Library:Psychiatric Hegemony: A Marxist Theory of Mental Illness

Psychiatric Hegemony: A Marxist Theory of Mental Illness
Written in	2016

Dedication

This book is dedicated to three critical sociologists who continue to inspire:

Stanley Cohen (1942–2013)

Stuart Hall (1932–2014)

Jock Young (1942–2013)

&

An old friend and revolutionary footballer: Hafty (d. 2014)

Es geht voran!

Preface

This book exists for two main reasons. First, to fill a gap in the current sociology of mental health scholarship. This omission was brought to my attention by my postgraduate students; though I was initially very sceptical of their research capabilities, it turned out that they were basically cor- rect. Granted, there are bits and pieces of Marxist analysis out there, but compared with the other mainstream areas of sociological investigation such as education, youth, crime, and the family, the use of the big man’s work to make sense of the continuing power of the mental health system is nearly non-existent. Second, this book offers a radical challenge to the conservative and theory-free scholarship which is currently infecting my area of sociology. I believe we need to bring critical scholarship back to the heart of the sociology of mental health; we desperately need to have the theoretical as well as the empirical debates.

The book title may suggest radical polemic, but at the same time, I think the argument is relatively simple and straightforward, and also, I think there is plenty of evidence to support it. Under capitalism, we live in a society of fundamental inequalities defined by our relation to the means of economic production. Public or private, every institution in capitalist society is framed by these same power disparities. The dominant understandings of who we are, what is expected of us, and the limits of our behaviour are constructed and defined by the capitalist class, then reproduced through the state and institutions of civil society (e.g., the systems of education, criminal justice, and health). This is necessary for the progression and survival of capitalism. For example, we are socialised by the family, the school, and the mass media to accept social and eco- nomic disparities as natural and common sense; as the inevitable result of differential talent and competition within the marketplace, rather than class privilege and the exploitation of the majority of the population. In this respect, the mental health system is no exception. Led by the insti- tution of psychiatry as the ultimate experts on the mind, mental health professionals are far from immune to the needs of capital. In fact, I will demonstrate in this book that the mental health system has been impres- sively compliant to the wishes of the ruling classes and, for that reason, has gained more power, authority, and professional jurisdiction as indus- trial society has developed. While this book is centrally a theoretical interrogation of psychiat- ric discourse and professional power, I have also attempted to make it accessible to practitioners and non-theoreticians. I think theory is vitally important to achieving a broader understanding of human existence within this world, but I appreciate that many put more faith in the “prac- tical solution,” in being “pragmatic,” and in changing the world through “doing.” I think mental health practitioners—and I have met plenty over the years—are particularly prone to this view. For this reason, there are four substantive chapters in the book (on the issues of work, youth, women, and political protest) which are written with the pragmatists in mind. These apply Marxist ideas to specific issues within the field and highlight the many dangers of simply “doing” mental health work with- out any thought to the wider structures in which they carry out such activities. Often performed by professionals who similarly believed that they were “acting in the best interests of the patient,” the history of psy- chiatry and its allies is littered with too many acts of violence, torture, and death to be able to write them off as aberrations or exceptions in a “progressive” and “scientific” system of health care. It can instead be seen as a regular service performed by the mental health system in support of the ruling elites.

What follows is my version of a Marxist theory of mental illness. It is only one contribution within the sociology of mental health, but nevertheless, I hope it inspires others to follow my analysis in equally challenging and critical directions. And if you want to continue the dis- cussion, you can email me at b.cohen@auckland.ac.nz or @BmzCohen on twitter.

Acknowledgements

This book could not have happened without the emphatic support of Palgrave Macmillan; I am eternally grateful for their faith and trust in this project. In particular I would like to thank my Editors, Nicola Jones and Sharla Plant, as well as the ever-helpful Assistant Editors, Eleanor Christie, Laura Aldridge and Cecilia Ghidotti. The idea for the book originated from my postgraduate “Sociology of Mental Health” class. I thank all of the students that I have had the pleasure to teach on that course over the years, in particular Dhakshi Gamage (a student who articulated the specific connection between neoliberal values and the construction of shyness as a mental disorder long before I did). In 2015 I had the chance to meet with a number of international colleagues working on critical issues in mental health and I would like to thank them all for their kind words of support and advice. They include Suman Fernando, China Mills, and Peter Morrall. My good friend Jeff Masson has become something of a mentor, what a guy! I would like to thank both him and his family for being such warm and generous people on the many occasions that we have visited them and outstayed our welcome. The Department of Sociology at the University of Auckland continues to be the home of a vibrant crowd of collegial people who understand how important it is to have the time and resources to complete a major research project like this one—many thanks to you all. Of particular note, hello to my friend and colleague Colin Cremin, with whom I have shared some really useful conversations on the slippery subject of academic writing. And he lets me win when we play PES 2016, result! Thanks also to Helen Sword for the conversation on the ferry about scholarly writing and her very useful book Stylish Academic Writing (I tried, Helen!). This would be an appropriate point to add that all the ideas and attempts at style in this book are my fault alone. My thanks and appreciation to the Faculty of Arts, who approved my research and study leave in 2015; this allowed me to complete most of the writing for the book. The Faculty also funded a summer scholar, Rearna Hartmann, for three months (from November 2014 to February 2015) to undertake some additional analysis of each edition of the Diagnostic and Statistical Manual of Mental Disorders. This work appears in Chaps. 3–7 of the book. Rearna should get a special mention here as she proved to be such an incredibly talented and efficient scholar-in-training; it was a real pleasure to work with you on this project.

