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In this volume, scholars of cinema studies, philosophy, English, sociology, health-care education, women’s studies, bioethics, and other fields demonstrate how the world of medicine engages and permeates the media that surround us. Whether examining the press coverage of the Jack Kevorkian–euthanasia controversy; pondering questions about accessibility, accountability, and professionalism raised by such films as Awakenings, The Doctor, and Lorenzo’s Oil; analyzing the depiction of doctors, patients, and medicine on E.R. and Chicago Hope; or considering the ways in which digital technologies have redefined the medical body, these essays are consistently illuminating and provocative.
Contributors. Arthur Caplan, Tod Chambers, Stephanie Clark-Brown, Marc R. Cohen, Kelly A. Cole, Lucy Fischer, Lester D. Friedman, Joy V. Fuqua, Sander L. Gilman, Norbert Goldfield, Joel Howell, Therese Jones, Timothy Lenoir, Gregory Makoul, Marilyn Chandler McEntyre, Faith McLellan, Jonathan M. Metzl, Christie Milliken, Martin F. Norden, Kirsten Ostherr, Limor Peer, Audrey Shafer, Joseph Turow, Greg VandeKieft, Otto F. Wahl
Psychiatry, Scopophilia, and Psychotropic Medication Advertising, 1964-1985
JONATHAN M. METZL
Scopophilia, literally the pleasure in looking, describes the ways in which post-Oedipal male subjects look. As defined in Freud's "Three Essays on Sexuality," scopophilia arises from the male child's preoccupation with sexual difference, and his desire to "complete a sexual object by revealing its hidden parts" (Freud 1905, 69, 181). In Freud's well-worn theory, the child scopophiliac becomes anxiously aware of "the private and forbidden," in the form of other people's private and forbidden genitals. The male child looks at these parts as if a voyeur, at the same time observing and completing his notion of himself in the process of observation. Thus do children learn-and then adults perfect-the technique of looking at another person as an object while coming to know themselves as subjects. In the process of observant apperception, men come to realize both the power of the gaze and the ways this power is gendered at the expense of something else. In the division of active and passive, men look and become empowered (active), while women are looked at (passive) (figure 1).
The assumptions embedded in a system in which men look and women lack have formed the basis of many social critiques of dominantmodes of seeing. In the discourse of the politics of looking that has emerged in the twenty-five years since Laura Mulvey, Mary Ann Doane, and other critics began to apply psychoanalysis to the study of the cinematic signifier, the argument has been quite convincingly made that scopophilia has larger political implications for a culture where male viewers enjoy the socially sanctioned position of the gaze. Visual images substitute for early life experiences, and responses are often seen as collective assertions of power, themselves structured like the unconscious. Dominant spectatorship is thus considered an act of filling in the gaps: men enjoy the privilege, to paraphrase Mulvey, of identifying with "more ideal, more complete" images of themselves, such as male movie stars, and of voyeuristically holding images of women in front of their own absences as if they were fig leaves in a gesture of pudeur (Mulvey 1989, 24). Patriarchal power is both destabilized by, and recuperated through, images of women (Mulvey 1989, 17; Pollock 1991, 22). Meanwhile, resistance to this order has until recently come through a retheorizing of spectator positions in the name of co-opting, or refusing, the dominant mode of seeing (Bal 1991, 14; Pollock 1999, 220-29).
