Wise Counsel Interview Transcript: An Interview with with Ronald Dworkin, MD, Ph.D. on Artificial Happiness

Dr. David Van Nuys: Welcome to Wise Counsel, a podcast interview series sponsored by CenterSite, LLC, covering topics on mental health, wellness, and psychotherapy. My name is Dr. David Van Nuys. I'm a clinical psychologist, and your host.

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Dr. Van Nuys: On today's show, we'll be talking about the book, "Artificial Happiness" with my guest, Dr. Ronald Dworkin. Ronald W. Dworkin, MD and Ph.D. is author of the 2006 book, "Artificial Happiness: The Dark Side of the New Happy Class".

According to the book's cover, his essays on religion, medical care, and health care have appeared in the weekly standard commentary public interest and policy reviews. In 2000, Dr. Dworkin joined the Hudson Institute as a senior Fellow while continuing to work part-time as an anesthesiologist. He lives in Baltimore, Maryland. Now, here's the interview.

Dr. Ronald Dworkin, welcome to Wise Counsel.

Dr. Ronald Dworkin: Thank you for having me.

Dr. Van Nuys: One of my listeners, actually a psychologist, heard a recorded talk you gave and insisted that I should interview you. Before we get into your book, "Artificial Happiness", I note that you're a fellow at the Hudson Institute. What can you tell us about the institute?

Dr. Dworkin:  The institute is mostly, I would call, think tanks are like government in exile. They have portfolios full of people to study education, foreign policy, health. Hudson is more like an institute of a collection of minds. People are interested in cultural events in society with no precise legislative bench. Their simply exploring them for their own sake because they think they're worthy and important to society.

That's what Hudson likes to do. I got interested in the issue of psychoactive drugs while working at Hudson. There's no clear legislative reason to do so. We weren't going to introduce a bill in congress, but I thought it was important to study the phenomenon, and that's why I got interested in it.

Dr. Van Nuys: Well it sounds like a luxurious position. I take it that the institute has no particular political or religious alignment. Is that right?

Dr. Dworkin:  No it doesn't. I suppose that all the think tanks, the institute; they all have some theological affiliation. Some are center left, some are center right, some are very right, for example, very conservative. If you were to ask me about Hudson, I would say, perhaps, center right, but there are liberals in Hudson, as well as conservatives. I myself do not pick any particular ideological bench in my work, I don't think I could be identified as liberal or conservative, and I try not to be. I simply look at the problems, hopefully, from a new angle.

Dr. Van Nuys: Good. I thought that would be an important context for us to establish as we get into your book, so that people can have a sense of where you're coming from. Now, an essential thesis of your 2000 book is that antidepressants are being over used. Is this still the case, or did your book achieve some miraculous reversal of the trend?

Dr. Dworkin: The book was written in 2006, and the actual numbers, which I could not include in the book because they came out in 2007, actually confirmed my thesis. I think in 2007 it was confirmed that one out of four to one out of five Americans is currently on an antidepressant. I wish I had those numbers available at the time; I would have certainly included them in the book. But, as of the recent stats data, one out of four to one out of five are on antidepressants of some kind.

Dr. Van Nuys: Wow! That's fairly shocking! I gather that you're particularly concerned about over medication when it comes to children. Is that right?

Dr. Dworkin: Yes. I make an important distinct, in the book, between those that are being medicated for clinical depression, which is a real illness and has definite criteria to be satisfied, and is dangerous and needs to be treated. And then, there's the much more nebulous world of everyday unhappiness, which is a different kettle of fish all together. I am concerned about the treatment of adults who are suffering from everyday unhappiness, and also children, that have even more important physiological ramifications. So that is the area I've been dealing with, not clinical depression that needs to be treated, but the phenomenon of everyday unhappiness.

Dr. Van Nuys: So, maybe you can help us with the distinction between depression and unhappiness because I think for many people, they would think, "well isn't that pretty much the same thing?"

