When Alfred Adler, one of Freud's early followers, saw a patient for an initial consultation, he would take a history and ask the patient to give an account of what he was suffering from, in the traditional medical way, and then, right at the end, he would say to the patient, "What would you do if you were cured?" The patient would answer, and Adler would say, "Well, go and do it then." The patient is assumed to know what he wants, to know what his preferred life is, and his illness is the way he has inhibited himself. The problem, in this sense, is a pragmatic one: the patient knows what he wants; the only problem is how to get it, how to successfully negotiate the obstacle course of desire. The patient's symptoms are self-imposed obstacles. The patient assumes that were he to get what he wants, he would feel better, but he has made himself into an incompetent hedonist. In this deprivation model of so-called mental illness, life is about doing what you can to get whatever you feel is lacking in your life. We are ill either when we are unable to do this or, worse, when we no longer believe in it. People who are depressed, as Gary Greenberg makes abundantly clear in his lucid and unusually revealing book Manufacturing Depression, are the casualties or critics (or both) of this modern view that life is there for the taking, if only we can find a way—that unhappiness is a form of inefficiency.
This is, of course, a very upbeat view of mental illness, because it presumes, first, that what we want, what will make us feel better, is there (i.e., there's no scarcity); and second, that wanting works, that the ways we have evolved of getting what we want are competent (i.e., there's nothing intrinsically difficult, nothing essentially conflictual about wanting); and third, that we are good at knowing what we want, good at knowing what's best for us (i.e., because we know who and what we are, we know what makes us happy). Each of these presumptions that masquerade as assumptions is obviously contentious. But the many people who discuss these issues—and they are discussed both implicitly and explicitly with shrewd tact by Greenberg in this book—don't always know that people who are depressed live as if none of this is even plausible. Is there something wrong with them? Is there perhaps something wrong with someone if he is suffering at all? And what are we trying to do to suffering when we redescribe it as illness, rather than as something else? Is something an illness, for example, if there is a drug for it? And if there is a drug for something, does that make it an illness? Is all suffering an illness now, and is all illness defined as something we want a drug for? Science has been one of the very few things that have helped us believe in progress, but, not surprisingly, it hasn't exactly made a breakthrough with mental illness.
"A good science story," Greenberg writes, "can make you feel even better about progress and the prospects for humankind," but it has become increasingly obvious that the story of antidepressants, not to mention many other wonder drugs of the pharmaceutical industry, may be a bad science story that will make us feel even worse about progress and the prospects for humankind than we do already. Depression, as Greenberg's title indicates, may have been manufactured, by which he means described in a way that made it the "target" for certain kinds of treatment. Depression was "an enormous market opportunity," he writes, "for an industry that would aim its magic bullets at insanity." As Greenberg knows, a lot is at stake, and not only money, in the medical treatment of depression; around 30 million Americans take antidepressants, and the World Health Organization has claimed that depression is "the leading cause of disability" and the fourth "leading contributor to the global burden of disease." We may not be able to stave off for much longer a catastrophic disillusionment about what science can do for what it insists on calling mental illness for its own good and bad reasons. What is at stake, Greenberg writes, when we begin to think of our unhappiness as a disease is "who we are, what kind of people we want to be, what we think it means to be human."
If the anti-psychiatrists of the 1960s and '70s—most notably R.D. Laing and Thomas Szasz—were up against the scapegoating of the mentally ill as people akin to political dissidents, people in possession of unruly truths, then the new critics of psychiatry, who do not idealize mental illness, are up against the money-makers, the drug companies and doctors who, in the name of science, exploit so-called "mental illness" for profit. Greenberg, a practicing psychotherapist and, as he reports so eloquently in this book, a patient with depression, wants to renew our sense that mental illness is one of the ways we make meaning, not one of the ways we fail to. Manufacturing Depression, that is to say, is part of a new backlash against scientific psychiatry. Science can be disproved only by its own criteria; when it comes to mental illness, its own criteria are often insufficient.
You don't need to be anti-science to believe that in certain areas of our lives there has been a confusion of realms; that it has never been a question of whether scientific method is a good thing but of what it is good for, of how it gets us the lives we want and how it doesn't. If your child dies, no amount of scientific explanation will make you feel better. If you get an infection, antibiotics will probably work. Depressed people may be more like people for whom someone (or something) has died (or has not been able to live) than people who have an infection. At its most minimal, how we read the signs, what we see our suffering as, what we describe it as being like, have fateful consequences. Scientists sometimes want us to believe that the evidence speaks for itself, but evidence is never self-evident; people often disagree both about what counts as evidence and what evidence is evidence of. It is as though, now, the cult of evidence—of "evidence-based research"—is the only alternative to the cults of religion. But the sciences, like the arts, like religions, are forms of interpretation, of people making something out of their experience. And our ideas about health, mental or otherwise, are just another way of talking about what a good life is for us, what we can make of it and what we can't. What Greenberg wants us to know and to remember is that "the depression doctors, and their drug company sponsors, have overstepped with us. They don't know any better than you and I what life is for or how we are supposed to feel about it."