The supposition that print advertisements for psychotropic medications have historically relied on a scopophiliac's gendered connection between active and passive-in the form of coherent men actively looking as subjects, and subsequently feeling empowered to think of women as objects-also lies at the heart of many critiques levied by scholars in the humanities and social sciences against the marketing of pharmaceuticals to doctors. Here scopophilia is assumed to function not only as a drive, but as a methodology of persuasion as well. Numerous studies of these advertisements over the past quarter century argue that pharmaceutical advertisements coerce their viewers to gaze at depictions of women in various forms of passive patienthood in ways that expand existing epidemiological gender imbalances between women and men for mental illness. For example, Janet Walker's analysis of pharmaceutical advertisements in Couching Resistance: Women, Film, and Psychoanalytic Psychiatry (1993) describes a visual regime in which images are "almost always positioned to demonstrate the superior vantage point of the male psychiatrist," whose power allows him to look down on the women in his purview (32). Similarly, Hawkins and Aber's "The Content of Advertisements in Medical Journals: Distorting the Image of Woman" (1988) decries the portrayal of women in medical advertisements, while speculating that "physicians and others who read medical journals might be influenced by overt and covert messages" of heterosexual conquest, which might cause them to "over-prescribe medications to women" (47). And Courtney and Whipple (1983) write that "such advertising reinforces a doctor's prejudice against women and causes them to prescribe mood altering drugs, rather than dealing with the cause of women's problems" (14). These studies, and many others, contain the implicit assumption of a coherent medical gaze that regulates the clinical interaction (Alpers 2000, 801; Glazer 1992, 56; Levy 1994, 327; Petroshius 1995, 41; Wolfe 1996, 4).
Such critiques have limitations. I have no doubt that pharmaceutical advertisements have historically benefited from bolstering the subjectivity of the male gaze while reifying the objectivity of its object: "mother and child" ads for Zoloft, Luvox, and Effexor are but a few contemporary examples of promotions that assume looking like a man is a requisite component of professional competency, even though many psychiatrists are women. Yet because the aforementioned studies set as their frame of vision the same heteronormative order insisted on by pharmaceutical advertisements, they risk reproducing the gender assumptions of scopophilia itself-and specifically the Oedipally derived, active/passive binary described in Three Essays on Sexuality. Focusing exclusively on the ways men look at representations of women then effaces the other types of identification-and indeed the other forms of anxiety-elicited by the advertisements. Although cited in Mulvey, subsequent critiques often overlook the fact that Freud later complicated the notion of scopophilia in "Instincts and Their Vicissitudes" (1915), among other works, to describe the ways in which the remnants of identification with the same-sex parent-the "negative Oedipus complex"-become manifest when the power of the gaze is transferred onto others, allowing the subject to feel the pleasure of being looked at (Freud 1915, 126-30). In my reading, this oversight becomes a metaphor for the ways many critiques of drug ads privilege the active/passive divide while ignoring the ways the advertisements also based their promotions on a man's concerns about his employment, his professional standing, and his feelings about looking at another man.
My brief visual analysis explores these anxieties by focusing on a shift in the representation of psychiatrists, and the pointedly psychotropic treatments they administered, in long-running, front and back cover advertisements in the American Journal of Psychiatry and Archives of General Psychiatry, arguably the two most influential psychiatric journals of the past half century, between the mid-1960s and the early 1980s. These time periods correspond roughly with the parameters of what is called the "biological revolution in psychiatry," in which prescriptive medication cures replaced psychoanalytic talking cures (Ayd 1991, 72; Shorter 1997, 324). Broadly speaking, psychoanalytic terms and concepts dominated the ways psychiatrists conceptualized and treated many mental illnesses through the 1960s (Brown 1976, 13). Images from this era assume the unquestioned power of the embodied male psychotherapist, while advertisements make the case, to an often doubtful audience, that medications are valid participants in the previously exclusive interaction between psychotherapist and patient. By the mid-1970s, however, psychotherapeutic techniques fell out of favor in key sectors of the profession as it moved from being "psychotherapy focused to drug-management focused" (Wallerstein 1991, 421; Pulver 1978, 615). Many psychiatrists and historians of psychiatry argue that these changes altered how psychiatrists saw their patients, specifically by replacing a diagnostic system that embodied gender biases with a system that treated everyone in the same fashion (Klerman 1984, 539). However, the ads suggest a concomitant shift in the ways psychiatrists saw themselves: once shown prominently, psychiatrists grow ever smaller in advertisements between 1965 and 1985 and are ultimately replaced by representations of both patients and larger-than-life medications. This trend continues to the present day: psychiatrists almost never appear in either direct-to-the-physician (DTP) or direct-to-the-consumer (DTC) advertisements, while patients and medications figure prominently.