Dr. Dworkin: Well, there are official criteria these problems if you look at the DSM, which is the psychiatrist's Bible. There are nine criteria for clinical depression. You have to satisfy five out of nine in order to get the diagnosis and to be treated with the medication. Well, they include a feeling of sadness, a loss of interest in daily activities, but also some physical signs and symptoms, such as severe weight gain, severe insomnia, a phenomenon called psycho-motor retardation, which is a slowness of movements.

If you satisfy five of the nine, you get the diagnosis of clinical depression. Everyday unhappiness has no real criteria. Now, there is a diagnosis called minor depression, which you get if you satisfy two of the nine. For example, if you have been feeling sad and have a loss of interest in daily activities, then you would get a diagnosis of minor depression, which as you can tell borders on everyday unhappiness.

The problem is that in America, people are being treated for major depression and minor depression with drugs at roughly the same rates, so there is no distinction being made between the two, out here in the population, among physicians.

Dr. Van Nuys: OK. And what's your evidence that these drugs are being used to treat unhappiness as opposed to some form of depression?

Dr. Dworkin: Well, if you look at the statistics which I just mentioned on minor depression, which sort of borders on everyday unhappiness, and really is probably everyday unhappiness, there are statistics to show that physicians are treating these maladies at the same rate. But if you simply just look at the numbers, it's distinctively instructively that it's simply not possible that one out of five Americans is going around with clinical depression. Because clinical depression is a real disease. You can tell when someone has it. That person has visible signs and symptoms, and most of the cases are not people with clinical depression.

It has already been estimated that the ratio of say, everyday unhappiness, or minor depression to clinical depression in the population is roughly four to one. So if we know that the instance of everyday unhappiness to major depression is four to one, and we know that people are being treated at roughly the same rate, we can the infer from that that probably the rate of people being treated for everyday unhappiness relative to major depression is probably four to one. That's a lot more people than being treated for unhappiness.

Dr. Van Nuys: OK. In your book, you talk about an engineering approach to treating unhappiness. What do you mean by the engineering approach?

Dr. Dworkin: Well, happiness now has been reduced, not by psychiatrists, I might add, the psychiatrist play no role in this revolution. Most of these drugs are being prescribed by primary care doctors. It's important to know this. Actually, psychiatrists are angry at the primary care doctors for doing this. They think that the primary care doctors are the source of quote, "all this trouble".

Dr. Van Nuys: Yes. That's one of the most fascinating aspects of your book, I think, is that dynamic. Please do go ahead and talk about that.

Dr. Dworkin: The primary care doctors look at unhappiness as a problem with neurotransmitters. Maybe some of you who are listening are familiar with what's called a biogenic immune theory and that associates clinical depression with a neurotransmitter imbalance. These drugs work on neurotransmitters.

But primary care doctors took that association and they extended it to include not just clinical depression but everyday unhappiness and then they made that association causation. So instead of neurotransmitter imbalance associated with everyday unhappiness, it's now neurotransmitter imbalance causing everyday unhappiness. These are all leaps of faith. This is not real science. This is sort of viewed as a belief.

But when the idea is out there, the idea is a sense that, "OK, every unhappiness is a problem of neurotransmitters, therefore it is a problem of biology, therefore it's an engineering problem." Doctors look at the body as an engineering problem; the heart, the lungs, the bones, the skin, and now we have the neurotransmitters. So the same attitude that doctors have used in all the other areas of the body are now being extended to everyday unhappiness by looking at neurotransmitters.

Dr. Van Nuys: What do you think about the role of the pharmaceutical companies? Do they play a role in pushing medications and creating new diagnosis that need to be treated? For example, I'm thinking of shaky leg syndrome among others that we see on the news every night.

Dr. Dworkin: I've been asked this question many times on national news shows and I think people get angry with my response because they want me to say, "Yes, it is the drug company's fault" and I must say no, it is not. The drug companies benefit from this, no doubt about it. They want to sell their drugs and they do sell their drugs in this culture where we have every unhappiness treated with drugs.

