The World Health Organization predicts that by 2020 depression will be the second most common illness worldwide. It is quite clear that an ever-increasing number of people are afflicted by doubts about their circumstances. They are worn down by stress and anxiety; they feel exhausted and burnt out; they experience violence, social exclusion and feel a sense of hopelessness about the future. In the global South in particular, marginalized people often suffer from massive psychic health problems, yet they seldom have access to any public health care infrastructure.
Scandalous though this development is, such forecasts are fraught with problems. Strangely, it is not only the discontents of globalization that are on the rise, but also the tendency to separate the anxiety caused by the prevailing conditions from its social context and to ascribe it to individual pathologies. Where care is available (i.e. mainly in the global North), mental illness is increasingly being treated with drugs or therapy in response to short-sighted goals determined by efficiency. Standardized diagnosis and therapy guidelines claim to be applicable to every situation. The risk is that psychosocial care will simply become a service provider to a profit-oriented healthcare industry. At the same time, responsibility for social anxieties and mental illness is being privatized, and the individual is expected to maximize his or her own performance; the right to health is being gradually transformed into a duty that is incumbent on each individual.
Hence it is not the circumstances that are at fault, but the individual. Yet the rise in diagnoses such as depression, post-traumatic stress disorder (PTSD) and ADHD is not simply a reflection of a highly alarming individualization of social ills, but also a neoliberal form of individuality that offers new possibilities for behavioural control and discipline.
Colonization of the lifeworld
On closer analysis what we call globalization turns out to be a global unleashing of capitalism. The capitalist economic system has now reached every corner of the earth, even if it takes a different form in each of these corners.
Capitalism’s success is not least down to its ability to standardize every expression of human life to make it predictable and subordinate it to the demands of an economy predicated on profit and growth. The aim has long since ceased to be the exploitation of labour; it is the capitalization of every area of human existence: food, education, emotions, social relations, communication and even the human body, which is increasingly commodified through genetic engineering, reproductive medicine and the organ trade. Globalization has not brought greater freedom and individuality, but a progressive subjugation of everything, even a person’s private life, to a purposive rationality determined by market forces and bureaucracy. As economic thinking increasingly permeates our bodies, emotions and institutions, this “colonization of the lifeworld” (Jürgen Habermas) reduces individual room for manoeuvre ever further. Humans are becoming Homo oeconomicus – and with it an exchangeable addendum to the all-conquering economy.
The ideal human being is a “bio-automaton”, who guarantees a smooth production process, accepts exclusion without complaint, doesn’t stand out at school, doesn’t become a burden on a social security provider and consumes goods and services - including ones that support his or her health and fitness - to a great age. The human body is no longer seen as something private, but rather as an object of political control (Michel Foucault) and of exploitation.
“There is no such thing as society,” announced Margaret Thatcher in the late 1980s, laying out a manifesto for the radical free-market transformation of the world. Since then, wherever social forms based on solidarity existed, they have been hollowed out and the institutions of public care for people’s livelihoods have been privatized. Healthcare, education and culture are less and less the defining characteristics of a humane civilization; they have been left to dwindle into “business models” governed by management benchmarks. Europe’s hospitals are no longer run so as to provide the best standard of care, but according to the most efficient beds occupancy rate; local authorities are judged by how successfully they can “cap” their budgets, television stations by their audience figures, cinemas and museums by entries and visitor numbers, schools and universities by how many pupils, students and doctoral students they can rush through, and research institutes by their fundraising, citations and the number of patent applications they have submitted. Health is becoming a commodity, doctors and professors are changing into entrepreneurs, and patients and students into customers. In these circumstances it is no surprise that psychotherapies are also being standardized into timed modules that must be “evidence-based” and effect a quick fix.
The subjugation of public-spiritedness to the interests of power and economics has had wide-ranging consequences. The principle of social responsibility has been replaced by the neoliberal-influenced notion of individual responsibility. This has created a new idea of man that has made people themselves, rather than social relations, responsible for their situation. Nowadays it is not the tabloid press alone that sees poverty or flight as being largely self-inflicted. Without a social safety net, without any civic sense, the idea of individual responsibility can only lead to a pervasive egotism driven by self-interest – or its reverse: imposed social exclusion.
The neoliberal transformation of the world has indeed eroded appreciation for mutual solidarity and has spread anxiety and social indifference. That people’s sense of justice has increased over the same period is no contradiction. Justice is seen less and less in relation to universal rights, i.e. in view of other people’s rights; instead, each person stakes out his or her individual rights. It is evident how deep the neoliberal message “If everyone takes care of themselves, everyone is taken care of” has burrowed itself into people’s minds – even into the imaginations of those who stand to lose the most from this “cultural erosion”.
Self-absorbed egotism presents a growing threat to solidarity and empathy. Every TV talent show sends out the message that there is only one winner; the rat race starts at the nursery and continues into the retirement home. Losers are covered in ridicule and consigned to insignificance. Their losses inspire feelings of shame and anxiety – and these psychic impulses must be deflected.
As capitalism’s great promises of freedom and autonomy are ultimately left unfulfilled, a general and virtually insatiable craving for compensation has arisen. Any such compensation is, of course, illusory. It may express itself in the incessant consumption of fetishized goods, as well as in ethnic excesses or identity-forging fundamentalism. Both of these – self-absorbed pleasure and exclusion – are not just an opiate for the masses (in the sense of ideological delusion and manipulation), but rather an opiate of the masses (in the sense of having to satisfy instincts and deflect anxiety).
