Library:Psychiatric Hegemony: A Marxist Theory of Mental Illness
Psychiatric Hegemony: A Marxist Theory of Mental Illness
|Author||Bruce M. Z. Cohen|
|First published||Palgrave Macmillian UK|
Stanley Cohen (1942–2013)
Stuart Hall (1932–2014)
Jock Young (1942–2013)
An old friend and revolutionary footballer: Hafty (d. 2014)Es geht voran!
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 firstname.lastname@example.org or @BmzCohen on twitter.
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!
|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|
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
|Fig. 2.1||Reasons for Admission to the Trans-Allegheny Lunatic Asylum, 1864–1889||39|
|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 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.
Critical Scholarship on Mental Illness
Most commonly, critical scholars focus on one major reason for the current expansion in the numbers and categories of mental illness in western society—namely, the influence of pharmaceutical corporations (colloquially referred to as “big pharma”) on the construction of new categories of disorder and the promotion of drug solutions for those disorders (see, e.g., Davies 2013 ; Healy 2004 ; Moncrieff 2009 ; Moynihan and Cassels 2005; Whitaker 2010a; Whitaker and Cosgrove 2015 ). The institution of psychiatry is the ultimate authority responsible for defining and treating mental pathologies, yet commentators argue that the profession has been steadily compromised by forming close relationships with big pharma, who are now effectively setting the mental health agenda. For example, critics point to the 69 per cent of psychiatrists responsible for the development of the latest edition of the DSM (DSM-5, see American Psychiatric Association 2013) who have financial ties to the pharmaceutical industry (Cosgrove and Wheeler 2013 : 95). Research has also demonstrated the close involvement of big pharma in the development of current mental illness categories including social anxiety disorder (SAD) (Lane 2007) and premenstrual dysphoric disorder (PMDD) (Cosgrove and Wheeler 2013). The more behaviour and experience that can be successfully medicalised—that is, reconceptualised as in need of medical intervention—through this medico-industrial partnership, the more drugs can be potentially sold to the public. Thus it is argued that the expansion of the mental illness discourse is the result of a market takeover of health care; corporations rather than medical practitioners are now designating what mental pathology is and, as a result, dictating treatment. The obvious solution to this situation involves the de-coupling of mental health services from the influence of big business. Tighter government regulation and oversight of pharmaceutical corporations is required, as is transparency within the relevant professional organisations.
While this critique of big pharma’s intervention in the production and promotion of the contemporary psychiatric discourse is relevant, it is perhaps the least surprising aspect of the operation of the mental health system within capitalist society. Scholars of medical history such as Andrew Scull (1989, 1993, 2015), for example, have profiled a continuing “trade in lunacy” which can be traced back to the beginnings of industrial society and witnessed throughout the development of modern mental health work. That the market is part of the workings of psychiatry and related professions should be self-evident to any scholar aware of the history of the mental health system in western society. Such critics would also acknowledge that while psychiatry legitimates the products of big pharma, pushing psychopharmaceuticals in turn helps legitimate the psychiatric profession. The prescribing of drugs is a key symbol of modern doctoring which serves to align psychiatric practice with other branches of medicine through a shared biomedical understanding of health and illness.
The medico-industrial relationship described above has raised an associated criticism from critical scholars as to the efficacy of the biomedical approach in understanding mental health problems more generally. Biomedicine conceptualises disease as a physical pathology of the body. Thus, biomedical psychiatry theorises mental disorder as having a physical aetiology (causation) that can be observed, measured, and treated. Modern psychiatry focuses on the brain as the organ that causes such “disease,” and most often regards mental illness as the result of faulty neurotransmitters or “chemical imbalances” in the brain. The biomedical approach to understanding mental illness have been a part of psychiatry since its emergence over 200 years ago, yet has become increasingly dominant within the mental health system since the 1980s (Chap. 2). According to critics, however, despite its current “hegemonic” moment (Cosgrove and Wheeler 2013: 100), bio-psychiatry lacks the legitimacy of scientific evidence. The scholars blame corrupt individuals and powerful interests both inside and outside of psychiatry for reiterating biomedical myths regarding the “normal” and “abnormal” workings of the brain so as to be able to promote physical interventions such as drugs and electroconvulsive therapy (ECT) as potential “cures” for mental illness. Such writers note the continuing lack of proof of biological causation for any mental disorder, the potential for corruption at the hands of big pharma, the perversion of the psychiatric profession by particular selfinterested, powerful parties and individuals, and the reductionist nature of the biomedical model which is seen to have damaged the founding aims of the profession to improve the care and treatment of people who suffer from mental disorders and to always perform their duties in the best interests of the patient (see, e.g., Bentall 2009; Breggin 1991 ; Davies 2013; Greenberg 2013 ; Whitaker and Cosgrove 2015).
Critics call for an understanding of mental disorder which goes beyond biological reductionism to consider psychological, social, and environmental factors which correlate with mental illness. Often conceptualised as the “psychosocial model” (or simply, the “social model”) of mental illness, scholars and experts highlight a range of evidence from socioeconomic data which demonstrates that such factors as family income, educational level, ethnic group, geographical location, and social class are all closely related to the chances of developing a mental health problem. While the social model suggests that we all have the potential to suffer mental disorders if exposed to traumatic situations, some groups are particularly vulnerable to mental illness due to experiencing comparatively more stressful life conditions and, at the same time, having less access to cultural and economic resources which can alleviate the threat of mental problems. As the WHO’s (2013) recent Mental Health Action Plan 2013–2020 has emphasised,
Depending on the local context, certain individuals and groups in society may be placed at a significantly higher risk of experiencing mental health problems. These vulnerable groups may (but do not necessarily) include members of households living in poverty, people with chronic health conditions, infants and children exposed to maltreatment and neglect, adolescents first exposed to substance use, minority groups, indigenous populations, older people, people experiencing discrimination and human rights violations, lesbian, gay, bisexual, and transgender persons, prisoners, and people exposed to conflict, natural disasters or other humanitarian emergencies.
