Editor’s Note: Over the next several months, Mad in America will publish a serialized version of Sami Timimi’s book, Insane Medicine. This week, he explores the concept of neoliberalism and its impact—creating distress, marketing it, and selling its treatment. Each Monday, a new section of the book will be published, and all chapters will be archived here.
What is neoliberalism? Neoliberalism refers to a way of organising our political and economic systems using a particular model of capitalism that promotes free market economics based around competition as the best way to organise and develop pretty much every aspect of society. It’s generally associated with policies of economic liberalisation that promote privatisation, deregulation, globalisation, free trade, austerity, and reductions in government spending in order to increase the role of the private sector across all sections of the economy.
The term neoliberalism was first used at a meeting in Paris in 1938, where two men who came to define the ideology, Ludwig von Mises and, in particular, Friedrich Hayek, argued that social democracy and a greater role for the government in running society (for example, through having a welfare state) leads to a collectivism that will eventually occupy the same spectrum as Nazism and Communism.
In his famous book The Road to Serfdom, published in 1944, Hayek argued that government planning crushed the creative potential of the individual and would inevitably lead to totalitarian control. Hayek’s ideas received enthusiastic support from millionaires and their foundations, which saw in this philosophy an ideology that would strengthen their rights and reduce their tax burden.
Over the following decades neoliberalism garnered considerable financial support as rich backers funded a series of think-tanks, as well as financing academic positions and departments at top universities. This network of well financed international bodies refined and promoted Hayek’s ideas until, in the 1970s, they started to become incorporated into some government’s policies.
Despite the illusion of freedom, the first proper trial in implementing neoliberal policies took place, under the guidance of US advisors, in the brutal military dictatorship of Augusto Pinochet. Pinochet assumed power in Chile in a US supported and financed military coup that overthrew the democratically elected government of Salvador Allende in 1973. It quickly demonstrated that the freedom neoliberalism referred to was for the rich to become richer at everyone else’s expense.
The fact that tens of thousands were executed, and many hundreds of thousands more arrested and tortured under Pinochet, was no impediment to Western regimes looking with interest at the Pinochet government’s experiment.
In the mid-1970s, many developed countries were experiencing economic crises which created an opportunity for the first elements of neoliberalism, especially its prescriptions for monetary policy, to be adopted by Jimmy Carter’s administration in the US and Jim Callaghan’s government in Britain.
After Margaret Thatcher and Ronald Reagan took power, the rest of the neoliberal package soon followed: massive tax cuts for the rich, the crushing of trade unions, deregulation, privatisation, and outsourcing and competition in public services. International financial and economic institutions such as the International Monetary Fund (IMF), the World Bank, and the World Trade Organisation, soon proscribed similar policies. When the IMF or World Bank lent money to a developing economy it now came with neoliberal strings attached, forcing their governments to adopt these policies as conditions of loans, thereby pushing the global economy to become increasingly structured by neoliberal ideology.
By the 1990s, most economies were operating on these free market principles and the ideology had seeped into public consciousness, resulting in apparently left-leaning parties, such as the Labour party in the UK, abandoning their roots in welfarism and working-class solidarity and adopting a slightly amended version of neoliberal politics and economics.
For decades after the end of the Second World War, levels of inequality had declined in Western countries. Once neoliberal policies took over, inequalities expanded again. The gap between the richest and poorest in society expanded furthest in the most neoliberally inclined countries, such as the US and the UK. Under neoliberalism, economic growth has been markedly slower than it was in the preceding decades; except for the very rich.
Neoliberal policies have been beset by market failures with crisis after crisis since they were adopted. Not only are the banks too big to fail, but so are the corporations now charged with delivering public services. The Covid-19 epidemic has not been the cause of the resulting economic crisis, but a trigger that reveals how fragile such a system is for the livelihoods of the majority. Lives have to be traded off against the economy as, in this system, one does not support the other.
Neoliberalism preys on the labour of the weakest to enhance the lives of the richest. Big business takes the profits; the state keeps the risk. The international super rich classes have persuaded governments to use the periodic economic crises as both excuse and opportunity to further cut taxes, privatise remaining public services, rip holes in social safety nets, deregulate corporations, and re-regulate citizens, further enhancing the wealth and power of elites.
