The Political Economy of Psychotherapy

IN THE U.S. TODAY, psychotherapy, or for that matter any study of the psychodynamics or interpersonal processes involved in mental and emotional difficulties in living, is on the wane. The cause of the decline is the subject here, but to understand it, it must be viewed in the context of the changes to health care in general that have taken place in the past several decades in the U.S. These changes amount to a transformation from care being provided by many more or less independent providers and institutions to it being sold by a corporate-run industry driven by a lust for profits.

The Current Condition of Psychotherapy ^*

HUGE INSURANCE COMPANIES call the shots in the mental health field. They dictate which treatment modalities are to be reimbursed, and, within those, how many appointments are needed, what drugs and dosages can be used, etc. Only a tiny percentage of citizens can afford to pay for psychotherapy "out of pocket," that is, without some reimbursement from insurance. Psychotherapy is a process whose results generally increase proportionately to the time and effort expended in it, so limiting the number of sessions covered by insurance also limits its effectiveness. Often the insurance-approved length of treatment is equivalent to applying a Band-Aid to a broken hip. The situation is the result of the rise of "managed care" over the past several decades, with giant for-profit corporations such as Aetna, Cigna, Metropolitan Life, and Prudential controlling the market. "Managed care" is a health care system in which access to services is controlled for the purpose of keeping costs down. Medication "therapy" has become the favored modality of these insurance companies. Medication "therapy" is the administration of drugs that sometimes alleviates some of the symptoms of what is assumed to be psychiatric "diseases." The word "therapy" is in quotes because the drugs only offer symptomatic relief and do not treat the underlying causes of peoples' problems in living. Psychiatric medication is often accompanied by dangerous side effects. Although reimbursements for medication are expensive, they are less than the costs of psychotherapy. After the initial examination, it takes only a few minutes to write or renew a prescription. The dangerous side effects that often accompany psychiatric medication can also be somewhat relieved by other medications. Thus medication "therapy" is favored by managed care companies.

The explicit rationale of such "treatment" is that the "disease" is caused by a chemical imbalance of biological origin that has always been and will always be present, whether or not it is manifest. The scientific evidence for this is controversial. Moreover, correlations found between certain thoughts and feelings with chemical reactions in the brain do not prove causality in one direction rather than the other. However, researchers increasingly pose the question in the chemical-to- psychological direction, because of the profitable consequences for drug companies. The effect of such profits upon research will be further discussed below. The implicit rationale of medication "therapy" is that people cannot change themselves or the circumstances in which they find themselves by means of empathic understanding and analysis by psychotherapists. A result of the promulgation of medication therapy for psychological and interpersonal difficulties has been the addition of vast funds to the coffers of the biggest profit-makers in the U.S., the pharmaceutical manufacturers.

Some Historical Background

IT SHOULD FIRST BE NOTED that psychotherapy has never prevailed. From Freud until now there has been a century of repression, denial, evasion, and so on, of the examination of interpersonal processes that transpire, to a great extent, beneath the surface appearance of social interactions. The "talking cure" has been viewed primarily as mystical or subjective by the quantitative, measurement-oriented, experimental psychologists, as well as the biologically-biased specialty of medicine, psychiatry. Psychotherapy flourished briefly, and only relatively, in the 1950s and 1960s. This was partially due to the inroads that psychological testing had made during World War II and in the post-WWII U.S. military. It was also due to the post-war economic boom that enabled people within a wider income bracket than before to afford what used to be an exclusive activity of the privileged. This short success was primarily with "neurotic" patients, conceived of, particularly by Freudians, as less disturbed than "psychotics," and more amenable. The Freudian approach, among others, suffered also from a class bias, stemming from its origins among the better off in Vienna.

The evolution of the state of affairs that has brought psychotherapy to its nadir is tied to the development of health care as a tremendously profitable industry in the U.S. The following is an overview of the post- WWII highlights of this development. During the 1950s and 1960s, unions demanded and often won health insurance benefits from their employers (including mental health services). These and other of their victories were generally passed on to the nonunion work force as well. However, there were limits to these victories. In 1946, the United Auto Workers, led by Walter Reuther, had signed an agreement with General Motors instituting company-sponsored health insurance. This effectively broke the more progressive demand of the Congress of Industrial Organizations (CIO) for a national health insurance that would cover organized as well as non-organized workers.{1 Also, the Taft-Hartley law of 1947 had mandated that workers obtain health benefits only through collective bargaining with their employers, rather than through government programs. Thus the possibility of a state-run health system similar to those in capitalist countries in Europe was outlawed.

