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I am not very sure of the meaning of « neuroeconomy ». But we could agree that we meet here to give a meaning to this word. It is a task to be made, not something already existing.

One of our main problems is the manner psychopharmaceutical drugs are changing, in a tremendous manner, what Michel Foucault called the “psy function”. We now have a neuroeconomy which combines a very powerful industry (the pharmaceutical industry), some very particular commodities (the psychopharmaceuticals), some professions (physicians, psychiatrist, and psychologists) and some experts who are on the verge of different fields of knowledge and propose new mental disorders or new manners to diagnostic them in relation with the psychopharmaceuticals. We have also a more and more important patient advocacy movement whose future needs to be discussed as Nikolas Rose has shown: will they be only “consumers” or will they invent a collective expertise essential for the future of psychiatry?

But there was a moving neuroeconomy before the invention of theses modern drugs beginning in 1952 with chlorpromazine.

I would like to propose here three historical situations which could help us to work on this issue. These three situations are very different not only because they are related to very different conceptions of what we call « neuro », or to different historical periods, but because it seems that we need different theories to observe them. This is the relation between the analyst and the facts which seem to be of diverse natures in theses three examples.

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1. The beginning of Chronicity

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To understand the new situation beginning in 1952, it could be useful to have a look at another period of the history of psychiatry.

The historians of French psychiatry had to solve a problem: to understand a deep change in psychiatry around 1880 (for this period it would be better to talk of alienism). A new idea surged at the end of the century: chronicity. You could find it before, but it was very marginal. From 1880, it became the centre of interest for alienists and in a short period of time it filled 80% of psychiatric textbooks. What happened?

In a paper published in 1971 by Les Annales, Georges Lantéri-Laura who was a psychiatrist and an historian, proposed a new explanation (Lantéri-Laura 1972). For him, alienists did not become more perspicacious than their predecessors without reason. He did not accept the idea of an abstract “progress of the reason” isolated from practices. You must find the reasons which allowed the alienists to see things that they did not see before. For what reasons?

Lantéri-Laura insisted on one point: the idea of chronicity expanded when the law of 1838 compelling each department to build an asylum became a reality in the 70s. In 1873 the Inspection générale counted 104 establishments (nearly the number of departments).

The asylums were built in the countryside. The internees had to do all the work necessary for the life of the establishment: they tilled, cooked, laundered, and so on. Each asylum had to function with the minimum of cost for the departments and the state. Lanteri-Laura made a comparison between the asylums and the large plantations in the south of the United-States in the slave period. They lived in autarky. He wrote:

“This sort of enterprise could exist only if labour was not rare, if the patients stayed for a long time, particularly the ones who could work; if they went out too quickly it was not profitable for the establishment. The long period of internment took the form of a particular characteristic of this branch of medicine, a natural one, when it was only the result of the conditions of observation. One took the conditions of possibility for the existence of asylums to be a characteristic of mental diseases. The patients are observed in an institution which could maintain itself only if the patients were hospitalised for a long time.”

We must understand that the alienists did not adopt a cynical point of view. They observed the patients in a new different manner and some features which existed before but were not considered important obtained a new status. A new pattern concerning what was a mental illness surged and there were a lot of reasons to consider it to be progress. It was now considered to be cruel to discharge patients not totally normalised. Working could help them.

If you look at the statistics in the main countries, you see the same thing: the numbers of patients in the asylums were in constant progression until 1952. In France you find 110 000 internees in 1940. They were only 59 500 in 1945 but this was because of starvation during the Second World War.

We can understand the logic of the situation. But what happened when this model became inconsistent with the economic conditions in the 30s?

For economic and structural reasons, it was necessary to keep the patients for a long time in asylums. For economic and structural reasons, it was also going to be necessary to find a way to get the patients out.

After the Second World War there was a lot of attempts to get the patients out. Some psychiatrist were convinced that asylums were iatrogenic. They tried new treatments as “institutional psychotherapy” but don’t forget that lobotomy or psychosurgery was the main event. We have very good books on this practise in United-States.

I was for a long time very enthousiastic with the explanation by Georges Lantéri-Laura. But I think now that it presents a difficulty.

