Sedated E-Book

James Davies

• Herausgeber: Atlantic Books
• Kategorie: Fachliteratur
• Sprache: Englisch
• Veröffentlichungsjahr: 2021

Beschreibung

A provocative and shocking look at how western society is misunderstanding and mistreating mental illness. Perfect for fans of Empire of Pain and Dope Sick. In Britain alone, more than 20% of the adult population take a psychiatric drug in any one year. This is an increase of over 500% since 1980 and the numbers continue to grow. Yet, despite this prescription epidemic, levels of mental illness of all types have actually increased in number and severity. Using a wealth of studies, interviews with experts, and detailed analysis, Dr James Davies argues that this is because we have fundamentally mischaracterised the problem. Rather than viewing most mental distress as an understandable reaction to wider societal problems, we have embraced a medical model which situates the problem solely within the sufferer and their brain. Urgent and persuasive, Sedated systematically examines why this individualistic view of mental illness has been promoted by successive governments and big business - and why it is so misplaced and dangerous.

Leseprobe

Sedated

James Davies is a reader in medical anthropology and mental health at the University of Roehampton, with a PhD in social and medical anthropology from the University of Oxford. He is a qualified psychotherapist (having previously worked in the NHS) and is the co-founder of the Council for Evidence-based Psychiatry (CEP), which is secretariat to the UK All Party Parliamentary Group for Prescribed Drug Dependence.

He has been an expert drug adviser for Public Health England and has appeared on Today, PM, Newsnight, Sky News, BBC World News and various national and local radio stations. He is the author of Cracked: Why Psychiatry is Doing More Harm than Good.

First published in hardback in Great Britain in 2021 by Atlantic Books, an imprint of Atlantic Books Ltd.

Copyright © James Davies, 2021

The moral right of James Davies to be identified as the author of this work has been asserted by him in accordance with the Copyright, Designs and Patents Act of 1988.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of both the copyright owner and the above publisher of this book.

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A CIP catalogue record for this book is available from the British Library.

Hardback ISBN: 978 1 78649 984 4

E-book ISBN: 978 1 78649 986 8

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Printed in Great Britain

Atlantic Books

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CONTENTS

Introduction

PART ONE: The New Opium

Chapter 1: An Economic Prelude

Chapter 2: The New Culture of Proliferating Debt and Drugs

Chapter 3: The New Dissatisfactions of Modern Work

Chapter 4: The New Back-to-Work Psychological Therapies

Chapter 5: The New Causes of Unemployment

Chapter 6: Education and the Rise of New Managerialism

PART TWO: How We Got Here

Chapter 7: Deregulating the So-Called Chemical Cure

Chapter 8: Materialism No More

Chapter 9: Dehumanising Productivity

Chapter 10: You Only Have Yourself to Blame

Chapter 11: The Social Determinants of Distress

Conclusion

Acknowledgements

Notes and References

Index

For my son, Oliver

INTRODUCTION

Medicine has progressed at an astonishing rate over the last forty years. Just consider the treatment of childhood leukaemia as an example. If in the late 1970s a child had contracted this heartbreaking disease, their chances of survival would have been around 20 per cent. But if a child contracts leukaemia today, their chances of survival are around 80 per cent. This means that outcomes in this area of medicine have improved by a full 300 per cent in the last four decades alone.1 And this wonderful feat is not only reserved for paediatric oncology, since impressive rates of improvement can also be found in almost every other area of medicine. I say almost every other area, as regrettably, there is one exception: the area of psychiatry and mental health.

In fact, in this area not only have clinical outcomes broadly flatlined over the last thirty years, but according to some measures they have actually got worse.2 And this outlier exists despite tens of billions of pounds having being spent on psychiatric research in the last two decades;3 despite £18 billion being spent on mental health services annually in the NHS; and despite nearly 25 per cent of the entire UK adult population now being prescribed a psychiatric drug each year.4 Despite all this spending and wide coverage, the mental health of the country has not been improving over the last two decades. In fact, things appear to have gone from bad to worse. So why are successive governments consistently failing to act? Is this really all down to poor investment and sparse resources, or is there something more ominous about our whole approach to mental health that our politicians have been simply unwilling to confront?

In this book I will provide an answer, by revealing how, since the 1980s, successive governments and big business have worked to promote a new vision of mental health; one that puts at its centre a new kind of person: resilient, optimistic, individualistic and above all, economically productive – the kind of person the new economy needs and wants. As a result of this shift, our entire approach to mental health has radically altered to meet these market demands. We define ‘return to health’ as a ‘return to work’. We blame suffering on faulty minds and brains rather than on harmful social, political and work environments. We promote highly profitable drug interventions, which, if great news for big pharmaceutical corporations, are in the long term holding millions of people back.