Interventions are then aimed at the personal and the social; therapy and counselling allows individuals to work through their disorder with trained professionals, while community health services target certain deprived communities for mental health promotions and the additional resourcing of mental illness prevention teams.
Explanations for the increase in rates of mental illness given by socially orientated models of mental health, therefore, draw attention to the widening social inequalities experienced in neoliberal society which impact levels of well-being in vulnerable populations. For example, Wilkinson and Pickett (2010: 67) draw on WHO data to claim that people suffer more mental illness in countries with wider inequalities (as measured by income distribution and the disparities between the richest and the poorest in that society). Their comparison of twelve advanced industrial nations shows the United States as having the highest rates of mental illness and, correspondingly, the highest rate of income inequalities. In comparison, Japan experiences the lowest rate of mental health problems and has a relatively equal distribution of income. It is a popular piece of sociologically orientated accounting in which society has the potential to make us sick; particularly those societies with higher levels of social and economic inequality appear to make us sicker. Thus, some Marxists have similarly argued that capitalism is ultimately responsible for causing mental illness (see, e.g., Robinson 1997 ; Rosenthal and Campbell 2016 ). However, as with most epidemiological work on mental illness, this analysis is weak and inconclusive. The research ultimately suffers from the same fundamental deficit as the biomedical model in that, while speculative correlations are made, there remains no proof of causation for any mental disorder.
As with psychiatrists, the many mental health workers in allied professions—such as the psychotherapists, psychologists, counsellors, and psychiatric social workers—who promote the more socially orientated approaches to mental illness, continue to stand by the validity of psychiatry’s knowledge base and for good reason: it is a discourse which furthers their own professional interests and legitimates their own “mental health” practices in a currently expanding market. Many scholars make the same mistake in arguing for such socially oriented approaches—they reinforce the psychiatric discourse as having validity where none has been established. Thus, what may first appear as serious critical scholarship on psychiatric knowledge production and the mental health system is often quite conservative and reformist in nature. These attempts at “critical” literature on the mental health system are most likely written by those inside the mental health profession, especially psychiatrists and psychologists (see, e.g., Bentall 2009; Davies 2013; Paris 2008). Unless they wish to give up their high-paid jobs—some escape into academia, others retire early—these writers continue to be complicit in supporting the mental health system that has produced them. For this reason their arguments go no further than pleas for reform (fewer drugs, more therapy, and so on) which allow their profession to continue to expand their operations relatively unhindered by serious critique.
To firmly ground the mental health system as a moral and political project, the following section discusses the continuing lack of validity of psychiatric knowledge. This deconstruction of the “science” of psychiatry is purposely undertaken here to highlight both the limits of previous critical scholarship—which has often failed to engage with the fundamental problems of mental health work—and the need to frame such institutions within structural systems of power and social control. Before this however, a brief note on a couple of key terms I will use in this discussion and subsequently throughout the book.
Psy-professions: my argument in this book implicates not only the psychiatric profession, but also allied groups such as psychologists, counsellors, psychiatric social workers, psychoanalysts, and the many other “talk therapy” professionals (for full critiques, see, e.g., Masson 1994; Morrall 2008). Collectively, I follow Rose (1999: viii) in understanding these groups as the “psy-professions”: “experts” who have over time acquired an authority on the supposed “real nature of humans as psychological subjects.” As medically trained practitioners, psychiatrists have the ultimate authority to define and police abnormal behaviour—which is why the book focuses primarily on this profession—yet they are ably assisted by other groups which have subsequently emerged and have vested interests in continuing to align themselves with the same knowledge base. The discussion in this book will demonstrate, for example, that psychologists, therapists, and counsellors can all be implicated in systematically serving the interests of the powerful.
Psychiatric discourse: I use this term to differentiate scientific evidence on “mental illness” (what some might call “psychiatric knowledge,” although this is also a highly problematic phrase) from psy-professional claims-making in the area. Psychiatric discourse is the totality of the propositions to expertise on “mental illness” and “mental health” (including the language, practices, and treatments) that psychiatric and allied professions have circulated to the public over the past 200 years. The term signifies the socially constructed nature of what is claimed to be expert knowledge in the area. For this reason, general terminology produced by the mental health system should be treated with caution. For example, in this book I refer to various labels of “mental illness,” to mental health “experts,” to “patients” and “users” of services, and so on; this does not, however, signal my acceptance of any such terminology as accurate or the truth of the matter.
Deconstructing the “Science” of Psychiatry
In his recent book Shrinks: The Untold Story of Psychiatry, former president of the APA, Jeffrey Lieberman (2015: 288–289), summarises the progress that psychiatry has made over the past 200 years in its knowledge and understanding of mental pathology. “We know that mental disorders exhibit consistent clusters of symptoms,” he declares,
We know that many disorders feature distinctive neural signatures in the brain. We know that many disorders express distinctive patterns of brain activity. We have gained some insight into the genetic underpinnings of mental disorders. We can treat persons with mental disorders using medications and somatic therapies that act uniquely on their symptoms but exert no effects in healthy people. We know that specific types of psychotherapy lead to clear improvements in patients suffering from specific types of disorders. And we know that, left untreated, these disorders cause anguish, misery, disability, violence, even death. Thus, mental disorders are abnormal, enduring, harmful, treatable, feature a biological component, and can be reliably diagnosed.
Underscoring psychiatry’s worth as a medical enterprise, Lieberman (2015: 289) concludes by stating of the above summary that “I believe this should satisfy anyone’s definition of medical illness.” Likewise, Shorter (1997: 325) concurs with Lieberman on the ascendancy of the psychiatric discipline to a valid branch of medical science when he reflects that
[i]n two hundred years ... psychiatrists [have] progressed from being the healers of the therapeutic asylum to serving as gatekeepers for Prozac. Psychiatric illness has passed from a feared sign of bad blood—a genetic curse—to an easily treatable condition not essentially different from any other medical problem, and possessing roughly the same affective valence.