Tying benefits to employment also added to the fears of losing one's job,² fears that were already considerable given the relative lack of a social safety net in the U.S. A U.S. worker who loses his or her job, if it is a job that comes with health insurance, is entitled to 18 months of benefits under COBRA. Essentially the insurance premiums are the same as the sum of what the employer and the employee paid while he/she was employed. This is a sizable amount, and if the employee does not find a job with an insurance plan by the time the 18 months are over, he/she either buys insurance on his or her own, which is even more expensive, or falls into the pool of the (now 45 million) uninsured. Fears of losing one's job, reinforced by the capital-labor accord that unions bought into after the late 1940s³ persist today and contribute to the decline of unions and worker militancy. The employment--insurance connection is the reason that each time General Motors closes a plant in the U.S., it zeros out not only the salaries of the fired workers, but also saves $1525 in health premiums that it had paid out for each car produced.⁴

The Great Society program of the 1960s brought Medicare for the elderly and Medicaid for the very poor, but nothing for the rest. The effect is still felt today, when 13 percent of Americans have no health insurance at all, and many of those who do pay for it pay at very high costs. The stagflation (slow economic growth coupled with inflation) of the 1970s was accompanied by capital flight, automation, and competition from other advanced capitalist economies that had recovered from the devastation of WWII. To maintain and/or increase profits, U.S. capitalists cut their work forces, lowered wages, and whittled away at benefits.

Throughout the 1980s, the government did its part to increase corporate profits by union busting (e.g., firing the striking air-traffic controllers), reducing corporate taxes, and attacking social programs. During this period, the insurance industry's control over health policies rose at a greater rate than ever before. Between 1981 and 1991 the domination of insurance companies was bolstered by 60 million dollars contributed to congressional representatives by the companies' political action committees.⁵ These contributions command a great deal of power over health care policies. They still do, as do the insurance companies' lobbyists.

By the 1990s, rising health care costs had become a battleground for large corporations looking to maintain profits and unions trying to maintain benefits. A grassroots movement arose to create a single- payer system, that is, one that the federal government administers, contracting directly with providers and bypassing insurance companies. Clinton's 1992 electoral victory was buoyed by his promise of universal comprehensive health benefits, co-opting much of the single-payer movement. He then appointed his wife, Hillary Rodham Clinton, to head a task force that implemented the "managed-competition" approach of the Jackson Hole group. The Jackson Hole group was comprised of representatives of large insurance companies, the pharmaceutical industry, other major corporations, and several professional organizations. "Managed competition" is health care operated and controlled by insurance companies. It attempts to force providers into networks controlled by the insurance companies that try to cut costs below what they were with free choice and fee-for-service arrangements. The theory was that insurance companies would compete for employer-paid premiums, and lower-cost plans would be chosen. "Managed competition" has so far prevailed over single-payer proposals, but instead of the relief that its theorists and Clinton had promised, the nation has experienced increasing costs and cutbacks in care. Corporations, to avoid cutting into their own profits, buy into plans that have less coverage and higher deductibles. For example, Wal-Mart workers, making average salaries of $14,000 per year pay a $1000 deductible, if they even qualify for the stingy health plan. Taxpayers in effect subsidize Wal-Mart, since many of its workers enroll in Medicaid to defray their expenses.⁶ In 2004, the growth in medical costs in the U.S. was nearly four times the growth of wages, making that year the eighth straight that medical cost growth outpaced wage growth.⁷

THE CORPORATE PROFITS of insurance companies, including those of the new entities called health care corporations, have skyrocketed. Health care is now the third largest industry and the U.S. tops the list of all countries in per person expenditures for health care. Fourteen percent of our gross domestic product goes to the health care industry. The per capita spending of countries such as Sweden and France is about a half of that of the U.S. Great Britain spends close to one-third. Nevertheless, the three countries cover almost their entire populations through national insurance programs.⁸ In 2003, the U.S. per capita spending of $5,635 was twice the average of countries of the Organization for Economic Cooperation and Development (OECD, an organization of advanced capitalist countries). Health insurance premiums will rise to an average of more than $14,500 for family coverage in 2006.⁹

Part of the triumph of the insurance companies is due to health maintenance organizations (HMOs). HMOs were created beginning in the 1950s to keep costs down. They have seen enormous growth recently, from 26 million subscribers in 1986 to 55 million in 1996.¹⁰ Insurance companies often sponsor HMOs, and people are forced or enticed into HMOs by lower premiums than plans offering freer choice of providers.¹¹ HMOs control all aspects of health care, including the selection of providers, authorization of treatment plans, monitoring treatment, etc. They thereby limit the ability of practitioners to determine treatments and the ability of patients to choose their providers. And, of course, they favor least expensive treatments. In the mental health field, this means medication rather than psychotherapy and very short-term rather than long-term psychotherapy.