I will show how this marketised vision of mental health has stripped our suffering of its deeper meaning and purpose. Consequently, our distress is no longer seen as a vital call to change or as anything potentially transformative or instructive. It has rather become, over the last few decades, an occasion for yet more buying and selling. Whole industries have thrived on the basis of this logic, offering self-interested explanations and solutions for the many pains of living. The cosmetics industry locates our misery in our ageing, the diet industry in our bodily imperfections, the fashion industry in our being passé, and the pharmaceutical industry in our so-called faulty brain chemicals. While each industry offers its own profitable elixir for emotional success, they all share and promote the same consumerist philosophy of suffering: your central problem is not that you’ve been mis-taught how to understand and engage with your difficulties (your ageing, your trauma, your sadness, your anxiety or grief), but the fact that you experience suffering at all – something that targeted consumption can address. Suffering is the new bad, and failing to consume the right ‘remedies’ is the new injustice.

This book tells the story of how, since the 1980s, this pro-market agenda has begun to harm both the UK and the West in general, turning our entire approach to mental health into something preoccupied with sedating us, depoliticising our discontent and keeping us productive and subservient to the economic status quo. By putting economic servitude before real individual health and flourishing, our priorities have become dramatically and dangerously misplaced, and more suffering, paradoxically, has been the unhappy result.

I have written this book to do my part in helping to correct this dominant yet misguided approach, and to discuss how we might put things right by understanding and solving the real roots of our mental and emotional distress. To do so, I have travelled widely to speak with leaders in the mental health and associated professions: senior politicians, public officials, civil servants and key academic thought leaders. I have become immersed in the relevant literature and archives, and have spent much time trawling the corridors of power in an attempt to help reform mental health from the inside. From these activities, I’ve gained invaluable insight into the socio-economic causes of our current mental health crisis, the revelations of which, often strange and disconcerting, litter the pages of this book.

As you follow me through the coming chapters, you will encounter an array of harms caused by the very professions that purport to help us: from the perils of over-medicalisation to excessive psychiatric drug prescribing, growing stigma, rising disability, the overvaluation of ineffective therapies, and poor clinical results. Yet, most crucially, you will also see that these problems did not emerge in a vacuum, but have thrived under the new style of capitalism that has governed us since the 1980s, one favouring a particular type of thinking about mental health and intervention; one that has put the needs of the economy before our own, while anaesthetising us to the often psychosocial roots of our despair. As a result, we are rapidly becoming a nation sedated by mental health interventions that greatly overplay the help they bring; that subtly teach us to accept and endure, rather than to stand up and challenge, the social and relational conditions harming us and holding us back.

In November 2013, in a small, tatty apartment on the Upper West Side of Manhattan, I sat searching the sales figures for perhaps the most influential book in the history of mental health: the Diagnostic and Statistical Manual of Mental Disorders, otherwise known simply as the DSM. The DSM, now in its fifth edition, is a weighty 947-page blue and silver tome. It is the book that lists and defines all the mental disorders that psychiatry believes to exist, and with which tens of millions of people across the globe are diagnosed each year.5

I was searching for the DSM’s sales figures that November evening because the following day, at Columbia University, I was set to deliver a two-hour lecture on the making of the manual. Between 2009 and 2012, with a grant from my university, I’d undertaken research into the DSM’s development, trawling its archives in Washington DC and interviewing its leading architects and writers. The data I had gathered appeared to support the growing international criticism of the DSM then playing out internationally in leading newspapers and medical journals.6

A central criticism of this sprawling ‘book of woe’ is that since the 1980s it has unjustifiably expanded the definition of mental illness to encompass more and more domains of human experience. It achieved this by rapidly increasing the number of mental disorders believed to exist (from 106 in the early 1970s to around 370 today), and by progressively lowering the bar for what constitutes a psychiatric disorder (making it easier for any of us to be classed as ‘mentally ill’).7 These processes resulted in much of our everyday human distress being wrongly medicalised, pathologised and eventually medicated. Grief at a significant loss, struggling to reach orgasm, experiencing lack of concentration at school, undergoing trauma, feeling anxious about public events or simply underperforming at work are just some of the manifold painful human experiences that the DSM has medically rebranded as symptoms of psychiatric illness.

