Neoliberal psychiatry and its discontents
I’m putting up a link here to my review of two books on the crisis in psychiatry — which has just appeared in the latest International Socialism journal in the UK — so that people can write comments and I can reply. The books are:
- Ethan Watters, Crazy Like Us: The Globalization of the American Psyche (Free Press, 2010)
- Gary Greenberg, Manufacturing Depression: The Secret History of a Modern Disease (Bloomsbury, 2010)
Special thanks go to former Deputy Editor Jonny Jones for commissioning this piece and encouraging me in the writing. Thanks also to the current editorial team, Alex Callinicos and Camilla Royle, for getting it into print.
I also promise to get a post up soon with audio and text from the session I organised on Peter Sedgwick’s legacy at Historical Materialism London last November.
Here’s a little snippet to get you interested…
In May last year the American Psychiatric Association (APA) launched the fifth edition of its diagnostic “bible”, the Diagnostic and Statistical Manual of Mental Disorders. The public controversy surrounding DSM-5 epitomises a major crisis of authority for US psychiatry, with psychiatric and other critics lining up to attack it. It also signals the exhaustion of the project codified in DSM-III in 1980, which laid the groundwork for a distinctly neoliberal psychiatry where pharmaceutical companies, medical elites and governments colluded in the massive expansion of an increasingly commercialised mental health industry.
Neoliberal psychiatry may have become dominant, but increasingly it has also been contested, with a number of recent books exploring its contradictions. By looking at two of the best examples of this new critical trend we can start to answer some key questions: How did the provision of basic mental health services get subjected to commodification and the profit motive? How did an important group of doctors come to provide a pseudo-scientific justification for this process? And why has resistance now started to emerge?
TO CONTINUE READING CLICK HERE (THEN COME BACK & COMMENT)
Tad Tietze’s book review raises a number of important questions. He is correct in raising the cultural and social issues in mental health, which have been widely ignored by many mainstream practitioners and sometimes resulted in terrible examples of misdiagosis and mistreatment.
These issues have been dealt with extensively by writers and practitioners like Richard Warner, Anthony Marsella, Derek Silove, Harry Minas and Zac Steel, and organisations like STARTTS and the NSW Transcultural Mental Health Centre (which has published ten books on the subject). This work has mainly been done outside a Marxist framework, but should be acknowledged.
Tietze is also correct to underline the profit-driven basis of much diagnosis and treatment in mental health and the need to look more broadly at the whole concept of illness. While there is massive over-diagnosis in mental health there are also some people who are helped by a combination of drugs and various forms of social support. In this respect both Tietze and Peter Sedgwick are correct in calling for ‘more and better mental hospitals, more and better doctors and nurses.’
Properly-funded and culturally appropriate mental health services are urgently needed to overcome decades of misdiagnosis and mistreatment. An understanding of the social and cultural roots of mental health must be incorporated into the training of medical and allied health students. This must include the mental health consequences of issues such as loss of work and the appalling treatment afforded to asylum seekers.
Thanks for your comment, Phil. One of the things that marks both psychiatric and physical medicine is a narrow technological reductionism that fails to appreciate the complex web of causative factors involved in producing what we call “illnesses”. Very little of physical medicine fits with germ theory, yet it is treated as the gold standard in elucidating causation.
On the other hand, treatment often misses the social change that is necessary to relieve many instances of distress and illness. The horrific treatment of asylum seekers for political reasons is one of the clearest cases in point, but it is only the tip of the iceberg in our alienated capitalist society.
Until modern (bio-deterministic) psychiatry recognises the unpleasant reality that its roots ARE in the eugenic movements of the late nineteenth, to mid twentieth centuries, there will be no change to its underlying paradigms. There is well researched material on these links in the work of Jay Joseph, Kate Rogers and Ross Jones, among others.
The real tragedy of this bio-determinism is the legal status of people with the diagnosis of ‘schizophrenia’. Anyone who has witnessed the proceedings of a Mental Health Tribunal (as I have in Vic, NSW, and Qld) will be aware that this diagnosis immediately and irrevocably places in jeopardy the right to freedom of the daignosee.
Despite the now substantial evidence (See Cutajar et al, 2011) that sexual abuse in childhood can raise the odds of developing a psychotic illness 13 times (1300%), and the recent decision by the New Zealand Court of Appeal that an appellant’s schizophrenia was caused by his childhood sexual abuse (LS v Accident Compensation Corporation  NZACC 385), these topics remain hidden with the current discourse on the left.
