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Locating the Neurochemical Self
2007
The world at hand makes all human beings part of a global community. The ties of this community are economic, political, and ideological. The power of institutions to shape people has grown to astonishing degrees over the last century. The influence of medicines, in particular, has approached a meaning unimaginable to most people a short time ago. But prescient social commentators like Aldous Huxley and George Orwell predicted a future of in which social and institutional control was paramount. In Huxley’s novel, Brave New World, he envisioned a future in which drugs were taken not for medical purposes but for purposes of conformity and for the avoidance of any negative affect. The world Huxley predicted is not dissimilar from the world we are beginning to see through the mist of the present. The ability of psychotropic medicines to shape society and ultimately to shape the individual’s idea of his own humanity has created a set of questions that social scientists and politicians will need to carefully investigate. In order to understand these questions, we will need to seek a definition of the self and then consider how medicines are capable of subtly—and not so subtly—shaping this self.
Ideas about the Self What is a self? Centuries of received wisdom persuade many that “the self” is a unitary, bounded, agentive thing. A more careful analysis reveals that rather than a self, there are never less than many selves that associate in the construction of the person. Additionally, rather than things, the many selves that combine in the creation of the person reflect processes and relationships. Selves are not things, they are systems.
The anthropologist Irving Hallowell, in “The Self and Its Behavioral Environment,” defines the self as culturally constituted (79). He believes self and culture to be interdependent systems. Just as there can be no cultures without selves, so there are no selves without cultures. The world we live in is a “culturally constituted behavioral environment” (87). The self, at its core, exists as awareness but the function of culture is to provide self-awareness with a set of orientations: self orientation, object orientation, spatio-temporal orientation, motivational orientation, and normative orientation (89-110). It is through these varied orientations that the self functions. But how does this self, a self that is a nexus point within a variety of relationships and orientations, apprehend itself? How, for instance, do people come to think of themselves as eternal souls rather than mortal brains.
Healing and the Self One way to study self-systems is through the investigation of healing practices. The way that a culture envisions health, well-being, and the knowledge it conveys about returning an ill self to a well self, deeply influence popular ideas about the self. In other words, how we understand mad selves inform us about our definitions of sane selves. But what becomes apparent upon reviewing a culture’s ideas about madness is the lack of any single, consistent idea about insanity.
To provide an example: the New Testament, which records the life and understandings of a group of Mediterranean Jews in the first centuries of the common era, evinces at least three different notions of madness. Madness is seen to be the possession of the individual by spiritual entities (Mark 5:1-18), as drunken behavior (Acts 2:1-13), and as grandiosity—the claim that one is more than one’s social position/background (Luke 4:14-30; Mark 3:20). In the New Testament, then, one finds notions of insanity as spiritual malady, as chemical/biological response, and as social dysfunction. Whether through the powerful influence of this text or from other sources, the notion of madness as one—or all—of these three dimensions remains prominent today in Western culture.
To approach the present, madness seems to have proceeded through three dominant phases: the spiritual, the social/psychological, and the biological/chemical. During much of European history, insanity was treated by exorcism and prayer (Porterfield 2005). But by the nineteenth century, after Enlightenment ideas had firmly taken root, a pervasive desecularization had forced the transition from spiritual notions about madness to other conceptions of it. With Freud, the psychological revolution truly commenced. Insanity could now be approached as a disturbance of internal mental processes, processes that had their root in one’s early development, in family dynamics. The language of the psychological so quickly took hold that ideas about insanity as a psychological disturbance thoroughly consolidated. Abnormal psychology developed as a complex agenda to understand, classify, and treat the dysfunctional mind.
Developing in parallel with the psychological approach to mental illness, was the production of medicines to treat the symptoms of madness. A host of psychotropic drugs began to be assembled so that, at the turn of the 20th century, Freud was—for a time—enamored of cocaine as a treatment for depression (Freud 1975). But so long as medicines were general in their treatment of symptoms and so long as they were plagued by strong side-effects, they would remain sidelined while psychological treatments took the ascendancy. Moreover, psychotropic medicines did not yet possess the cultural power necessary to overturn entrenched ideas about madness as a type of character weakness. But by the middle of the twentieth century sufficient advancements had occurred, especially in the development of powerful antipsychotics, so that these medicines combined with strong economic pressures to accelerate psychotropic drug discovery. Barely fifty years later, it seems as if there were no other proper understanding of madness than as an issue of biological diathesis, of chemical imbalance. Reflecting on the present medical establishment, Rose writes that: “A way of thinking has taken shape, and a growing proportion of psychiatrists find it difficult to think otherwise. In this way of thinking, all explanations of mental pathology must "pass through" the brain and its neurochemistry—neurons, synapses, membranes, receptors, ion channels, neurotransmitters, enzymes, etc.” (Rose 2003:57). Indeed, in this environment Freud has become all but a laughingstock. And insurance companies, prodded by studies of efficacy as well as by the bottom line, have set up many obstacles before those patients who would seek counseling before medication.