What strengthened the international critique was that this expansion occurred without any real biological justification. Unlike for most physical illnesses in general medicine (e.g. heart disease, cancer and infectious diseases), no biological causes have been found for the vast majority of mental disorders in the DSM. This explains why there are still no blood or urine tests, no scans, X-rays or other objective assessments that can verify any psychiatric diagnosis. There are simply no discovered biological abnormalities for which to test. Psychiatric labels, in other words, do not correspond to known biological pathologies that treatments can then target and ‘cure’. They are rather socially constructed labels ascribed to collections of feelings and behaviours deemed disordered or pathological by the psychiatric committees who compiled the DSM.

Given that the manual’s expansion was therefore not driven by advancements in neurobiological research (DSM disorders were not first discovered in our biology and then later added to the book), on what basis did it so rapidly expand? Well, that was the question I set out to discuss in my seminar the very next day, and I did so by first citing research showing that its expansion largely occurred by way of committee consensus8 – that is, through small teams of psychiatrists coming together and reaching agreements among themselves about whether new disorders should be devised and included, how they should be defined and what symptom thresholds people must meet to receive a diagnosis. The fact that these agreements were mostly made in the face of weak and contradictory evidence has long been a bone of contention in the mental health community. As one of the most important figures in the seminal edition of the DSM (DSM-III) summarised rather well: ‘There was very little systematic research [guiding the creation of the DSM], and much of the research that existed was really a hodgepodge – scattered, inconsistent, and ambiguous. I think the majority of us recognised that the amount of good, solid science upon which we were making our decisions was pretty modest.’9

Given that the evidence base was scattered and ambiguous, how was DSM committee agreement eventually reached? According to the archival and interview data regarding the most important modern edition,10 it was mostly done by way of committee vote. One leading member of the DSM-III committee described to me a typical voting process: ‘Some things were discussed over a number of different meetings, [which would sometimes be] followed by an exchange of memoranda about it, and then there would simply be a vote … people would raise hands, there weren’t that many people.’ Another said: ‘We had very little in the way of data, so we were forced to rely on clinical consensus, which, admittedly, is a very poor way to do things. But it was better than anything else we had … If people were divided, the matter would be eventually decided by a vote.’11

The DSM’s categorisation of diverse human experiences into approximately 370 separate psychiatric disorders was not, then, the outcome of solid neurobiological research. It was mostly based on vote-based judgements reached by small, select groups of DSM psychiatrists – judgements then ratified and seemingly scientifically legitimised by their inclusion in the manual.

The fact that the majority of these psychiatrists (including the DSM’s three previous chairs) also had financial ties to the pharmaceutical industry is of course hardly inconsequential, given that the industry has profited immensely from the vast expansion of DSM that such financially conflicted psychiatrists have engineered.12

As I sat in that Manhattan apartment, searching for the DSM’s sales figures, I soon stumbled upon a webpage that made me sit bolt upright: DSM-5, its most recent edition, had somehow managed to reach number one on Amazon’s bestseller list. Odder still, it turned out that it had been in the Amazon top ten for six months since its publication earlier that year. To give you a sense of scale: the most recent Harry Potter book came in at number six, while Fifty Shades of Grey was listed at number nine. But what bemused me more was that DSM-5 cost a whopping $88 a copy (in paperback). So who on earth was buying this vast and pricey dictionary of distress?

The following day, I put that question to a professor working in the Department of Psychology at New York University. While undertaking research in the New York State primary care sector, she had discovered why DSM sales were so high: ‘The bottom line is that the pharmaceutical industry has been buying DSM in bulk and then distributing copies for free to clinicians up and down the country,’ she said. ‘That’s why the figures are soaring.’ For her, it was obvious why the pharmaceutical industry would do this: ‘As almost any kind of suffering is caught by the DSM, disseminating it is just good business: it drives up diagnosis rates and with this, prescriptions.’ Indeed, as the most important chairperson in the history of the DSM, Robert Spitzer, later acknowledged: ‘the pharmaceuticals were delighted’ with the manual’s widespread medicalisation of distress, as it created a vast and highly profitable market for their products.13

The above claim about pharma’s distribution of DSM14 is perfectly consistent with what we have come to learn about the tactics drugs companies have deployed over the last thirty years to aggressively promote psychiatric drugs, on both sides of the Atlantic. The truth is, since the 1990s, the pharmaceutical industry has been a major financial sponsor of UK and US academic psychiatry, significantly shaping psychiatric research, training and practice within the field.15 It has also opaquely funded many influential mental health charities, patient groups, heads of psychiatry departments,16 as well as leading professional psychiatric organisations – including, naturally, the publisher of the DSM.17