Hi Philip, while I think the Eugenics movement did for a long time play a malign role in psychiatry in some parts of the world, I think the bio-determinism of both eugenics and psychiatry have deeper roots, and further in the past.
Psychiatry’s bio-determinism is really part of medicine’s shift to bio-determinism that happened in the course of the industrial revolution. One beautiful description I’ve read is that medicine went from being about people’s problems to hospitals becoming museums of symptoms; i.e. a reductionist view of health and illness. This then combined with a growing faith in modern technology to uncover all the secrets of health and illness and then instrument to obtain a cure. This, I think, is at least in part a product of how the things people produce come to dominate their social relationships with each other, and seem to have an independent life of their own.
Interestingly, while most psychiatrists seem to hold to biologically reductionist views, in my state at least (NSW) the ability to detain and forcibly treat patients requires no such view of the world. Indeed, you don’t even need a diagnosis (there is no legal place for diagnosis in the process of detaining and having the detention upheld). Thus, even if someone’s symptoms were at least partly contributed to by social conditions (including such things as child abuse) it makes no difference to the legal situation.
Nice work. I have just taken on a Masters of Mental Health student in the area of “recovery from suicide”.
I just finished reading David Webb’s book ‘Thinking about suicide’ which is a description of one person’s lived experience of being a mental health system survivor. It was a strange stroke of luck that he was a heroin addict and so that always had to be dealt with first so
He mentions Durkheim but pursues the literature into the psych realm (suicide is a “crisis of the self”) and ultimately alternative spirituality which is a bit disappointing for a sociologist.
My question I guess is about the “anti-psychiatrists” despite their limitations I think they deserve to be much better known and represent something of a last stand against the biologisation of mental illness.
I think the problem is that to “de-biologise” mental health the anti-psychiatrists (with the exception of Foucault, whose project is much more complex and to do with the struggle between reason and non-reason) falsely “biologise” and technologise health and illness in general.
Although this may seem a bit controversial, I think all mental disorders are biological. But rather than this being a profound statement — as the biological reductionists intend it to be — I think it is a banal claim, given that biology is a necessary precondition of human society existing in the first place.
One of the problems with the bio-technical approach is that it presumes a straight line of causation from biology to psychology and society, and if we make the right technological breakthroughs at the biological level, we will automatically negate the need to address the other levels of analysis. This is the reductionist fallacy.
While I am not settled on what I think, I am drawn to Voloshinov’s idea that psychology (and consciousness) are boundary phenomena, at the intersection between the individual biological organism and the social organism, which in itself suggests a quite different way of looking at things than straight-line causation.
Hi Dr Tad
Interesting stuff. I’ve had the Watters book for a while and will now make time to read it!
I’m not sure I follow your response here, however. Does de-biologising mental illness (by which I assume we mean arguing against the view that mental illness has purely biological causes) *necessarily* entail distinguishing mental illness from physical illness by reductively biologising (disavowing social causes of) the latter? I wouldn’t think so, whatever the arguments of particular anti-psychiatry proponents.
I think its indisputable that life under Neoliberalism is harsher, more unequal, less conducive to solidarity etc. and that these are causes of the vast bulk of psychological distress. In that sense, I’ve come to the conclusion that we need to think really critically about the conservative and pacificatory social role of the talking therapies. It’s worth noting that conservative governments in the UK (IAPT), Aus (Better Access) and elsewhere seem happy to fund mass CBT programs (and prescription anti depressants) even as they gut other social programs. But there’s no contradiction, because the talking therapies reinforce a very neoliberal focus on the individual (or at best the family unit) as cause of and solution to psychological distress, while disavowing the social, and the material conditions under which people struggle. It is so pervasive in neoliberal culture that we need something like an ‘anti-psychology’ movement.
But I’m interested in whether you think that some ‘mental disorders’ (allowing that diagnostic labels are problematic) have a greater biological component, or perhaps a more straightforwardly organic cause. I wonder do you think it makes analytical sense to distinguish ‘high prevalence’ disorders (what I’m talking about in relation to talking therpies, and anti depressants) from severe disorders e.g. psychotic illnesses? Policy documents these days tend to talk vaguely about a ‘continuum’ of mental illness, but I’m not convinced.
Or to put it very crudely, will there still be ‘schizophrenia’ (the clusters of symptoms taken to mean schizophrenia) or psychosis after the fall of capitalism? This is linked to your comments about Sedgwick: will we really always need better mental health services, better doctors and nurses? Might they wither away with the state that provides them?