The only option when faced with anxiety about failing and about one’s uselessness is to embark on an endless quest. A quest for identity, though one that now lacks any fixed reference points; a permanent striving to connect to circumstances that are so fast moving that planning for them is virtually impossible. The result of this fleeting quest is a “flickering consciousness”, with disquiet as its guiding principle. This disquiet is in total conformity with the system. It is impressive how closely the feeling of inner drift corresponds with the omnipresence of a market whose evanescent imagery demands permanent yet evanescent motion. It is no surprise that people become exhausted as they pursue this restless quest that never actually reaches its goal. The consequence of the entrepreneurial self is an “exhausted self” and depression.
Survival of the fittest
These dynamics are not only operating in the North; they have established themselves across the globe. In the global South social exclusion is accompanied not only by structural violence, but by open violence too. Their correlation is closer than ever, but also less evident. The political scientist Peter Lock sees the everyday occurrence of military and criminal violence as a regulator of neoliberal globalization, which has produced extreme concentrations of wealth on the one hand and expanding zones of social exclusion on the other. Instead of a global village with perfectly self-regulating markets, the world has become a maze of continuously emerging walls, fences and virtual barriers creating a range of sharp social divisions that exclude people, reduce their participation in neoliberal globalization to virtually nothing, and spreads scandalously exploitative conditions.
Cascading social exclusion is also evident in geographical realignment and aggressive gentrification. Gated communities and secure apartment blocks that tower above a sea of shantytowns are a feature of every “global city”. Fear of a fall in social status dictates people’s attitudes to life at each level of this cascading social and spatial fragmentation, and division and exclusion are becoming central to how people organize their lives. It is at the bottom of the cascade that the “shadow society” is to be found in the city slums that house at least 1.4 billion people live worldwide. These lifeworlds predominantly lie beyond the reach of state care and security, and their lack of protection encourages the emergence of criminal organizations under various “godfathers”, gangs, fundamentalist sects and terrorist groups, whose violence-based economy nonetheless has close ties to the formal economy.
The common characteristics of people’s personal lives within this “shadow society” are the survival of the fittest, social and sexual violence, a lack of rights and protection, an erosion of solidarity and a loss of empathy.
We have learned about the real-life consequences of these developments through our longstanding contacts and conversations with project partners in over 30 countries. From Mexico we hear that Central American migrants on their way to the USA have to jump aboard moving trains so as to avoid discovery and often lose arms, legs and even their lives as they hit power lines. Local gangs lie in wait for them, repeatedly attacking and robbing them when they take a break from their travels. Quite a few are kidnapped and used to extort money from their despairing families who have stayed at home.
We have learned that many Congolese women who fled from Congo after being raped now live in the inner-city slums of Johannesburg, a city of several million inhabitants. With no other means of making a living, they sometimes hire out their bodies, in the knowledge that the price is likely to be infection with HIV. Should they succeed in earning a little as hawkers, they live in fear of being forced out by other hawkers and of xenophobic attacks by South Africans who are just as poor as themselves. These women live with the constant threat of interlocking structural and individual violence. medico partners in KwaZulu Natal, a province of South Africa that is blighted by political violence, systemic poverty and an extremely high incidence of HIV/AIDS infection, report an increasing number of cases of people with HIV being mugged for their medicine as they return from the clinic. It is mixed with other ingredients to make whoonga, a synthetic drug whose use is spreading among marginalized youths in line with their realization that they will never find an apprenticeship or an acceptable job.
Even in these situations, poverty and failure are attributed to the individual, not to the social and economic circumstances; people seek compensation or demonize other socially marginalized groups. Very few of these people can count on sympathy and help from traditional family and neighbourhood ties and other social security institutions; at best they can hope for charitable handouts. Those who are unable to come to terms with this life consider themselves losers, see family violence and conflicts as their personal failing, face mental illness, drug and alcohol dependency, encounter religious promises of salvation, and come to know the world as a place that they can neither influence nor change.
Ambivalence about helping
“Rapid Reaction Force for the Soul” is the title of a medico publication from 15 years ago, in which we began to argue against defining a trauma known as post-traumatic stress disorder (PTSD) as a personal disorder, because it separates an illness caused by society from its context and considers it a private health problem. From this perspective trauma is no longer seen as a “normal” reaction to the experience of “abnormal” human violence, but as an individual health problem to be treated with therapy. It is becoming increasingly clear that efforts to avoid traumatic experiences and change inhumane social conditions are no longer the priority, which is instead to help people to adjust to the terrors of real life and bolster their “resilience” so that they can cope with these terrors.
This privatization of social suffering is well advanced as diagnosis attributes it to a number of recently discovered illnesses. “Psychopathologies” such as ADHD, burnout, anxiety disorders and depression have become a mass phenomenon and are generally treated with (short) therapies and drugs. This standardized interpretation of the globalized world’s discontents as individual illnesses makes it possible to stigmatize, control and exploit those that suffer from them. There has been a huge rise in the worldwide consumption of psychotropic drugs, and the pharmaceutical industry is eyeing up the promising new markets in the global South. The discoveries made by neuroscience provide ideological mood music to a conception of mental illness as a functional neurological disorder. According to this view, one should be able to treat even people in the Congo, Uganda and Afghanistan who have endured extreme ordeals in wars, sometime over decades, with psychotropic drugs and short-term therapies.
It would seem that progress is nothing more than the adaptation of an unruly individual to the will of authority and the economy. Yet the course of history is defined not by progress, but by suffering. Social utopias do not draw their inspiration from an abstract ideal, but from people’s experience of suffering and their rebelling against its injustice. Despite the increasing sense of despair, there is also a perceptible whiff of rebellion against the current state of affairs. This too is an expression of the growing discontentment. Loners and members of social movements, trades unions and human rights organizations around the world are calling for changes that give them new opportunities and offer them some perspectives. “A civilization,” wrote Sigmund Freud, “which leaves so large a number of its participants unsatisfied and drives them into revolt neither has nor deserves the prospect of a lasting existence.”