Besides insurance companies' profits, the profits of the pharmaceutical corporations skyrocketed as well in the past two decades, but they had already been beyond the beyond. Since the early 1980s the legal drug industry has been by far the most profitable industry in the country. The ascendancy of the pharmaceutical industry is well documented by Marcia Angell,¹² a former editor-in-chief of the New England Journal of Medicine. She reports that in 2002, the combined profits of the ten drug companies in the Fortune 500 were more than the profits of all the other 490 firms put together.

Angell also details how the success of the pharmaceutical firms was facilitated by industry-friendly legislation beginning in 1980 with the Bayh-Dole Act. It allowed universities and small businesses to patent discoveries emanating from research sponsored by the National Institutes of Health (NIH), the major distributor of dollars for medical research. Before that, taxpayer-financed discoveries were in the public domain. After that, the universities could patent their discoveries and grant exclusive licenses to drug companies in return for royalties. Other legislation allowed NIH to make deals with drug companies to directly transfer NIH discoveries to industry. Medical schools and teaching hospitals were transformed into "partners of industry." The Joint Economic Committee of Congress found that publicly funded research led to 15 of the 21 drugs introduced between 1965 and 1992 that are considered to have the highest therapeutic value,¹³ while the pharmaceutical firms reap the profits.

In 1995, an internal NIH memo lifted limits on the outside income of its personnel, reversed its prohibitions against taking stock or stock options, and freed its leaders to start making personal deals with companies.¹⁴ Between 2000 and 2004, at least 530 government scientists at the NIH, upon whose recommendations doctors rely, took fees, stocks or stock options from biomedical companies.¹⁵ A 2002 survey of medical experts who write practice guidelines found that about nine of ten had a financial relationship with a drug manufacturer and six of ten were tied to companies whose drugs were either considered or recommended in the guidelines they wrote.¹⁶ The financial ties were almost never disclosed.

Angell also states that starting with the Hatch-Waxman Act of 1984 laws were passed that extended the monopoly rights of brand-name drugs, another boon to the pharmaceutical industry. With these mega- profits came the increasing ability of drug companies, directly and through Congress, to control decisions made by the Federal Drug Administration (FDA) as to the safety of medications. Their lobbyists have made the FDA a de facto partner in industry and successfully pushed laws to have the FDA fast-track approval of new drugs.¹⁷. This was facilitated by the passage of the Prescription Drug User Fee Act in 1992. The drug companies agreed to pay the FDA $300,000 for each new medication, and in return, the FDA promised speedier approval of new medicine.¹⁸

As an example of this partnership Angell points to the FDA committees that review new drug applications as to whether or not they should be approved. The financial connections of members of the committees to "interested companies" is exemplified by a report that found that at least one member at 92 percent of the meetings had a conflict of interest, and half or more at 55 percent of the meetings had conflicts.¹⁹ Ten of 32 panelists recently advising the FDA concerning removing pain control pills associated with heart attacks were consultants for drug makers. Without their votes, Vioxx and Bextra would have been pulled from the market. They were not, and the stocks of the drugs' makers soared after the vote.²⁰

Tax revenues, a decreasing proportion of which come from private corporations and the wealthy, subsidize the drug corporations that control the most profitable industry in the nation. Those profits fund the drug lobby. The most powerful in Washington, the drug lobby spends nearly $100 million a year pushing its weight around. The drug lobby invested $26 million in the 2000 election cycle.²¹ The new president and CEO of the lobby, a.k.a. PhRMA (Pharmaceutical Research and Manufacturers of America), is former Louisiana congressman W.J. Tauzin. Tauzin's appointment was his reward for making sure that the new Medicare prescription drug law precluded discounts for Medicaid and Medicare and barred the importation of cheaper drugs from Canada.²² The power of the drug lobby precludes the possibility of the regulation of drug prices. All other developed nations have some form of such regulation.

The rampant march of the profit-making insurance and drug corporations has been merciless in its effects upon mental health research. George Albee, a past president of the American Psychological Association summarizes the situation:

Unfortunately, in psychiatry, much that passes as research is financed by the pharmaceutical corporate giants. They pay for the research. They pay the referees who judge the research. They underwrite the cost of the conferences where results are announced and the cost of publishing the psychiatric journals where they are published. The usual freedoms of scientific inquiry are missing.²³

The Results: Drug Company Dominance of the Mental Health Field

THE POWER OF THE DRUG INDUSTRY is acutely evidenced in the mental health field. Breggin²⁴ documents its influence upon the professional organization of psychiatrists, the American Psychiatric Association (APA). APA journals, conferences, and projects receive massive funding from the pharmaceutical firms. This started primarily as a result of the loss in membership and income that APA experienced in the early 1970s as it was losing the competition for psychotherapy patients to lower cost providers like psychologists and social workers. In 1980 the APA board of directors voted to encourage pharmaceutical companies to support scientific activities. This unholy alliance has promoted the self-serving view that has been pushed within psychiatry for most of its existence, that mental illnesses have biochemical etiologies and thus biochemical solutions.

