By glancing at the table of contents, one gets the impression that this book of 293 pages is about the phenomenon of successful, mentally stable, individuals taking psychotropic medication for the balance of their lives. While this clinical issue is definitely explored, there is also considerable coverage of this phenomenon's sociological implications, and even how a meaningful and significant life might be redefined. Essentially, there is a book within the book about how this trend was preceded by intense power struggles between various helping professions.
Ronald Dworkin, who has a Ph.D. and MD in anesthesiology, can probably read, and can definitely write. His style conveys someone who knows his subject from both a clinical and business angle, and can also wax philosophical, in the best sense of the term.
Artificial Intelligence reminds the reader of Peter Kramer's Listening to Prozac (1989), an enormous bestseller, which largely encouraged the masses to take psychotropic medication without hesitation. Peter Breggin's Talking Back to Prozac was an attempt to directly rebut Kramer's contention. However, it focused primarily on the immediate intended effects and side effects of Prozac. Along that line, Dworkin believes such questions about physiology was peripheral Justifiably or not, the medical community ostracized Breggin. Additionally, his association with Scientology allowed that same community to discredit him by effectively playing the 'cult' card (The medical establishment's cyclical alliance/estrangement from religious circles is one of Dworkin's recurring themes). Like Breggin, Dworkin attempts to rebut Kramer, but less stridently.
He begins by citing examples of Artificial Happiness. These include medicating to tolerate an abusive relationship, staying in an otherwise unbearable job, or quelling guilt about mistreating others (" As a consequence, they felt better about their lives and did nothing to change them.").
The author is not overly concerned with how contemporary adults will be affected by medication because their consciences have been fully developed by the time that medication is first prescribed. He is more concerned with its effect on children, believing their consciences are not fully formed, and medication can interfere with that formation. He worries that "Happy Children are relieved from this unhappiness at the very moment they need to feel it, assimilate it, and learn from it." Something Dworkin also alludes to is that unhappy people, while occasionally harmless, are not always pleasant, and medicating these people can make them more tolerable, especially children.
While many bemoan the present fragmentation of treatment for various physical and emotional ailments, this complaint is not new. By the early 1960's, Dworkin writes that primary care physicians (PCPs) had long ceased being glorified. Instead, they had been reduced to mere engineers of the body due to regular outsourcing. Emotional issues were farmed out to psychologists and psychiatrists. Socioeconomic ones went to social workers. Bioethics wrestled about morally debatable treatment Ambiguous 'spiritual' concerns was addressed by peer support groups. Long before the 15-minute appointment, the public perceived doctors as "cold, overpaid technicians. . . Shocked by the depth of anger, primary care doctors tried to reconnect with patients".
This development compelled them to respond to common patient unhappiness not as something situational, like poverty, loneliness or victimization. Rather, unhappiness became framed as something comparable to a rash or lower back pain.
Pay dirt occurred when some studies demonstrated that some medication could block reuptake amines inside the brain. Amines also became known as 'neurotransmitters', and reinforced the "new belief that doctors had a right and a duty to medicate unhappiness." While the causal relationship may have been specious, it was still repeated enough to convince the general public, just as most Americans also believe that squinting causes nearsightedness and that most federal taxes pays for 'foreign aid'.
It would seem intuitive for psychiatrists to have led such a movement. However, Dworkin insists that they initially distanced themselves from the Happiness Revolution, preferring to work on complex psychological issues such as schizophrenia or bipolar disorder. In the 1980's, some psychiatrists ridiculed PCPs for hijacking their biogenic amine theory, and then dumming it down to connect with laypeople. Also in the 1980's, despite seeing more troubled patients, psychiatrists prescribed psychotropics at half the rate as primary care physicians. The fact that most psychiatrists now have their prescription pad out before a patient walks in the office may not be so much the cause as the effect of these same laypeople demanding that the psychiatrists give them 'something to clear up' their conditions.
Apparently, psychiatrists did not play their hand too well. Initially, they criticized PCPs for under diagnosing depression. Their accusation was hardly ignored. In response, the Quick Reference Guide for Clinicians encouraged pharmacotherapy as the primary treatment for depression. Depression here was broadly defined without regard to length of symptoms or situational sources. More specifically, it discouraged primary care physicians from referring 'depressed' patients to psychiatrists "until two trials of antidepressants had failed."