Furthermore, the industry has paid for, commissioned, designed and conducted nearly all the clinical trials into psychiatric drugs (antidepressants, antipsychotics, tranquillisers).18 This has enabled companies to literally create an evidence base in their favour, often by way of dubious research practices designed to legitimise their products.19 These include burying negative data; ghostwriting academic articles; manipulating outcomes to boost the appearance of effectiveness; hiding inconvenient harms; enticing journals and editors with financial incentives, and concealing bad science behind slick and deceptive medical marketing campaigns.20 We also know, through countless academic studies, how most leading psychiatric drug researchers have received industry money (i.e. funding, consultancy fees, speaker’s fees or other honoraria), and how such financial entanglements exert demonstrable biasing effects.21 This is to say that clinicians, researchers, organisations and DSM committee members who receive industry money are far more likely to promote and advocate drug company products in their research, clinical practices, teaching and public statements than those without such financial links. Given that these links have literally littered the profession over the last thirty years, it is little wonder that the over-medicalisation and medicating of emotional distress has similarly proliferated.22

But this book is not about the unholy alliance between drug companies and establishment psychiatry, which I covered more extensively in my previous book, Cracked. It is about how the wider social and economic climate of late capitalism has allowed this highly medicalised, marketised and depoliticised way of managing our emotional distress to flourish unimpeded, despite its clear failings on a whole host of the most important outcome metrics.

According to the NHS’s own Independent Mental Health Taskforce, mental health outcomes have actually worsened in recent years, as have rates of suicide.23 In fact, since 2006, there has been an 11 per cent increase in suicides in people who use mental health services,24 and, despite widening access to services,25 no reduction at all in the prevalence of mental disorders since the 1980s.26 Additionally, while as a society we have made some extraordinary gains in life expectancy over the last fifty years (largely due to biomedical advances in general medicine), for people diagnosed with severe mental health problems, the gap between their life expectancy and everyone else’s has doubled since the 1980s.27 In fact, in the UK, the mortality of those suffering from severe and sustained emotional distress is now 3.6 times higher than in the general population, with people so diagnosed dying approximately twenty years earlier than the average person.28

There are many reasons given for these dire statistics. Those diagnosed with mental health conditions often have to contend with discrimination, social isolation and exclusion, poorly funded social and mental health support, as well as more intangible factors like ‘diagnostic overshadowing’, where physical complaints are often wrongly attributed to the mental health problem, making it more likely that these complaints will go unexplored and untreated.29 But while such factors certainly play a role in bad outcomes and lower mortality, they clearly do not provide the whole picture. They exclude, in particular, growing concerns regarding the harmful effects of psychiatric drugs themselves, like antipsychotics, anxiolytics and antidepressants.

For instance, in precisely those nations where antidepressant prescriptions have doubled in the last twenty years (e.g. the US, the UK, Australia, Iceland, Canada), we have also witnessed the doubling of mental health disability during the same time period. This means that rising prescriptions, in country after country, has presided over rising mental health disability, which is the opposite of what you would expect if the drugs were working. This worrying correlation suggests, as I will explore in Chapter Two, that our drug-heavy approach may partly explain why mental health outcomes are falling far behind other areas of health care, especially since the long-term use of psychiatric drugs is associated with an increase in a whole host of problems: dependence on medical help,30 weight gain,31 relapse rates,32 risk of neurodegenerative diseases such as dementia,33 likelihood of severe and protracted withdrawal,34 sexual dysfunction,35 worse functional outcomes, mortality,36 and so on.

While the data show that our over-reliance on drug interventions may be doing more harm than good over the long term, another critical driver of poor mental health outcomes has been the effect of over-medicalisation itself, something widely promoted by diagnostic manuals like the DSM. While some people report feeling validated by receiving a psychiatric diagnosis, building their identity around it, research shows that having our emotional distress reframed as mental ‘disorder’, ‘illness’ or ‘dysfunction’ (which, incidentally, is now a precondition for accessing NHS services in the UK) may adversely impact our recovery. This is especially true if people are led to believe that their problems are rooted in biological abnormalities, which calling these problems ‘medical’ or ‘mental illness’ encourages.37 For example, people who come to believe their problems are due to chemical imbalances experience worse pessimism about their recovery, increased self-stigma, more negative expectations and self-blame38 as well as more depressive symptoms after the close of their treatment,39 compared to people who reject this hypothesis. Similar results have been found for those who embrace biogenetic explanations for their distress,40 which regularly increases stigmatising attitudes among patients and mental health professionals41 as well as hopelessness in those believing their conditions to be chronic (i.e. lifelong).42

