existential and political dimensions of my malady. In the absence of that distance I was so crushed and overwhelmed by the affect of these symptoms that I couldn’t reflect on these other causal factors at all.
Likewise, as Tim points out in the case of his schizophrenic brother, his drugs created a space in which he no longer “soiled himself”. That is, these drugs allowed him to get a minimal foothold in his life. In this regard, I think Mark tends to overstate his positions. He seems to claim that psychotropics in and of themselves are a negative, when, in fact, the problem is not so much with psychotropics (though we should take their side effects very seriously) as the manner in which a contemporary dominant discourse about psychotropics forecloses questions of an existential and political nature.
I think a big part of the problem here lies in how impoverished our concept of causality has become. The Enlightenment famously reduced all causes to the efficient and material cause, getting rid of Aristotle’s formal and final cause. When we approach self-reflexive objects like human beings we’re thus placed in a straight jacket where we have to decide whether the material cause is cultural (the signifier/discourse) or material (the brain/genetics) and where we have to decide whether the efficient cause is cultural or genetic. Yet if we reintroduce formal and final causation back into our thought, treating the formal cause as the cultural and natural milieu in which we develop and where the final cause is treated as the goals and aims we set for ourselves, we get a much richer developmental picture of human beings where we’re no longer forced to decide between biology and culture, genes and signifiers, but can instead think an interplay between culture, genetics, environment, goals, and biology in the course of our lifelong development. In other words, we now get a democracy of causes where we don’t treat one factor as the cause, but rather see these phenomena as multilaterally determined. This gives us a far wider set of means for engaging with our psychic maladies, allowing both political engagement and chemical engagement.