My institutional homes keep me crossing the Atlantic, between Montreal and Paris. During my current stay in Paris I’m concentrating on one of the stickiest questions in my research on social phobia, or social anxiety disorder, which has recently been imported into France. I am pre-occupied with the question: why here, why now? Basically: why it is that people in France have recently started to identify themselves as ‘social phobics’ and what brought about this change?
A few details will help to set the scene. A change is taking place in France that began forty years ago in North America. Cognitive, behavioural and biological models of the mind/brain and mental illness are replacing psychoanalytic theories of the self and psychic unrest. In North America this process was officially complete by 1980, making it unproblematic to accept psychic unrest as a disorder essentially separate from the self. This made mood, and later anxiety, disorders appear manageable by cognitive training and medication use. The conditions were shorn of their previous stigma related to a failure to take responsibility for one’s difficult personality and a pathological unconscious mind.
A similar process is underway in France with similar psychiatric models being adopted. Cognitive, behavioural and DSM-style biological psychiatry took some time to establish its institutional foundations, but is gaining currency rapidly and social phobia is closely tied to its professional and public popularization. The French therapeutic model is not the carbon copy of the American model and there are local differences in how the therapeutic orientation is understood and implemented. For instance, basic psychoanalytic concepts appear to be folded into the new French therapeutic orientation and an effort seems to be made by cognitive and behavioural therapists to introduce philosophical concepts into their patient care and public descriptions of their therapeutic approach. This is perhaps in an attempt to prevent the ‘lowering’ of their practice to something that could be done by any trained interventionist. Cognitive and behavioural therapy (CBT) was, after all, created with the aim of enabling multiple types of health care workers, not just psychiatrists or psychologists, to provide psychiatric support for patients. French psychiatry historically has a strong tradition of intellectual inquiry that contemporary psychiatrists are reluctant to leave behind. Despite these differences, and for the sake of this field note, the most important point is that despite these differences, a North American cognitive, behavioural and biological psychiatry has arrived in France.
To return to my basic question, why has this perspective, and the related diagnoses such as social phobia, installed itself in France now, rather than earlier, later or not at all? Why was a new psychic identity imported? There are a few obvious factors. Interested parties actively worked to introduce social phobia and CBT into France, including psychiatrists who were interested in promoting their new form of therapy to strengthen their careers and better situate their therapeutic orientation in French society. The pharmaceutical industry has also played a role in supporting the dissemination of information about CBT and social phobia. But of course, these factors cannot ‘make’ people ‘social phobics’ in the sense that they adopt the diagnostic category as a part of their identity and as a means of explaining their life troubles. The diagnosis needs to offer them something to help them get by in day to day life. The ‘social phobics’ (as they refer to themselves) I’ve spoken to over the years state without fail that their goal at the end of their therapy for social phobia is that they want to live a normal life, have a boyfriend or girlfriend, a job they want. This may not be entirely different from neurotics or other patients seeking care for their anxiety via other therapeutic interventions so that they can also be ‘good’ people and live ‘normal’ lives. However, identification with these particular symptoms and this particular therapeutic approach relates to a couple of key changes in French society.
First, anxiety in social situations makes the sufferer as well as the people around him or her uncomfortable and it is increasingly something that appears necessary to take charge of. It questions the validity of our social interactions and ways of living. Is it possible that current social conditions in France, including fears about social integration and social insecurity, have made the symptoms of social phobia particularly unacceptable? After all, these sentiments are not entirely new. They were either considered of little significance until recently or, the patients’ problems were seen as having different significance. For example, that they were a sign of depression or an expression of neurosis. Perhaps it is only now that social unease is considered important, even shameful. This represents a change in French society in terms of social expectation. In what has traditionally been a society in which a few authoritative leaders guided others–who had every right, and in fact a responsibility–to be diminutive, there is an increasing expectation that one will assertively work on charting one’s own course. In this new French society, argumentation is expected from all members of society, not the select few. A diagnosis of social phobia helps individuals to explain, and justify, why they are unable to cope in this competitive climate.
Second, the adoption this new therapeutic approach reflects changes in French society and culture more broadly. France’s previous means of dealing with anxiety, psychoanalysis, reflected a distrust of medicine and the government, a desire to reach autonomy through self understanding. It highlighted the importance of history, insight and through its eclectic formation, provided a nationally-particular means of addressing anxiety. The increasing adoption of a perspective which casts aside personal history as relatively unimportant and which values functionality above all else reflects a significant shift in French society. Further, the new therapy is based not on a French, but on an American model. Is it possible that this globalization of sentiments is a part of the battle to situate French individuals and French society in a changing world, in which traditional French values are losing their currency? Perhaps it reflects a critique of a nation that is struggling with its place in a new world order where France is a bygone empire.
I’m not yet fully convinced by these explanations, which have grown out of discussions with informants throughout my research, but what does appear to be happening is that biomedical technologies are morphing in parallel with the social changes around them, providing the grounds to both criticize society and simultaneously to be able to function more smoothly within the new social conditions. The social and the biological are tightly wound in this case, making it difficult for all players to discern where one ends and the other begins.