The Perpetually Sick Self
Authors: Gardner Paula 
Published: October 2020

Since the mid-eighties, personality and mood have undergone vigorous surveillance and repair across new populations in the United States. While government and the psy-complexes 1 have always had a stake in promoting citizen health, it is unique that, today, State, industry, and non-governmental organisations recruit consumers to act upon their own mental health. And while citizen behaviours in public spaces have long been fodder for diagnosis, the scope of behaviours and the breadth of the surveyed population has expanded significantly over the past twenty years. How has the notion of behavioural illness been successfully spun to recruit new populations to behavioural diagnosis and repair? Why is it a reasonable proposition that our personalities might be sick, our moods ill? This essay investigates the cultural promotion of a 'script' that assumes sick moods are possible, encourages the self-assessment of risk and self-management of dysfunctional mood, and has thus helped to create a new, adjustable subject.
Michel Foucault (1976, 1988) contended that in order for subjects to act upon their selves -- for example, assess themselves via the behavioural health script -- we must view the Self as a construction, a work in progress that is alterable and in need of alteration in order for psychiatric action to seem appropriate. This conception of the self constitutes an extreme theoretical shift from the early modern belief (of Rousseau or Kant) that a core soul inhabited and shaped being, or the moral self.2 Foucault (1976) insisted that subjects are 'not born but made' through formal and informal social discourses that construct knowledge of the 'normal' self. Throughout the 19th century and the modern era, as medical, juridical, and psychiatric institutions gained increasing cultural capital, the normal self became allegedly 'knowable' through science. In turn, the citizen became 'professionalised' (Funicello 1993) -- answerable to these constructed standards, or subject to what Foucault termed biopower. In order to avoid punishments wrested upon the 'deviant' such as being placed in asylum or criminalised, citizens capitulated to social norms, and thus helped the State to achieve social order. 3
While 'technologies of power' or domination determined the conduct of individuals in the premodern era, 'technologies of the self' became prominent in the modern era.4 (Foucault, 'Technologies of the Self') These, explained Foucault, permit individuals to act upon their 'bodies, souls, thoughts, conduct and ways of being' to transform them, to attain happiness, or perfection, among other things (18). Contemporary psychiatric discourses, for example, call upon citizens to transform via self-regulation, and thus lessened the State's disciplinary burden.
Since the mid-twentieth century, biopsychiatry has been embraced nationally, and played a key role in propagating self-disciplining citizens. Biopsychiatric logic is viewed culturally as common sense due to a number of occurrences. The dominant media have enthusiastically celebrated so-called biotechnical successes, such as sheep cloning and the development of better drugs to treat Schizophrenia. Hype has also surrounded newer drugs to treat depression (i.e. Prozac) and anxiety (i.e. Paxil), as well as the 'cosmetic' use of antidepressants to allegedly improve personality.5 Citizens, then, are enlisted to trust in psychiatric science to repair mood dysfunction, but also to reveal the 'true' self, occluded by biologically impaired mood. Suggesting that biopsychiatry's 'knowledge' of the human brain has revealed the human condition and can repair sick selves, these discourses have helped to launch the behavioural health script into the national psyche.
The successful marketing of the script was also achieved by the diagnostic philosophy encouraged by revisions of Diagnostic and Statistical Manual or Mental Disorders(the DSM; these renovations increased the number of affective (mood) and personality diagnoses and broadened diagnostic criteria. The new DSMs 6 institutionalised the pathologisation of common personality and mood distresses as biological or genetic disorders. The texts constitute 'knowledge' of normal personality and behaviour, and press consumers toward biotechnical tools to repair the defunct self. Ian Hacking (1995) suggests that new moral concepts emerge when old ones acquire new connotations, thereby affecting our sense of who we are. The once moral self, known through introspection, is thus transformed via biopsychiatry into a self that is constructed in accordance with scientific 'knowledge'. The State and various private industries have a stake in promoting this Sick Self script.