But it is the doctors and the patients themselves who have sort of formed a binding contract in understanding unhappiness the way we do now. People naturally want the quickest and surest route to getting their unhappiness treated and doctors want to help their patients. So both of them benefit from this understanding that unhappiness is a disease of neurotransmitters and both are eager to use the drugs. Drug companies benefit from this but they don't actually cause this.

I am a physician. I know the drug companies try every which way to get me to prescribe a drug but they can't make me do it and they know that. Only I can prescribe the drugs if I want to. So it's really the doctors themselves, not the drug companies, that are pushing this. And drug companies, I don't blame them for this. It's more culture itself.

Dr. Van Nuys: Well, let me challenge you just a little bit on that because it's like consumers often say, "Oh, I don't pay attention to advertising. Advertising doesn't affect my choices." Yet companies wouldn't spend the huge budgets that they do on advertising if they didn't know that it was effective. And isn't it the same thing with the marketing of various kinds of medications to physicians?

Dr. Dworkin: No, I would say not. Let me explain why. The drug company push to advertise directly to consumers has only been happening for the last 15 years. Now during the 1970s, when there also was an enormous increase in the use of psychoactive drugs for unhappiness - at that time it was valium. So really drug companies advertising directly to consumers, that was forbidden. It was only to doctors. So you can't say drug companies advertising to consumers caused the valium spike. It wasn't around in those days.

If anything, the drug companies are advertising directly to consumers because they know they cannot make doctors do what they don't want to do. To get around the doctors they're trying another way; to talk to the consumers directly. So precisely because they could not influence the doctors to the degree they wanted to that they went to advertise directly to consumers.

But as I said, they did not advertise to consumers in the 70s when valium was spiking at one in five per Americans for everyday unhappiness. So you can't use that argument to explain the whole phenomenon. If anything, there's something else that's going on.

Dr. Van Nuys:  OK, that's a good point. Now what do you think about contemporary psychological approaches for treating depression and, I guess by some extension, unhappiness such as those based on some version of cognitive therapy or even mindfulness?

Dr. Dworkin: My book looks at three modalities to treat everyday unhappiness: the medications, alternative medicine, and exercise. I don't deal with psychotherapy at all in this book. At the end of the book I say that a thoughtful person talking to someone with everyday unhappiness is always more beneficial than someone taking medication. So if a psychologist or psychotherapist is thoughtful and wise and is helping illuminate the unhappiness for the person, that is always better than the medication.

You see, the problem with the medication when I interview people was that it was coupling how people felt and how they lived, so that they had a life problem. But instead of attacking the problem or dealing with the problem, they took the medication, they felt better and, therefore, did nothing to change their lives because there was no reason to. They had lost the impulse to do so because they felt better.

So a psychologist, obviously, who uses words and they cannot use drugs, they must talk to people and, therefore, it's not so easily done to uncouple how people feel from how they live. A psychologist deals with life and makes the patient deal with life and talk about life and so that would have to be infinitely better than simply using drugs for unhappiness.

Dr. Van Nuys: It seems like we all, at least in our society, kind of crave the silver bullet -- the easy, quick-fix solution. Now it seems like a growing number of people are becoming disaffected with traditional medical care and are turning to alternative or complimentary health care and I gather this disturbs you.

Dr. Dworkin: Well, people look at it as it being the opposite of the use of psychoactive drugs, but it's not. The use of alternative medicine is somewhat similar. Let me explain how. First of all, again, the same doctors are involved. Primary care doctors prescribe or over-prescribe psychoactive drugs, and primary care doctors are the ones who are involved in alternative medicine - not psychiatrists, not specialists, but again, primary care doctors.