Maybe the weakness of his point of view is that he made his historical approach only in France. Of course, it would be interesting to make comparisons between France and others countries. Take it as an encouragement for other enquiries. But the main problem is about the relation between the economic field and the attitude of the psychiatrist. For Georges Lanteri-Laura, “chronicity” is the counterpart of a new economic system. This is a massive explanation.

How do psychiatrists change their point of view concerning how to determine and treat the troubles of their patients? What is the mechanism which explains the adequacy? How do we obtain a cognitive attitude of the physicians which is coherent with the economics needs? If we refuse, rightly, to consider they were cynics how can we explain they change their manner to see the patients? It seems that the explanation by Georges Lantéri-Laura goes too fast. We miss a link. May be it relates to a more specific difficulty: can we explain a specific problem (the change of diagnostics) in reference to a general one (an economic situation)? Bruno Latour is very sensitive about such an issue and argues that we should never give general reasons, or structures the power to explain, but follow the imbricated agency of tiny reasons. In a way he proposes to shift from the classical sociology of Durkheim to a new one whose founder could be Gabriel Tarde.

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2. What differences made psychoanalysis ?

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I would like to take a second example. What is the « neuroeconomy » of psychoanalysis and how could it help us to better understand its very particular history?

Generally we agree to consider that Freud inherited of hypnotism after his travel in Paris and his encounter with Charcot in La Salpêtrière. The historians explained how he transformed hypnotism in the cathartic method with Breuer, then in psychoanalysis, which he thought could have much better results with every patients and not only with some patients well chosen like it was the case with hypnotism.

We also know very well that Charcot was not an alienist but a neurologist. He was not in charge of men and women in asylums which originated in the work of Pinel and the project of his main pupil Esquirol. Freud did not established relations with alienists during his travel in Paris.

Edward Shorter (1997) writes: “For several decades, psychiatrists were glad to adopt this theory of illness causation as their own, because it permitted them to shift the locus of psychiatry from the asylum to private psychiatry.” For the first time, analysis opened the road to private practice.

For Shorter, Freud “had privileged access to a group of patients who were especially needy in psychological terms: middle-class Jewish women in families undergoing rapid acculturation to Western European values.” Shorter explains the success of psychoanalysis in the context of “the Jewish emancipation of the nineteenth century, the small-town Jews of the east flocked to the cities of the west, using the high-school diploma as launching pas for careers in the liberal professions”. Psychoanalysis was well adjusted “to the psychological needs of a deracinated group in transition: young middle-class Jewish women who aspired to be like non-Jewish counterparts.”

He adds: “It would be hard to imagine a therapy less appropriate for the needs of people with serious psychiatric illnesses.”

And he can conclude that the decline of psychoanalysis can be explained by “the increasing assimilation of the Jews. They no longer required psychoanalysis as a badge of collective identity because they were no longer affirming themselves. Instead they were becoming like every one else.”

May be the proposal of Shorter is only partial and cannot explain the success of psychoanalysis in a country like France, particularly its transformation by Lacan. Notwithstanding, this explanation is very interesting because, in this case, it is not the “economy” which made a new “neuro” but a new “neuro” which allowed a new economy to flourish.

Maybe we could go further.

Psychoanalysis originated another big change in the field of “neuroeconomy”. The education of psychoanalysts is not a classical one in the universities. Freud considered that psychoanalysis had not to be restricted to physician, but could be “profane”. His daughter, Anna Freud was not a physician. The way to be psychoanalyst is very specific: you must have been psychoanalysed. It’s the only thing which matters. Of course, every professional practising a form of psychotherapy has very often experienced the one he practises. But in the case of psychoanalysis it is something very different. It is not an experiment. It’s a long way and the psychoanalytic institutions have been created to give the guarantee that your personal analysis has been very deep, generally for long years. The community of the other psychoanalysts is only here to check it. The “epidemic” nature of psychoanalysis is very interesting. You can choose any psychoanalyst and you can trace them back to Freud. So, you can draw a very good cartography of psychoanalysis.

It is more an initiation than an education, which explains that to discuss psychoanalysis may be seen as an existential menace: each psychoanalyst has been deeply transformed by his experience. It could be its main efficiency. That has a lot of consequences. I will take only one, namely that it could explain the nature of the resistance of psychoanalysts to the changes in the field of psychiatry.