And I haven’t even mentioned the ingraining and embedding of historical racism that is further woven into the institutional structures of discrimination and exploitation.
Neoliberalism has shifted political power upwards too, with the moneyed classes controlling both the media and the funding of major political parties. As the domain of the state is reduced, our ability to change the course of our lives through voting also contracts. Instead, people are persuaded that they can exercise choice through spending. As parties of the right and former left adopt similar policies, disempowerment turns to disenfranchisement and large numbers of people turn away from collective and organised power and leave behind national politics to become more occupied with personal battles for subsistence and financial survival. Neoliberalism privatises the political as well as the economic.
What model of human does neoliberalism encourage?
Neoliberalism sees Darwinian-like competition as the defining characteristic of human relations. It redefines citizens as consumers, whose democratic choices are best exercised by buying and selling. It maintains that the market delivers benefits that could never be achieved by planning. It runs on the illusion that we have created a meritocratic society, where the most intelligent and hardest working rise to the top.
Conversely, this ideology also assumes that those at the bottom of the social status are the most stupid and/or lazy.
Attempts to limit competition are treated as anti-libertarian and a constraint on the smooth running of the meritocratic Darwinian natural order. Inequality is recast as virtuous—a reward for hard work and a generator of wealth, which trickles down to enrich everyone. Efforts to create a more equal society are seen as both counterproductive and morally dangerous. The market ensures that everyone gets what they deserve.
Not surprisingly, we then internalise and reproduce this logic. The super-rich persuade themselves that they deserve their vast wealth, ignoring the advantages of private education, inheritance, and class that most have had to help secure it, and the many lives they cast off and exploited to reach their dizzying heights.
The poorer classes blame themselves for their “failures,” even when they can do little to change their circumstances. Their disadvantage is the natural order of things and they can be grateful for what they manage to get in zero hours contracts and the kindness of those who give to food-banks.
Never mind the insecure employment tenures; if you can’t keep a job it’s because you’re not applying yourself. Never mind the impossible costs of housing; if your credit card is maxed out, you’re uncontrolled and irresponsible. Never mind that you don’t get time or money to cook proper meals; if your children get fat, it’s your poor parenting at fault. In a world governed by competition, those who fall behind become defined and self-defined as “losers.”
This model of neoliberal citizenship leads to each individual seeing themselves as if they were a “mini-business” in competition with others around them in the social jungle of survival of the fittest. More collectivist values such as duty, compassion, and solidarity are brought forth only if they can increase your access to the market, only if they give you some sort of advantage in the people market.
A creeping alienation from each other develops as our instinct to socially connect is reshaped as a vehicle to gain advantage. A degree of distrust and paranoia pervades relationships as we silently compare our social status to those around us, wondering where we stand and how others perceive us. This sense of personal insecurity and status anxiety worsens if we imagine or actually move upward or downward through the social classes.
We become image (brand) conscious and tempted into a process of an ongoing search for self-improvement, and the efficient application of our skills to maximise future returns. In today’s world you have to learn how to “sell yourself” as the language of the market enters ordinary human relationships and our model of self. It’s as if we have abolished slavery only to replace it with a system of entirely voluntary self-enslavement. As not only the macro-economy but everyday relationships become regulated by a version of market logic, what happens to those who feel themselves to be failing at their attempts to swim in the shark-infested waters of competitive performance?
Kate Pickett and Richard Wilkinson’s renowned 2009 book, The Spirit Level, examined, empirically and theoretically, the effects of inequality on societies across the world. Although in my opinion, they didn’t properly account for the impact of regional cultural differences and historical drivers, and some of their interpretation of the data was over-generous, they nonetheless provided a strong case that it is not just poverty per se, but the level of inequality in any given society that has the biggest impact on all sorts of health and wellbeing outcomes, including the prevalence of mental disorders, stress, and unhappiness.