Now what happens in alternative medicine is that some of the herbs used for unhappiness in alternative medicine have psychoactive effects and, therefore, if they do, it's no different than using Prozac or Zoloft. You have the same effect; it's simply an herb and not a pharmaceutical drug. But even if you don't have a pharmaceutical real effect - a real bioactive effect - you have what's called a placebo effect. So the unhappy person takes the herb, maybe there's no real bioactive effect, but the patient feels better, feels happier as a result.

But what have you accomplished other than giving that person another form of artificial happiness? It's not a real form in a form of the drug effect but the patient has deluded himself into thinking that he is happy and once again he arrests his impulse to change his life because he feels better, artificially, through these external means. So even if alternative medicine doesn't actually have a real effect, it works by the placebo effect, the effect is nonetheless the same; you have an artificial happiness felt irrespective of life.

So instead of saying alternative medicine is the opposite of psychoactive drugs, I group the whole field with psychoactive drugs, at least in the area of treating unhappiness.

Dr. Van Nuys: OK. Now, psychoneuroimmunology is a buzzword and it has a very scientific sounding term, but you're not impressed. Why not?

Dr. Dworkin: Well psyconeuroimmunology argues that how your mind is has an impact on your body's heath, mediated through the immune system. If you feel more stressed that effects the immune system and, therefore, you are more likely to get sick My concern with psyconeuroimmunology is first of all, it is not clear if it is true or not. Second of all my concern is that doctors are using that rather flimsy theory to justify treating people who are unhappy with these herbs because their argument is this: you give someone an herb who is feeling unhappy an herb and they feel better and it is good for them to feel better because it is healthier for them to do. So you are a healthier person if you are a happier person because your immune system is better.

Therefore, that justifies using any alternative medicine in cases of unhappiness because if you make someone happy, their bodies will be healthier and they will live longer. And this is a rather dangerous argument because it implies that the physician has a right to use any medications, inert or not, to treat unhappiness because as long as he can make that patient happy he has done something good. He has helped that person's body be healthier. That allows an open road to all kinds of deception, and that is my concern.

Dr. Van Nuys: OK now you're even critical of the exercise boom. I recently interviewed Harvard psychologist John Radie about his book "Spark" in which he marshals a lot of the evidence for the assertion that exercise is a great antidepressant and also good for your brain. Do you disagree with that position?

Dr. Dworkin: No I don't. Let me explain my concern though. If you are unhappy because your life isn't going well and instead of tackling your problem in life, you go and jog around a track for four hours a day. What have you done to resolve that life issue? You have done nothing. You have numbed yourself with theoretical endorphins, done nothing at all. Or you can view it this way. There is a whole phenomenon called fitness culture, where people who have life problems. They avoid life problems by going into the gyms and spending hours there tuning their bodies making them perfect.

As a result they have sort of pushed themselves outside of the mainstream of life and done so in a way that they think is correct because it is good and healthy for them. But is it really healthy for someone to spend hours in the gym, hours and hours to the disregard of other aspects of life. I don't think so. So even if it is good for the brain, if it helps you feel happy, to exercise. If you are uncoupling how you feel from how you live, that happiness is preventing you from doing the things you be doing and being aware of certain things, well then it is not a good thing.

Dr. Van Nuys: So I'm really hearing that the bottom line for you is people need to deal with the issues in their live and not look for easy substitutes to facing them squarely.

Dr. Dworkin: Yes, and I have so many examples, so many interviews with people. One women for example, she had a bad relationship and she wanted to get out of she wasn't sure she wanted to marry the guy and was unsure what to do and wasn't very happy. She went to her primary care doctor. He gave her Prozac. She felt better. She lost the impulse to get out of that relationship.

And so she stayed in that bad relationship for about a year and then she got off the drug and she eventually felt unhappy. This time she felt a critical mass of unhappiness and she left the man. And when I asked her later, would you have left that man if you had not been on the drug, and she admitted yes. I would have but I felt better and so I didn't.

