The Age of Melancholy, Dan G. Blazer, Routledge,
Anyone interested in the history of ideas would find this book very interesting. Currently the medical model of mental illness is so all-pervasive and powerful that people born after 1950 could be led to think that this has always been the accepted explanation for mental distress. The subtitle of Dan Blazer’s book is “’Major Depression’ and Its Social Origins” but the book is essentially a history of the ideas in psychiatry in the twentieth century.
Psychiatry did not come into its own until after the First World War and in time for American psychiatrists to be greatly influenced by psychoanalysis. This was the point where psychiatry began to be associated with the image of the couch, an image which bears no relationship to present day psychiatry in the USA where psychiatrists do not sit beside a couch and probe their patient’s unconscious. Rather, they sit at a desk, question their patient, make a diagnosis, and write a prescription. An efficient psychiatrist can complete this in 10 to 15 minutes.
Freud saw neurosis as the conflict between the individual and society. Blazer wrote, ‘For Freud . . .a neurosis, such as melancholia, arose because of anger originally directed outward towards a lost object of social support; for example, a dead spouse. Expressed anger towards a lost object is not tolerated by society (and the internalized representation of society – the superego). Anger is thus directed inward, leading to melancholia. The conflict between the innate drives and society is inevitable, for civilization requires the sublimation, suppression, or repression of fundamental human drives.’ (p.61) In a similar way the social epidemiologist Durkheim saw suicide as reflecting ‘the relationship between individual and society.’ (p.62)
Social psychiatry grew out of psychoanalysis and social epidemiology. It flourished in the 1950s and 1960s. Dan Blazer describes himself as being old enough to remember ‘the heyday of social psychiatry’.(p.4) He deeply regrets its passing. I would guess that Blazer wrote this book both as the expression of his regret and as a warning to his younger colleagues who believe that ‘There is no primary prevention of major depression’, as one of his colleagues stated.(p.4)
Social psychiatry was concerned with prevention, and thus was involved in social activism. Blazer writes, ‘Social activism rode the wave of Johnson’s Great Society, which stimulated an extraordinary growth in federal social programmes. In rapid succession Congress enacted laws intended to diminish economic inequalities, stop racial discrimination, and ensure that all Americans would have access to medical care (e.g., Medicare). Mental health rhetoric and ideology paralleled the rhetoric of the Great Society and emerged from the belief that social programs could improve a deficient environment. The emphasis on community mental health services responded to that belief by stressing the empowerment of individuals and small groups at the local level. Their involvement in all decisions that affected the lives of the mentally ill should greatly improve their condition. The demand for social justice was coupled with a demand to destroy any and all barriers to individuals reaching their full potential.’ (p.70)
How very different all of this is from George Bush’s America! Richard Nixon followed Lyndon Johnson as President, the ideas involved in the Great society vanished, and the anti-psychotic and antidepressant drugs created in the 1960s became the treatment of choice by psychiatrists. Blazer has little time for the medical model. He writes, ‘The depressed seek to be understood, yet modern psychiatry reinterprets the emotional suffering of the depressed into its own symptomatic language, a language which must fit the procrustean bed of the DSM-IV. The psychiatrist hears what he or she wants to hear. . . . Descriptions of depression as a chemical imbalance, emphasis on depression as a disease (apart from the real you), and the focus on treating the depression without attention to the person treated (such as the 15-minute medication check) separate depression from the self who is experiencing the depression.’ (pp.154, 155)
Blazer speaks of social psychiatry as retreating rather than as being defeated by the advocates of the medical model and the use of drugs. He writes, ‘Some have questioned if the investigation of the social origins of depression and other psychiatric conditions is discouraged at the federal level.’ (p.86) He goes on to suggest that such discouragement comes from the problems inherent in studying social risk factors and social therapies. He does not suggest that there might be political reasons for such discouragement.
Recently I met the American linguist Deborah Tannen at the BBC where we were to discuss her new book about the conversations between mothers and daughters. During our discussion the question of guilt arose and I said, ‘The Church and mothers keep me in business.’ When we were off air I discovered that Deborah was somewhat shaken by my comment. She explained, ‘In America we never criticise the Church.’ If this is so then it might go some way in explaining why Blazer does not bring politics into his history of American psychiatry.
The USA is one country occupying a huge land mass and populated by many diverse groups of people. In contrast, a similarly sized land mass populated by many diverse groups – Europe – is divided into different countries with different languages. How can a President and a federal government hold the USA together? It is ideas that hold people together, and the ideas which hold America together can be summarized as ‘America’ and ‘God’. George Bush reiterates these ideas in every speech. ‘America’ and ‘the American people’ and ‘God’ feature many times. The American people can be happy and successful simply by having a dream (the American Dream) and working hard to make it come true, as it certainly will. God is on America’s side, and He will make sure that the American Dream always comes true. The fact that many Americans become melancholy, despairing, and depressed throws all these ideas into doubt. The way to remove this doubt is to say that Americans who are melancholy, despairing, depressed are either mad or bad. If they are bad, put them in jail, and if they are mad, give them drugs. Anyone who disagrees with this is un-American, and must be punished for this crime. Those American psychiatrists like Peter Breggin who dare to disagree are reviled. Perhaps this is why Dan Blazer has written a history of social psychiatry and left out the politics. But, if you’re writing about ideas, the politics are there like the proverbial elephant in the living room. Power is the ability to get other people to accept your ideas. Politics is about power. Ideas and politics are indivisible.
Deborah Tannen You’re Wearing That? Understanding Mothers and Daughters in Conversation Virago Press, London, 2006.
Peter Breggin Toxic Psychiatry St Martin’s Press, New York, 1991.
June 29, 2006
Dorothy Rowe is a clinical psychologist and writer, best known for her work in depression, and especially for her book Depression: The Way Out of Your Prison third edition, Routledge.