APA has also aligned itself with the National Alliance for the Mentally Ill (NAMI). NAMI consists of parents of mentally ill offspring who deny any parental role contributing to the interpersonal or emotional problems of their grown children. NAMI promotes genetic and biological explanations of interpersonal behavior as well as drug treatment and electroshock to control it. Major drug corporations contribute to NAMI.²⁵ Albee has warned the mental health field against the alliance of NAMI and biological psychiatry and that the alliance's ideology of dismissing family dynamics as causes of severe mental problems.²⁶ NAMI's counterpart in the realm of children's problems is Children with Attention Deficit Disorders (CH.A.D.D.). Because CH.A.D.D advocates the neurological etiology of attention deficits, the blame is placed on the children for their parents' frustrations. Socioeconomic factors, problems with parenting and/or schools, etc. are downplayed. CH.A.D.D. receives drug company funding, from, for example, CIBA-Geigy, the manufacturer of Ritalin, the stimulant with the biggest share of the attention deficit market.²⁷

Psychiatrists are reaping their share of the NIH/pharmaceutical bonanza. For example, Dr. P. Trey Sunderland III, a senior researcher at NIH, endorsed an Alzheimer's drug marketed by Pfizer at an NIH national television broadcast in 2003. He failed to mention that his research was done in collaboration with Pfizer, and that his research had received $508,050 worth of reimbursement by the company.²⁸ Psychologists, through their own professional organization (the American Psychological Association), have pushed for parity in benefit reimbursement, so that mental health services can be covered as much as medical ones. However, whereas many psychologists used to voice displeasure with the medicalization of mental health, now they primarily have taken a "if you can't beat ‘em, join ‘em" stance, pushing for their own right to write prescriptions.²⁹

About half the U.S. population popped prescription pills in 2003 alone -- 3.5 billion prescriptions and $231 billion in drug industry revenues³⁰ for everything from lowering cholesterol to raising penises. The success of the latter also typifies a slight of hand that the drug companies have become quite adept at, the invention of new diagnoses to accommodate their marketing ambitions. In Angell's words, "Once upon a time, drug companies promoted drugs to treat diseases. Now...they promote diseases to fit their drugs."³¹ Although "impotence" certainly had its problematic connotations, "erectile dysfunction" takes the problem out of the mental and emotional field completely. It over-biologizes and chemicalizes interpersonal interactions.

The same dangerous diagnostic inventiveness fills the APA's Diagnostic and Statistical Manual (DSM), the official authority of psychiatry. Recent years have seen additions, for example, of adolescent rebelliousness, arithmetic learning problems, childhood hyperactivity, and attention deficit.³² Angell documents the finesse with which GlaxoSmithKline pushed Paxil to treat their invented "social anxiety disorder." The original DSM listed about 60 disorders, while the latest³³ has about five times as many.^**

Not only have these new "diseases" spread like the plague, but the old ones -- depression, schizophrenia, etc. -- are now framed in terms of chemicals. We see this in television commercials and in the drug company publicity adopted by psychiatry. A brochure distributed in a major psychiatric facility in New York is published by drug profiteer Pfizer and typifies the backwardness of the "science" behind it by stating, "The importance of dopamine [a chemical that carries messages within the brain] in psychotic symptoms is clear from the fact that medications that are used to treat psychotic symptoms affect dopamine to some degree."³⁴ This statement is akin to saying that histamines are important to understanding insomnia because some antihistamines make people drowsy.

The marketing reach of the psychiatric drug business has extended, with newly created diagnoses, toward younger and younger children. Spending on drugs to treat children and adolescents for behavior- related "disorders" rose 77 percent between 2000 and 2003.³⁵ The expense, $536 per patient per year, is mostly for diagnoses of depression and attention deficit disorder. Sixty-five percent of children and adolescents taking behavioral medicines were on antidepressants, about which even the FDA ordered to include warnings of side effects, such as suicide, in March 2004. Attention disorder drug use by children under age five rose 49 percent in that period. Twenty-nine million prescriptions were written in 2004 for Ritalin and similar stimulants--23 million of them for children. A recent study found chromosome damage to all 12 children who took Ritalin for three months, suggesting increased cancer risk. Ritalin "expert" Lawrence Greenhill, who consults for the companies that make stimulants, questioned why the government became so concerned.³⁶ In addition, pharmaceutical companies buy influence from state mental health officials. This results in the overmedication of children with anti-psychotic drugs.³⁷

The Economic Context of These Developments

THE INDUSTRIALIZATION OF HEALTH CARE and, within it, "mental health" care must be viewed within the context of the advance of the capitalist mode of production. The tide that has swept away many crafts and the family farm, and transformed the family itself has tumultuously changed health care and medical research. Capitalism has succeeded in commodifying much that was heretofore unthinkable -- water, even air, in the form of pollution credits. Why not health?