One of the probable reasons why medicalising our distress can cause such harm is that once people identify with being ‘mentally ill’, it may become harder for them to think of themselves as healthy participants in normal life, or as being in control of their own fate. They now have a psychiatric illness that has set them apart and rendered them dependent long term on psychiatric authority. As a result, they are subtly requested to rethink, or even downgrade, their prospects and ambitions for the future, as well as to relinquish part of their agency. While all this can exacerbate self-stigma, self-blame and pessimism for many people, being medicalised can also negatively influence how others treat and perceive those who have been diagnosed. We know, for example, that framing emotional problems in terms of an illness or disorder is more likely to kindle fear, suspicion and hostility in other people than if we articulate those very same problems in non-medical, psychological terms.43 When a research team at Auburn University asked volunteers to administer mild or strong electric shocks to two groups of patients – if these patients failed at a given test, for example – it turned out that those believed to suffer from a biochemical disease rooted in their brains were shocked at a faster and harder rate than those believed to be suffering from problems caused by psychosocial events in their past.44 Framing emotional distress in brain-based, medical terms appeared to exert a subliminal effect on the volunteers, leading them to treat those who had been medicalised less humanely.

Similar forms of stigma even exist when people are ascribed the least stigmatising labels, such as depression. For example, recipients so labelled are still more likely than non-recipients to be viewed by others as having frail wills or character flaws, as being afflicted by personal weakness, or as being lazy and unpredictable.45 And when people are ascribed with more serious labels, like schizophrenia, they are more likely to be perceived as highly unpredictable and potentially dangerous, which can compound their sense of isolation through social rejection.46 In fact, even when people are given false diagnoses by researchers, members of the public will still stigmatise the behaviour of these patients, despite such patients behaving completely normally. The labels, in other words, have powerful cultural effects that shape public perceptions of those being diagnosed, even if these negative perceptions bear no relation to the person at all. It is perhaps for these reasons that the largest ever meta-study into how medicalisation impacts outcomes simply concluded that ‘Medicalisation is no cure for stigma and may create barriers to recovery.’47 If we want to reduce stigma and its various harms, the research implied, we should start by reducing the medicalisation that drives it up.48

Compared to even twenty years ago, public conversations around mental health have hugely proliferated. We are perhaps more able and willing than ever before to open up about our private woes. This of course is a good thing. But it is clearly insufficient in making things better. What matters more is how a person’s actual distress is understood and managed once it has been courageously disclosed, and whether this is done in humane and effective ways. And with respect to honouring this part of the deal, we certainly have a very long way to go. Despite the various ways in which we’re told it’s ‘good to talk’, the responses awaiting most people when they do are fairly homogenous and predictable. Whether we encounter these messages at school, at work, at home or on social media, most are still laden with an underpinning medicalised philosophy that subtly pathologises and depoliticises our distress. And in the post-COVID world, where we are all being asked to open up ever more readily, the effects of this are only set to spread further, as rising distress is reframed as rising mental illness, and as psychiatric prescriptions further vault in response.

Given this culture’s continued expansion, it is absolutely vital that we question why it thrives year on year despite its presiding over the very worst outcomes in our health sector. To answer this, I believe we must move beyond the expansive power and ambition of Big Pharma and the mental health professions themselves, and look at the wider political and economic arrangements that have enabled a particular ideology of suffering to dominate our lives over the last thirty years. Only by doing this will we be able to glimpse the various hidden mechanisms that keep our failing system operational at considerable human and economic expense.

PART ONE

THE NEW OPIUM

1

AN ECONOMIC PRELUDE

In October 2017, a parliamentary assistant walked me down the central hallway of the Houses of Parliament. As we turned into a narrow corridor, she suddenly halted, before ushering me into a small enclave. ‘Wait here, please,’ she said briskly, pointing to some green leather benches lining the wall. She then slipped through a large wood-panelled door, before appearing again a few moments later. ‘This way,’ she said with a smile. ‘He’s ready to see you now. You only have thirty minutes – he’d give you more but it’s been a long day.’

As I entered the bustling Peers’ Common Room in the House of Lords, I immediately began scouring the room for my interviewee. I soon spotted him nestled in a quiet corner, framed by a stately Gothic window that looked out onto the Thames. As I approached, he slowly rose, one hand extended, with the other clutching the armrest for support. ‘Welcome, James,’ he said kindly. ‘Please sit down and join me for coffee.’ As I settled in the plush seat opposite him, it seemed suddenly surreal to be interviewing one of the most influential politicians of the modern age, the man who masterminded the historic economic reforms of Thatcher’s Britain and the new style of capitalism under which we now all live.

I was meeting Lord Nigel Lawson, the former Chancellor of the Exchequer, in order to explore an event that had fascinated me for many years. It concerned an encounter that had taken place over thirty-five years earlier, in a room at Number 10 Downing Street, between Prime Minister Margaret Thatcher and the eminent journalist Ronald Butt. In that meeting, Butt wanted to know whether Thatcher was pleased with her government’s performance since being elected two years earlier. Over the course of an hour, little was said that would surprise any informed listener, until something unexpected happened – perhaps something that shouldn’t have happened.

