Mental Health Inc.: The Political Economy of Disorder � Specific Mental Health Organisations and Their Impact on the Construction of Mental Illness Discourses
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By 1988, an estimated 12 million Americans were helping themselves and others by participating in approximately 500,000 self - help, or more appropriately termed mutual � aid groups (Hurley, 1988). A sizeable number of these mutual � aid groups were established and operated by people with psychiatric disorders, their significant others or mental health professionals. In the era of community � based care, these mutual � aid groups were hailed as a panacea for people with psychiatric disorders.
Two decades later, this enthusiasm has been replaced with cynicism and unfulfilled expectations.
This paper will explore how informal, loosely structured mutual � aid groups evolved into bureaucratic, hierarchical and commercially � orientated disorder � specific mental health organisations. The focus of these organisations having shifted from addressing the needs of individuals to their programmes� and services� "cost � effectiveness" and "economic viability". Unlike previous studies (Everett, 1994; Chamberlin, 1990), which focused on the evolution of the consumer and psychiatric survivor movement in North America, the focus of this paper will be the evolution of disorder � specific mental health organisations in North America, South Africa and on an international level. Specific case studies will be used to illustrate how the process of corporatisation has influenced the construction of meaning around what we understand mental illness to be and how people with mental illness experience it.
Mutual � aid groups are certainly not new. On the 10th June 1935, Bill W and Dr. Bob first met to help each other stay sober. They eventually founded Alcoholics Anonymous (AA) (Hurley, 1988). However, the roots of the modern mutual � aid group movement can be traced to the socio-political upheavals of the late 1960s � early 1970s in the United States in general and the deinstitutionalisation movement in particular (Everett, 1994). For example, during the Vietnam War, a small group of Vietnam veterans in New York established an organisation called Vietnam Veterans Against the War (VVAW) (Shephard, 2000). "VVAW also organised �rap groups� � meetings at which members talked together about their own experiences during the war and their feelings about them" (Shephard, 2000, p. 355). According to Everett (1994), the deinstitutionalisation movement had little or no effect on the continuing abuse suffered by those still institutionalised. It also released enraged and disillusioned middle class patients. "These ex-patients, particularly those who were well � educated and articulate, were well equipped to organise and lead their own protest, the consumer and psychiatric survivor movement" (Everett, 1994, p. 61). It was also from this group of well � educated, middle class individuals who had suffered from Major Depressive Disorder and Bipolar Mood Disorder, Anxiety Disorders and Obsessive � Compulsive Disorder, under whose leadership the first disorder- specific mutual � aid groups would emerge in the 1980s.
Initially, these groups were populist in outlook, very participatory and were keen to destigmatize the disorders they were concerned with (Hurley, 1988). Hurley (1988) identifies three factors which he believes were crucial for the success of these mutual � aid groups. It will be argued however, that these key ingredients provided the basis for the evolution of the disorder � specific mental health organisations of the 1990s and the new millennium.
The three key ingredients identified by Hurley (1988) that contributed to the success of the mutual � aid groups include:
Information giving, especially personal disclosure and factual information about a particular psychopathology.
Acceptance of an Ideology: This resulted in those with a specific disorder reattributing the cause of their problem and thereby changing their behaviour or as Hurley (1988) suggests, providing a "cognitive antidote" to the problem. In the case of members of these disorder � specific mutual � aid groups and their significant others this meant that the problems they were experiencing could be attributed to faulty neurochemistry, neuroanatomy and genetics, rather than, for example, to maladaptive child � rearing practices.
Homogeneity: What set members of the disorder � specific mutual aid groups apart from those that identified themselves as consumers or psychiatric survivors, was their desire to separate themselves from others by emphasising the uniqueness of their situation as determined by the diagnosis they had been given.