Technological Innovation and Scientific Research

Technological innovation and scientific discovery have been crucial to the advance of capitalism. Marx was an astute observer and analyst of this in during what can now be called the childhood of capitalist development: "[M]odern industry…makes science a productive force distinct from labor and presses it into the service of capital;"³⁸ and "Invention then becomes a business, and the application of science to direct production itself becomes a prospect which determines and solicits it."³⁹ He saw the motivating force behind this development in capitalists, who in order to cut costs, strive to increase productivity via technical innovation, particularly mechanization, to undersell other capitalists (or capitalist firms). They then could expand their market share, and their profits, relative to others, allowing their survival. This also has the effect of enforcing the adoption of their new production methods by competitors.

Mandel describes how, as capitalism matured, research and development became organized as an autonomous investment, first as a branch of each company, then as independent enterprises themselves.⁴⁰ Noble⁴¹ built upon this and Braverman's⁴² work in analyzing how industry monopolized science, controlling the products of technology by controlling patents, and directing the process of scientific production by means of organized and regulated industrial research. By the middle of the twentieth century, technology and science had submitted to corporate concerns. This is not only attested to by analysts of left-wing persuasion such as Mandel, Noble, and Braverman, but also by the widely respected economic historian Nathan Rosenberg. He writes:

Industrial societies have created a vast technological realm that is very closely shaped by economic needs and incentives. This technological realm, in turn, provides numerous ways in which daily economic life has become closely linked with science. That realm defines the directions that promise large financial rewards and provides many problems and empirical observations that stimulate creative scientific research. These statements are supported by the increasing institutionalization of research in private industrial laboratories. It is fair to assume that decisions in the pursuit of science are subjected, in these profit-making firms to a calculus of private costs and benefits.⁴³

Note that "economic needs" referred to by Rosenberg have no necessary correspondence to any notion of interpersonal, biological or other kinds of "needs." They may conveniently overlap with these other needs, for example, when the food produced by corporate agriculture has some nutritional value. But "economic needs" may just as well be those that are constructed by the same agents that provide their fulfillment. There are countless technological inventions being created for which the "need" (a.k.a. "demand") is manufactured and marketed with it. Commercials pound at us about our "needs" for cellular phones that take pictures and download music and the "need" for sufferers of the newly invented "social anxiety disorder" to take Paxil. For drug companies, as for any capitalist firms, "need" is profit and this dictates the direction of research: "[T]he pharmaceutical industry is supremely uninterested in finding drugs to treat tropical diseases...since those who suffer from them are in countries too poor to buy drugs," states Angell.⁴⁴ While railing against ACT-UP and other groups that protest the greed of drug companies, American Enterprise Institute resident fellow Roger Bate states,

We are seeing 27 percent fewer companies working in HIV research than there were six years ago… If they are not making money on their research, they're unlikely to keep funding it. . . These drugs will not be like Lipitor, which made $10.9 billion last year. Compared to such a blockbuster drug, even the best AIDS drug will not earn anywhere near that kind of money.⁴⁵

On the other hand, the profitability of drugs that treat poorly timed penile flaccidity has lead to the investment of extraordinary sums in R&D and marketing. And profit making has inspired (so far unsuccessfully) attempts to bridge the "gender gap" in the "sexual dysfunction" market, to fulfill economic "need."⁴⁶

The subjugation of science to the profit demands of corporate capitalists, foretold by Marx and elaborated by Rosenberg and others above, merits a revised description of what had been known as scientific research. Firstly, the incentives to fudge are eclipsing ethical concerns. More than 15 percent of the thousands of NIH scientists responding to a recent survey admitted they had changed a study's design or results to satisfy a sponsor.⁴⁷ Determining how many fudge in actuality would require more sophisticated techniques. Secondly, 13.5 percent of the scientists in the same survey said that they knew their research designs would not yield accurate results. Again, these are just the admitted transgressions. Even so, how "scientific" can such knowledge be? Brian Martinson, one of the surveys' investigators concludes, "Science has changed a lot in terms of its competitiveness, the level of funding and the commercial pressures on scientists. We've turned science into a big business but failed to note that some of the rules of science don't fit well with that model."⁴⁸

Thus, the health care industry, spurred by the profit-seeking insurance and drug corporations, has followed the path of other industries within the capitalist economy. Profits have determined the direction of innovation and research. Each firm has tried to expand its market share to survive against the competition. New products are then built upon or changed slightly by competitors. Since patents are central to their profitability through monopoly pricing, the drug companies patent minor changes to existing drugs and claim that their new one works better. Since they control the research, even to the extent of falsifying evidence, the pursuit of science is subjected to the calculations of profit, and their profits allow them to buy further influence in government.

