Affluenza: How to be sick without being sick

The four pedestrians never saw it coming.

Around 11:45 p.m on June 15, 2013 on a road in Burleson, Texas (a suburb of Fort Worth), the driver of a stranded SUV and three people who had stopped to help her change a flat tire were killed when 16-year-old Ethan Couch smashed into them with his red pickup truck. Seven other teens were in the truck with him. Drunk, and driving 70 mph in a 40 mph zone, Couch then plowed into the parked Silverado pickup that belonged to one of the victims, who was — in a cruel twist of fate — a youth pastor. Nine other people — seven passengers in Couch’s vehicle, and two in the pastor’s — were also injured, two seriously. At the time of the crash Couch’s blood-alcohol level was found to be 0.24, three times the legal limit.

On September 11th Couch was charged in juvenile court with four counts of intoxication manslaughter, and pleaded guilty. At the conclusion of his trial on December 10, 2013 Judge Jean Boyd sentenced him to 10 years probation. The prosecution had argued for a 20-year prison term. Adding anguish to the prosecution, as part of the sentence the judge ordered that Couch spend time in a Southern California rehabilitation facility, a posh establishment for which his wealthy father would pay $450,000 a year.

The judge’s ruling provoked outrage among authorities, the victims’ families, citizens in Texas and other States, and even observers abroad. In her ruling the judge accepted the defense’s argument, based on the testimony of Dr. G. Dick Miller, a clinical psychologist who testified on Couch’s behalf, that Ethan was not responsible for his actions. The boy suffered from “affluenza, ” Dr. Miller argued. Couch, he said, had been brought up in wealth and privilege, and had never learned to face adverse consequences for bad behavior. His parents had instilled in him a sense of entitlement, along with the conviction that wealth would cushion him.

Affluenza is not recognized as a diagnostic category by the American Psychiatric Association (DSM-5). Not having seen the trial transcript, I don’t know whether the prosecution challenged Dr. Miller’s use of the word. However, it seems everyone else did after the verdict came down.  Dr. Christopher J. Ferguson, a psychologist, said, “As a clinical psychologist, I’ve never before seen a mental health practitioner try to diagnose someone with affluenza. And there is practically nothing in the research literature about it.” Writing for the British Guardian, journalist Jessica Luther called affluenza “the latest excuse for the wealthy to do whatever they want.” Paul Callan, a former New York homicide prosecutor seethed, “In a system where rich and poor are supposed to be treated equally, affluenza as a defense is an insult to us all.”

Dr. Miller was nearly on the ropes. After the trial he appeared in a long interview with CNN correspondent Anderson Cooper, on CNN’s AC360o. During one segment (13 December 2013), Dr. Miller said, “We used to call these people spoiled brats. I wish I hadn’t used that term [affluenza]. Everyone seems to have hooked on to it.” He was distressed over the flak he received, which overshadowed his victory in court.

So why did he use “affluenza,” which he probably knew wasn’t a recognized psychiatric diagnosis? Or — since we can’t read his mind — what effect did he expect this word (rather than, say, “spoiled brat,”) to have on the judge, the prosecution, the victims’ families, other observers in the courtroom, and finally us? He probably used the term because he expected everyone to accept it as a legitimate diagnosis. But only Judge Boyd accepted it.

“Affluenza” is a blend of “affluence” and “influenza.” In a blend the first part of one word is attached to the second part of another. Although “affluenza” might have been in minimal use as early as the 1950s, the Oxford English Dictionary (OED) enters first documented use as 1973.  The OED indicates that affluenza usually affects young wealthy people, with symptoms that include “a lack of motivation, feelings of guilt, and a sense of isolation.” Since the 1970s the word has gained traction. Its main current meanings are social: It attaches to modern Western nations, particularly the U.S., and denotes consumerism, materialism, and a desire to “keep up with the Joneses.” John deGraaf, co-producer of the 1997 PBS documentary “Affluenza”, highlighted the show as an exploration of “the high social and environmental costs of materialism and overconsumption.” Nevertheless, when social critics use the term “affluenza” to describe these social problems, they attach to the problems a clinical connotation, suggesting that consumerism and materialism are diseases.

Now, a real diagnosed disease is something that happens to us. We’re sufferers, patients, even if some of our behavior might have led to a disease (e.g. smoking leading to lung cancer). And we’re treated for a disease by medical practitioners. “Affluenza” implies that Ethan Couch was not responsible for killing four people and injuring nine. He was sick. And true to its clinical spin, the defense argued—and Judge Boyd agreed—that Ethan needed treatment (for a disease), not punishment (for a crime).

The flak Dr. Miller received for his “affluenza” defense surprised him. Yet he would have been justified in believing that the term would not cause offense. After all, we live in an era in which many expected behaviors (good and bad), as well as the normal processes of maturity and aging, are now medicalized, given a clinical spin. Researchers, among them anthropologists, physicians, and social critics deplore what they call this “medicalization of society”, which has pathologized shyness, menopause, aging, wrinkles, inattentiveness, pregnancy, male pattern baldness, perceived physical defects (e.g. shape of one’s nose), rudeness, and other conditions—even in the absence of clearly diagnosed disease.

