“Chemically Imbalanced”

Source: David Perkins/University of Chicago Press

“At the heart of everyday suffering,” writes University of Virginia sociologist Joseph E. Davis in his fascinating new book, Chemically Imbalanced: Everyday Suffering, Medication, and Our Troubled Quest for Self-Mastery (University of Chicago Press, 2020), “is anomalous experience” and how we make sense of it.

Davis conducted interviews with multiple American adults aged 18 to 63, encouraging them to respond “if they struggled with being sad, with being anxious in social settings, or with concentration or attention problems, and if they would be willing to talk about their experience.” Participants were recruited from metropolitan Chicago, Baltimore, and Boston, as well as central Virginia.

Almost half of Davis’s sample was taking medication, the others not, yet virtually all participants described their suffering “in mechanistic, typically biological terms” involving—or conducive to—medication. They were most likely to invoke brain states as explanations for stress, frustration, disappointment, and unhappiness—precisely the everyday suffering that the DSM asserts should be exempt from psychiatric diagnosis.

Yet for those everyday states, too, respondents almost universally spoke of a “chemical imbalance” or “misfiring brain circuitry,” leading them to think of their condition as a somatic malfunction needing psychotropic medication. They were far less likely to say they had encountered psychological difficulties needing a change of behavior, outlook, or perspective.

Across the book, the biological emphasis is remarkably consistent, despite widespread debunking of both “chemical imbalance” and “serotonin deficiency” theories by leading psychiatrists and by a range of empirical studies. Participants nonetheless spoke of “a chemical thing in the brain”; “a slightly miswired brain”; a “nerve symptoms thing”; “the wiring, it’s wackomo”; “just a messed-up thing in my brain that needed to be fixed.” They sometimes took these self-diagnoses to their doctors as well and ensured receipt of medication for them.

“Everyone has been exposed to this biomedical healthscape,” Davis contends, amassing a large amount of supporting evidence from popular culture and the rise of biological psychiatry and of psychopharmacology since the 1950s. “The lay environment is saturated with medicalizing language and expectations for dealing with everyday suffering.”

Of her shyness, for example, one respondent tells him: “It’s definitely something I needed medication for. So, it’s something biological.” Just as circular and uniform, responses asserted biological causality even when the source of difficulty was work-related, relationship-focused, tied to finances, or self-described successes and failures.

The amount and degree of self-directed criticism recorded, chiefly from female respondents, is also stark, not least when it collides rhetorically with its presumed origins in biology: “constantly angry with herself”; “a bit hard on herself”; “I have very high standards of myself”; “I’m a failure and a disgrace”; felt “an imperative to ‘have it all together all the time’”; even, saw her “tendency to berate herself as indicative of a genetic condition—a slightly miswired brain.”

Part of the appeal of the “neurobiological imaginary,” Davis notes, is its apparent simplicity, efficiency, and exemption from blame, along with the notion that it “optimizes” both patient and treatment. Everyday struggles are recast as “symptoms of ‘real medical conditions.’” Through lowered diagnostic thresholds, those conditions are then pronounced widespread, with virtually everyone considered susceptible. Blame evaporates; the suffering is “caused by neurochemical aberrations that are outside conscious control.” And then the problem is typically rendered as “easily treated,” with drugs presented as “working to correct the underlying somatic malfunction.”

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Largely as a result of this misleading chain of assumptions, promoted nationally through “awareness campaigns” and ubiquitous pharma advertising, “medication enjoyed a far better reputation than psychotherapy.” It did so, Davis found, despite psychotropics’ well-documented sexual side effects and withdrawal problems. The book also reports that “patients take popular medications far longer than they used to,” are prescribed them in much-greater numbers at increasingly younger ages, and are far more likely than in past decades to take more than one treatment at a time.

The rise in pharmaceuticals is also associated with “a sharp move away from psychotherapy,” and Davis can document a corresponding “thinning” in descriptions of personal experience in favor of assumptions that are impersonal, mechanical, instrumental, and behaviorist. After all, as he notes, “the very use of a drug—a chemical substance—speaks to and convinces people of neurochemical causation.”

No less concerning, Davis finds that “exposure to therapists was nearly as highly associated with a medicalizing explanation as exposure to medical doctors.” He traces how some psychotherapists in the 1990s encouraged stimulant medication, such as Ritalin, as “promoting the verbalization of repressed and subconscious material.”

That Americans at almost all ages are now routinely de-psychologizing traits and behaviors, and representing them instead as exclusively biological phenomena has profound social and cultural consequences, and Chemically Imbalanced is alert to all of them. To begin, that we are entirely “recasting” emotions and states like shame, remorse, pride, envy, self-contempt, disappointment, and guilt “fundamentally alters the way that we conceive of them and how best to express and control them.”

“With a medicalizing perspective,” too, “troublesome experience is flattened out, reduced and recast in an impersonal language of symptoms, diagnoses, and brain states.” The new emphasis may appeal with its promise of making us optimized and “very high functioning,” but ultimately, it “obscures the whole person who suffers with a shallow, mechanical view of human being that impoverishes us all.” It blinds us collectively to “the social dimension of our struggles,” including that they are widely shared, and is not just flattening and oversimplifying, but practically misleading.

Perhaps most paradoxical of all, Davis can demonstrate, a brain-focused approach actually worsens psychological distress by intensifying expectations that life should result in seamless, efficient functioning—a notably (though not exclusively) American fantasy, where, as another commentator puts it, “Everything is about going forward … Falling back is the American nightmare.”

Chemically Imbalanced is a book focused on the resultant “strain between ideals and standard.” The notion—arguably, the cultural and diagnostic fantasy—that “a type of person, a way of being—and perceived insufficiency can be wiped away, as by grace.” When that process almost inevitably falters—when, as Davis writes, the prescribed drug does not “actually deliver desired feats of self-transformation—what it did do,” he reports, “is support and affirm a causal interpretation and the sense-making that interpretation offers.”

One of the book’s strengths lies in documenting and examining this complex gray area between diagnostic theory and everyday reality with prescribed drugs, to spotlight how “medical symbolism, neurobiological concepts, and pharmaceutical being [are] taken up as social objects or narratives that people invoke to make sense of and alter their life trajectories.”

It is nonetheless concerning that just as Americans and others look to neurobiology to understand and explain their distress, “psychiatry and medicine more generally find themselves without any clear neurobiological basis for clinical work and, at the same time, without depth models of subjectivity and the sort of languages for exploring inwardness.”

In our “troubled quest for self-mastery,” Davis implies, the risk that we’ll misconstrue factors as pervasive as self-criticism and self-contempt by rendering them somatic malfunctions all but guarantees that the suffering will continue—and will, as a result, continue to be misunderstood and mistreated.