Such positive appraisal of the knowledge and treatment of mental disorders by the official historians of psychiatry necessarily rationalises the jurisdictional exclusivity of the profession as based on a progressive narrative of medical science and discovery. Nevertheless, it is a successfully cultivated rhetoric of truth claims which crucially lacks evidence to sustain the desired picture of medical advancement in the field. This section surveys the main issues with the current state of psychiatric knowledge— namely, the disagreements over aetiology and treatment of mental illness, the lack of agreement on what “mental illness” is, and consequently the lack of validity to any category of mental disorder. This deconstruction of psychiatric knowledge claims will lead us to question what the purpose of the psy-professions in capitalist society actually is.
A recent review of the science behind the psychiatric discourse concluded that “no biological sign has ever been found for any ‘mental disorder.’ Correspondingly, there is no known physiological etiology” (Burstow 2015 : 75). This conclusion also became clear to the APA’s own DSM-5 task force when they began work on the new manual in 2002. As Whitaker and Cosgrove (2015: 60) record, in reviewing the available research evidence it was plain to the committee members that “[t] he etiology of mental disorders remained unknown. The field [of mental health] still did not have a biological marker or genetic test that could be used for diagnostic purposes.” Furthermore, the research also showed that psychiatrists could still not distinguish between mentally healthy and mentally sick people, and consequently had failed to define their area of supposed expertise. This issue was recently highlighted with reference to comments made by Allen Frances, the chair of the previous DSM-IV task force. When the DSM-IV (American Psychiatric Association 1994 : xxi) was published in 1994, it stated that “mental disorder” was
conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.
However, as the architect of the DSM-IV, Frances was later quoted by Greenberg (2013: 35–36) as stating of the above definition, “[h]ere’s the problem ... There is no definition of a mental disorder ... it’s bullshit ... I mean you can’t define it.” The lack of knowledge on mental health and illness has haunted the entire history of psychiatry. Some have dismissed critics who highlight this fundamental hole in the science of psychiatry as “antipsychiatry” or “mental illness deniers.” Such attacks on scholars who attempt to investigate the accuracy of the central pillars of psychiatric knowledge should further concern us, as it perhaps signals that plenty in the profession are already aware of the flimsy nature on which their “expertise” continues to rest. Together with an understanding of the history of the psychiatric profession—summed up by Scull (1989 : 8) as “dismal and depressing”—I would argue that it should be the duty of all social scientists concerned with the mental health field that, in good conscience and putting the needs of the public first, they remain highly sceptical of a psychiatric discourse that poses as expert knowledge on the mind but produces little actual evidence to back up the assertions made.
Though at first glance historical mental disorders such as masturbatory insanity (Chap. 2), drapetomania (Chap. 7), hysteria (Chap. 5), and homosexuality may appear as evidence of the profession reflecting the dominant norms and values of wider society, they are argued by the official historians of psychiatry to be examples of the false starts, early experimentations, and theoretical innovations of an emerging scientific discipline. It is suggested that this history is evidence of medical and scientific progress within the area of mental health to the current point where we know more about mental distress than ever before. Yet problems in the legitimacy of psychiatry’s vocation have remained, and reached crisis point at the cusp of deinstitutionalisation in the 1970s. At the time, a number of significant studies demonstrated the profession’s inherent tendency to label people as “mentally ill,” to stigmatise everyday aspects of a person’s behaviour as signs of pathology, and to make judgements on a person’s mental health status based on subjective judgements rather than objective criteria.
The study that had the most direct impact on the psychiatric profession— as well as public consciousness—at this time was David Rosenhan’s (1973) classic research On Being Sane in Insane Places which found that psychiatrists could not distinguish between “real” and “pseudo” patients presenting at psychiatric hospitals in the United States. All of Rosenhan’s “pseudo” patients (college students/researchers involved in the experiment) were admitted and given a psychotic label, and all the subsequent behaviour of the researchers—including their note-taking—was labelled by staff as further symptoms of their disorder (for a summary, see Burstow 2015: 75–76). This research was a culmination of earlier studies on labelling and mental illness which had begun in the 1960s with Irving Goffman (1961) and Thomas Scheff (1966). Goffman’s (1961) ethnographic study of psychiatric incarceration demonstrated many of the features which Rosenhan’s study would later succinctly outline, including the arbitrary nature of psychiatric assessment, the labelling of patient behaviour as further evidence of “mental illness,” and the processes of institutional conformity by which the inmates learned to accept such labels if they wanted to have any chance of being released from the institution at a later date. Scheff’s (1966) work on diagnostic decision making in psychiatry formulated a general labelling theory for the sociology of mental health. Again, his research found that psychiatrists made arbitrary and subjective decisions on those designated as “mentally ill,” sometimes retaining people in institutions even when there was no evidence to support such a decision. Psychiatrists, he argued, relied on a common sense set of beliefs and practices rather than observable, scientific evidence. Scheff (1966) concluded that the labelling of a person with a “mental illness” was contingent on the violation of social norms by low-status rule-breakers who are judged by higher status agents of social control (in this case, the psychiatric profession). Thus, according to these studies, the nature of “mental illness” is not a fixed object of medical study but rather a form of “social deviance”—a moral marker of societal infraction by the powerful inflicted on the powerless. This situation is summated in Becker’s (1963: 9, emphasis original) general theory of social deviance which stated that
deviance is not a quality of the act the person commits, but rather a consequence of the application by others of rules and sanctions to an “offender.” The deviant is one to whom that label has successfully been applied; deviant behavior is behavior that people so label.
