The Death of the Clinic? Emerging Biotechnologies and the Reconfiguration of Mental Health

Introduction

At the turn of the nineteenth century, the clinic became the main site of medical knowledge production. It assembled a hitherto unprecedented number of sick bodies and brought them into a new spatial proximity to the dissection room. The clinic thus established the conditions of possibility for a “medical gaze” to emerge that localizes diseases inside of the human body(Foucault 2003; see also Lachmund 1997). ¹ Since then, however, medicine has undergone various transformations. In the course of the twentieth century, the development of new biotechnologies (such as genetic, reproductive, and imaging technologies) and the use of large data sets have resulted in new modes of thinking and doing medicine. This is why scholars engaged in the social studies of medicine often refer to this new configuration as “techno-” or “bio-” medicine (e.g., Burri and Dumit 2007; Clarke et al. 2010). ²

Nikolas Rose (2007) conceptualizes the current transformation as a “molecularization” of the “medical gaze”: while clinical medicine had primarily localized diseases within the “molar body” based on anatomical-pathological knowledge, current medicine increasingly visualizes, understands, and intervenes at the “molecular level.” This shift in medical knowledge production is often linked to a vision of personalization. Proponents of personalized or precision medicine argue that medicine should overcome the current “one-size-fits-all approach.” Based primarily on genetic information and biomarkers, it provides diagnoses and interventions tailored to the individual characteristics of each patient (e.g., Tutton 2014; Prainsack 2017). This emerging “molecular gaze” not only corresponds to a new “government of the living” and a “new biopolitics of mental disorders” (Rose 2007, 216) but might even result in new forms of subjectification. It might reshape how humans experience, articulate, judge, and act upon themselves as “somatic individuals” (Rose 2007, 26).

Between “Hype” and Crisis: Emerging Biotechnologies and the Transformation of Mental Health

During the twentieth century, the “psy-disciplines”—psychiatry, psychology, and psychoanalysis—taught us to understand and act upon ourselves in terms of internal conscious and unconscious processes (e.g., Rose 1998; McAvoy 2014). However, the implementation of various antipsychotics and antidepressants since the 1950s has substantially altered psychiatric and psychotherapeutic practice in the second half of the 20th century (e.g., Healy 1997; Shorter 2009). In addition, these novel drugs seemed to confirm models of mental disorders that causally attribute them to a neurochemical deficiency (e.g. the monoamine hypothesis of depression, see Hirschfeld 2006; on the influence of the pharmaceutical industries, see Sismondo 2018, 24-27). In other words, what we observe is a shift in the way patients and their disorders are conceptualized in the psy-disciplines. In this logic, mental health and illness increasingly became questions of neurobiological processes that can be analyzed, and, in cases of what are considered to be malfunction, fixed using neuropharmacological interventions. In line with this reconceptualization, an increasing number of people in Western countries take psychiatric drugs at least once in their life or for long durations. According to a recent statistic of the Organisation for Economic Co-operation and Development (OECD 2017, 190-91), the population of its member states consumes twice as much antidepressants in 2015 than it did in the year 2000.

Corresponding to this shift in clinical practice, biopsychiatric approaches gained in importance within mental health research. Using novel imaging technologies that became available in the 1980s, such as fMRI, PET, and MEG, psychiatrists and (clinical) psychologists have intensified efforts to visualize the “disordered brain” (e.g., Dumit 2004; Rose and Abi-Rached 2013, 53-81). The former president of the United States, George H. W. Bush, prominently articulated the promise that neuroscience may lead to new and more effective treatments of various neurological and psychiatric disorders. Accordingly, he established an enormous funding initiative for neuroscientific research and proclaimed the 1990s to be the “decade of the brain.” ³