The Commodification of Care

THE ABOVE-MENTIONED ANALYSTS of technological innovation primarily referred to commodities that were physical goods like clothing, machines, food, medicines, etc. However in capitalist societies, not only physical goods become commodified, but services as well. Marx wrote, "A service is nothing more than the useful effect of a use-value, be it of a commodity, or be it of labor."⁴⁹ Braverman points out that when the useful effect of labor does not take the form of an object, but is rather sold directly to the consumer, the effect of the labor becomes the commodity, and "[w]hen the worker does not offer this labor directly to the user of its effects, but instead sells it to a capitalist, who re-sells it on the commodity market, then we have the capitalist form of production in the field of services."⁵⁰

Thus, services become commodities that are produced and sold for profit as well. This has become increasingly true for health care. It is now an industry that not only produces medicines, hospitals and dialysis machines, but care. Care includes surgery, advice, TLC, counseling, laboratory testing, etc. Some of the care is aided by computers and other electrical or mechanical apparatuses, but all care involves human labor. The labor is increasingly paid for in the form wages and fees, by firms that reap profits from the labor that they buy. The providers of that labor, who own no part of these companies, become proletarianized. That is, they become workers whose only way to earn income is to sell their labor power. Whether they are being compensated well, as are most physicians, or poorly, as are many other health workers, they are, in the last analysis, workers. In the mental health field the product that is commodified and profited from consists of the relief of symptoms, control of behavior, sociability, etc., and is marketed wherever demand exists or can be created.

As in other profit- making industries, capitalist firms depend upon their workers -- physicians, attendants, nurses, technicians, etc. -- not being paid for the entire value that they create by their productive activity. Some of the value that these workers create goes towards profits. The value derived from the surplus labor, the portion of their efforts that they are not paid for, is called surplus value, and is the source of profit. Thus, what we see in the commodification of health care and the proletarianization of its workers is in essence the conversion of "the helping professions" to a capitalist industry like any other, assembly lines and all.

Turning the Tide

THE MORAL OUTRAGE expressed by Szasz⁵¹ concerning the abuses of psychiatry resonated with compassionate observers in the mental health field as well as sociologists who noted the coercive function of many social norms. Since then, psychiatry's abuses have become less visually appalling as medicines have replaced straightjackets for tools of control. Medicalized control is not only more convenient; it is also more insidious and tremendously more widespread. More recent expressions of outrage such as Breggin⁵² are as justifiable as were those of the Luddites, who destroyed machines in the early 1800s. However, those machines formed the material mode of existence for the rising capitalist mode of production. "It took both time and experience before the workers learnt to distinguish between machinery and its employment by capital, and therefore to transfer their attacks from the material instruments of production to the form of society which utilizes those instruments."⁵³ Breggin's well- intentioned pleas for therapy, empathy, and love to replace drugs, electroshock and biochemical theories similarly blur the distinction between the instruments of production and the form of society which uses them. In the mental health field, the fightback against psychiatric drugging and other abuses needs to be expanded to take on the profit system from which they stem.

The treatment of mental disorders is now part of an industry dominated by corporate capitalists engaged in an unbridled rush for profits. The system of agencies, political institutions, and laws, serves a class whose morality consists only in the accumulation of more and more profits. The capitalist class can be likened to an addict that requires more and more of the addictive substance to try unsuccessfully to satisfy the urge and then pushes it upon others to insure an ever-expanding supply line. Capitalists can be influenced by persuasion as easily as a vampire can be convinced to give up its blood-sucking habit. A stake through its heart, or in the case of the capitalist system, a radical transformation of that class system, is the treatment of choice.

The implementation of such a treatment plan demands organization and associations of providers and patients -- the producers and consumers of care -- in mental health and health care in general. Some steps in organizing the providers have already been taken. For years, "professionalism" has kept health workers from uniting to fight for at least better pay and benefits. This elitist ideology, promulgated by their employers, warned doctors, nurses, and others, not to sully themselves by joining unions. In the name of being professionals, they did not challenge employers' offers, and many remained underpaid. However, about thirty years ago, nurses began to organize. As a result 17 percent are in unions now⁵⁴ and make respectable wages--15.6 percent more than nurses not in a union.⁵⁵ Other health care workers have made advances in recent decades, but not enough. There have even been inroads in the unionization of physicians.⁵⁶

The ascendant power of capital, especially since its victory in the "cold war," makes it a more formidable opponent to human needs. But the victims of its commodification of everything and proletarianization of everyone in its path are swelling in numbers here and abroad. A renewal of truly helpful mental and physical care is tied to the success that those billions of people potentially have in eliminating capitalist exploitation.