What is the function of psychoanalysis? A treatment for neurotic patients AND a method to form new analysts. If the first objective disappears, the second one can continue to exist creating a very specific economy outside the field of psychiatry. But, in this case, the possibilities of a discussion between psychoanalysts and others healers (hypnotists for example) becomes very difficult. Psychoanalysis takes the risk to become something like a sect. Some French psychoanalysts assume this position.

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3. The tremendous change made by the modern drugs

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I would like now to try to understand the very particular “neuroeconomy” which appears with the psychopharmaceuticals, my main concern.

Everybody knows their tremendous consequence. In the fifties, Ludwig Binswanger told a psychiatrist: “Fritz, with two pills, you destroyed a psychodynamic castle that took me 50 years to build.”

Like their colleagues, after the Second World War, the psychiatrists in Paris’ Sainte-Anne psychiatric hospital wanted to find a way to empty the psychiatric hospitals. Without this preoccupation, they would not have conceived the idea that an antihistaminic drug (belonging to the class of phenothiazines used for a long time against allergy: maybe you know by your own experience that they make people sleepy) could be used to calm patients, to be what specialists called a “major tranquiliser”.

The invention of chlorpromazine is not per se an event. Humans always used psychotropic drugs. The important fact is not chlorpromazine. It is the second one: imipramine put on the market a few years later by a Swiss company, Geigy. With imipramine we can understand that chlorpromazine was not another drug like others used before, but the beginning of something we could call a “phylum”, a lineage.

When you compare the chemical structures of imipramine and chlorpromazine, the differences are actually very tiny. This is not surprising: Geigy had the project to make what we call now a chlorpromazine “me-too”. So, they tested molecules very similar to chlorpromazine and which could be easily made. You can learn all about this story in David Healy’s book, The Antidepressant Era (Healy 1997).

But there is an important fact: imipramine was a disappointment. It did not have the effects of chlorpromazine on schizophrenic patients. Clinicians and the pharmaceutical company hesitated for some time: the molecule seemed to have euphoric effect. It “produced an increase in vivacity and a restoration of interest in activities in general and in social interaction in particular.” (Healy 1997). It was the first antidepressant.

With these four facts – chlorpromazine, chemical synthesis of a me-too (imipramine), disappointment, and a new indication – we have all the factors allowing us to understand the new period. Let’s see why. A lot of pharmaceutical companies tried (and it is still the case today) to invent successors to chlorpromazine. How did they conduct research? They didn’t try to test their molecules on schizophrenic or depressed animals (rats, mice and dogs). This is impossible in the present state of the art. They tested them on normal animals. And this is still the case today. They tried to find molecules provoking the same (or, better, nearly the same) effects on the animal’s comportments or on the biochemistry of cellular’s receptors (dopamine for instance) as the first compounds discovered by serendipity.

Something new began in 1952: not chlorpromazine per se, but a new process of testing molecules and inventing drugs which is an open one, from one to the next, with the only concern to obtain only small differences in effects between the new ones and the old ones. It is interesting to observe that all the compounds which could not initiate such a phylum fell in decline (Rauwolfia).

It is a sort of “machinery” which was established in the centre of the psychiatric field. Possibly you know that the philosophers Gilles Deleuze and Felix Guattari used the term “machine” to describe something very similar to my machinery: it produces a phylum, like living species. But more, a “machine” is always in interaction with other machines: “A technical machine, for instance in a factory, interacts with a social machine, an educational machine, a research machine, a marketing machine, and so on.” (Guattari 2007).

We can say that it was a fantastic opportunity for pharmaceutical companies to invent with chlorpromazine a treatment which was not perfect, to say the least. And it is the same history with imipramine and their successors. If these first treatments had been definitive, perfect ones, they could not be the beginning of a phylum.

Now, we can try to understand better how this machine functions. We must take the proposition “machine” seriously and not as a metaphor. This machine produces on one side what I propose to call a “light biology” and on the other, a “light psychology”. “Light biology” is the sum of knowledge, instruments, and technologies concerning living animals, organs, cells, which are used to invent successors. Dopamine is for instance one of these instruments. You know that if you want to create a new compound for schizophrenic patients, it must have an action on dopamine. “Light psychology” takes the place of the psychic apparatus of the psychoanalysts. If you read the DSM you have a good description of this light psychology when it is disordered.