Today, it is widely held that the future of psychiatry and clinical psychology will entail the integration of genetic and neurobiological forms of knowledge (Rose and Abi-Rached 2013, 6). Although biographical and environmental conditions are considered significant factors contributing to psychological distress, various influential actors in this field conceptualize mental disorders as brain diseases, in other words as disorders of neurotransmitter chemistry or neural network activity (e.g., Insel and Cuthbert 2015). In light of these transformations, Nikolas Rose already in 2007 argued that we are increasingly becoming “neurochemical selves”:

The deep psychological space opened in the twentieth century has flatted out. In this new account of personhood, psychiatry no longer distinguishes between organic and functional disorders. It no longer concerns itself with the mind or the psyche. Mind is simply what the brain does. (…) This is a shift in human ontology—in the kinds of persons we take ourselves to be. It entails a new way of seeing, judging, and acting upon human normality and abnormality. (p. 192)

Furthermore, the transformation of psychiatry and clinical psychology outlined above is by no means consistent and monolithic. Empirical studies reveal various (a)synchronicities and even contradictions. Despite enormous research efforts, not a single genetic or biological marker has been identified so far that is specific to any of the major psychiatric disorders (see Rüppel in this special issue). ⁵ Correspondingly, diagnostic procedures in psychiatry and clinical psychology still rely on the narratives of patients and questionnaires, supposedly subjective assessments by clinicians. Psychiatric diagnoses, such as major depressive disorder, autism spectrum disorder, or schizophrenia, are labels for clusters of clinical symptoms based on diagnostic handbooks such as the US Diagnostic and Statistical Manual of Mental Disorders (DSM) (Wilson 1993; Mayes and Horwitz 2005; Decker 2013). Furthermore, professionals frequently argue that treatment decisions still follow a strategy of trial and error. Individual symptoms, on the one hand, and side-effect profiles of psychotropic drugs, on the other, are still the most important features that inform psychiatric treatment. In addition, since the late 1980s, there has been no major advancement in attempts to develop more effective drugs. In fact, in the past decades, several pharmaceutical companies have shut down their units for research and development of psychotropic drugs because they were unable to design new pharmacological agents during this time (Bahn and Schwarz 2011; Wegener and Rujescu 2013; see also Langlitz 2013). Other kinds of novel neuromodulatory interventions, transcranial magnetic stimulation (TMS) or deep brain stimulation (DBS), for example, have been only partially adopted in mental health care so far (Holtzheimer and Mayberg 2011; Guo, Li, and Wang 2017; Gardner 2013; Gardner and Warren 2018)

Therefore, one could argue that neurobiological approaches are both gaining in importance in psychiatry and clinical psychology and simultaneously in a fundamental crisis (Vidal and Ortega 2017, 139-43). Accordingly, many mental health researchers and clinicians not only ask for new approaches but also for an entirely new framework for diagnostics and treatment. A significant attempt to reshape the way mental health and illness are conceptualized is the so-called Research Domain Criteria Initiative (RDoC) started by the influential US National Institute of Mental Health (NIMH) in 2009 (e.g., Cuthbert and Insel 2013). RDoC can be considered a framework for research funding that seeks to go beyond the well-established “descriptive” diagnostics of mental disorders and to lay the foundations for a new “basic science”-based classification system (Whooley 2014; Kirmayer and Crafa 2014; see Pickersgill in this special issue). The call for a radical shift in the way mental health care is conceptualized and studied is certainly not new and was already famously expressed by George Engel in 1977. However, unlike RDoC, Engel proposed a biopsychosocial model that accounts for both biomedical foundations and “social, psychological, and behavioral dimensions” (1977, 135). As we have shown above, these currently most influential approaches do not tend to integrate biomedical and social dimensions but rather only tend to focus on the former.