For inspiration, support, and temporary escape from the book writing, I would like to thank my football team, Tripzville/University-Mt Wellington (the 2015 Division Three (Seniors) Over-35s champions!), especially the boss, Mark Rossi, and my left-back partner in the crime, Tony Westmoreland. The music from the Killers kept me reasonably buoyant throughout the writing phase. Thanks also to friends and family in England, Germany, Australia, and New Zealand for all the good times, including the constant flow of alcohol, much needed. Maeby and Milo constantly interrupted my writing to show me wildlife they had “found” in the garden; on reflection, probably useful exercise for me. Finally, from the east to the west, the north to the south, she is the love of my life and the brains of the operation, Dr Jessica Terruhn—thanks for all the feedback on the drafts and, you know, everything else. I love you, honey!

Contents

1 Introduction: Thinking Critically About Mental Illness	1
2 Marxist Theory and Mental Illness: A Critique of Political Economy	27
3 Psychiatric Hegemony: Mental Illness in Neoliberal Society	69
4 Work: Enforcing Compliance	97
5 Youth: Medicalising Deviance	113
6 Women: Reproducing Patriarchal Relations	139
7 Resistance: Pathologising Dissent	169
8 Conclusion: Challenging the Psychiatric Hegemon	205
Appendix A: Methodology for Textual Analysis of the DSMs	213
Appendix B: Youth-Related Diagnostic Categories in the DSM, 1952–2013	215
Appendix C: “Feminised” Diagnostic Categories in the DSM, 1952–2013	221
Index	225

List of Abbreviations

ADD	Attention Deficit Disorder
ADHD	Attention-Deficit/Hyperactivity Disorder
APA	American Psychiatric Association*
APD	Antisocial Personality Disorder
BPD	Borderline Personality Disorder
CTO	Community Treatment Order
DSM	Diagnostic and Statistical Manual of Mental Disorders
ECT	Electroconvulsive Therapy
EL	Encephalitis Lethargica
FDA	Food and Drug Administration
GD	Gender Dysphoria
GID	Gender Identity Disorder
HPD	Histrionic Personality Disorder
ISA	Ideological State Apparatus
LLPDD	Late Luteal Phase Dysphoric Disorder
NIMH	National Institute of Mental Health
OSDD	Other Specified Dissociative Disorder
PENS	Psychological Ethics and National Security
PMDD	Premenstrual Dysphoric Disorder
PMS	Premenstrual Syndrome
PMT	Premenstrual Tension
PTSD	Posttraumatic Stress Disorder
xvi	List of Abbreviations
SAD	Social Anxiety Disorder
SSRI	Selective Serotonin Reuptake Inhibitors
UK	United Kingdom
US	United States
WHO	World Health Organization
	(*to distinguish the American Psychiatric Association from the American Psychological Association, the full name for the latter is always given in the text)

List of Figures and Tables

Figures
Fig. 2.1	Reasons for Admission to the Trans-Allegheny Lunatic Asylum, 1864–1889	39
Tables
Table 3.1	Increase in the use of work, home, and school phrasings in the DSM, 1952–2013	79
Table 4.1	Number of work-related words/phrases in the DSM, 1952–2013	104
Table 5.1	Number of youth-related diagnostic categories in the DSM, 1952–2013	121
Table 5.2	Number of youth-related words/phrases in the DSM, 1952–2013	122
Table 6.1	Number of “feminised” diagnostic categories in the DSM, 1952–2013	152
Table 6.2	Number of gender-related words/phrases in the DSM, 1952–2013	155
Table 7.1	Number of protest-related words/phrases in the DSM, 1952–2013	194

1: Introduction: Thinking Critically About Mental Illness

This book is a critical reflection on the current global epidemic of mental disease, and with that, the global proliferation of mental health professionals and the expanding discourse on mental illness. Over the past 35 years, scientific ideas on mental pathology from the designated experts on the mind have seeped outwards from the psychiatric institution into many spheres of public and private life. It is part of my role as a sociologist to explain how this epidemic has come about and the extent to which it is a valid reflection of real medical progress in the area. I am not alone in undertaking such a project; other social scientists—as well as psychiatrists and psychologists themselves—have investigated the recent expansion in the varieties of mental disorder and their usage among western populations, and have voiced similar concerns to the ones that I will articulate in this book. However, as the title suggests, this work goes further than most other scholars and mental health experts appear able to. This is because I frame the business of mental health within its wider structural context, within a system of power relations of which economic exploitation is the determinant one. Ignoring the development and current dynamics of capitalist society has been a significant omission of most other scholarship in the area; this is my contribution to getting critical social theory back to the heart of research and scholarship in the sociology of mental health.