Inequality—the gap between rich and poor—has profound impacts on people. After a decade of austerity since the publishing of that book, most families were further impacted by stagnant wages, increased job insecurity, swingeing cuts, and changes to the benefits system and public services nationally and locally in the UK (and many other countries) while the inequality gap grew.
The drivers of self-doubt, social anxiety, stress, and fear of how we are seen by others, which all have an impact on our day-to-day emotions and relationships, are massively exacerbated by inequality. A belief in meritocracy means that any failure is deemed a personal failure. According to Wilkinson and Pickett, greater inequality heightens social threat and status anxiety, evoking feelings of shame which feed into our instincts for withdrawal, submission, and subordination. When the social pyramid gets higher and steeper, status insecurity increases, leading to widespread psychological costs.
Furthermore, the social demarcations of class, from what we eat and how we talk to what culture we consume, are also rigorously upheld in more unequal societies, making all sorts of discriminations much easier. These social divides exacerbate the individualisation of all social phenomena that neoliberalism encourages.
In the neoliberal view, social change doesn’t occur through organised, class-based action, but through individuals acting in a “responsible” way. Saving the world from the proliferation of pollutant plastics happens through individuals being more conscious of their responsibility to nature, rather than through governmental policy. Then we can point the finger at those feckless idiots who are ruining the environment for the rest of us, whilst turning a blind eye to putting controls on the fashion industry, one of the planets biggest polluters. Class-based divide and rule emerges from behind the individualisation smoke screen as we fall in line with stereotypes of what these irresponsible “chavs” that ruin things for everyone else look like.
Am I performing well enough?
Competition is a key economic driver in neoliberal economies, and so this then also becomes a prominent social and cultural value. Market forces are freed to govern all aspects of societal functioning, including institutions previously owned, regulated, or managed by the state. From transport to schools, the dominant ideology is that competition will improve “standards” and is preferred to cooperation and/or social responsibility as a vehicle for improving population and personal wellbeing.
In neoliberalism, citizens are viewed as consumers who exercise their rights to “freedom” through buying and selling whatever they want. It’s a process that extols the virtues of success (often measured in material wealth) at the same time as making people anxious about failing in whatever arena they have found themselves competing. Inequality is viewed as inevitable, and being on the “failure” side of inequality is regarded as being due to personal deficiency and/or inefficiency in that competition.
The importance of social solidarity gives way to preoccupation with individual performance. The social unit and concept of “self” therefore becomes the individual in competition with those around her, involved in a never-ending struggle to be “better” (smarter, stronger, wealthier, more famous etc.) than their peers. Of course, very few will achieve such neoliberal-style “self-actualisation.” Most are then subject to the ongoing fear of falling behind and becoming defined (and/or self-defined) as being a member of a class of “losers.”
To live in a social scenario where you perceive that you are in the loser class and where this is individualised (as evidence of weakness, dysfunction, being undeserving, or, to soothe the guilt of the winner, being “vulnerable”) is obviously painful. Neoliberalism, however, has commodities to sell to help you deal with this.
This pressure to perform invades a wide diversity of domains of contemporary life. From corporate management to academic practices, from image to games, performance has become central. Knowledge is also produced through measuring a system’s (and by extension an individual’s) performance—be it organisational, cultural, or technological. Systems, organisations, and individuals are subject to ongoing surveillance and monitoring of their performance using surrogate measures of efficiency (from exam results and school league tables to work appraisals and stock market share values).
Knowledge and power are thus produced less through hierarchical imposition (though plenty of that still exists) but more subtly through production of competitive performance-related information.
The effect of absorbing this ideology is to privatise individuals to the degree where obligations to others and harmony with the wider community can become obstacles rather than objectives, unless of course this can place them higher in the “giving to charity” league table. In this “look after number one” value system, other individuals are there to be competed against as they too chase after their personal desires across a variety of performative areas. Figuring out who is the top dog in what, and once achieved, how to stay there, is more defining of personhood than how we support each other.
Children are cultured into the virtues of competition and consumerism, through competitive performing across a variety of arenas and by virtue of living within societal institutions (such as schools) that embody these values. The emotional correlates of failure such as misery, fear, and demoralisation are naturalised, individualised, and so depoliticised.