One of the most popular clinical terms attached to non-disease conditions is “syndrome.” It’s not only used to describe political events (e.g. the Iraq syndrome, meaning the erosion of public support for wars in which American casualties increase), but also social and personal events. A person who envies another’s good fortune suffers from “tall poppy syndrome”, an expression familiar in Australia and New Zealand. Parents whose children grow up and move out suffer from the “empty nest syndrome.”

Not surprisingly, wealth and entitlement have also generated syndromes. “Sudden wealth syndrome” affects those who suddenly come into money; for instance, through winning the lottery. They may feel undeserving of it and fear that they’ll suddenly lose it. “Rich kid syndrome” affects children born to privilege and wealth. They lead self-centered lives, exercising little responsibility and suffering few consequences for bad behavior. Author Jennifer Senior lamented, “America’s burgeoning money culture is producing a record number of heirs—but handing down values is harder than handing down wealth.” In 1989 Bruce J. McIntosh, a pediatrician, coined the term “spoiled child syndrome” which, he argued, resulted from the failure of parents to discipline their children consistently and age-appropriately. These wealth-related syndromes dovetail with “affluenza.”

If affluenza is indeed a sickness, it can be treated. Paul Callan, the former New York homicide prosecutor, proposed for Ethan Couch “a solid dose of state-inflicted poverty in a prison cell.”

Janet Byron Anderson is medical linguist and medical editor, and author of Sick English: Medicalization in the English Language. She can be reached at MedLinguistics.

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  • DoubtfulGuest

    Fascinating post, Dr. Anderson. Makes me want to find that documentary and watch it again. I have made up different names for “syndromes” when joking around with friends, but you’ve made a compelling case that that isn’t such a good idea!

    • Janet Byron Anderson

      We’re not going to be able to stop “syndrome”, DoubtfulGuest. This is one aggressive verbal dude. Contrary to what many people think, it’s not a new term. It’s been in the language for centuries, but when it was first used (15th/16th centuries), speakers hated it for being pretentious. So “syndrome” lay low, so to speak, biding its time until the 20th century, when clinicians and medical researchers found convenient contexts for it. The term is now indispensable in medicine. We’ve picked it up, and what I find fascinating is that we nonclinical speakers have no difficulty understanding its core meaning—the meaning it had for the ancient Greeks! [The word is a Greek borrowing] We modern speakers have a “feel” for this word, which is why it’s on nearly everyone’s tongue. Everybody loves “syndrome”, and as you pointed out, it’s so easy to make up syndromes. Time for a T-shirt:
      I – [picture of heart] – syndrome. Thanks for your comment.

      • DoubtfulGuest

        Perhaps the word ‘syndrome’ itself has a bit of John Wayne Syndrome…

        • Janet Byron Anderson

          You’re right. This is one tough term!

  • NewMexicoRam

    You do the crime, you should do the time.
    The real problem is the liberal judges who let their emotions rule their verdicts.

    • saurabh jha

      Quite correct! This is a legacy of Rousseau’s noble savage. Except when applied to rich brats we can see how utterly specious the theory.

    • Patient Kit

      Liberal judges aren’t best known for protecting rich people. This sounds more like a case of a judge who could be bought than a judge who bought the defense.

      • May Wright

        “Mary Jo Kopechne could not be reached for comment.”

        • Patient Kit

          Agreed. Money is power regardless of what end of the political spectrum it comes from.

        • Janet Byron Anderson

          Another sad story. Thanks for bringing this up. Many books and articles have been written about that case by people who believed justice for Mary Jo had been undermined by power, politics, and money. Unfortunately, the Ethan Couch case doesn’t have an outsized public figure to draw unrelenting suspicion and media attention. So this youth’s victims may in time be forgotten. Perhaps a serious story will emerge, and be told, when we finally see the full-blown effects of affluenza upon Couch. I just hope these effects won’t entail more innocent victims. Thanks again for the apt analogy.

  • Patient Kit

    Obscene case of injustice. And yet, I hear “sense of entitlement” used to describe the poor far more often than the rich. But somehow feeling entitled to medical care when you’re sick even though you don’t have money doesn’t compare to feeling entitled to gettting away with murder because you (or your parents) have unlimited money. Entitlement is a word that’s as misused as syndrome.

  • Sally

    Thanks for an interesting discussion. I use the old “Affluenza” video in a Positive Psychology course as part of an assignment to build awareness of materialism and consumerism. Students also read empirical studies and comment on an exercise in changing a consumer habit of their own. I survey the classes about the dated nature of the video, expecting every year it’s relevancy will drop off. Surprisingly to me, my students appear captivated by this old PBS documentary and its message.

    If interested, you can find the background here:

    And conveniently view the one-hour documentary here:

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