So it's an example of someone who knows that they have to make a decision to do something but it's uncomfortable and so therefore they rest the impulse by feeling this artificial happiness. And they can do this with an exercise, or an herb, or a psychoactive drug. But the problem is when you uncouple how you feel from how you live you rest your impulse to change your life. That cannot be a good thing.

Dr. Van Nuys:  OK I didn't notice any mention of the new positive psychology movement which was launched by Dr. Martin Seligman when he was president of the American Physiological Association. I don't know if you are familiar with his work, he is the author of the book, Authentic Happiness, among others and this movement grabbed a lot of mind share. Are you familiar with it and, if so, what is your take on it?

Dr. Dworkin: I am aware of the movement I think Dr. Seligman was one of the opponents of making psychology relevant to peoples' everyday lives. Not just sickness but for health, I believe I don't discuss that in "Artificial Happiness" but may in a later book so ill have to just leave it there. The focus of "Artificial Happiness" is the drugs and alternative medicine and exercise. I as I said before if someone talks to an unhappy person about their problems, and doesn't conceal these problems from the person and gets that person to make decisions to think or act differently. That has to be a better thing than simply numbing the person. Now there may be other issues or dimensions to the work that I might have questions with but it is better than just numbing people out of their unhappiness.

Dr. Van Nuys:  You know this kind of raises the question of what is your notion of happiness, we've been talking about unhappiness. Do you have a view of what constitutes happiness?

Dr. Dworkin: The prefix hap comes from Greek and it means luck and I'm often asked this question that's the wrong question. You see if you want to find happiness don't ask me. Patterns of happiness have long been established. Find work you find interesting. Get rich. Find a lover. Get a family. There are many ways to happiness.

The point being what do you do when you feel the inevitable unhappiness? That's the issue here. The path to happiness has been pretty well marked out. I'm not going to reinvent the wheel on this. The problem is what you do when you feel unhappy?

Now 100 years ago it was considered to be wrong to stupefy yourself with alcohol. Now people didn't do it when they were unhappy but they did it in shame in private. And now all the sudden we have this phenomenon where we have a major respected institution in the United States, the medical profession putting its imprimatur on what is basically an act of stupefaction, which is not using alcohol but psychoactive drugs to feel happy when you are unhappy.

So that's the phenomenon that I'm talking about. It's how do you find happiness but what is happiness everyone knows that. You don't need a physiologist or a psychiatrist anyone to tell you just being yourself. The point being what happens when life goes awry? How would you deal with it? And that's the new phenomenon that we suffer today.

Dr. Van Nuys: I think political activists have sometimes leveled the charge at psychology and psychiatry in general that we help adjust people to the status quo, so that they are less likely to be upset by things that are wrong in society. What's your take on that?

Dr. Dworkin: It's interesting because the primary care doctors have actually used that to justify what they're doing. They say you know in the 1950s psychiatrists, psychologists, they were making people be normal. They we making them conform, they were adjusting people. We don't do that. We are sort of, whatever a person's values are, however they want to function in life, it's fine with us. We are not judgmental. We simply want to give that person a feeling of happiness.

They could argue, and they do, that in a way they have a leg up over the psychiatrists and psychologists because they don't do the adjusting. They don't make people conform or be normal. They simply give the people the feeling of happiness with respect to how they live their lives.

Dr. Van Nuys: What do you think about the media, television and so on as another stupefying factor?

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Dr. Dworkin: I think that, you know in Rome they said, "Give them bread and circuses." OK, so this is not new. There has been a way to, you know when people are unhappy what do you do? You give them more distractions and so you entertain them. You give them a feeling of uplifted spirits and whether that's what television does and that's what the Roman circus did.

This is not new. They said find an unhappiness and feeling an unhappiness feeling, define happiness and feeling happiness. This is not a new phenomenon. I don't write about that and people criticize me. They say, "Why don't you give it a deeper understanding of what happiness is?" And I said, "Well I could have been so brilliant that I could have invented the definition of happiness that is the opposite of what everyone thinks it is." But no one would have read such a book and quite rightly because people have a general understanding of what happiness is and that's fine.