“We are,” according to the psychotherapist James Davies (2013: 1), “a population on the brink.” The figures for mental disease suggest that not only are we currently in the grip of an illness epidemic but we are nearing a tipping point towards catastrophe: out of a global population of seven billion inhabitants, 450 million people are estimated to be currently affected by a mental or behavioural disorder (World Health Organization 2003: 4), with 100 million of them taking psychotropic drugs (Chalasani 2016: 1184). The projected rates in developed countries such as the United States and the United Kingdom are even higher with one in four people suffering from a mental disorder each year (Davies 2013: 1). The World Health Organization (WHO) (2003: 5) estimates that the expenditure on mental health problems in western society amounts to between 3 and 4 per cent of gross national product; the cost in the United States alone is over $100 billion per year (Wilkinson and Pickett 2010: 65). By 2020, according to the WHO, depression—a disease which will affect one-fifth of all Americans at some point in their life (Horwitz and Wakefield 2007: 4)—will be “the second leading cause of worldwide disability, behind only heart disease” (Horwitz and Wakefield 2007: 5).

Consequently, the WHO (2003: 3) states of this mental illness epidemic that “[t]he magnitude, suffering and burden in terms of disability and costs for individuals, families and societies are staggering.” From being a relatively rare affliction just 60 years ago, mental illness is now everybody’s concern. Whitaker (2010a: 6–7) has noted of this change that the rates of debilitating mental illness among US adults has increased sixfold between 1955 and 2007. However, the “plague of disabling mental illness” as he calls it has fallen particularly hard on young people in the country, with an incredible 35-fold increase between 1997 and 2007. This makes mental disease the “leading cause of disability in children” in the United States (Whitaker 2010a: 8). The varieties of known mental illnesses have also increased over time, with the American Psychiatric Association’s (APA) Diagnostic and Statistical Psychiatric Hegemony: A Marxist Theory of Mental Illness 3 Manual of Mental Disorders (DSM) identifying 106 mental disorders in 1952, yet 374 today (Davies 2013: 2).

In the current milieu it is no surprise that the power and influence of the mental health professionals are—like the above statistics—“growing at a remarkable rate” (Davies 2013: 2). However, as every critical scholar on the topic is aware, very serious problems remain with the current science and practice within the mental health system. These concerns inevitably lead us to questioning the reality of the claims to a mental illness “epidemic” made by health organisations such as the APA and the WHO, and to ask who really benefits from the global expansion of the psychiatric discourse. An essential issue here is the continuing contested nature of “mental illness,” for there remains no proof that any “mental disorder” is a real, observable disease. Consequently, the “experts” still cannot distinguish the mentally ill from the mentally healthy. In fact, a recent attempt by the APA—the most powerful psychiatric body in the world—to define mental illness was bluntly described by one of their most senior figures as “bullshit” (see discussion below). Accordingly, it also follows that no “treatment” has been shown to work on any specific “mental illness” and that there is no known causation for any disorder. Of course, these issues are highly disputed by many mental health professionals, so the evidence and debates are outlined in detail in the chapters that follow. I appreciate that questioning the validity of mental illness comes as little comfort to those people who are currently experiencing stress, trauma, or behaviour which causes what Thomas Szasz (1974) has previously referred to as “problems in living.” Let me clarify briefly here that this book is not denying such experience; rather it is questioning the discourse of “mental illness” which is produced by groups of professionals who claim an expert knowledge over this experience. Therefore, the current discussion is a critique of professional power not of personal experience and behaviour which may have been labelled (or self-labelled) as a “mental illness.” Though my previous work has investigated the multifaceted meanings of illness and recovery for those so labelled (see, e.g., Cohen 2015), this is not the focus of the current book. Instead, the issue at hand is how to explain the incredible expansion of what we might 1 Introduction: Thinking Critically About Mental Illness 3 4 call the “mental health industry”—that is, the entirety of the professionals, businesses, and discourse surrounding the area of mental health and illness—without a concurrent progression in the scientific evidence on mental pathology. The next section briefly explores some of the main explanations given for the dominance of the current mental health system and the gaps in this work.