Eventually, those same psychiatrists castigated those same PCPs for overly diagnosing depression. But it was too late. Presently, psychiatrists now provide psychotropic medication for less than a third of all individuals diagnosed with mental illness. Dworkin summarizes it succinctly:
"Americans traditionally gravitate toward general ideas because general ideas let a busy person explain many things at once in the shortest amount of time. Compared to psychiatrists' arcane explanations for unhappiness, the primary care doctor's more straightforward explanations--unhappiness is a disease--was grasped quickly and easily by both the public and other doctors, letting them understand something important without much effort."
The author continues that the "engineering approach to unhappiness makes the long deep conversation with the unhappy patient superfluous." While this may have relieved PCP'S under the pressure of managed care, it jeopardized the whole professional identity of psychoanalytically oriented psychiatrists, as well as similar professionals down the food chain, such as psychologists, social workers and licensed counselors.
Oddly though, he focuses less on the above professions than the effect on theologians, clergyman and pastoral counselors, who he believes were even worse at playing their hand. Historically, these subgroups in religion focused on the larger meaning of life and how to implement it, with happiness in this world, artificial or otherwise, being an afterthought. However, in the 1950's major influences like Norman Vincent Peale emphasized how religious practices were not only proper, but would truly make one feel better in the here and now. This emerged when "dualism" still predominated, which is the distinction between the mind/spirit and body. With the ascent of "monism", the distinction ended. Subsequently,'neuroscience' started reducing all choices, behaviors and emotions to single neurons. Thereafter, examining anything that could not fit under a microscope was deemed pointless.
Dworkin recalls a contemporary faith-based counselor seeking referrals for his practice. The counselor could only acquire them by getting on the good side of a managed care PCP. He describes being on the receiving end of this counselor's business card:
"The doctor glanced at it out of courtesy then put it in his back pocket with all the confidence of a man who knows he's in control and all the contempt of man who hates bootlickers."
And he goes on to describe the deeper poignancy:
"Over the centuries, millions of believers confused by their momentary, vacillating existences have unburdened themselves to clergymen, who in turn responded by inspiring these people to see life in a new way. Sophisticated, subtle, almost aristocratic, clergymen guided worshipers toward an idea that was clear and eternally significant. Yet here he was this minister, heir to the tradition of Saint Augustine, Thomas Aquinas, Martin Luther, and John Calvin, pathetically begging a doctor for patients so he could teach them biofeedback and meditation. This minister had ceased to be the representative of a glorious tradition; he was now the emissary of a defeated and humbled power."
Less convincing are pages in which the author ties Artificial Happiness into alternative medicine movements and the "fitness craze", emerging in the seventies. The former includes acupuncture, aromatherapy and herbal medicine. However, its influence has been largely contained to a small subset of all those seeking medical treatment. Concerning the latter, Dworkin is under whelmed. He suggests that evidence of emotional benefits of 'endorphins' is scientifically dubious. Dworkin almost sounds contemptuous of those who exercise regularly, dismissing them as vain narcissists who are seeking validation from pop culture. His attitude is curious, considering that he has spent much of the book chiding those who are passive and depending on others for their health and well-being. Even the perception of "obsessive exercise" sweeping the nation is questionable if one considers that diabetes and other obesity-related conditions have doubled in the last 40 years. On the subject of vanity, it is puzzling that Dworkin does not speak at all about cosmetic surgery's almost literal relationship to Artificial Happiness.
Yet another concern of the author is that Artificial Happiness could create a whole new kind of life cycle as individuals and their PCPs find a reason to medicate at every phase of life. Seemingly, it is natural to be disillusioned as one phase of life begins to wane. And perhaps it's equally natural to see a new form of 'happiness' on the horizon as one decides to proceed to the next phase. Logical or absurd, he describes a not so natural scenario in which a terminally ill adult, medicated his entire life, has his "dosage upped" one last time to help him ride out any feelings of mortality.
Dworkin explains less why, than how, happiness has become the focal point of our lives. Regarding the book within the book, the narration of the process leading to this result demonstrates how helping professions are no less driven by conquest, acclaim, and profit. When such drives happen to benefit those being 'served', it's though the former stumbled upon the latter. Anyone who has experienced a tinge of professional honor has to also experience momentary, yet deep sorrow, reading about the multiple casualties in this Machiavellian drama. Evidently, Artificial Happiness has little to do with feeling good.
© 2007 Eric Lindquist
Eric Lindquist, LCPC, CADC has worked in mental health for 18 years. His employment has included a group home and psychiatric hospital. For the past 12 years, he has worked in an outpatient setting in Chicago, where he also resides.
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