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PSYCHIATRIC DIAGNOSIS AND THE MARKET RICHARD U'REN* Market forces are decisively altering the practice of psychiatry in the United States. One example, familiar to all psychiatrists, is the decline of private practice, caused by a combination of cost-containment measures imposed by third-party insurers, increased competition from other mental health professionals, accelerated practice costs, and loss of traditional fee-paying patients to health maintenance organizations [I]. But there are other, more subtle, and usually less noticed ways that market forces affect psychiatry. One example is the impact of these forces on psychiatric diagnosis. To develop this argument, some remarks about the capitalist economic system are necessary. "The single most important element in capitalism," writes Robert Heilbroner, "is the driving need to extract wealth from the productive activities of society in the form of capital" [2]. By "capital" Heilbroner here means money or profit, though he points out that money is not the only form of capital. In fact, capital is not a thing at all but, rather, a process by which money is transformed into commodities that are then retransformed into more money: the famous M-C-M1 formula of Marx. Absent from conventional definitions of capitalism (an economic system characterized by private ownership of means of production, production for private profit, etc. [3]) is the exceptionally dynamic, ever-changing, expansionary nature of this unique economic system, in which wealth is not used as an end itself but as a means of gathering yet more wealth. In precapitalist feudal society, in contrast, economic surplus was "invested " in cathedrals, palaces, armies, etc., and thus permanently "bound" to tangible objects. What drives this unrelenting effort to expand, besides human nature? One factor, Heilbroner notes, is that capital exists in a constant state of vulnerability as it passes through its M-C-M1 circuit. Capitalists are *Department of Psychiatry, OP02, Oregon Health Sciences University, Portland, Oregon 97201.© 1992 by The University of Chicago. AU rights reserved. 003 1-5982/92/3504-0802$0 1 .00 612 Richard U'Ren ¦ Psychiatric Diagnosis forced to compete with each other as they sell commodities or services to the public in order to regain the money capital they have dispersed to the public in the form of wages and other costs. In this struggle, capitalists seek to gain advantage of other capitals. The most effective way to achieve this is by developing new ways of organizing the M-C-M1 circuit in its middle link, which means refining technology to either produce new commodities or refine old ones [2]. The unending introduction of new models of cars, cameras, VCRs, and personal computers are familiar examples. Less often appreciated, however, is the scope of capitalism's search for new investment opportunities. There is no place, activity, task, feeling, personal relationship, body function, or experience that cannot be enlisted in the quest for profit, through either commodification or advertising . In capitalism, Heilbroner observes, "Daily life is scanned for possibilities that can be brought within the circuit of accumulation." He cites the "steady movement of tasks" such as laundering, cooking, and cleaning from the private household into the world of business as a testament "to the internal expansion of capital" [2]. Programmable washing machines, microwaves, and self-cleaning ovens are three obvious examples of this process. These products represent physical activities that have been brought into "the circuit of accumulation" through commodification. David Smail caught the spirit of this process perfectly when he observed that, in this system, anything people can do for themselves is a waste of an opportunity for someone else to make money [4]. If a manufacturer hopes to sell products to the general public, these commodities must of course be brought to notice. Vast monies are spent in advertising, and it is here that space and time are pressed into service by the market. Advertisements are now beamed into school classrooms and doctors' waiting rooms. It is the rare T-shirt, sweatshirt, or even dress shirt that does not bear some company's logo. Even parking meters and the doors of bathroom stalls have been used for advertisements. Emotions and feelings associated with marriage, engagement, and anniversaries have long been evoked to sell products...


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