But again the question is, when you are unhappy how will TV help you? How will celebrity culture help you? It doesn't, so you have to rely on something else. There has to be stronger reads within your mind. Some people have religion, some people have family, some have community, some have a philosophical outlook but you better have something.

Many people who take the drugs who I interviewed, they didn't have anything and, therefore, when they felt unhappy they panicked. They got afraid. They weren't sure what to do and they reach for the medication almost out of fear because they didn't expect the problem and they didn't know what to do about it. That's the issue, how do you deal with the inevitable unhappiness.

Dr. Van Nuys: Yes, so what's been reception to your book among professionals and among the general public?

Dr. Dworkin: Well, I think it sold well, the public was happy.

Dr. Van Nuys: [laughs]

Dr. Dworkin: I did notice one interesting, two interesting things. First of all there were many people who said they loved the book and people who said they hated the book and they never read the book. [laughs]

Dr. Van Nuys: [laughs]

Dr. Dworkin: Now that may be how it is in publishing in general. I don't know. What happened certain people had preconceived notions of what the book would be about. I'd be slamming their drugs or I would be praising their drugs and I don't necessarily do that. Actually the drugs are only a small part of it.

The other thing I noticed is that many people reacted angrily but in a funny way. In the sense that doctors when they read what I had to say they liked what I had to say about alternative medicine, exercise but they didn't like what I had to say about them and the drugs. The religious people liked what I had to say about the drugs and the exercise and the alternative medicine but they didn't like what I said about religion.

So everyone liked what I said about the others but no one liked what I said about them. No one wants a mirror held to themselves, of course not. That's what I noticed most. People got angry when I criticized them but they were happy when I criticized their competitors or someone in their fields, that's the other thing I noticed.

Dr. Van Nuys:  That sounds very human. [laughs]

Dr. Dworkin: Yes, it is.

Dr. Van Nuys: Yes, well it's been a couple of years since you wrote your book. In what ways, if any has your thinking on the topic changed or expanded?

Dr. Dworkin: I believe what I wrote and I think that the trends I outlined in "Artificial Happiness", they still exist to this day. There's nothing really that changed my thinking on that. If anything I think the problem is you know in some ways getting worse because the census numbers came out are being more widely prescribed than even I thought at the time I wrote the book.

I think there is a general understanding within the profession now, the medical profession, and it comes out in also the prestige media a little bit that there is a distinction between everyday happiness and depression.

All I really wanted to accomplish in the book is not to outlaw these drugs; these are important drugs for people who are depressed or to prescribe them to everyone. All I wanted is the Doctor and the patient themselves to think twice about medicating and to think are we doing this for the pressure of happiness and that was all.

If you can get people to think twice about what they're doing, that's a very good start. That's really what I wanted to accomplish with the book and I think that may be happening. People are having second thoughts. They still may allow themselves to be medicated, or use alternative medicine, or use exercise for their unhappiness but at least they have thought about it for a split second -- thought, "What am I doing or what are the ramifications of this?" That's all you can really hope or expect from writing these books.

Dr. Van Nuys: Well that's certainly advice I can't argue with. Dr. Ronald Dworkin, thanks so much for being my guest today on Wise Counsel.

Dr. Dworkin: Thank you for having me.

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Dr. Van Nuys: I hope you enjoyed this interview with author Dr. Ronald Dworkin. If you're interested in learning more, you may want to read his very thought provoking book. You may not agree with everything he has to say but you'll almost certainly end up examining some of your own assumptions.

Also you'll find additional publications by Dr. Dworkin if you go to his web page at www.hudson.org.

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Dr. Van Nuys: You've been listening to Wise Counsel, a podcast interview series sponsored by CenterSite, LLC.

Until next time this is Dr. David Van Nuys and you've been listening to Wise Counsel.