It was in particular the acceptance of an ideology and the homogeneity of the disorder � specific mutual aid groups that allowed them to evolve into national organisations with a bureaucratic, hierarchical organisational structure and the human and financial resources to run it. For it is through the embracing of the biological and the acceptance of psychiatric nosology that these organisations found themselves located within the Psychiatry � Capitalism Nexus. The Psychiatry � Capitalism Nexus refers to the convergence of the ideologies inherent in psychiatry and capitalism. Psychiatry locates dysfunction in the individual, while capitalism attributes economic expansion and greater prosperity to the actions of individuals (U�Ren, 1997, p. 5). Hard work will liberate a person from mental illness and it is the capitalist belief in hard work that drives the economy and allows for individual reward (U�Ren, 1997, p.5) . However, it is in the commercialising of human experiences and needs that psychiatry and capitalism are most effective.
The involvement of the disorder�specific mental health organisations in the Psychiatry � Capitalism Nexus has influenced how these organisations and their members construct meaning around what mental illness is and what it is to suffer from mental illness. Therefore, it is prudent that we first explore the ideologies of capitalism and psychiatry and how these ideologies are intertwined before examining the characteristics of the disorder � specific mental health organisations.
The converging ideologies of psychiatry and capitalism
At first glance, it would seem unlikely that psychiatry would have much in common with the capitalist mode of production. Psychiatry, as a specialisation within medicine, prides itself on its commitment to the amelioration of psychic distress through the administration of scientifically proven remedies and therapies. Conversely, capitalism is concerned with turning products and services into commodities that can be sold on the open market (U�Ren, 1997). However, commodifying products and services is a risky business. Large sums of money need to be spent in order to develop new products and services. Furthermore, there is no guarantee that the capitalist will recoup his investment due to a lack of consumer demand for the commodity or competition from other capitalists. The capitalist needs to create demand for this commodity. This is achieved through advertising (U�Ren, 1997).
Unlike other capitalist enterprises, pharmaceuticals cannot promote their products directly to the general public. In most parts of the world, pharmaceuticals require the assistance of the medical profession to ensure the sale of their products. Therefore, a pharmaceutical company will invest a great deal of capital to ensure the medical profession prescribes its products instead of a competitor�s product.
The relationship between the pharmaceuticals and the medical profession, psychiatry in particular, goes beyond the prescribing of medications for certain maladies. The logic of capitalism is such that new markets need to be created for existing and new products. Likewise, in order to create and maintain a market for its services, psychiatry must constantly enlarge the public�s awareness of the kinds of problems it can address (U�Ren, 1997). As U�Ren (1997) indicates, "it does this, in large part, by expanding its diagnostic system so that more and more experiences are brought within its domain, just as capitalism scans daily life for activities that can be brought into its circuit of accumulation."
The inclusion of premenstrual syndrome as "Premenstrual dysphoric disorder" in the appendix of DSM � IV (American Psychiatric Association, 1994, pp. 715-718), hoping in the future to move into the ranks of established psychiatric disorders (U�Ren, 1997), is a classic example of how the psychiatric diagnostic system has been expanded to bring more human experiences within its domain. Financial benefits from this inclusion have begun to be accrued by both psychiatrists and the pharmaceuticals.
Women have begun seeking psychiatric treatment for PMDD as it is now being referred to in the psychiatric literature (Altshuler, 2002). Furthermore, pharmaceutical companies have commissioned psychiatric researchers to investigate the possibility of using an ageing group of antidepressants in this condition (Altshuler, 2002). Should these trials produce positive results, then the pharmaceuticals will have a new market to exploit.
Despite the success of individual capitalists and groups of capitalist enterprises being able to accumulate capital through the commodifying of products and services, these capitalists have experienced competition from other capitalist groupings or industries. Nowhere has this be more evident than in the present struggle over the funding of healthcare internationally and in South Africa in particular. The funding of healthcare is as much a capitalist enterprise as the selling of medications is. Medical aid administrators and insurance companies, for profit organisations, that administer non � profit medical aid schemes have seen the steady decline in their profits through the increasing cost of medicines and healthcare providers, including psychiatrists�, increasing consultation charges. Like all capitalist enterprises, the healthcare funders cannot allow their profits to be eroded by escalating costs (U�Ren, 1997). This has resulted in healthcare funders introducing cost � cutting measures, for example, paying only for generic medicines. This has brought this group of capitalists into direct conflict with the pharmaceuticals and their allies in the medical profession, whose survival is dependent on the sale of expensive ethical medicines. The medical profession and in particular psychiatry has been singled � out by the healthcare funders for cost � cutting. Consequently psychiatrists are finding it increasingly more difficult to maintain themselves financially (P.F. Colin, personal communication, August, 2002).