When you get feelings of insecurity, anxiety, and stress, and “epidemics” of self-harm, eating disorders, depression, loneliness, performance anxiety, and social phobia, these are simply the disorders of individuals with “dysfunctions.” They are medical conditions that arise from internal failings and that require health professionals to correct. They are most certainly not the outcome of the “winner” and “loser” social structure.
The impact of competitive performance starts young. An analysis of the academic performance of the entire state school population of England in 2013 replicates a common finding: the fortunes of the youngest in the class compared to the eldest in their class are dramatically different over the course of a lifetime. August-born children (the youngest in the class) get consistently lower results in school exams, are more likely to leave education early, get a diagnosis of ADHD, report feeling “unhappy,” and have a lower chance of getting into a high-performing university.
Performative competition, it seems, starts young and its impact continues for years. The effects go across the childhood population and are not just confined to various subgroups. Thus, surveys for various aspects of childhood well-being and happiness consistently put those countries that pursue the most aggressive neoliberal policies (such as the UK and the USA) at the bottom of these league tables for the developed world.
Selling to the vulnerable
Commodification refers to the process by which goods, ideas—indeed, anything—can become a “thing” with a commercial value that can be bought and sold, and subject to the influence of the market. Once a market industry grows around a commodified “thing” and it becomes available for making monetary profits, this “thing” becomes vulnerable to manipulation of consumers by the money-makers (with promises of a better life if they “buy” or have this “thing”). Childhood, parenting, mood, stress, and professional approaches to intervening in these, have all become subjects of commodification.
Human suffering, which follows from the pressures that inequality puts on people’s material and psychological well-being, is turned into opportunities to create individualised explanations and treatments. The growth of commodification contributes to both an increase in certain behavioural problems and the continual expansion of the repertoire of behaviours and emotional states considered to be “abnormal” (and therefore in need of correcting and treating with this or that product).
Neoliberal political economy has successfully commodified most domains of contemporary life, moving from goods to services, and in recent decades this has included the commodification of subjective states; from those considered “disorders” (such as ADHD, autism, and depression) to enhancing well-being, emotional intelligence, and self-esteem.
Commodification distances people from a more considered and involved understanding of the problems being experienced. It also disconnects people from the possibility that they already possess the knowledge to know how to deal with their subjective states, at the same time as reinforcing the idea that any perceived failing or suffering is the result of personal and internal factors that needs experts who have the technical know-how in order to manipulate and cure these internal “dysfunctions.” Individuals buy expert/technically developed commodities such as particular diagnoses, medications, and psychotherapies, which they are led to believe will enhance their quality of life with little adverse effects.
In a culture that is driven by the social arrangement in which the buying and selling of goods and services is not only the predominant activity of everyday life, but is also an important organiser of social exchanges, the commodification of distress and perceived deviance should come as no surprise. Thus, diagnostic categories relegate the individual differences of those given that “diagnosis” to being less important, instead promoting a more uniform and standardised set of “types,” which are easier to package, promote, and sell.
As distress and non-winner status migrates into being the remit of a professional class to deal with in a free market context, then commodification of distress, wellness, and competitiveness enhancement is just around the corner. Once we have categorised states of emotional and behavioural difference and these categories enter the market, they become subject to the process of “branding.” Each brand (such as autism, ADHD, bipolar disorder etc.) will develop a market that includes a variety of products and services such as professionals (with expertise in the brand), books, courses, and of course particular treatments (such as a particular medication or a particular form of psychotherapy).
Potential consumers for these brands will be a mixture of people with worries about their mental state and others in caring relationships with these people (such as their parents, colleagues, or teachers), who have come to be concerned that a problem is beyond their capability to resolve.