The growing perception that psychiatric work was “unscientific” and, in turn, “mental illness” was a label of social deviance was further amplified in the 1970s by the APA’s very public battle over the continuation of homosexuality as a classification of mental disorder in the DSM (for a full discussion, see Kutchins and Kirk 1997: 55–99). As with the rationale for the profession labelling this sexual orientation as a mental illness in both the DSM-I (American Psychiatric Association 1952: 38–39) and the DSM-II (American Psychiatric Association 1968: 44), the successful decision to subsequently remove the label from the manual in 1973 was anything but scientific. On the contrary, Burstow (2015: 80) records how a mix of disruptive protests by gay rights campaigners, along with an internal power struggle between psychoanalysts and biomedical-orientated psychiatrists, brought about the change in APA policy. The end result was a decision based not on research evidence but rather a simple postal vote of APA members (Burstow 2015: 80). With institutional psychiatry in decline, community alternatives developing, and related mental health disciplines encroaching on traditional psychiatric territory, the profession entered a period of political and epistemological crisis. To regain credibility, the APA needed to prove the robustness of its knowledge base and convince the public as well as policy makers of their continuing usefulness and expertise.
The solution was to boost the scientific credibility of the field through improving the reliability of mental illness categories—that is, the identification and agreement among different practitioners of patients presenting with a specific disorder—which would then aid in validating such pathologies as real disease rather than professionally produced constructions. As Whitaker and Cosgrove (2015: 45–46) state of the importance of the reliability and validity concepts,
In infectious medicine, a diagnostic manual needs to be both reliable and valid in order to be truly useful. A classification system that is reliable enables physicians to distinguish between different diseases, and to then prescribe a treatment specific to a disease, which has been validated— through studies of its clinical course and, if possible, an understanding of its pathology—as real.
Under the leadership of Robert Spitzer, the APA carried out extensive field trials with the aim of testing the reliability of different diagnostic categories towards the creation of a more robust and scientifically sound DSM (to be released in 1980 as the DSM-III). Spitzer and Fleiss’ (cited in Kirk and Kutchins 1994: 75) own assessment of the reliability of categories of mental disorder in the DSM-I and the DSM-II was that none of them were more than “satisfactory,” frankly admitting that
[t]here are no diagnostic categories for which reliability is uniformly high. Reliability appears only satisfactory for three categories: mental deficiency, organic brain syndrome (but not its subtypes), and alcoholism. The level of reliability is no better than fair for psychosis and schizophrenia and is poor for the remaining categories.
To rectify this situation, Spitzer’s team coordinated a number of largescale pieces of research on psychiatric classification, including “the largest reliability study in history” (Burstow 2015: 77; for full details, see Williams et al. 1992) involving 592 people—both psychiatric patients and those without a previous history of mental health problems— being interviewed by pairs of psychiatrists spread over six sites in the United States and one in Germany. Kirk and Kutchins (1994: 83) have described the time, planning, and resourcing that went into this study as “the envy of researchers who attempt to conduct rigorous studies in clinical settings.” Subsequently, the data was claimed by the developers of the DSM-III to be of “far greater reliability” for most classes of mental disorder than that utilised in previous DSMs; the results showed a generally “quite good” level of agreement between psychiatrists, especially on the classic categories of schizophrenia and major affective disorders (American Psychiatric Association, cited in Kirk and Kutchins 1994: 79). On its release in 1980, the DSM-III was hailed as a great success for the discipline—a document which would finally silence detractors through accurately demonstrating the effective scientific progress of the discipline in the twentieth century. Consequently, the DSM-III has come to mark a “revolution” within the discipline (Decker 2013: xv). For western psychiatry, the manual was the “book that changed everything” (Lieberman 2015: 134).
It was, however, a revolution based on a scientific lie. The DSM-III field trials were “[b]latently rigged” (Burstow 2015: 77) by Spitzer’s task force to produce higher rates of reliability. A summary of the research biases in the construction of the studies—including the non- representative nature of the samples—has been noted by Whitaker and Cosgrove (2015 : 48–49), following extensive meta-analysis of the original field trial data by Kirk and Kutchins (1992). However, Kirk and Kutchins’ own evaluation of the DSM-III research revealed something even more surprising— namely, that there was no improvement in the previous poor levels of diagnostic reliability. In fact, in some categories of mental disorder, there were even greater levels of disagreement between psychiatrists than there had been with previous DSMs (Kirk and Kutchins 1994: 82–83). In large part, the claimed success of the DSM-III was due to a “linguistic sleight of hand” (Whitaker and Cosgrove 2015: 49) in which Spitzer and his task force re-phrased the same statistical levels of agreement between psychiatric professions (in this case, defined by kappa mean values between 0 and 1, where 1 is complete agreement and 0 complete disagreement) in different ways when comparing the DSM-I and the DSM-II with the DSM-III. For example, a mental disorder in the previous DSMs with a kappa score of .7 had been presented as “only satisfactory,” but was then redefined in the DSM-III as a “good” level of inter-rater agreement (Whitaker and Cosgrove 2015: 49). Thus, Kirk and Kutchins (1994 : 83) concluded that “despite the scientific claims of great success, reliability appears to have improved very little in three decades.” The DSM-III can therefore be seen as the success of the rhetoric of psychiatry rather than the result of any actual scientific progress within the discipline (Kirk and Kutchins 1992 ).
Predictably, subsequent research has shown no improvement in inter-rater reliability and, in many cases, has produced kappa scores below those reported in the original DSM-III field trials (Whitaker and Cosgrove 2015 : 50). The implications for the DSM on which psychiatry bases its claims to scientific rigour are clear—“the latest versions of DSM as a clinical tool,” state Kirk and Kutchins (1994: 84), “are unreliable and therefore of questionable validity as a classification system.” As the authors proceeded to document with the DSM-IV, rather than attempt to tighten mental illness classifications, the APA actually loosened them further, thereby increasing the potential number of people who could be labelled under each mental disorder (Kutchins and Kirk 1997 ). Following the DSM-III field trials, subsequent DSM task forces have abandoned the reliability issue, believing it to have been solved despite ongoing criticisms from health researchers and social scientists. And, lest we forget, even if psychiatry did one day solve the reliability problem, it still does not solve the validity issue for mental disorder classifications. After all, “[t]he fact that people can be trained to apply a label in a consistent way,” Burstow (2015 : 78) reminds us, “does not mean that the label points to anything real.”