Notes

* Views of psychotherapy as an attempt to adjust social deviants to a system that actually needs adjustment itself are not being dismissed here. Indeed, many psychotherapies have served that very purpose. The premise here is that they do not have to. Rather, psychotherapy can be a process to facilitate people's effectiveness in changing themselves so they can expand their abilities to transform society towards a more just and equitable one. return

**APA, however, "cured" millions of "sick" Americans by dropping homosexuality from the DSM in 1973. return

1. Elly Leary, "Crisis in the U.S. Labor Movement: The Roads Not Taken," Monthly Review (June, 2005), 28-37. return

2. Vincent Navarro, Dangerous to Your Health: Capitalism in Health Care (New York: Monthly Review Press, 1993), 50-51. return

3. See David Gordon, Thomas E. Weisskopf & Samuel Bowles, "Power, Accumulation and Crisis,' in R. Cherry, C. D'Onofrio, C.Kurdas, T.R. Michl, F. Moseley & M.I. Naples, eds. The Imperiled Economy, Book I: Macroeconomics from a Left Perspective, (New York: The Union for Radical Political Economics, 1978), 43-57. The accord assured "management control over enterprise decision-making (with union submission and cooperation) in exchange for the promise to workers of real compensation rising along with labor productivity, improved working conditions, and greater job security. ...The accord also consolidated the relative advantages of the unionized over the non-unionized part of the workforce and contributed to an intensification of labor segmentation along job, gender, and racial lines," 48-49. return

4. Leonard Wiener, "The Big Benefit Squeeze: Companies Are Paring Costs by Clamping Down on Health Care, USNews.com, March 21, 2005. return

5. Navarro, Dangerous to Your Health, 31-32. return

6. Jonathan Tasini, "The Best Corporate Health Plan," Tompaine.com, June 30, 2005. return

7. Ceci Connolly, "Insurance Costs Soar," AMNewYork,. June 23, 2005, 42 return

8. Margaret L. Anderson & Howard F. Taylor, Sociology: The Essentials (3rd Ed.) (Belmont, Ca: Thomson-Wadsworth, 2005), 375. return

9. National Coalition of Health Care, quoted in Tasini, "The Best Corporate Health Plan." return

10. Anderson & Taylor, Sociology, 376. return

11. See, for example, Milt Freudenheim, "Efforts Grow to Steer Elderly Retirees to HMOs," The New York Times, June 13, 1995, C2. return

12. Marcia Angell, The Truth about the Drug Companies: How They Deceive Us and What to Do About It (New York: Random House, 2004). return

13. Merrill Goozner, "The Price Isn't Right," The American Prospect, September 11, 2000. return

14. David Willman, "Stealth Merger: Drug Companies and Government Medical Research, Los Angeles Times, December 7, 2003, A1. return

15. David Willman, "The National Institutes of Mental Health: Public Servant or Private Marketer?'' Los Angeles Times, December 22, 2004. In August 2005, after considerable outrage, the NIH director banned agency scientists from consulting for drug companies, while assuring his employees that he would "re-examine the new rules in a year to make sure they have not had negative effects on the agency's ability to recruit top scientists." See Gardiner Harris, "A Businessman-scientist Shakes Up the Health Institutes," The New York Times, Aug. 30, 2005. At the same time, he softened a proposed rule to require 6,000 NIH scientists to sell their shares in drug and biotechnology companies. "Instead, only the top 200 officials must keep their holdings in any one drug firm below a $15,000 cap." See Gardiner Harris, "Health Agency Tightens Rules Governing Federal Scientists," The New York Times, Aug. 1, 2005. return

16. Sheryl Gay Stolberg, "Study Says Clinical Guides Often Hide Ties of Doctors," The New York Times, February 6, 2002. return

17. David Willman, "The National Institutes of Mental Health: Public Servant or Private Marketer?" return

18. John Abramson, Overdo$ed America: The Broken Promise of American Medicine (New York: HarperCollins, 2004). return

19. Dennis Cauchon, "FDA Advisors Tied to Industry," USA Today, September 25, 2004, 1A, cited in Marcia Angell, The Truth about the Drug Companies. return

20. Gardiner Harris & Alex Berenson, "10 Voters on Panel Backing Pain Pills Had Industry Ties," The New York Times, Late Edition, Final, Feb. 25, 2005, A1. return

21. Jim Hightower, "Looting the Treasury Under the Cover of the Flag," The Hightower Lowdown, February, 2002, 1-4. return