However, it is not just the person and their immediate social network of those who care for them, but also layers of social pressures and cultural beliefs (mediated by, for example, politicians and the press) that play an important role as consumer advocates encouraging us to seek commodity cures. These consumers now seek out a brand or a product (a diagnosis, an expert, books, a treatment) based on the information they receive (from advocates, media and a variety of other marketing sources) in the hope that the product will offer a form of validation (of the struggles and anxieties being experiencing) and/or a sense of promise (having the product or brand such as a diagnosis will lead to an improvement in their or their child’s life). Like all commodities, the appeal is more at the emotional/desire level than the rational one.
Once this system is set in motion we can predict a number of things will happen. Commodities tend to give only temporary experiences of satisfaction, as markets must keep selling to keep the monetary flow going and so must keep convincing consumers that there is a better product available or that if they stop consuming the brand (e.g. renounce a diagnosis or stop a medicine) their life would deteriorate.
Once an area of life has been subject to market commodification, we should predict that the market would grow in volume as the pressure to make profit continues and new products enter the arena. Thus, the number of available psychiatric diagnostic categories has continued to expand, both in the “official” manuals and in everyday practice. Not only do new categories emerge, but so do new subcategories, the number of professionals providing services, the number of professionals with specialisations and sub-specialisations, the number of treatment models, and so on. There is now a bewildering array of commodities out there for the concerned person or parent to browse.
Like any market, there are periods of high consumption resulting in a “bubble” and eventual pruning off of some competitors. Likewise, commodities can be subject to the changing whims of the producers and consumers as certain products go in and out of fashion (such as “autism” becoming more popular and “learning difficulties” becoming less popular).
As a relatively young market, the globalisation of this “McDonaldisation” of mental health has plenty of the world left to colonise. The owners of these new products (for example, institutional psychiatry and psychology based in the West and in partnership with the financial and marketing prowess of the pharmaceutical industry) are only just beginning the mass export and globalisation of this market and all the ideological implications this contains.
It’s a bit like the relationship of the dieting industry to the food one—our consumer culture contributes to creating mental stress and, as it spreads, this distress now presents itself as a new and growing market for exploitation and profit.
Selling with scientism
“Scientism,” as I have discussed, is the belief in the universal applicability of the scientific method and approach, and the view that empirical science constitutes the most “authoritative” worldview. Scientism reflects a tendency of putting too high a value on natural science in comparison with other branches of learning or culture.
I use the term “scientism” to describe the inappropriate usage of science or scientific claims and the deferential lack of critical questioning of claims made by those in the mental health industries who call themselves “scientists” or claim that their arguments, results, or practice are “scientific.” The idea that what they do is scientific is based more on what they do looking like science, rather than what the actual scientific findings are.
In order to gain a market in a culture using a narrative of science for authority, use of the idea of “science” becomes a more valuable selling point than the actual science, if what science discovers is not helpful for the selling of the product. Thus “evidence-based” becomes a phrase liberally attached to products (whether pharmaceutical or psychotherapeutic) as the narrative of advancement in health is associated with technology and the rhetoric of scientific progress.
Mental health is now an arena dominated by the language of scientism, where the use of brain scans, discussions about genetics, and the concept of evidence-based treatments fits into the image of a scientific technology that sheds light on and offers hope and remedies to the problems of living. This scientism has enabled the hiding of the actual evidence, which, as I have discussed, shows that the dominant paradigms we use are not evidence based and have utterly and miserably failed.
Maintaining the concept of “freedom” in neoliberal societies means that control is often maintained through mechanisms that encourage populations to internalise, self-monitor, and self-censor, rather than through more overt mechanisms of direct military/police state control. This process is encouraged by the large the amount of surveillance to which we are all, particularly parents and their children, subjected to, with an “army” of professionals tasked with this monitoring and an array of commodities made available that are promised to enhance lives by treating or otherwise improving their wellness when “disorder” is spotted.
When a young person is not reaching the expected high-level efficiency or shows what are considered deviations from the expected pre-destiny inscribed for successful neoliberal subjects (such as having fun at the same time as achieving academic success), introspection on personal failures and a search for an individualised solution is deepened. If they cannot be returned back to being successful neoliberal subjects, then they may be categorised as “vulnerable” and within the growing numbers assumed to be unwell (from mental illness—a defect within them) and who may need to become a long-term consumer of mental illness-related products.