Psychiatric insiders have openly admitted the lack of science to their area of operations. Allen Frances (cited in Whitaker and Cosgrove 2015 : 61), for example, has recently stated that the mental disorders given in the DSM are “better understood as no more than currently convenient constructs or heuristics that allow [psychiatrists] to communicate with one another.” This has included the classic constructs of schizophrenia and bipolar disorder (formerly manic-depression), of which the mental health researcher Joel Paris at the Department of Psychiatry, McGill University, has admitted “[i]n reality, we do not know whether [such] conditions ... are true diseases” (cited in Whitaker and Cosgrove 2015: 61). Even National Institute of Mental Health (NIMH) director and strong advocate of biomedical psychiatry, Thomas Insel (cited in Masson 2015 : xii), announced on the release of the DSM-5 in 2013 that the categories of mental disorder lacked validity and NIMH would no longer be using such diagnoses for research purposes.
Despite the claims to “progress” made by official historians of psychiatry such as Lieberman and Shorter, there is no evidence for the supposed “science” of psychiatry. There is no test for any mental illness, no proof of causation, no evidence of successful “treatment” that relates specifically to an individual disorder, and no accurate prediction of future cases. Thus, the claim that psychiatric constructs are real disease has not been proven. Consequently, it is necessary to utilise the existing evidence to more accurately theorise the real vocation of the psy-professions in capitalist society. As the faulty knowledge claims of the DSM are summarised by Burstow (2015: 78, emphasis original), “reliability cannot legitimately function as a validity claim and no studies have established validity”; therefore, “it follows that ... no foundation of any sort exists for the DSM categories. This is a serious issue that calls into question the power vested in psychiatry.” It necessarily leads us to consider such institutions as moral and political enterprises rather than medical ones (Szasz 1974: xii) because psy-professionals make historically and culturally bound judgements on the “correct” and “appropriate” behaviour of society’s members. This is a point summated by Ingelby (1980: 55, emphasis added) when he states that
what one thinks psychiatrists are up to depends crucially on what one thinks their patients are up to; and the latter question cannot be answered without taking an essentially political stand on what constitutes a “reasonable” response to a social situation.
In the same manner, British psychiatrist Joanna Moncrieff (2010 : 371) agrees that a “psychiatric diagnosis can be understood as functioning as a political device, in the sense that it legitimates a particular social response to aberrant behaviour of various sorts, but protects that response from any democratic challenge.” Even Shorter (1997: viii) accepts that the profession is responsible for policing social deviance when he remarks that “[p]sychiatry is, to be sure, the ultimate rulemaker of acceptable behaviour through its ability to specify what counts as ‘crazy.’” Likewise, the concept of “health” within the mental health system is understood as whatever counts as “normal” within a specific historical epoch and cultural setting. Sayers (cited in Christian 1997: 33–34) states of this relative concept of “health” that
[t]he society and the individual’s role within it are assumed to be normal (that is to say, “healthy”: “normality” is a common synonym for “health” in psychiatry as in other areas of medicine). Indeed, the prevailing social environment is made the very criterion of normality, and the individual is judged ill insofar as he or she fails to “adjust” to it.
The Urgency for Marxist Theory
Despite the lack of validity to the “science” of psychiatry, most “critical” texts fail to adequately explain the expansion of mental health work because they lack sustained theoretical engagement. Most commentators refuse to conceptualise the mental health business beyond what they can see with their own eyes, and this in turn hides the wider structural forces which can shape, inhabit, and direct the institutional priorities of the mental health experts. For instance, if Wilkinson and Pickett (2010 : 67) had spent more time critically investigating the production of psychiatric knowledge, they might have come to the conclusion that the more unequal the society, the more likely it is that people will be labelled with a mental disorder. Stated in a slightly different manner, countries that have faced the brunt of neoliberal polices are more likely to apply labels of “mental disorder” onto the population.
This is not, however, to suggest that there has been a complete absence of critical social theorising on the activities of the psy-professionals within capitalist society. On the contrary, from labelling and social constructionist accounts to critical realism, post-psychiatry, and mad studies, there has been a considerable tradition of engagement with the issues of societal inequalities, institutional power, and psychiatric mechanisms of social control since the 1960s (see Cohen, forthcoming). Such literature has been highly valuable to the sociology of mental health and is utilised throughout this book. Nevertheless, this scholarship still fails to fully contextualise the political project of psychiatry in relation to the fundamental conditions of economic exploitation under capitalism. The critical analysis lacks either a full understanding of the dynamics of capitalist society or an adequate historical and contemporary contextualisation of the institution of psychiatry. Without attending to both of these issues, the scholarship will remain piecemeal and theoretically incomplete. It is my contention that an inherently political institution such as psychiatry can only be fully understood through an appropriate framing of the profession within wider socio-historical processes and with the aid of Marxist theory. This allows us to make sense of the emergence and development of the psy-professions within industrial society, their changing practices and priorities, points of internal and external competition and conflict, as well as their current period of expansion in neoliberal society.
It has been left to a small handful of Marxist scholars to outline a fundamental truth of the mental health system: that its priorities and practices are fundamentally shaped by the goals of capitalism (see, e.g., Brown 1974; Nahem 1981; Parker 2007; Roberts 2015; Robinson 1997 ; Rosenthal and Campbell 2016). As Brown (1974: 1) has remarked of psychology, it is “more than just a professional field of work. It is also a codified ideology and practice that arises from the nature of our capitalist society and functions to bolster that society.” This is less surprising, states Nahem (1981 : 7), when it is understood that, as with psychiatry, “[p]sychology arose and developed in capitalist society, a class society. In all class societies, the dominant social, cultural and political views are those of the dominant class.” And more so, with the continuing expansion of the psy-professions, Parker (2007 : 1–2) argues that psychology has become
an increasingly powerful component of ideology, ruling ideas that endorse exploitation and sabotage struggles against oppression. This psychology circulates way beyond colleges and clinics, and different versions of psychology as ideology are now to be found nearly everywhere in capitalist society.