Butt asked Thatcher what her priorities were for her remaining term as prime minister. She responded by declaring that politics over the past thirty years had become far too socialist; that people had come to rely too much on the state rather than on themselves and each other. ‘That approach is wrong,’ she stated flatly. ‘We have to change the approach.’

She then explained how she would do it: ‘It isn’t that I set out on economic policies,’ she said earnestly, ‘it’s that I set out to change the approach, and changing the economics is the means of changing that approach. If you change the approach, you really are after the heart and soul of the nation. Economics are the method, the object is to change the heart and soul.’1

This confession had long captivated me, because it unmistakably exposed a core principle of Thatcher’s political philosophy: that economic reform was not an end in itself, but a means to what she believed to be a far greater social good – to transform the hearts and minds of an entire population; to shape people into better versions of themselves.

‘Thatcher’s aim to bring about human change through economic reform raises a critical question,’ I said to Lord Lawson. ‘What changes in the national psyche did her new economics aspire to achieve? In what direction do you think she wanted our collective hearts and souls to strive?’

“Well, James,’ answered Lawson slowly, ‘I think that by talking about the heart and soul, Margaret Thatcher felt very strongly that there were certain important virtues – self-reliance, independence and self-responsibility – that economic reform could nurture and develop.’

He then elaborated by referring to the founding text of modern capitalism: Adam Smith’s The Wealth of Nations. ‘You see, there is a widespread view out there that for Adam Smith, the wealth of nations consisted of actual gold. But actual gold had absolutely nothing to do with it. The true wealth of any nation exists in people working to better their own and their children’s lives. For Smith, the true gold was not found in vaults, but rather in who people were and what they did.’

For Lawson and Thatcher, the 1970s economy they’d inherited from their predecessors simply did not encourage these golden virtues: hard work, competitiveness and personal initiative. Rather it fostered baser metals: dependency, complacency and entitlement to state support. ‘For us, big government was a critical problem in the 1970s,’ Lord Lawson continued, ‘something even demeaning to human nature itself. Being a creature of the state created dependency. We believed, and still believe, that a high degree of self-reliance is what makes a good society. So in that sense, yes, Margaret was right: our objective to reform the economy went far beyond economics.’

As I sat listening to Lord Lawson, a childhood memory flashed through my mind of eating with my family by candlelight. No lights in the house were working that evening, and it all felt a little ominous. I remember my sister asking my mother why it was so dark. Her response suggested that something serious was happening in ways that we just wouldn’t understand. ‘It’s dark because we have to save energy – most people in the country have no lights tonight.’

The scene I describe occurred in the mid 1970s, a period of acute economic volatility and widespread industrial unrest. A key problem was spiralling inflation, which was triggered by the oil crisis earlier that decade. This led the Labour government of the day to reject union demands for higher wages. As the government dug in, the unions fought back, and widespread strikes and blackouts were the result for many households across the country.

For Thatcher, the strikes were yet another symptom of a deeper national malaise rooted in the economic policies of the 1970s. In her view, the growing power of the unions was encouraging feelings of selfish entitlement in the working population, while the expansion of the welfare state was rewarding dependency on the state and economic lethargy. Additionally, the tight regulation of business was discouraging innovation, while the nationalisation of key sectors was stifling the competitive spirit. In the end, too many individuals had come to view the state as a kind of benevolent father, something Thatcher believed was corroding individual initiative, independence and responsibility. If Britain were to thrive, these state-created flaws in the national character needed to be excised. Economic reform would be the surgical procedure, and moral and economic health the national reward.

While the perceived corrosion of the national character was a central target of Thatcher’s reforms, by rejecting the 1970s social order, she was also rejecting an entire economic worldview that had dominated in the UK and most other developed Western nations since the end of World War II. ‘For us,’ as Lord Lawson confirmed to me, ‘there was a very strong sense [in our 1980s administration] that social democracy had been tried and failed. The question for us was now what to put in its place.’

What Thatcher’s government saw as tried and failed in the 1970s was the very same economic worldview that had, during the 1950s and 1960s, created widespread economic prosperity and growth. Whatever names have been given to this previous paradigm (‘social democracy’, ‘regulated capitalism’, ‘the post-war consensus’, ‘Keynesian capitalism’), they all point to a style of capitalism in which the state played a more central role in the economy than it does today (discounting the emergency measures during COVID, of course). In essence, this period of post-war ‘regulated capitalism’ embraced the idea that the state could create a prosperous and equal society by playing a central role in regulating the economy, developing national institutions and infrastructure, investing heavily in public services, and restraining market forces.