This representational shift reveals much more than an evolution of advertising techniques or cultural aesthetics, although these were obviously major causes of the phenomenon I describe. Rather, the disappearance of the psychiatrist's corporeal form suggests an alteration in the construction of the psychiatric spectator position-and its inherent connection to power and privilege-during the era in which pharmaceuticals and pharmaceutical companies rose to enormous clinical and financial influence in the field of psychiatry (Luhrman 2000, 203). Subtle manipulations of perspective, point of view, and other variables allow me to theorize that as prescription-writing skills replaced talking skills, a visual power once embodied in the human form was transferred onto the ever-growing symbol of medications. This transference yields two readings of the psychiatric gaze: the emergence of psychotropic medication may have enhanced a psychiatrist's power by offering new forms of disciplinary regulation; or, in light of the emergence of HMOS, conglomerated pharmaceutical companies, and encroachment from other medical specialties, medication may have forced psychiatrists to consider the tenuous nature of their own professional identities.
If mainstream film worked through a narcissistic pleasure by allowing male viewers to identify with their ego ideal, then print advertisements for psychotropic medications in 1964 worked even harder. Here men did not have to imagine an identification with a more powerful, more complete representation of themselves. In a visual system in which doctors were still doctors, patients were patients, and medications were hardly ever pictured, a doctor's identification was enacted effortlessly on the page. Such relations were enforced through the conventions of visual representation in the year an advertising campaign for the sedative Deprol ran in the pages of the American Journal of Psychiatry and Archives of General Psychiatry (figure 2).
The advertisement presents a dilemma common to many representations of clinical scenes in the 1960s: How can a visual image convey an entirely verbal interaction, a talking cure? And how can this image then introduce its product into the narrative, when the privileged interaction takes place only in the company of men? The image does so by using subtle visual cues to enact a visual hierarchy in which psychotherapy is marked as the site of power, while medications are relegated to the role of humble adjuncts. Psychotherapy, in this instance, involves an interaction between men who appear to have much in common in terms of the visual markers of race, gender, and class. Both doctor and patient appear to be white, clean shaven, short haired, well groomed, and both dress in the white-collar clothes of suits and ties. As a result of these similarities, the advertisement reveals in an image what can only be partially described in words: a strong bond exists between the two men, who work together in the creation of "Rapport!"
But rather than equality between the two figures, the image highlights the authority of the physician by well-marked differences. One of the men appears significantly older than the other; he is also bespectacled and shown in profile, thus obstructing much of his face, while the younger man is seen in frontal view, his mouth slightly ajar. These markings work to identify the older man as the listener (a point highlighted by the prominence of his right ear in the image), and the younger man as the speaker (highlighted by the now superfluous quotes below). However, perspective and position are the most important differences separating the two men. The bespectacled older man, who appears in the foreground, is thus phantasmagorically larger than the younger man. Moreover, his placement to the side of the image, and in near direct opposition to the younger man, situates him in the position of privilege and power-if following the discourse on the gaze, privilege and power mean the right to look without being looked at. His off-center position allows the older man to gaze at the younger man while not opening himself up to the scrutiny of the socially and psychically produced look, the "non-innocent look of culture" (Olin 1996, 208-19). Meanwhile, the younger man is placed in the position of object not only as the result of appearing smaller than the older man but because his frontal, centered position (and his lack of eyeglasses) casts him as the focus of the older man's gaze. These points of contrast serve to illustrate differences in status between the two men. And the power that allows for this distinction, ironically in a scene illustrating a verbal interaction, is visual. The gaze sanctions and identifies the bespectacled older man as the "psychiatrist." Suddenly interpolated, the younger man is therefore marked as "the patient" by his position in this symbolic order.