The dominant norms and values of the ruling classes are reflected in the psychiatric discourse on human behaviour and the workings of the mind. Consequently, the psy-professions are responsible for facilitating the maximisation of profit for the ruling classes while individualising the social and economic conditions of the workers. The mental health system seeks to normalise the fundamentally oppressive relations of capitalism by focusing on the individual—rather than the society—as pathological and in need of adjustment through “treatment” options such as drugs, ECT, and therapy. These arguments will be discussed in further detail in the chapters that follow. To end this section, however, I briefly want to highlight a key problem with previous Marxist literature.
Almost all of the Marxist scholars cited above come from inside the psy-professions (usually psychology), and for that reason most attempt to still rescue their discipline from capitalism. For example, Nahem (1981 : 7) speaks of the mental health system as being “co-opted” by capitalism, a situation in which the true evidence-based practice of psychiatry and psychology has been replaced by the ideology of the ruling classes. Similarly, Robinson (1997) and Rosenthal and Campbell (2016 ) argue that the psy-professions have been tainted by capitalism, and that, consequently, a socialist society would have “a genuinely scientific psychology [which] will constitute an essential part of human culture” (Robinson 1997: 77). However, the idea of a “new psychiatry” or “new psychology” based on Marxist principles (as suggested in Brown 1974) is fundamentally incompatible with the socio-historical reality of these institutions (Chap. 2). As I argue throughout this book, the psy-professions are a product of capitalism; they were created to police dissent and reinforce conformity, not to emancipate people. Thus, they cannot be reformed or rescued from capitalism; they are and will always be institutions of social control, and for that reason they have no positive role to play in a socialist society (Chap. 8). As important as the previous Marxist scholarship on mental health has been, this book avoids the potential biases of the reformed therapist, psychologist, or psychiatrist in assessing the history and current expansion of the psy-professionals.
Twenty years ago, Thomas Harris (1995: xv), the bestselling author of I’m OK-You’re OK—one of the first “popular psychology” texts on the market—stated that “[t]he question [for psychiatry] has always been how to get Freud off the couch and to the masses.” This book explains how and why the psychiatric discourse has proliferated over the past few decades and achieved its current hegemonic status in neoliberal society. The following chapter appropriately grounds the discussion in Marx’s classic theory of historical materialism. This is contextualised within a socio-historical analysis of the philosophies and treatments of the psychiatric profession over the past 200 years. The discussion demonstrates how the mental health system has served both the economic and ideological needs of capitalist society. With reference to the work of neo-Marxist scholarship, the specific linkage of neoliberalism to the expansion of the psychiatric discourse is explained in Chap. 3. The “crisis” of psychiatry in the mid-1970s and the construction of the DSM-III in 1980 need to be understood within the wider political framework of a declining welfare state and an increasing focus on individualism. To explore how the psyprofessionals serve capitalist society in specific areas of private and public life, Chaps. 4–7 analyse the impingement of psychiatric hegemony on young people and women, as well as in work lives and with forms of social and political protest. Each of these chapters includes textual research on the DSM, demonstrating how categories and symptoms of mental disorder have come to increasingly mirror the dominant norms and values of neoliberal society. Chapter 4 investigates the psychological sciences’ engagement with the world of work, including a case study of social anxiety disorder—the construction of which can only be fully understood in the context of neoliberal demands for “employability” and “sellable selves” within the labour force. As part of the future workforce, Chap. 5 investigates the growth in mental disorders aimed specifically at young people. Including a socio-historical analysis of the most commonly diagnosed childhood mental illness (attention-deficit/hyperactivity disorder (ADHD)), the discussion demonstrates that the contemporary moment of labelling children with mental disorders is strongly related to the requirements of late capitalism for compliant, disciplined, and higherskilled workers. In comparison to the mental health system’s relatively recent focus on young people, women have been an ongoing obsession for the psy-professions since the beginning of industrial society. From hysteria to borderline personality disorder (BPD), Chap. 6 recounts the systematic pathologisation of female emotions and experiences by psyprofessionals, showing how these activities have primarily functioned to reinforce the division of labour, traditional gender roles, and patriarchal power. Chapter 7 explores some of the darkest moments in the history of the mental health system including their support for slavery, the central role they played in the Nazi holocaust, and their recent involvement in torturing prisoners of the “war on terror.” This discussion will demonstrate that, rather than being isolated events carried out by rogue elements, these activities achieved widespread support among the mental health experts and were fundamentally considered to be “in the best interests of the patient.” Further, the analysis will also show that the post-9/11 “culture of fear” in western society has only served to further enforce psychiatry hegemony, a situation achieved through the closer surveillance of social and political dissent as reflected in the DSM-5. Chapter 8 concludes the discussion in this book by briefly offering a few practical ways in which we can begin to challenge the psychiatric hegemon. These include challenging the academic apologists for the psy-professions, campaigning for the outlawing of psychiatric violence and compulsory treatment, and the forming of alliances with fellow radical scholars, psychiatric survivors, and left-wing activists.
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2: Marxist Theory and Mental Illness: A Critique of Political Economy
Over the past 35 years, social theory has largely disappeared from scholarship on mental illness. In sociology and related disciplines, critical thinking has been sacrificed in the face of a neoliberal agenda which prioritises “pragmatic” scholarship relevant to current social policy. Consequently, dominant approaches to mental health research do little more than support the contemporary political agenda. Whether big-data epidemiological studies on the levels of “mental illness” within the general population or small in-depth analysis of psychiatric experiences, contemporary research is usually bereft of any problematising of the mental health system, the psy-professions, or the psychiatric discourse on which such professions lay claims to expertise. Shamefully, we have left it largely to those within these professions to raise the most awkward questions on the mental health business including the lack of validity of current mental disorders, the increasing medicalisation of everyday behaviour, the close ties to pharmaceutical companies, and the role of these groups as agents of social control. Too many sociologists are scared of engaging with the critical issues—they fear being labelled as “antipsychiatry” or of denying survivor/user experience, and they worry about being excluded from funding streams if they raise serious issues about the nature and purpose of the mental health system in capitalist society. Yet if sociologists of medicine are truly serious about accurately researching issues of health and illness, if we still “care” about our subject area, then there is an urgent need to contextualise our work in a set of historical and contemporary power relations. As Vincente Navarro (1980 : 200) has previously made clear,
The actual way of studying disease in any society is by analyzing its historical presence within the political, economic, and ideological power relations in that specific social formation. And by this, I do not mean the analysis of the natural history of disease but rather the political, economic, and ideological determinants of that disease, determinants resulting from the overall power relations which are primarily based on the social relations of production. These power relations are the ones which determine the nature and definition of disease, medical knowledge, and medical practice.