The pharmaceuticals and the psychiatrists have found an ally in the disorder � specific mental health organisations in their struggle against the healthcare funders. A close examination of the characteristics of these organisations will show why it is not at all surprising that people with specific psychiatric disorders and their significant others would be willing to side with the pharmaceuticals and the psychiatrists in their struggle with the medical aid administrators.
The ability of disorder � specific mental health organisations to locate themselves within the Psychiatry � Capitalism Nexus is in large part due to the characteristics of these organisations, which are in large part fashioned on the ideologies of psychiatry and capitalism.
The past two decades have witnessed the phenomenal increase in the use of psychotropic medications in the treatment of psychiatric disorders. Furthermore, psychiatric research has become overwhelming concerned with identifying the aetiology and pathophysiology of common psychopathologies (Terre Blanche, 1999). The serendipitous discovery that Lithium was an effective mood stabiliser and that Iproniazid, the first of the monoamine oxidase inhibitors, which was initially used in the treatment of tuberculosis and exhibited antidepressant properties (Terre Blanche, 1999), encouraged the pharmaceuticals and psychiatry to believe that deliberate efforts to synthesis new therapeutic compounds could alleviate much suffering while generating huge profits.
By emphasising the biological, that is psychopathology is a consequence of inheritance and other constitutional factors, psychiatry has located the source of the problem in the individual. As such, treatment must be directed at the individual (U� Ren, 1997). As U�Ren (1997) suggests, psychiatry in effect is emptying symptoms of their possible moral, political, economic or social meanings since symptoms have only biological significance.
Since a biological dysfunction is responsible for the symptoms an individual experiences and since this dysfunction is located in the individual, it follows that there is something wrong with that individual, in short that individual has some sort of deficit. This " language of deficit" informs how people with psychiatric disorders view themselves and their problems. For these individuals, nothing positive can come from experiencing depression, anxiety or mania. Everywhere they turn, they are being reminded that there is something wrong with them and need to be liberated from these symptoms through treatment (Evans, 1999).
In contrast to the consumer and psychiatric survivor movement, the disorder � specific mental health organisations are not concerned with the human rights of people with psychiatric disorders. When cases of institutional abuse have been reported in the media (Ratshitanga, 1997), these organisations have been silent. It is only around the issue of access to treatment and the cost thereof that the disorder � specific mental health organisations have been vocal. In the United States, they have focused on the issue of parity in healthcare benefits for those with psychiatric disorders paying for health insurance (Peschel and Peschel, 1993). In Europe, GAMIAN � Europe (Global Alliance of Mental Illness Advocacy Networks) has been lobbying for greater access to information for people with psychiatric disorders when it comes to information on psychotropic medications and specific treatment modalities (Elgie, 2002). In South Africa, the Depression and Anxiety Support Group (DASG) and the South African Society of Psychiatrists (SASOP) have highlighted the disparity between benefits for psychiatric disorders and "physical" health complaints. Since these organisations endorse prevailing psychiatric practice, it is not surprising that they advocate for more money for psychiatric treatment, but do little to highlight or condemn the coercive nature of certain aspects of psychiatric care (Butterfield and Doherty, 1999).
A case study: The Depression and Anxiety Support Group (DASG)
Thus far, the paper has focused on the embracing of the psychiatric discourse by the disorder � specific mental health organisations. It has already been suggested that these organisations are located within the Psychiatry � Capitalism nexus. Therefore, the remainder of this paper will be concerned with exploring how the discourse of capitalism has influenced the philosophy and operation of these organisations.