22. Patrick Martin, "Top House Republican Becomes Chief US Drug Company Lobbyist." David Willman in "The National Institutes of Mental Health: Public Servant or Private Marketer?" attributes Tauzin's appointment to another cause, one that would not be contradictory to that of Martin. Tauzin, while chairing the House Energy and Commerce Committee, had begun an investigation into conflicts of interest at the NIH. According to Willman, Tauzin's decision not to run for re-election and subsequent PhRMA appointment exemplified the drug industry's method of winning over its critics. Willman also points to the decision of former Pennsylvania congressman Greenwood to retire. Greenwood chaired a subcommittee of Energy and Commerce and led three hearings on NIH conflicts of interest. After retiring he became president of the Biotechnology Industry Organization, a group that urged policymakers not to prohibit NIH scientists from making paid consulting deals. return

23. George Albee, "Another Surprise from American Psychiatry," 2002. return

24. Peter Breggin, Toxic Psychiatry: Why Therapy, Empathy and Love Must Replace the Drugs, Electroshock and Biochemical Theories of the 'New Psychiatry' (New York: St. Martin's Press, 1991). return

25. Breggin, Toxic Psychiatry. return

26. George Albee, "The Futility of Psychotherapy," Journal of Mind and Behaviour, 1990, 11, 369-384. return

27. Peter Breggin & Ginger Breggin, Talking Back to Prozac (New York: St. Martin's Press, 1994). return

28. David Willman, "The National Institutes of Mental Health: Public Servant or Private Marketer?" return

29. See for example, APApractice.org, "A PA Testifies Before Federal Trade Commission," June 13, 2003. return

30. David Willman, "The National Institutes of Mental Health: Public Servant or Private Marketer?" return

31. Marcia Angell, The Truth about the Drug Companies, 86. return

32. George Albee, "Another Surprise from American Psychiatry." return

33. American Psychiatric Association, Diagnostic and Statistical Manual: Mental Disorders (Washington: American Psychiatric Association, 1952 and 1994). return

34. Pfizer, "Understanding Schizophrenia," Trust (Treatment Resources for Understanding Schizophrenia Therapy) Brochures, 2001. return

35. Milt Freudenheim, "Behavior Drugs Lead in Sales for Children," New York Times, May 17, 2004. return

36. Gardiner Harris, "Report of Ritalin Risks Prompts a Federal Study," New York Times, Jul.1, 2005. return

37. Rob Waters, "Medicating Aliah," Mother Jones, May/June, 2005. return

38. Karl Marx, Capital, Vol. 1 (New York: International Publishers,1967 [1867]), 361. return

39. Karl Marx, Grundrisse (New York: Random House, 1973) 704. return

40. Ernest Mandel, Late Capitalism (New York: Verso, 1978 [1975]). return

41. David Noble, America by Design: Science, Technology, and the Rise of Corporate Capitalism (New York: Alfred A. Knopf, Inc., 1977). return

42. Harry Braverman, Labor and Monopoly Capital: The Degradation of Work in the Twentieth Century (New York: Monthly Review Press, 1998 [1974]). return

43. Nathan Rosenberg, Inside the Black Box: Technology and Economics (Cambridge: Cambridge University Press, 1982), 159. return

44. Marcia Angell, The Truth about the Drug Companies, 84. return

45. Roger Bate, quoted in Deroy Murdock, "AIDing Disease," National Review Online, June 10, 2005. return

46. See, for example, Gardiner Harris, "Pfizer Gives Up Testing Viagra on Women," New York Times, Feb. 29, 2004, p. C1, and Andrew Pollack, "Panel to Review Drug for Low Female Sex Drive," New York Times, Dec. 2, 2004, C1. return

47. Rick Weiss, "Many Scientists Admit to Misconduct," Washington Post, June 9, 2005, A03. return

48. Brian Martinson, quoted in Rick Weiss, "Many Scientists Admit to Misconduct." return

49. Karl Marx, Capital, Vol. 1, 299-300. return

50. Harry Braverman, Labor and Monopoly Capital, 248. return

51. Thomas Szasz, The Myth of Mental Illness: Foundations of a Theory of Personal Conduct (New York, Harper & Row, 1974 [1960]). return

52. Breggin, Toxic Psychiatry. return

53. Karl Marx, Capital, Vol. 1, 554-555. return

54. Sarah A. Webster, "Nurses Seek Union's Clout to Gain Benefits and Voice," The Detroit News, Nov. 19, 2001. return

55. United American Nurses, UAN website, 2005. return

56. Richard A. Sherer, "Physicians' Unions: A Growing Power," Psychiatric Times, May, 1999. return

 

DAVID SINGER is a psychologist in New York City. He has a master's degree in economics and teaches sociology. His writing recently appeared in the online journal, Gloves Off: Bare-fisted Political Economy.