Chemically Imbalanced: Everyday Suffering, Medication, and Our Troubled Quest for Self‐mastery. Joseph E. Davis, Chicago: University of Chicago Press, 2020, 256 pp.
In Chemically Imbalanced, Joseph E. Davis examines how ordinary people work toward improving themselves through the pursuit of self-mastery, a process filtered through practices of mental health care. Based on interviews with psychotropically medicated and unmedicated people in cities (e.g., Chicago and Boston) and rural Harrisonburg, Virginia, participants were suffering from mental health disorders such as depression and anxiety but were not diagnosed with more severe disorders such as schizophrenia. That Davis’s participants sought effective treatments, at times with multiple mental health providers, is an important point: The narratives illustrate how people live and negotiate within what Davis describes as the “neurobiological imaginary” (p. 37), which encompasses both internal processes (their sense of self) and external relationships (with providers, friends, and family).
To engage in this imaginary means people and stakeholders who inform their sense of self (e.g., prescribers of medication) perceive life predicaments such as failed intimate relationships or loss of solidarity with friend groups through our current biopsychiatric mental health lens. When predicaments create distress and suffering, people reinterpret their inner/outer worlds through the symptoms and categories provided in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as well as the dominant narratives around neurotransmitters (e.g., lack of serotonin). These are invoked through participants’ encounters with prescribers and family members’ experiences with psychotropics as well as media/Internet ads.
Davis highlights two key patterns that reflect how people placed themselves within the imaginary: the psychologizing perspective (PP) and medicalizing perspective (MP). PP was a catchall category for people who did not reference the brain or heredity as the cause of their problems—these individuals felt they could fix their problems with or without medications. The MP category was present for all participants who identified the locus of trouble in the brain as a result of “chemical imbalance” or other somatic factors. Rachel exemplifies the MP: Her predicament was not performing well in high school math and science, which led to panic attacks and an eventual generalized anxiety disorder diagnosis. She frames this as faulty “biological anxiety” and readily takes medication to improve her ability to cope. Phil was more typical of the PP; isolated after an accident put him in a wheelchair, he blames his unhappiness on his own inability to “[do] something about it” (p. 26). There are also outliers, like Dwayne, who felt medication and therapy were unthinkable, and Ernest, who tried medication with little effect, both of whom found relief instead by reconnecting with friends, community, and God. These two were African American, and although race/ethnicity is not a major emphasis of the book, Davis notes that many of the 16 African American participants stressed that stigma remained in their communities and often led to a denial of one’s suffering by themselves and others. Although he discusses the feminist critique of psychoanalysis, gender does not emerge as a key factor and an intersectional analysis could have been pushed further. Direct-to-consumer (DTC) advertising remains highly gendered, and Davis highlights an antidepressant ad for Pristiq featuring a female windup doll, which could have been used to critique how stereotypical gender roles have been exploited and normalized through the DTC imaginary for a century.
A key contribution is Davis’s analysis of the ways participants manage and interpret their own notions of selfhood, wellness, and illness through PP or MP. American culture, with its pragmatic view of success and achievement as well as self-help movements is interpolated through the neurobiological imaginary. Participants show a desire to feel, work, live, and love better, and within the context of these everyday pragmatics, they are free to do so. However, he argues they fall short of seeking genuine self-knowledge or gaining insight into their deepest self through medication and/or psychotherapy. The neurobiological imaginary offers a “powerful interpretive possibility,” yet paradoxically the source of one’s trouble can be “split off from the self,” located elsewhere in a faulty biology and detached from one’s history and context (p. 149).
The first three chapters deepen our understanding of how everyday suffering has been reframed by the pharmaceutical industry, psychiatric practices, and the DSM. Chapter 2 is especially rich in detailing how psychotropic medication pushed new practices for treating anxiety and discourses that privilege the DSM III and biologically based psychiatry. Davis effectively interrogates what is at stake when one’s life predicaments are filtered through the medicalizing perspective.
The second half of the monograph critiques how new forms of selfhood are limited through the neurobiological imaginary. In particular, Davis’s notion of the “third condition” places people’s suffering somewhere between ab/normality (the moral question) and illness (am I sick?). ADHD makes sense here, as sufferers question whether it is an illness and whether taking medication to perform better at work or school is bettering themselves or even morally acceptable. Davis’s analysis of the persistence of stigma (despite ongoing antistigma campaigns) is persuasive by showing that “biogenetic beliefs” correlate with more professional help seeking, the use of medication, and some reduction in self-blame. Yet, paradoxically, pessimistic, stigmatizing, and social avoidance attitudes toward sufferers of mental illness continue.
Most of the participants were linked by their search for viable selfhood. Medication, beyond being a diagnostic test for a disorder, allowed participants to re-emplot their lives, predicaments, suffering, and their sense of self within the neurobiological imaginary. Davis describes the kind of “good self” (p. 127) that emerges as mechanistic, enterprising, and adaptable; in other words, “being more normal in just the way that American society requires” (p. 162). It’s also flat, resisting insight-based treatments (e.g., psychotherapy) that accesses the depth of the self. People now work on themselves through a fix-it narrative in which the causes of predicaments are beyond their control, located in the brain, and the efficacy of pills is both real and symbolic.
In the end, Davis argues what has been lost in the imaginary is “the slow work of reflection” (p. 170). Drawing on a diverse range of thinkers (anthropological, sociological, and philosophical), Chemically Imbalanced forces the reader to consider how our modern selves are anchored differently (if at all) in diffuse social networks and imaginaries. “Depth models” of subjectivity have been replaced with compelling “fix it” models for people, who are drawn to the neurobiological way of imagining ourselves because it is promoted by “the social organization and tenor of our times” (p. 172).
Davis argues throughout his monograph that the neurobiological imaginary is good to think with, and by the end he shows that it remains a kind of “quiet” revolution (pp. 174–75). It now seems natural and holds out a kind of promise for “self-mastery” that is often never fully realized through medication. Yet, it persists through powerful stakeholders, such as Pharma and the American Psychiatric Association, and the not-so-powerful— ordinary people. He argues we have surrendered, even eliminated, a rich emotional vocabulary of stories and histories for technical explanations, brain-based notions of the self, and neurobiological interpretations of our predicaments—leading to what Davis calls “a crisis of the spirit” (p. 183).
Another crisis is mentioned on the final pages, leading to perhaps my lone criticism of this important contribution to critical pharmaceutical studies. Davis notes that to the surprise and frustration of some participants, “even the professional” (i.e., the prescriber), focused on the symptom to the exclusion of them as “suffering persons,” eclipsing any larger discussion of their situation and flattening the psychiatric clinical encounter—the med-check appointment. One could argue psychiatry is in a paradoxical crisis when the writing of scripts usurps discussion of life predicaments, suffering, and the sense or meaning of symptoms (Freud 1956 ). However, the med-check space—a space that is underexamined in Davis’s work—is relational and remains a site of negotiation between patients and providers. Nonetheless, Chemically Imbalanced will no doubt motivate important scholarship in this area as well.
Freud, S. 1956 . (Seventeenth Lecture) The Meaning of Symptoms. In A GeneralIntroduction to Psycho-analysis, translated by J. Riviere, 268–83. New York: Permabooks.