Promoting Diagnosis of the Sick Self
Employing the DSM's broad criteria, research by the National Institute of Mental Health (NIMH), contends that a significant percentage of the population is behaviourally ill. The most recent Surgeon General report on Mental Health (from 1999) which also employed broad criteria, argues that a striking 50 million Americans are afflicted with a mental illness each year, most of which were non-major disorders affecting behaviour, personality and mood.7 Additionally, studies suggest that behavioural illness results in lost work days and increases demand for health services, thus constituting a severe financial burden to the State. Such studies consequently provide the State with ample reason to promote behavioural illness.
In predicting an epidemic in behavioural illness and a huge increase in mental health service needs, the State has constructed health policy in accordance with the behavioural sickness script. Health policy embraces DSM diagnostic tools that sweep in a wide population by diagnosing risk as illness and links diagnosis with biotechnical recovery methods. Because criteria for these disorders have expanded and diagnoses have become more vague, however, over-diagnosis of the population has become common . 8 Depression, for example, is broadly defined to include moods ranging from the blues to suicidal ideation. Yet, the Sick Self script is ubiquitously embraced by NGO, industry, and State discourses, calling for consumer self-scrutiny and strongly promoting psychopharmaceuticals. These activities has been most successful; to wit: personality disorders were among the most common diagnoses of the 80's, and depression, which was a rare disorder thirty-five years ago, became the most common mental illness in the late 90's (Healy).
Consumer Health Groups & Industry Promotions
Health institutions and drug industries promote mood illness and market drug remedies as a means of profit maximisation. Broad spectrum diagnoses are, by definition, easy to sell to a wide population and create a vast market for recovery products. Pharmaceutical and insurance companies (each multibillion dollar industries), an expanding variety of self-help industries, consumer health web sites, and an array of psy-complex workers all have a stake in promoting the broad diagnosis of mood and behavioural disorders. 9 In so doing, consumer groups and the health and pharmaceutical industries not only encourage self-discipline (aligning themselves with State productivity goals), but create a vast, ongoing market for recovery products.
Promoting Illness and Recovery
So strong is the linkage between illness and recovery that pharmaceutical company Eli Lilly sells Prozac by promoting the broad notion of depression, rather than the drug itself. It does so through depression brochures (advertised on TV) and a web page that discusses depression symptoms and offers a depression quiz, instead of product information. Likewise, Psych Central, a typical informational health site, provides consumers standard DSM depression definitions and information (from the biopsychiatric-driven American Psychiatric Association (APA) or the NIMH, and liberal behavioural illness quizzes that typically over-diagnose consumers. 10The Psych Central site also lists a broad range of depression symptoms, while its FAQ link promotes the self-management of mood ailments. For example, the site directs those who believe that they are depressed and want help to contact a physician, obtain a diagnosis, and initiate antidepressant treatment. Such web sites, viewed as a whole, appear to deliver certified knowledge that a 'normal' mood exists, that mood disorders are common, and that abiding citizens should diagnosis and treat their mood ailment.
Another essential component of the behavioural script is the suggestion that the modern self's mood is interminably sick. Because common mood distresses are fodder for diagnosis, the self is always at risk of illness, and requires vigilant self-scrutiny. The self is never a finished product. Moreover, mood sickness is insidious and quickly spirals from risk to full-blown disorder. 11 As such, behavioural illness requires on-going self-assessment. Finally, because mood sickness threatens social productivity and State financial solvency, a moral overtone is added to the mix -- good citizens are encouraged to treat their mood dysfunctions promptly, for the common good. The script thus constructs citizenship as a motive for behavioural self-scrutiny; as such, it can naturally recommend that individuals, rather than experts, take charge of the surveillance process. The recommendation of self-determined illness is also a sales feature of the script, appealing to the American ethic of individualism -- even, paradoxically, as the script proposes that science best directs us to our selves.