This book is my contribution to reigniting critical thinking within the sociology of mental health.
This chapter begins by outlining the Marxist theory of “materialism,” a critique of the political economy of capitalist society which aims to explain economic and social disparities as a historical process. An understanding of Marxist theory allows us to view capitalism as an economic system of fundamental inequalities which are reproduced not only in activities specifically related to the exchange of labour and commodities but rather in all aspects of social, cultural, and political life. In other words, capitalism frames institutional, group, and personal understandings of the world and responses to it. This includes the structure, practices, and priorities of the mental health system itself—an issue which is discussed with reference to those scholars who have previously applied Marxist theory to medicine and psychiatry including Navarro, Waitzkin, Brown, and Parker. Following these scholars, I spend the remainder of the chapter performing a Marxist assessment of the political economy of the mental health system. This is done through analysing a range of colourful and horrific socio-historical examples—including tranquilizer chairs, masturbation, lobotomies, vibrators, shock treatment, and a lot of drugs—to demonstrate how psychiatry and allied professions have served the needs of capitalism both economically and ideologically.
Karl Marx’s analysis of capitalism is recognised by scholars on both the right and the left as highly significant in explaining the formation and continuance of the fundamental economic and social inequalities witnessed within advanced industrial societies. His theory of historical materialism states that the source of human progress and historical change is not to be found in “legal relations” or “political forms,” but rather “in the material conditions of life” (cited in Howard and King 1985: 4). By this Marx means that the economic relations of human beings determine all other relations in that society. Material survival rather than the development of rationality and spiritual thinking forms the fundamental basis of human endeavour in each historical epoch (Palumbo and Scott 2005: 42). In challenging the individualist, liberal theorising of many of his contemporaries, Marx argued that industrial society had not created a radically new society of rational individuals endowed with free will, but instead introduced a new form of industrial slavery which in many ways replicated the medieval serfdom of feudal society. “Freedom” in industrial society is thus an illusion created by a more complex set of societal relations in which political and legal institutions—designated by Marx as part of the “superstructure” of capitalism—reproduced and reinforced these economic relations as appropriate and just. In explaining this contention, Marx (cited in Howard and King 1985: 5, emphasis added) argues,
In the social production of their existence, men inevitably enter into definite relations, which are independent of their will, namely relations of production appropriate to a given stage in the development of their material forces of production. The totality of these relations of production constitutes the economic structure of society, the real foundation, on which arises a legal and political superstructure and to which correspond definite forms of social consciousness. The mode of production of material life conditions the general process of social, political and intellectual life. It is not the consciousness of men that determines their existence, but their social existence that determines their consciousness.
For Marx, the mode of production in any given epoch consists of the forces of production (technologies, raw materials, and so on) and the relations of production entailing “forms of social organized labour based on the laws of ownership” (Palumbo and Scott 2005: 44). The relations of production determine the status and social-class position of the population dependent on whether they are the owners—the ruling classes, or “bourgeoisie”—or the workers—the working classes, or “proletariat”—of the means of production (in this case, factories, offices, businesses, and so on). Unique to capitalist society, the means of production are privately owned, with the goal of the ruling classes to accumulate and maximise profit through a competitive and expanding market for commodities (Palumbo and Scott 2005 : 45). Capitalist society is therefore marked by a fundamental disparity in the distribution of economic resources between the majority of the population—the working classes—who are only “free” to sell their labour to the bourgeoisie, and the small elite who own and control the economic base. It is a system of exploitation in which the workers generate “surplus value” for the ruling classes from their labour, are alienated from what they produce, and in turn are commodified by this process (Palumbo and Scott 2005: 46). The workers are kept at subsistence wages, while the elite accumulate greater wealth— the rich will get richer, prophesied Marx, while the poor will get poorer. Though this has not precisely been the case as industrial capitalism has progressed, there is still plenty of evidence for the continuance of huge inequalities in income and wealth in western society, as well as increasing of gaps between the rich and the poor since the emergence of neoliberalism 35 years ago (see, e.g., Organisation for Economic Co-operation and Development 2015).
On this basis, Marx conceptualises capitalist society as chaotic, anarchic, and riddled with contradictions. Ultimately, it is a system defined by the permanent struggle between the proletariat and the bourgeoisie over the means of production—a conflict which the workers are destined to win through uprising and revolution, eventually creating a new socialist or communist society defined by common ownership and an equal distribution of resources based on need (Crossley 2005: 291). It is “one of the contradictions of capitalism,” Brown (1974 : 17) notes, “that as capitalism creates a working class that it then exploits, the development 30 Psychiatric Hegemony of that class seals the fate of the capitalist system, for the working class will overthrow the bourgeois class.” Within capitalist society lies the seed of its own destruction. The conflict between the social classes will come to a conclusion when the working classes reach “class consciousness”— that is, a recognition of their true social and economic existence under capitalism. However, in the meantime, Marx argued that the exploitative conditions of capitalism led to the alienation of workers from their social environment. The natural sociability and communality of the people is displaced by the brutality of lived conditions under capitalism (Palumbo and Scott 2005: 47). Marx theorised that the workers had exchanged “relations between persons into relations between things,” a “commodity fetishism” in which objects instead of social relations embody worth and value (Palumbo and Scott 2005: 47). This was one form of “false consciousness” of the working classes, a process of exchanging awareness of the true nature of capitalism for the false values of commodities, a part of ruling class ideology. This ideology of capitalism is perpetuated by the superstructure and institutions of civil society such as the church, the state, the criminal justice system, the education system, the media, and the health system.