In recent years, empirical social scientific research has revealed several dimensions of the various ways of living with new forms of psychiatric knowledge and technology. Some scholars investigated the everyday practices related to psychiatric drugs. With regard to Rose’s assumption of an emerging “neurochemical self,” Sandell (2016) found evidence that individuals treated with antidepressants understand their condition as a “biological, constitutional malfunctioning” instead of an effect of psychological processes (see also Fullagar 2009; Fullagar and O’Brien 2012). In her ethnography of “manic depression” in the United States, Emily Martin (2009) reveals the manifold practices and social meanings of this so-called bipolar disorder. She also notes that most actors in the field, members of support groups, physicians, or pharmaceutical marketers, for example, considered “manic depression” to be a “brain disorder” that is determined to significant extent by genetic factors. They correspondingly welcomed empirical evidence that was consistent with this assumption (Martin 2009, 11). Martin stresses, however, that there are still multiple ways of performing “manic depression”—of “what people do with ‘mania’ and why they do it” (2009, 9). Pickersgill, Cunningham-Burley, and Martin (2011) have likewise documented how neuroscientific ideas influence understandings of personhood and processes of subjectification. However, their study makes clear that the significance of such ideas for individual subjectivity varies between situations and is only a “part of a multiplicity of conceptions of self and others” (Pickersgill, Cunningham-Burley, and Martin 2011, 361). Fernando Vidal and Francisco Ortega describe what they call the “cerebralization of psychological distress” as an essentially ambivalent process (2017, 8). While it is often feared that this transformation leads to new forms of stigma, discrimination, and exclusion, it might also generate liberating effects. In this context, Vidal and Ortega (2017, 166-88) point to the “neurodiversity movement”. This term refers to a group of people mostly diagnosed with autism spectrum disorders who embrace the turn to neurobiological and genetic approaches as a means of identity politics. ⁶ From their point of view, these forms of knowledge enable them to reframe their condition as a “human specificity” instead of a disease requiring treatment.

According to Pickersgill (2011a, 74), mental health research and practice are characterized by fundamental “ontological and epistemological uncertainties.” There is no professional consensus regarding what mental disorders really are and how they should be investigated. Proponents of neuroscientific research frequently promise that this biopsychiatric research will resolve these uncertainties in the not so distant future (e.g., Rose and Abi-Rached 2013, 110-40). Focusing on antisocial personality disorder (APD), Pickersgill (2009a, 2009b, 2011a, 2014) shows, however, that these approaches so far have had little to no impact on clinical practice but instead add to the “ontological anarchy” in mental health. “By consistently failing to fully specify psychopathy, psychiatry comes to be further disunified as new knowledge is produced and circulated” (Pickersgill 2014, 165). His findings suggest that neurobiological accounts of mental disorders are “far more multifaceted” than this label and related terms (e.g., biopsychiatric) suggest (Pickersgill 2011b, 460). Further, for Pickersgill, these accounts are only one of many forms of knowledge that mental health professionals refer or not refer to, depending on practical considerations and clinical usefulness. ⁷ Clinicians are and remain “ontological bricoleurs” who assemble different interpretative frameworks for mental disorders (Pickersgill 2014, 165). Finally, the various forms of knowledge or interpretative frameworks that exist side by side in contemporary mental health research do “not determine in any uniform way the social practices and subjective understandings with which it is (or has the potential to be) associated” (Pickersgill 2012, 339-40).

Against this backdrop, in this special issue, we call for critical social studies of the psy-disciplines that take into account the diverse forms of knowledge and practice structuring the field of mental health. For science and technology studies of mental health to be successful, it is crucial to take the developments in the field seriously and try to understand them through empirical investigations and adequate theoretical conceptualizations. In other words, it is important to extend existing strands of social science research on the domain of medicine, biomedicalization (Clarke et al. 2010), or the sociology of diagnosis (Jutel 2011), for example, to the field of psychiatry and mental health. In order to do so, there can be no doubt that biotechnologies transform the epistemological foundations, research, and clinical practice of mental health. At the same time, we must recognize that so far biotechnologies have certainly not revolutionized mental health, and there is no indication that a fundamental transformation is on the horizon. The clinic as conceptualized by Foucault (2003) lives. Although during the twentieth century, a variety of new forms of biological knowledge have challenged or even replaced anatomical pathology in its foundational role for medical thought, the laboratory has by no means replaced clinical knowledge and expertise. Instead, we observe a “rebirthing of the clinic” (Latimer et al. 2006). In order to capture these processes, it is necessary to focus on the interaction between clinical and laboratory practices of knowledge production (see Hollin in this special issue). Accordingly, psychiatry and clinical psychology should be considered as “heterogeneous assemblage(s) of interacting material and symbolic elements” (Pickersgill 2012, 329).