Self-Managed Recovery
Health institutions and industries that deploy this script recommend not only self-diagnosis, but also self-managed treatment as the ideal treatment. Health information web sites, for example, tend to displace the expert by encouraging consumers to pre-diagnose their selves (often via on-line quizzes) and to then consult an expert for formal diagnosis and to organise a treatment program. Like governmental heath organisation's web sites, these commonly link consumer-driven, broad-spectrum diagnosis to psycho-pharmaceutical treatment, primarily by listing drugs as the first line of treatment, and linking consumers to drug information. Unsurprisingly, pharmaceutical companies support or own many 'informational' sites. Depression-net.com, for example, is owned by Organon, maker of Remeron, an SSRI in competition with Prozac.12 Still, even sites that receive little or no funding tend to display drugs prominently; for example, Internet Mental Health, which accepts no drug funding lists drugs immediately after diagnosis on the sidebar. This trend illustrates the extent to which drugs are viewed by consumers as a first step in addressing all types of mood sicknesses.
Consumer health sites, geared toward Internet users seeking health care information (estimated to be 43% of the 120 million users) promote the illness-recovery link more aggressively. Dr.koop.com, one of the most visited sites on the Internet, describes itself as 'consumer-focused' and 'interactive'. Yet, the homepage of this site tends to include 'news' stories that relay the success of drugs or report on new biopsychiatric studies in depression or mental health. Some consumer sites such as Consumer health sites, geared toward Internet users seeking health care information (estimated to be 43% of the 120 million users) promote the illness-recovery link more aggressively. Dr.koop.com, one of the most visited sites on the Internet, describes itself as 'consumer-focused' and 'interactive'. Yet, the homepage of this site tends to include 'news' stories that relay the success of drugs or report on new biopsychiatric studies in depression or mental health. Some consumer sites such as WebMD prominently display links to drugstores, (such as Drugstore.com), many of which are owned in part or entirely by pharmaceutical companies.13 Similar to the common practices of direct-to-consumer advertising, both informational and consumer sites by-pass the expert, promote recovery via drugs, and direct the consumer to a doctor in search of a prescription, rather than health care advice.
State, informational and consumer web sites all help to construct certain populations as at-risk for behavioural sickness. The NIMH information page on depression -- uncanny in its likeness to consumer health and pharmaceutical sites -- utilises the DSM definition of depression and recommends the standard regime of diagnosis and biotechnical treatments (highlighting antidepressants) most appropriate for a diagnosis of major, rather than minor, depression. The site also elaborates the broad approach to mood illness, and recommends that women, children and seniors -- groups deemed at-risk by the broad criteria -- be especially scrutinised for depression. By articulating the broad DSM definition of depression, a generalisable 'self' -- anyone suffering common ailments including sadness, lethargy or weight change -- is deemed at risk of depression or other behavioural illness. At the same time, at-risk groups are constructed as populations in need of more urgent scrutiny, namely society's less powerful individuals, rather than middle-aged males. That is, society's decision-makers--psychiatric researchers, State policy-makers, pharmaceutical CEO's, (etc) are considered least at risk for having defunct selves and productivity functioning.
Selling Mood Sickness
These brief examples illustrate the standard presentation of behavioural illness information on the Web and from traditional resources such as mailings, brochures, and consumer manuals. Presenting the ideal self as knowable and achievable with the help of bio-psychiatric science, these discourses encourage citizens to self-scrutinise, self-define, and even self-manage the possibility of mood or behavioural dysfunction. Because the individual gathers information, determines her pre-diagnosis, and seeks out a recovery technology, the many choices involved in behavioural scrutiny make it appear to be a free and 'democratic' activity. Additionally, as individuals take on the role of the expert, self-diagnosing via questionnaires, the highly disciplinary nature of the behavioural diagnosis appears unthreatening to individual sovereignty. Thus, this technology of the self solves an age-old problem of capitalist democracy -- how to simultaneously instill citizen's faith in absolute individual liberty (as a source of good government), and, at the same time, the need to achieve the absolute governance of the individual (Miller). Foucault contended that citizens are brought into the social contract of citizenship not simply through social and governmental contracts but by processes of policing that become embedded in our notions of citizenship. The process of self-management recommended by the ubiquitous behavioural script functions smoothly as a technology of surveillance in this era, where the ideal self is known and repaired through biopsychiatric science, the democratic responsibility of a good citizen. The liberal contract has always entailed an exchange of rights for freedoms -- in Rousseau's terms 'making men free by making them subjects.' (Miller xviii) When we make ourselves subjects to ongoing behavioural scrutiny, the resulting Self is not freed, rather it is constrained by a perpetual sickness.
