In a recent encounter with a patient struggling with anxiety, it became obvious that the patient had been experiencing significant stressors at work and had limited supports. Due diligence as a mental healthcare provider means the patient would have been screened for an anxiety disorder, and having been duly diagnosed, would have been offered first-line “treatment” in the form of cognitive behavioural therapy and a Selective Serotonin Reuptake Inhibitor (SSRI) drug. This might have helped alleviate some of the patient’s anxiety, or “symptoms”, to enable them to tolerate their work conditions.
In fact, an ever increasing number of workplaces have developed initiatives aimed at alleviating emotional difficulties. However, these have received mixed reactions from employees. A particularly notable example is that of a major Canadian telecommunications company’s national campaign, ostensibly in support of mental health, whose employees have complained of physical and emotional suffering under significant pressure to perform “created by the top, down” [2]. Indeed, numerous employees from across all major Canadian telecommunications companies have complained of the high pressure to carry out aggressive sales practices that include misleading customers [3]. Health campaigns by such companies have been criticised as being more about marketing than mental wellbeing, and the reliance on such campaigns by private corporations has been described as consistent with neoliberal policy [4].
An endless stream of publications about widespread mental health struggles deal in particular with anxiety and sadness. Given the current dominant paradigm that such struggles may be indicative of mental illness, many of those struggling will seek out care in the medical system. This has resulted in increasing pressures on the mental health system, leading to the narrative that access to care needs to be increased [5]. With the focus on the struggling individual as being mentally ill, scant attention has been given by the psychiatric system to understanding — much less addressing — the socioeconomic conditions underlying prevalent complaints of emotional difficulties in society.
Medical and social anthropologist and psychotherapist Dr James Davies is one of the leading critics of mainstream psychiatry. In Sedated: How Modern Capitalism Created Our Mental Health Crisis, he discusses numerous interrelated issues: a) the overuse of medications to address emotional problems; b) the problem of treating individuals with psychiatric treatments for problems probably arising from social, political and environmental issues; and c) stigmatising emotional experience as an illness. He argues that mainstream psychiatry serves to sedate people and to depoliticise their problems in order to serve the interests of capitalism. This is not just a philosophical argument. A common yet underappreciated effect of psychiatric medications, in particular the SSRI antidepressant drugs, is an emotional blunting or apathy [6, 7].
In the words of psychiatrist, Dr Joanna Moncrieff, psychiatry in a “marriage of convenience” [8], assists large multinational corporations and the neoliberal governments that support them, by labelling social and political problems, eg, climate destruction, political and economic inequality, as problems arising from within the individual that can be cured with individual treatments. Despite extensive evidence for the association between socioeconomic inequality and various mental health measures in society [9], there has been little interest in this issue within psychiatry. Thus, with the help of mainstream psychiatry, society avoids addressing the root causes of distress.
Dr Davies ties this dynamic to the neoliberal style of capitalism that arose in the late twentieth century. He argues that there has been an “unholy alliance” between psychiatry and pharmaceutical companies generating great profits through the marketing of mental health treatments. This is a problem because capitalism has limited concern for human well-being, as long as people are able to serve as workers and consumers. He points to research that suggests that materialism, the way of being that prioritises owning and consuming objects, is the outcome of living in a society that does not meet our emotional needs. Beyond this, he argues that the public’s understanding of the nature and meaning of human suffering has been distorted by these influences.
Dr Davies highlights these dynamics in various areas. He argues that mainstream mental health interventions serve the interests of neoliberal governments and employers that aim to maximise the productivity of workers, rather than their wellbeing. He discusses how the neoliberal policy of austerity, whereby drastically reduced investment in services such as public education and public healthcare, have impacted the mental health of students and others. He shows how reduced regulation of industry has led to the rise of psychopharmaceutical marketing and profits without necessarily benefitting the public.
He advocates for reform of mental health services, pointing to the work of those “calling for less medicalization, medication and depoliticization while implementing more trauma-focused, relational and community care, more humanistic, psychosocial and non-biomedical alternatives.” He points to examples of how people benefit less from being diagnosed and treated as ill, and more from having “the structural roots of their suffering understood and addressed.”
However, facing the reality that mental health services are integrated within the larger political, social and economic landscape, he concludes that these services cannot undergo adequate reform without there also being a reform of the larger political and social environment: “[F]undamental mental health reform is most likely to occur only once we have changed the economic approach and instituted more regulated, progressive and socially democratic arrangements throughout our economy.” He points to the impact of the global Covid-19 pandemic which has laid bare the contradictions and inequalities of modern capitalism, and highlighted the social and political causes of mental distress. Indeed, the recent United States Surgeon General advisory on Protecting Youth Mental Health mentions socioeconomic inequality several times in its introduction. Yet, the term is not once mentioned during discussion of government action, with the focus instead being again on identification and “treatment” of the individual [10].
The challenge that Dr Davies raises is to embrace the vast complexity of mental health and not to retreat into comforting, narrow camps of thinking. Biological research and treatments of mental health should continue, but they must be grounded in democratic and egalitarian methods that are primarily responsive to the needs and interests of patients and the public, as opposed to those of pharmaceutical companies and neoliberal authorities. The social, political, and environmental causes of distress must be understood and addressed by the mental health fields. As suggested by Lucy Johnston [11], the Covid-19 pandemic is an opportunity to challenge simplistic diagnoses and work to “create a fairer society that is better for everyone’s emotional well-being”. This will require the courage to reform mental health fields in various areas, including medical education, post-graduate training, and service provision.
Dr Davies’ book is well-worth reading for anyone who has an interest in the larger political implications of mainstream mental health practice. We hope the readership will include psychiatry leaders and policy makers. Psychiatrist and former United Nations Special Rapporteur on the Right to Health, Dr Dainius Pūras, has called for us to learn from the “collective failures of our past”, and adopt “a rights-based approach that avoids excessive medicalization and instead follows modern public health principles which focus on addressing societal determinants, promoting autonomy and resilience through social connection, tolerance, justice, and healthy relationships” [12]. Dr Davies’ book provides a clear and engaging account of criticisms of mainstream psychiatry, while also pointing to ways to make mental health services more just and humane.