The Neurochemical Self One of the best studies of this transformation of the person into a “neurochemical self” is that of the sociologist Nikolas Rose. Rose helps to clarify the intersection of social, medical, and economic forces in the construction of the biomedical model of the person in his various works. He notes that the biomedical model of the person has a “long past, but a short history” (2007:188). One can find ideas about the biological basis of mental health at least as far back as Hippocrates who developed the theory of humors as a way to explain mood and personality (McManus 1963:40). Consider this remarkably “modern” discussion of the brain that Hippocrates wrote 2400 years ago:
In addition to the flirtation that ancient Greek culture had with biomedical notions about the self, we have already seen that one of the ways to understand madness in the New Testament was by attributing it to drunkenness. It was eminently clear to these Mediterranean Jews that alcohol could profoundly alter mood and personality. In spite of such ideas, the biomedical approach, if always present, rarely stepped out from the shadow of spiritual and psychological conceptions of insanity.
The idea that one’s hopes, fears, desires, memories—his personality—is to be found in the meat of the body has become an increasingly dominant conception: “While discontents might previously have been mapped onto a psychological space—the space of neurosis, repression, psychological trauma—they are now mapped upon the body itself, or one particular organ of the body, the brain” (Rose 2003:54). For much of history, one could attribute character failings and mental stability to the willful choices of a soul, a spiritual notion of the self to be sure. The body served as a vehicle for this soul but the idea that such things as moods and proclivities could be located in the body rather than in the soul held little sway. But in contemporary settings people increasingly think of their innermost moods as functions of their bodily health, of their neurochemistry. Thus, if a person feels down he may take a jog to increase the oxygen in his blood, eat a snack to raise his blood sugar, or he may even make the commitment to take a pill—on a daily basis—to better regulate his serotonin levels so that his moods are cheerier. Such understandings represent a dramatic transformation of the self. The strength of this belief among medical professionals has become all but dogma. In the diagnosis of mental illness it is “not that biographical effects are ruled out, but biography—family stress, sexual abuse—has effects through its impact on this brain. Environment plays its part, but unemployment, poverty and the like have their effects only through their impact upon this brain. And experiences play their part substance abuse or trauma for example but once again, through their impact on this neurochemical brain. A few decades ago, such claims would have seemed extraordinarily bold, for many medicopsychiatric researchers and practitioners, they now seem "only common sense" (Rose 2003:57). The acceptance, the internalization, of beliefs about locus of one’s mood and personality in the intricate balance of neurotransmitters and receptor regulation forces one rethink a great deal about their own personhood. For understanding that not only one’s mortality is defined by the body but that one’s very personality—one’s capacity to function in life and to enjoy things—originates in an interplay of chemicals can lead to dire ruminations. In Is it Me or My Meds?, David Karp articulates this nicely: “If people can change so dramatically by altering even slightly the volume of neurotransmitters in their brains, we need to wonder just who we are and what exactly makes us human. Consequently, people’s attitudes and feelings about psychiatric medicines go well beyond questions of health and illness. These drugs often cause people to confront basic issues about their own humanity” (13).
One important way this transition to a biomedical model of personhood came about was through an increased focus on the body within modern culture. Rose considers how ideas about the “somatic” individual came about:
What forces, what historical conditions coalesced to create these somatic understandings of the person? A good deal of it derives from the medical establishment.
During the era of the psychological self an abnormal person could commit himself to countless hours of talk therapy or even be committed to a psychiatric hospital for an indefinite period of supervision and therapy (cf. Kesey 1962). But with the development of successful antipsychotics in the 1950s came a dramatic movement formerly committed patients to outpatient status (Starks & Braslow 2005). With the development of tricyclic antidepressants—and later the popular SSRIs—the idea of committing oneself to long-term, expensive talk therapy began to wane. By popping a pill one could overcome depression, by taking medicine one could allay chronic anxiety. Not only was this method much easier, it was also cheaper.