If this is another version of Max Weber's irrefutable remark in Science as a Vocation—"Science presupposes that what is produced by scientific work should be important in the sense of being 'worth knowing.' And it is obvious that all our problems lie here, for this presupposition cannot be proved by scientific means"—it also demonstrates Greenberg's characteristic evenhandedness. Or rather, what distinguishes Manufacturing Depression is that Greenberg never needs to take the upper hand. In the story he has to tell, which is a useful history of psychiatric diagnoses of depression interwoven with a riveting account of his own depression and his participation in an antidepressant drug trial, he doesn't assume—as the historians of madness and the anti-psychiatrists have been prone to do—that the depression doctors and their drug-company sponsors have straightforwardly got it wrong. Nor does he in any way minimize the scandalous complicity of the psychiatric profession and the drug companies, and the ways in which they have made false claims about their drugs and how they work.
They haven't straightforwardly got it wrong because depression, possibly like all so-called mental illness, is not the kind of thing you can be right about in the way you can be right about a broken arm. A broken life has many aspects to it, because to fail at one thing is always to succeed at another. Knowing better what life is for and what we are supposed to feel about it is one of the most interesting questions we can explore; it's only a problem, at least for liberals, when we need other people to agree with our answers (madness, the psychoanalyst D.W. Winnicott once remarked, is the need to be believed; liberals attempt to conciliate rival claims). For Greenberg, the problem with depression doctors and their accomplices is not that they are wrong but that they need to narrow our minds to sell their product, that they have got the answer only if no one else has. When the best cure needs to describe itself as the only cure, what the liberal wants to know is what has happened to the competition. Once antidepressants became the only game in town, it was no longer a town; it was only a game.
It is not Greenberg's way to be illiberal, so he wants us to be skeptical of those, like many of the depression doctors, who will not allow us our skepticism; he hopes we will not use our will to trust to endanger ourselves. He wants us to curb our childish passion to let other people speak on our behalf, and given that's what modern politics is, choosing or not choosing people to speak on our behalf, there is a sense in which Greenberg's book is both liberal and antipolitical. "I suppose I'll never know," he writes by way of conclusion, "whose story is the right one. But I know what mine is, and I'm sticking to it for now. The greatest injustice that Eliphaz and his friends inflicted on Job was that they refused to let him have his version of events. That's what the depression doctors want to do to you."
Job's comforters, or sticking to your guns. The plot, as Greenberg knows, is always thicker than this, because one's own version has always been informed by the versions of many others, and one's own version always meets somebody else's. It is a terrible thing not to be able or not to be allowed to have one's own version, and it is a terrible thing to have only one's own version. If one's own version is that one's life is not worth living, as anybody might feel some of the time and some depressed people can feel most of the time—or, indeed, that life itself is not worth living—why, let alone how, could one be dissuaded? This, at least, Greenberg's book allows us to consider. We can't help but ask, since Manufacturing Depression is such a stirring defense of and testament to the value of each person having his own version of events, and having it taken seriously, which version of events would be absolutely unacceptable to Greenberg? At which point in the conversation would he call the doctor or the police? All the available mental health treatments are inevitably complicit, to varying degrees, with the forms of discipline and punishment in operation in their societies. The depression doctors and the pharmaceutical industry have regressed, in Greenberg's view, to the late-nineteenth-century psychiatry of Kraepelin and his followers—"the important biography, then, was not of the patient...but of the disease"—in order to silence and confine the seriously unhappy. To rob them, essentially, of the story of their lives, and to make them pay for this as though it were a service.
In this sense, whatever else it is—and it is an interesting book about many things—Manufacturing Depression is a book about liberal democracy, which allows people the freedom to tell competing stories, and the scientific rather than religious forces that threaten to undermine it. It is also a book that shows us how deeply wedded all the talking cures—the nonmedical mental health treatments—are to the defense of liberal democracy rather than, as they once were, to a more radical politics. (Fantasies of liberation are not what they were.) "You can tell your own story about your discontents," Greenberg writes, "and my guess is that it will be better than the one that the depression doctors have manufactured." It's when therapies don't err on the side of guessing games, and don't acknowledge that this is what they are, that they become dangerous. The only therapies we should trust are the enemies of militant competence. Manufacturing Depression is an unusually amusing, moving and spirited account of why this is true, and of what we might be doing to ourselves by not believing it.