Unlike the consumer and psychiatric survivor movement, whose member groups and organisations are loosely structured and lack administrative and business acumen (Everett, 1994), the disorder � specific mental health organisations have created smooth running bureaucracies that would be the envy of any corporate manager. Since these organisations are almost exclusively funded by the pharmaceuticals, they have to be seen to be emulating their corporate sponsors in terms of efficiency and productivity. Tasks that would take forever to complete if left to a depressed or manic person are now speedily dealt with by psychology graduates, secretaries or managers.
To fund these smooth running bureaucracies requires a large sum of money. The employees� commitment to the cause is partly reinforced by their monthly salary cheques. In 1998, the DASG received R 1.7 million from the pharmaceuticals to run its operation (L Woods, personal communication, 2002). Unfortunately, difficult trading conditions and unfulfilled expectations have resulted in the DASG �s budget being slashed to approximately R 650,000.00 for 2002 (L Woods, personal communication, 2002). Like any other capitalist enterprise, the DASG is vulnerable to fluctuating economic and market conditions.
The DASG �s history reflects how since its inception in October 1995, as the Panic Disorder Support Group, it has had to continually seek new markets for its products and services, much the same way that traditional capitalist enterprises do. In 1997 the Panic Disorder Support Group changed its name to the Anxiety Support Group as it had expanded its services and area of operation to include Social Phobia, Generalised Anxiety Disorder and Post Traumatic Stress Disorder. This expansion was undertaken so that it could raise more funds, in order to cover its escalating overheads. This is in line with traditional capitalist orthodoxy, whereby the expansion into new markets is seen as an effective way of generating revenue (U�Ren, 1997).
The Anxiety Support Group soon realised that anxiety disorders were not particularly profitable and the needs of the depressed appeared to outweigh the needs of the anxious. Since the major focus of the pharmaceuticals was on Major Depressive Disorder and the sale of antidepressants, the Anxiety Support Group made a strategic move away from anxiety disorders to Major Depressive Disorder. In January 1998, the Anxiety Support Group became the Depression and Anxiety Support Group (DASG). Since then, the DASG has focused almost exclusively on Major Depressive Disorder and its associated problem, suicide and its prevention. This has been accompanied by lessening its exposure to the less profitable anxiety disorder market.
The purpose of this paper has been to chart the evolution of mutual � aid groups for people with psychiatric disorders into commercially � orientated disorder � specific mental health organisations. Locating themselves within the dominant discourses of psychiatry and capitalism, these organisations have encouraged the view that mental illness is located in the individual and as such are not a consequence of social or economic dislocation, but rather of individual dysfunction. This dysfunction can only be remedied by interventions approved by psychiatry. By highlighting these discourses, the paper has tried to focus attention on the folly of holding such views and thereby encourage the creation of alternative discourses of psychic distress.
A number of possible alternatives to the commercially � orientated disorder � specific mental health organisations can be proffered. In opposition to the dominant discourses of psychiatry and capitalism , the consumer and psychiatric survivor movement has emerged. Not concerned with specific psychopathologies, these groups and organisations are primarily concerned with the protection of human rights and the socio-economic and political empowerment of people with psychiatric disorders. However, they lack the sophistication and hence impact of the disorder � specific mental health organisations. The Obsessive � Compulsive Disorder Association of South Africa (OCDSA) is a national disorder � specific mental health organisation established to assist people with Obsessive- Compulsive Disorder (OCD). This is achieved by highlighting the plight of people with OCD through the provision of services specifically tailored to their needs. In some respects, the OCDSA is a hybrid structure in that it incorporates elements of the dominant discourses, while attempting to operate in a human rights and empowerment culture. Consequently, the OCDSA finds itself on the periphery of the Psychiatry � Capitalism Nexus, preventing it from accessing the resources the DASG has access to.
The inability or at best, the partial success of alternative discourses to challenge the dominant discourses of psychiatry and capitalism, is in large measure the result of the transitional phase in human history society finds itself in. The demise of socialism has, for the moment, left an ideological void that will hopefully with time be filled. However, at present, capitalism and its fellow ideologies dominate the discursive landscape. The success of the ideologies of psychiatry and capitalism to dominate the discourses around mental illness should be seen in this context.
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