Identification between a viewer-either a viewer of a movie or a reader of a medical journal-and a visual image is a rather tangled web, and certainly much more complicated than a simple binary of doctor and patient. As theorist Jacqueline Rose rightly argues, "the relationship between viewer and scene is always one of fracture, partial identification, pleasure, and distrust" (Rose 1986, 89). In other words, viewers are as likely to identify with the subservience of a patient as with the dominance of a doctor, and often with both at the same time. Similarly, overt constructions of power are often built on acknowledgments of power's unsteady ground. I thus make no claim that an audience of physicians, an oversimplified and visually stereotyped category by design, looked at this or any image in a quantifiable or predictable way. What can be claimed, however, is that a Deprol image showing two men provides insight into the ways in which visual power and authority were constructed in many pharmaceutical advertisements in the 1960s. By foregrounding the viewer at the expense of the viewed, the ad's construction almost forces viewers of the advertisement to look from the position of privilege, to look through the doctor-literally through his glasses-and down at the patient. This configuration allowed the physician-viewers to enter into a visual identification with the doctor and against the patient. The image subtly coerces these viewers into helping the doctor gaze at the patient, while the patient is therefore defined in opposition to these two medical gazes.
In contrast to cinema and painting, advertisements deploy the assumptions of the dominant culture from which they emanate to promote specific products. However, no medications are pictured in the image. Rather, the advertisement asks viewers to assume that unseen medications are already inside the patient, and that the interaction takes place after medication treatment has begun. Moreover, while the text claims that medications "help the patient work with you," the visual message implies that by helping the patient act like a patient, they help the doctor much more. Secretly working in the service of the doctor, the medications yield to the constructed power dynamic in which the doctor looks on, and in looking controls the interaction. A psychiatrist who saw the ad, the image seems to say, should feel helped and supported by Deprol in his work, but not threatened by the notion, however subtly implied, that Deprol might in fact be doing his work for him.
Constructing medications as unseen helpers in the scopic interactions of psychiatrists and patients is a convention common to many psychotropic advertisements through the mid- to late 1960s. Medications hardly ever appear in these images and are often described as "adjuncts" or "helpers" in the work of psychotherapy, but never primary treatments. Ads for Miltown between 1960 and 1967, for example, describe the minor tranquilizer as "an effective adjunct to psychotherapy," a point often illustrated by clinician's eyeglasses. Similarly, in a two-scene advertisement for the phenothiazine Taractan from September 1966, the psychiatrist is marked in the initial image by his foregrounded, enlarged position, and by his thick-framed spectacles (figure 3). In the subsequent image (not shown), the patient is markedly calmer, while the physician is able to remove his glasses when the medications begin to "work." In these and other instances, medications are constructed as giving way to the much more important, man's work of psychotherapy. And the power depicted is not the power to listen to patients but the power to look at them as if looking at an advertisement.
Set up for easy access and a seemingly unidirectional flow of identification, these images thus suggest a visual transference without the murkiness of countertransference. Psychiatrists were asked to observe more powerful, more complete images of themselves, and to employ their diagnostic acuity and powers of observation to gaze as men while locating mental illness-itself deliberately ill defined to maximize the use value of the product-entirely on the patient. Medications, though unpictured, facilitated and focused this interaction as if a pair of glasses. Thus did the images suggest a visual hierarchy in which psychotherapists dominated many clinical interactions, and medications were on the upward slope of acceptance and success.
Excerpted from Cultural sutures by Lester D. Friedman Excerpted by permission.
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Library of Congress Subject Headings for this publication: Health in mass media, Social medicine, Television in health education, Journalism, Medical, Mass media, Attitude to Health, Mass Media, Ethics, Medical, Public Opinion, Technology, Medical