Notes
1 This term is used in a Foucaultian sense, to refer to all those who work under and benefit or profit from the dominant biological model of psychiatry dominant since the 1950's in the U.S.
2 For more discussion, see Ian Hacking, Rewriting the Soul; Multiple Personality and the Sciences of Memory. (1995)
3 In his essay 'Technologies of the Self' (1988) Foucault outlines the four major types of technologies that function as practical reason and entice citizens to behave according to constructed social standards. Among these are technologies of production (that permit us to produce things), technologies of sign systems (permitting us to use symbols), and the technologies of power and self mentioned in the above text. Through these technologies, operations of individuals become highly regulated, some visible and some difficult to perceive. The less visible technologies of the self became essential to the smooth functioning of society in the modern era.
4 'Technologies' is used to refer to mechanisms and actions of institutions or simply social norms and habits, that work, ultimately, to govern the individual, or create behaviour that serves desires of the State and dominant social bodies.
5 Peter Kramer, author of the best-selling book Listening to Prozac (1995) contends that his patients using Prozac often credited the drug with helping their true personalities to surface.
6 The two revisions occurred in 1987 and 1994.
7 Of that group, only five percent of that group suffers a 'severe' form of mental illness (such as schizophrenia, or extreme form of bipolar or obsessive compulsive disorder), while the rest suffer less severe behavioural and mood disorders. Similar research (also based on broad criteria) was published throughout the 90's suggesting an American epidemic of behavioural illness; it was claimed that 17% of the population is neurotic, while 10-15% of the population (and 30-50% of those seeking care) was said to possess a personality disorder. (Hales and Hales, 1995)
8 The most widely assigned diagnoses in this category today are: depression, multiple personality, adjustment disorder, eating disorders and Attention Deficit Hyperactivity Disorder (ADHD), which have extremely broad criteria, and are easily assigned to a wide segment of the population.
9The quizzes offered at these sites are standard in psychiatry; the difference here is that these are consumer-conducted. Lilly uses the Zung Self-Assessment Tool, which asks 20 broad questions regarding mood, and overdiagnoses individuals with potential depression. By responding to vague questions such as 'Morning is when I feel the best', 'I notice that I am losing weight', and 'I feel downhearted, blue and sad' with the choice of 'sometimes', individuals are thereby pre-diagnosed with potential depression. (https://secure.prozac.com/Main/zung.jsp) Psych central uses the Goldberg Inventory that is similarly broad, consumer-operated, and also tends to overdiagnose.
10 The DSM and other psychiatric texts and consumer manuals commonly suggest that undiagnosed depression will lead, eventually, to full-blown major depression. While a minority of individuals who suffer ongoing episodes of major depression will eventually suffer chronic major depression, it has not been found that minor depression will snowball into major depression or chronic major depression. This in fact, is one of the many suspicions among researchers that is referred to as fact in psychiatric literature and consumer manuals. A similar case in point is the suggestion that depression is a brain disorder, when in fact, research has not determined biochemistry or genetics to be the 'cause' of major depression.
11 Increasingly, Pharmaceutical sites are indistinguishable from consumer sites, as in the case of Bristol-Meyers Squibb's depression page, (http://www.livinglifebetter.com/src/htdo...) offering a layperson's depression definition and, immediately thereafter, information on its antidepressant Serzone.
12 Like the informational and State sites, these also link consumers to depression information (generally NIMH, FDA or APA research), as well as questionnaires.

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Links

http://www.drugstore.com
http://psychcentral.com/library/depression_faq.htm
http://www.wikipedia.com/wiki/DSM-IV
http://www.nimh.nih.gov/publicat/depression.cfm
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http://my.webmd.com/
http://www.a-silver-lining.org/BPNDepth/criteria_d.html#MDD
http://psychcentral.com/depquiz.htm

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