But what is a pill? What do medicines mean in our culturally constituted world? In “An Anthropology of Materia Medica,” Susan Whyte provides a definition of medicines as dynamic tokens: “…they can be exchanged between social actors, they objectify meanings, they move from one meaningful setting to another. They are commodities with economic significance, and resources with political value. Above all they are potent symbols and tokens of hope for people in distress” (5). Medicines have meanings, medicines are meanings. And the meanings they express tie together many dimensions of personal existence and social realities. Karp writes that “psychothropic drugs have as their purpose the transformation of people’s moods, feeling, and perceptions. These drugs act on—perhaps even create—people’s consciousness and, therefore, have profound effects on the nature of their identities” (Karp 12). But given the philosophical ramifications of these medicines, why would a person ever take them? For what reason would someone consent to change their consciousness and potentially alter their very identity?
People take such risks, of course, to treat diseases. In the cost-benefit analysis of drug and illness, many people decide the bad feelings of continuing life as an ill person are just too great. Whatever risks they might pose, a medicine is potentially an escape from illness to health. And how are health and illness constructed? How do I know I am depressed rather than sensitive? When do I decide that my occasional flights of fancy and my recurrent doldrums are, in fact, symptoms of an underlying mental disease namely, bipolar disorder? Understandings about health and illness come both through a review of one’s awareness and through culturally mediated messages about mental illness. One of the most important sources of this information comes through “awareness campaigns.”
Sometime in the second half of the twentieth century depression and other mental abnormalities gained the status of treatable diseases:
A new social message became dominant: if one has a mental disease, his responsibility is to seek medical treatment and to comply with a course of drug treatments. To leave such diseases untreated is a moral failure not because one has the disease but because he isn’t living up to the responsibility of treating his affliction. Why are anti-stigma campaigns so prevalent? Have they developed as a need to counterbalance older prejudices? Did they come about as a way to improve public health? Were they engineered by companies to increase profits? All of these things—these morally laudable motivations and these morally questionable ones—combine in the awareness campaigns:
What we have in such campaigns is the “co-production of the disease, the diagnosis and the treatment. This can be seen in the strategies of psychiatrists, of health care professionals, of some support and anti-stigma groups, but most significantly of the pharmaceutical companies themselves” (Rose 2003:54). In a tangled mess, disease, diagnosis, and treatment become causally intertwined. One does not receive the diagnosis often until after a drug is found to be effective. Post hoc a diagnosis is given and treatment—namely the drugs already sampled—is to be followed for an indefinite period, often in perpetuity.
The pharmaceutical companies themselves do not claim to understand the precise mechanism of their psychotropic drugs. Comprehension of the brain and its regulation of moods is not so well worked out that we can actually ‘engineer’ medicines or even predict, with any certainty, what a new drug will do. Rather, it is through serendipity and the subsequent experimentation with molecules that have shown some treatment efficacy that we are able to come up with new drugs. Each of these drugs, taken into a particular individual’s system, leads to an ultimately unique set of responses, both biochemically and cognitively. A drug that successfully treats an illness in one person may be useless or even harmful in someone else. The diagnosis, treatment, and even personal understanding of a mental illness thus relate to each other in a looped system. Rose offers an interesting example of this:
What becomes clear in this example is that a confluence of medical opinions and economic motivations lie behind contemporary understandings of diseases like depression. This “marriage” of capitalism and medicine has amplified the institutional power of pharmaceutical companies many times over:
Rose does not mean to imply any kind of conspiratorial agenda at work. There is, of course, a profit motivation behind all of this but there is also the genuine desire to provide useful and effective drugs to those who need them. But if the second motivation were primary, then far more drugs would be in development for conditions of chronic pain and for the rare but terrible congenital diseases that plague humankind. In fact, though, most of the money for research goes into those drugs that generate the greatest profit for the pharmaceutical company. Often such drugs are not even vital for one’s health (e.g. Propecia and Viagra). Economic capital, marketing, and subsequent consumer demand cycle recursively. The economic and the medical are inextricably bound:
One of the messiest outcomes of this highly complex system is its shaping of new concepts of the self. From our treatment of illness we often derive what we consider to be normal. Because medicines are used in the treatment of suffering and human dignity, they often become linked to significant moral judgments. To call a person a cripple, to mock a hunchback, and to makes jests about idiocy are just some examples of the way that illness, abnormality, and human beliefs about persons created tremendous stigma not too long ago. In the creation of drugs, then, we also create novel ways of understanding people. The medicines that companies produce through a combination of market forces, profit motives, and consumer demand:
Guidelines for drug usage have expanded rapidly over the last few decades so that more and more people find themselves eligible for therapeutic intervention. Whereas depression, once called melancholy (see Figure 1), was a rare and severe state (Radden 2002) it is now thought of as the “common cold” of psychiatry. And just as people suffering from the periodic common cold are now prescribed powerful regimens of antibiotics, so are awkward teens and recent divorcees prescribed Prozac and Paxil. While the treatment of psychological suffering by medicine reveals the progress that has been made in our scientific understanding of the
brain, a host of ethical questions arise when people who do not truly need such medicines can be convinced, or convince themselves, that negative affect is abnormal and ought to be medically controlled. The powerful marketing forces behind the creation of consumer demand, as well as the legal and political loosening of medical advertising restrictions, have created a growing market for medicines. People can, with a minimal amount of information, find a medical diagnosis for some negative affect and request psychotropic medicine from their family doctor. If the family doctor feels that such medicine is unwarranted consumers will often turn to other medical professionals or even to the black market. This has led to such a proliferation of drug usage that many people take medicines not even to treat themselves for a mood disorder but because they want to feel “better than well.” People may take an SSRI not as a needed medicine but as a “mood enhancer” (Kramer 1993). Of course, there may be nothing wrong with this. If a product is available that people want and if it does them no harm then who is to say it should be limited for use of only severe cases of psychological dysfunction? Rose describes a changing world where “We are seeing an enhancement in our capacities to adjust and readjust our somatic existence according to the exigencies of the life to which we aspire” (Rose 2003:58). In the same way that plastic surgery—that is the invasive surgical alteration of one’s physical body—may be used to augment one’s breasts, to efface one’s Jewish identity, or to eliminate unwanted bulge, so are medicines being consumed to improve one’s cheeriness and to rid oneself of any unwanted guilt, justified or not. The biomedical model of the person is extending its boundaries from treatment of the ill to enhancement of the well, to “cosmetic psychopharmacology” (Kramer 1993). Whether good or bad, right or wrong, the prescribing guidelines for medicines—as well as their quickly expanding off-label usage—continues to create a larger and larger market for such drugs, which creates the demand for more drug production and discovery, which promotes the medicalization of everything from tapping feet to obnoxious children:
Indeed, the medical establishment is a rising power.
With the juggernaut of medicalization moving forward with increasing mass, its influences began to be felt further and further away from medicine’s traditional domain. One of the most important changes it has helped to effect is the creation of the “neurochemical self” already mentioned. The philosophical and social consequences of so fundamental a shift are vast:
Perhaps the most significant way that a society transmits its values and practices are in the education of children. If this is a fair criterion, then the implications of medical power are quite clear. In schools nowadays children who might once have been deemed ‘spirited’ or ‘spastic’ are now diagnosed with ADHD. Labeled as such, school systems now cause parents to assist their children in compliance to a drug regimen. Parents and students must consent to pharmaceutical ‘management’ of the disorder if they want to continue in their school districts. The subtle social and psychological consequences of being labeled as mentally diseased cannot be easily studied.
But in this example, as in the others, there are no simple resolutions. These children, in another time and place, may have excelled due to their energy or been consigned to subaltern status because of their inability to conform to educational standards. With pharmaceutical interventions these children probably stand a better chance of developing those skills and habits that their society deem important. Through the use of such agents as Ritalin and Adderall, these children may have a better opportunity to meet socially accepted standards of education and employability. But these children may also be developing unusual conceptions about their own personhood. They may be inculcated with a philosophy that promotes the medicalization of life problems. They will form part of the brick-and-mortar of the social and economic institutions that lie behind these drugs.
Conclusion The self is a very difficult thing to define. Because the self is fundamentally based in awareness and because this awareness is channeled through culturally constituted orientations, culture and the self will always be deeply intertwined. Moreover, because awareness is always fleeting, because one cannot hold—at any moment—enough in awareness to assess something as complex as the self, human beings rely a great deal on cultural institutions, tokens, and received ideas about health and wellness. While healing has always helped people to define themselves and to gain some handle on their problems, the purview of medicine has expanded so much that people are beginning to understand themselves almost primarily as “somatic individuals”, and as “neurochemical selves.” This focus on embodiment has a great many benefits including an access to technologies for personal enhancement and the creation of some stability in one’s well-being. But it may also convey a set of understandings that, in an increasingly global world, makes people even more susceptible to marketing campaigns and to an insatiable consumerism, a turn which threatens to convert all into a simple dialectic of supply and demand. While the material conditions of human existence ought to be well appreciated, an overemphasis on materiality—both in its economic and its biological meanings—may rob persons of their very personhood.
References Hallowell, A. Irving
Hippocrates
James, William
Freud, Sigmund
Kesey, Ken
Kramer, Peter
McManus, J.F.A.
Porterfield, Amanda
Radden, Jennifer
Rose, Nikolas
Rose, Nikolas
Starks, Sarah & Joel Braslow
Whyte, Susan
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copyright © 2008 by John J. McGraw. All rights reserved.