The post-Covid world
Not all economies have run on purely neoliberal ideology, and the degree of penetration of its logic is variable. Whilst neoliberalism has undoubtedly been the dominant global economic and political creed, different and competing versions exist.
For example, China, now the second biggest economy on the planet, entered into the global markets under a system which believes in strong rather than weakened state interference. China’s capitalism is more command based (from the political centre) and its financial sector is mostly state-owned, meaning it has greater state control over internal markets.
Scandinavian countries, although partly swept up in the neoliberal globalisation trend, have largely maintained their roots in strong welfarism and provide a viable democratic alternative to rampant neoliberalism. Levels of inequality are much lower in Scandinavian nations and they regularly top international surveys of happiness and wellness. These are just two of many examples of national variations.
The years of post-2008 financial crash austerity gave rise, in many countries, to a sense of disenfranchisement and loss of trust in the political classes, who were felt to be not listening to or understanding the daily struggles of their populace. Politicians were stuck in the dominant dysfunctional economic model and didn’t anticipate the extent to which anti-politics would encourage the dangerous rise of right-wing nationalistic populism.
However, this has heralded an era where it is hard to see neoliberal politics as usual being able to carry on. Ultimately, right-wing populism serves the same elites and cannot have lasting solutions that will empower the powerless. It cannot deal with inequality. It is in this political vacuum that resistance to austerity and neoliberal logic have emerged.
It’s possible that some change in the political and economic order may occur. If it does, it may have some positive knock-on effects on the mental well-being of our populations, particularly if health ministers start hearing the case against the current mental health industry propaganda.
The human spirit is also tremendously resilient. We have not succumbed as a species to the isolationist demands of the Hayekian free market vision. No culture can be boiled down to single stories. Whilst neoliberalism promotes a particular version of the human subject, many others co-exist. Solidarity, compassion, altruism, and even love for our fellow humans keep breaking out. Our instinct to care for each other is intact. We are regularly reminded of this in Hollywood yarns that tell of the conflict between making money and strengthening relationships, where the good of being more relational in your life choices wins out. My many years of meeting and working with families have reassured me that love and concern for the welfare of each other is a fundamentally human trait that cannot be snuffed out.
Crises bring opportunities. Whichever way you look at it, the worst examples of dealing with the Covid-19 outbreak have been in the more neoliberally dominated, unequal societies. Whether it’s the death rate or economic impact, countries like the UK and US screwed up—big time. Obsessed with light-touch government and the individual, they tried to avoid policy injunctions that tell people, but most importantly businesses, what they have to do. We saw how quickly the economies then fell apart. The fragility of neoliberal economics has been laid bare; in a time of crisis, we have to trade saving lives with saving the economy, as they are antithetical. But it has also forced government hands and introduced new logics and heroes.
Not only are we seeing that governments can create, overnight, vast sums of money, which we were told we couldn’t afford in the years of austerity, but it has also shown how austerity was a mistake that left us unprepared for the challenge we face. Massive government intervention in the economy and public services has been shown to be possible and desirable in such a situation.
The market is not only seen as incapable of dealing with the new reality, but a potential villain, as those trying to profit from the situation (which is the purpose of business in any situation) are now seen as irresponsible. Entrepreneurial heroes like Richard Branson fall one by one off their pedestal and in their place, the looked down upon so-called “low-skilled,” but definitely “low-waged,” key workers, from those in the care sector to the health sector, are the new heroes, whose invisibility has overnight been transformed. What other changes emerge from these new circumstances, we will have to wait and see.
Neoliberalism teaches and encourages individualistic and competitive behaviour. Our common narratives tell us that “you can’t trust anyone,” and that people are by nature lazy and selfish unless given incentives. We are taught that human nature is inherently greedy and we have to accept this as a fact of nature.
In reality, there is a lot more evidence that humans are inherently cooperative, and tend to want to share from an early age. We have both a tendency to be individualistic and selfish and a tendency to be cooperative and altruistic. How we organise our politics, economies, and therefore societies determines which of these instincts will be nourished and encouraged to flourish.
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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.