During the 1950s and 1960s wherever this model was embraced – from Western Europe to east Asia and the United States – positive economic and social development followed.2 This was the period of expanding social security and health coverage, and of historically low levels of unemployment across many developed nations. Steady economic growth soon became the norm too, reaching an annual average of 4–5 per cent in those areas where the paradigm dominated. For these reasons, this period is now regularly referred to as the Golden Age of Capitalism – a period when personal debt was low, inequality went down, wages went up, social liberalism and civil rights expanded, social mobility grew, unemployment almost disappeared, industrial, scientific and technological innovation unfolded at a steady and productive pace, and sustained international peace (between Western nations at least) was broadly secured.3

By rejecting the 1970s, then, Thatcher was also rejecting an entire economic and social model that had brought high and sustained levels of economic prosperity throughout the 1950s, 1960s and part of the 1970s. From now on, that old paradigm – regulated capitalism – would be superseded by a new economic order: a new capitalism, a neo-liberalism, increasing the role of market forces in society and encouraging the kinds of personal qualities – competitiveness, self-reliance, entrepreneurialism and productivity – esteemed by Thatcher’s political elite.

Thatcher set about unleashing the market to do its work. From now on the state would reduce its role in the economy, while corporations would be given far greater freedoms to expand, state-run industries would be privatised and many labour, welfare and social protections would be cut. Standing before the US Congress in 1985, Thatcher praised the effect such reforms had already exerted in America under Ronald Reagan, and described how Britain was, by copying the US, rapidly catching up:

Now the sun is rising in the West [Congress applauds]. For many years our vitality in Britain was blunted by excessive reliance on the state. Our industries were nationalised, controlled and subsidised in a way that yours never were. We are having to recover the spirit of enterprise which you never lost. Many of the policies you are following are the policies we are following. You have brought inflation down, so have we. You have declared war on regulations and controls, so have we … But above all, we are carrying out the largest programme of denationalisation in our history [large applause]. Just a few years ago in Britain, privatisation was thought to be a pipe dream. Now it is a reality, and a popular one … Members of Congress, that is what capitalism is. A system which brings wealth to the many, and not just to the few [standing ovation].4

To understand how these sweeping economic changes would soon transform not just the deeper structures of society, but the internal structures of our psychological, personal and moral lives, we must first take a detour to a time and place far removed from late-twentieth-century Britain; to a time when capitalism was undergoing its first major industrial expansion; to a place where some of our most radical economic ideas were first being forged.

In August 1844, two intellectuals in their mid twenties met at the Café de la Régence on the Place du Palais in Paris. The conversation that ensued was so engrossing for both of them that it would continue each day for a further ten days. What captivated both men was a radical conclusion that each had reached independently of the other: that the industrial revolution then sweeping across Europe was crippling the many while enriching the few. This was due to the relationship between the owners of industry and those working in their factories, a relationship that had become one of essential exploitation. The two men had grown convinced that if balance were to be restored, employees must learn that their economic interest lay in fighting for a new set of working relations – one forbidding their exploitation and more evenly distributing profits while at the same time honouring employees’ basic dignity and rights.

The first man in that Parisian café had come to this conclusion by observing the desperate plight of factory workers in the mills of Manchester. His moral shock at the conditions under which they worked had been exacerbated by his meeting and falling in love with one of these very workers – a twenty-year-old woman called Mary Burns, who would later become his wife. A potent brew of moral outrage and heady passion led him to begin writing political pamphlets criticising the industrialism of the age; these soon fell into the hands of the man who sat opposite him in the café: a man whose journey to the same conclusion had followed a course only slightly less romantic. It involved his mixing with other young radical thinkers in Parisian salons and reading widely in philosophy and political economy. As the conversations unfurled over the next ten days, the two men finally committed to collaborating on a new writing project together. Six months later, that commitment materialised in a book entitled The Holy Family. Its authors were, of course, Friedrich Engels and Karl Marx.

Both men believed that the exploitation of factory workers could only succeed if the workers themselves accepted their own oppression to be both natural and inevitable. What concerned them was the extent to which this acceptance had become deeply engrained in the workers they observed, keeping them in a state of servitude (which compounded their oppression) and a state of isolation from each other (which inhibited their working together for constructive change). Oppressive working conditions had dehumanised people to the extent that they had become detached or alienated from their essential human rights and needs, leaving them in a state of moral and political limbo. And in this demoralised and politically apathetic state, all that remained for them were soothing illusions and anaesthetics – sedatives to compensate them for the painful oppression they endured. Before Marx and Engels met in that café, Marx had already set about identifying one such powerful sedative: organised religion.