By affirming this heterogeneity, however, we should be cautious not to lose sight of power relations. For us, critically studying the “psy-disciplines” means, first and foremost, taking into account conflict and contestation and raising the questions about whose costs and in whose interests a transformation is taking place. Furthermore, it is crucial to be sensitive to “epistemic hierarchies” (Vidal and Ortega 2017, 136) that can characterize supposedly integrative models and approaches in the domain of mental health.

For this reason, we put together this special issue on “emerging biotechnologies in mental health.” The issue comprises the work of scholars carrying out empirical studies and innovative theoretical reflections in this field. The articles contribute to debates in the social sciences that are relevant for scholars interested in mental health, the intersection of medicine, technology, and society, the links between bio- and psychopolitics (e.g., Eyal et al. 2014), the sociology of diagnosis (e.g., Jutel 2011) and science and technology studies in general.

Contributions to this Special Issue

Visions and expectations about technological and scientific progress have been a driving force in biomedicine. With the completion of the Human Genome Project, visions of individualized treatment and personalized medicine have been key themes in debates about the future of healthcare. Jonas Rüppel’s contribution opens this special issue with an analysis of the vision of personalized medicine in psychiatry. He outlines how this vision is being sustained and institutionalized in mental health, even though related research has repeatedly failed. Based on a document analysis and expert interviews, Jonas Rüppel identifies discursive strategies that help to keep the vision of personalization alive by securing its plausibility, protecting it from criticism, and maintaining stakeholder support.

As outlined above, experts in psychiatry and clinical psychology are concerned about a lack of investment and progress in psychopharmacology and the treatment of mental health issues. This development, or the lack thereof, is often attributed to an insufficient understanding of the underlying neurobiological processes of mental health and illness. In order to address this issue, the NIMH therefore suggests going beyond the existing categorizations in the DSM that have dominated and guided research and clinical practice for more than a half century. Instead, new studies should focus on the biological foundations of mental health and their respective interventions. In order to do this, the NIMH proposed an epistemic infrastructure called RDoC. Martyn Pickersgill’s article offers a novel perspective on this initiative. Based on interviews with different stakeholders and an extensive document and literature analysis, he does not provide a critique of RDoC’s biological emphasis but instead delineates how key figures of US and UK psychiatry account for its purpose, nature, and implications. In so doing, he shows that novelty is not an intrinsic feature of an entity or practice such as RDoC but is socially located and constituted through institutional contexts. Pickersgill thus advocates for a sociology that considers novelty as an empirical object in its own right.

In his fascinating article on autism genetics, Gregory Hollin questions social scientific narratives, such as biomedicalization or geneticization, that postulate fundamental transformations of medicine and the life sciences in the second half the twentieth century. Referring to Thomas Hughes’s notion of “reverse salients”, he points to the ongoing dependency of biopsychiatric research on the “mundane” technology of questionnaires. At least in the case of autism genetics, the “developed” and “emerging” technologies in psychiatry and clinical psychology shall be understood as constitutive parts of one “technological system.”

Victoria Pitts-Taylor concludes this special issue with a highly relevant and timely analysis of the neuroscience of poverty. She uses an intersectional approach in order to explore how some methodological and conceptual framings of the “brain on poverty” mark poor and minority children for intervention in concert with neoliberal approaches to poverty. She highlights the conceptual transformation of poverty in neuroscientific research from a social problem to a biomedical one. Framing a social problem as neurobiological at its core warrants different solutions provided by the life sciences. Pitts-Taylor’s article, therefore, shows how the life sciences create authority and become an important player in addressing perceived challenges of contemporary society.