As we saw in the case of imipramine, the machine doesn’t produce absolutely identical products. The new ones have always little differences. The pharmaceutical industry tries to invent molecules which are less potent. They are less potent, so they have fewer side effects, and hence they have a great market quality: physicians do not hesitate to prescribe them to less severe cases. There are plenty of them now.

“Light psychology” and “light biology” act in cooperation. The light psychology gives to physicians a new manner of looking at patients, of questioning and examining them. It makes psychiatric diagnosis easy for general practitioners. We could say that the psychotropic drugs invented since chlorpromazine must transform the physicians first. Then, they transform the patients! We could add something very provocative: the less they have a positive effect on patients, the more they have a positive effect on psychiatrists. They will await the next molecules with impatience! They are caught in the phylum.

Psychiatry went out with the psychiatric wards. General practitioners have now become the main prescribers. There is a big irony in this history: psychoanalysis invented psychiatry out of the asylums, in the cities. But this new psychiatry developed itself tremendously only when the new psychotropics drugs were available.

Each molecule forms a pair with a diagnostic. Each element of the “light biology” is related to an element of the “light psychology”. This little machine can recruit new patients. If you separate them, psychotropic drugs appear as molecules concerning which we know very few things; and the disorders also appear very flimsy.

I would like to conclude with some proposals which could help us to invent the new field of neuroeconomy.

1. My analysis of the role of the drugs in the performation of a new neuroeconomy is very similar to the one proposed by Andrew Lakoff in his book The Pharmaceutical Reason. It implies that the growth of some mental disorders, like depression, cannot be explained by too general patterns, for instance as “a sign of changing cultural models of the self” in relation with “recent social transformations and new personal demands” (I quote Lakoff). With the deleuzian concept of “machine”, we escape the choice between an economic and a neuro determinism.

2. The philosopher Ian Hacking is the author of a very interesting book on the surge of the Multiple Personality Disorder in United-States. He proposes the metaphor of the “ecological niche” to explain the “transient mental illnesses”. I think this metaphor can have a much wider use, not only in the case of transient mental disorders. What makes some medical diagnoses possible and some impossible ? It will oblige us to find in each situation the vectors, the mechanism which explains how something rare (for example the diagnostic of hyperactivity) becomes more and more frequent.

3. A “neureconomy” never pre-exists. It must always be built. We should study attentively the works of Donald Mackenzie or of Michel Callon on the shaping of economies by economics. How economics is producing economies. Kalman Applbaum published a beautiful work “Educating for Global Mental Health: the Adoption of SSRIs in Japan” in the collective book Global pharmaceutical. He explains how “a moralizing rhetoric and mega-marketing program” are necessary to link science and commerce, and make a market.

4. Neuroeconomy must be a place where very different people, historians, sociologists, philosophers, but also physicians, psychologists and patients could work together. Not only for academics proposals but to understand the new world which appears and to be able to act on it. It could be the only manner to fight the disease mongering.

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References

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Barrett R. (1996). The Psychiatric team and the Social definition of Schizophrenia. Cambridge University Press, Cambridge.

Guattari F., Rolnik S. (2007). Micropolitiques. Les Empêcheurs de penser en rond, Paris.

Healy D. (1997). The Antidepressant Era. Harvard University Press, Cambridge (Mass.).

Lakoff A. (2005). Pharmaceutical Reason. Knowledge and Value in Global Psychiatry. Cambridge University Press, Cambridge.

Lantéri-Laura G. (1972). La chronicité dans la psychiatrie française moderne. Annales ESC, 2, 548-568.

Lantéri-Laura G. (1997). La Chronicité en psychiatrie. Les Empêcheurs de penser en rond, Paris.

MacKenzie D., Muniesa F., Siu L. (2007). Do Economists Make Markets? On the Performativity of Economics. Princeton University Press, Princeton and Oxford.

Petryna A., Lakoff A., Kleinman A. (2006). Global Pharmaceuticals: Ethocs, Markets, Practises. Duke University Press, Durham and London.

Shorter E. (1997), A History of Psychiatry. Wiley, New York.