Marx felt that religion, unknown to itself, was helping to support the exploitation of factory workers by sedating them to the very suffering that, if fully experienced, would lead them to unite to fight for reform. His view was based on the idea that suffering had always been a powerful driver of social reform: once people experienced the full force of their own despair, they would be compelled to identify and overthrow its causes. Religion, he believed, was interfering with this natural process by recasting the suffering of workers not as a legitimate response to their oppressed situation, but as a ‘hallmark of the pious life’; a godly experience that, if simply endured in this life, would be handsomely rewarded in the next.

Marx believed that by making a religious virtue of suffering, Christianity was indirectly teaching people to accept and endure rather than fight and reform the oppressive conditions harming them.5 Just like any other sedative, religion could offer temporary respite from harsh social and economic realities. But in the long run it would end up causing greater harm, suppressing the human instinct for social reform and allowing harmful circumstances and institutions to live on. It was in this sense that Marx characterised religion as the real opium of the masses, as it sedated the drive for necessary social transformation.

While any student of economics or sociology will be familiar with this aspect of Marx’s critique, we forget how radical it was at the time. In fact, what his early writings on religion helped establish was an entirely new and enduring style of enquiry in the social sciences, one that focused on how the main institutions of society (religion, education, law, media and medicine) always evolved to serve the aims of the particular economic system in which they were rooted.6 While Marx’s early analysis was specific to how religion served industrial capitalism of the mid 1800s, the fundamental idea that all institutions of society would gradually conform to the main economic aims of the day would have a huge impact on twentieth-century social science, whether those deploying this idea sat on the economic left or right – whether they sympathised more with Karl Marx or Fredrick Hayek.

Over the course of the century, this type of social science would have enormous impact on social and political thought, whether those using it identified as Marxists, centrists or neo-liberal capitalists. Studies would proliferate identifying the many ways in which a given style of economy reshaped its various social institutions as these institutions literally bent themselves to satisfy the economy’s will.7 This was particularly true for those institutions, like religion, that directly explained and managed human suffering. After all, once a sufficient proportion of the population came to suffer under a given set of economic arrangements, those arrangements would not survive for long. People would challenge them either through the democratic process, through organised opposition or, when such processes failed, through civil unrest.

What Marx had in effect discovered through his analysis of religion was that those social institutions responsible for understanding and managing suffering were critically important to the aims of an economy. They had the power to defuse politically dangerous emotions by sedating people to the true origins of their distress (cutting off the route to finding the right social solutions). As this understanding unhitched itself from Marxism, and became part of mainstream social science, it started to be applied to the domain of mental health, with many new insights emerging from the 1980s onwards. These revealed the precise ways in which our distress was being misread, exploited and depoliticised for clear economic ends. If I were to draw up a list of how this works, it would look something like this:

• Conceptualise human suffering in ways that protect the current economy from criticism. That is, reframe suffering as being rooted in individual rather than social causes, leading individuals to think that it is them rather than the economic and social system in which they live that is at fault and in need of reform.

• Redefine individual well-being in terms consistent with the goals of the economy. Well-being should be characterised as comprising those feelings, values and behaviours (e.g. personal ambition, competition and industrious endeavour) that serve economic growth and increased productivity, irrespective of whether they are actually good for the individual and the community.

• Turn behaviours and emotions that might negatively impact the economy into a call for more medical intervention. Behaviours and feelings that perturb or disrupt the established order (e.g. low worker satisfaction) should be medicalised and treated, as these can frustrate the economic interests of powerful financial institutions and elites.

• Turn suffering into a vibrant market opportunity for more consumption. Suffering should become highly lucrative to big business as it begins to manufacture and market its so-called solutions – solutions from which increased tax revenues, profits and higher share value can be extracted.

Now, while it is tempting to dismiss the above devices on the grounds that they all sound a little too conspiratorial, it is important to understand that those who exposed them never claimed that they were deliberately concocted in small smoky rooms with calculated intent.8 Their point was far subtler than that: if any institution is to thrive, it must broadly adapt to what its society wants. And so, in the case of mental health, these strategies arose spontaneously as the sector struggled to endure under a new set of economic arrangements. The embracing of a mental health ideology favourable to the wider economy would not just reconfigure the entire mental health enterprise, but would increasingly help alter the psychological outlook of a whole generation. In this sense, Margaret Thatcher was correct when she said that if you wanted to change the heart and soul of a nation, you must change the whole economic approach, as this is the surest mechanism for influencing in powerful ways the direction in which people and institutions ultimately strive.