The next section draws on the Marxist understandings of historical materialism to explore how these ideas can be applied to the field of medicine and psychiatry. My contention is that the priorities and practices of the western health care system facilitate capitalist goals in two distinct ways: first, through direct and indirect profit accumulation, and second, through the social control of deviant populations and the ideological reproduction of dominant norms and values of the ruling classes.
Marxism, Medicine, and Mental Health
Many years ago when the Channel Tunnel—connecting England and France—was being built (1986–1992), I got the chance to talk to a nurse working on the project on the English side. The project was big, deadlines were tight, and the workers, she told me, were suffering terrible conditions in the tunnel (a total of ten workers died during the construction (Smith 2015 )). I wondered how complicated her job was as part of the onsite health personnel for such a large project. Not very. “The men mostly come to me complaining of terrible headaches,” she explained, “my job is to give them two aspirin and get them back down the tunnel as quickly as possible.”
Speaking of medicine under capitalism, Waitzkin (2000: 37) notes the fundamental contradiction between the perception of health as the ultimate “caring profession” and a society which establishes obstacles to the goal of alleviating “needless suffering and death,” for “[t]he social organization of medicine also fosters patterns of oppression that are antithetical to medicine’s more humane purposes. These patterns within medicine mirror and reproduce oppressive features of the wider society as well.” Marxist scholars of medicine have theorised this replication of the wider class struggle within the health system in a number of ways. First, the priorities of the institution favour those of capitalism and the ruling class. For example, the modern system of health care emerged out of the need for a healthier and more reliable industrial workforce (Waitzkin 2000 : 48); concern for the health of the working classes has tended to peak when there are imperialist wars to be fought, while the majority of current medical research prioritises lifestyle and “me too” cosmetic treatments for the global market rather than research on life-saving treatments for cancer and infectious diseases (see, e.g., Rapaport 2015). Second, the exploitative work relations within capitalist societies are replicated within the rigid hierarchy of medicine, with high-waged, upper middle-class consultants holding a great amount of decision-making power at the top, the lower middle-class nursing managers administering consultants’ needs in the middle, and—holding no power whatsoever and subject to the whims of health managers—the low-earning working-class orderlies and auxiliary staff at the bottom of the pyramid. Navarro (1976 : 446) also notes the tendency of the medical profession to maintain and reinforce these class relations through “both the distribution of skills and knowledge and the control of technology” within the health service. Third, the health system functions as an institution of social control. That is, it reinforces the dominant values and norms of capitalism through its surveillance and labelling practices. In the words of Freidson (1988 : 252), medicine acts as a “moral entrepreneur” to the extent that illness is viewed negatively and as something to be “eradicated or contained.” Even cancer, he states, is a social valuation by the profession, a moral rather than an objective judgement of the body, even if it is one “on which most people happen to agree” (Freidson 1988: 252). Taking a Marxist approach to medicine includes recognising the policing function of the health professions to label and “medicalise” social deviance as illness, as well as reinforce the ideological prerogatives of capitalism as natural and common sense (for instance, through biomedical interventions focused on the individual rather than the wider social environment).
The social control function within psy-professional work practices and knowledge claims is reasonably easy to identify and has been a major focus of critical scholars—Marxist and otherwise—since the 1960s (see, e.g., Conrad 1975; Goffman 1961; Rosenhan 1973 ; Scheff 1966 ). The moral judgements that mental health experts make of people’s behaviour under the claims of scientific neutrality and objectivity allow them to sanction forms of deviance which run contrary to the prevailing social order. For example, Szasz (cited in Freidson 1988: 249) stated in 1964 that “agoraphobia is illness because one should not be afraid of open spaces. Homosexuality is an illness because heterosexuality is the social norm. Divorce is illness because it signals failure of marriage.” Specifically, Marxist contentions of the psy-professions as agents of social control focus on the ways in which these experts contribute to the alienation of people from their own creative abilities. These experts utilise their knowledge claims on human behaviour to depoliticise attempts at social transformation at the group and community level, in turn acknowledging only individual solutions as possible. Consequently, states Parker (2007 : 2), this “psychologisation of social life” performed by mental health workers “encourages people to think that the only possible change they could ever make would be in the way they dress and present themselves to others.”
Ultimately, however, a Marxist critique of political economy needs to consider the ideological function in the context of the underlying economic prerogatives of capitalism. The social control of populations considered as deviant and labelled as “mentally ill” by the psy-professions serves specific requirements of the market, whether this is through the profiteering from individual treatments, the expansion of professional services, or the reinforcement of work and family regimes in the name of appropriate treatment outcomes. In his critical work on the history of psychiatry, Scull (1993: 10) argues that the emergence of the psychiatric profession can be explained as a result of the changes in the social organisation of deviance brought about by new market relations. He asserts that the rise of industrial society required a more complex response to social deviance; there was especially a need to adequately control such groups—who were no longer tied to the land, but instead “free” to sell their labour to the emerging bourgeois—and separate the non-able bodied (e.g., the sick, disabled, poor, alcoholic, vagrant, and elderly) from the “healthy” population. Thus, the growth of the asylums for “the mad” is understood as an economically efficient means by which groups of deviants could be physically separated from the rest of society and kept under close surveillance by new professional authorities (Scull 1993: 33). In Scull’s (1993 : 29) words,
the main driving force behind the rise of a segregative response to madness (and to other forms of deviance) can ... be asserted to lie in the effects of a mature capitalist market economy and the associated ever more thoroughgoing commercialization of existence.
Therefore, it is ultimately the goals of capitalism which directs industrial society’s response to social deviance and, in this way, brings about the formation of the medical attendants/mad doctors/alienists who would in time become the psychiatric profession.
A Marxist approach to understanding the mental health system necessarily has to analyse professional organisation, discourse, and practice, at both the economic and ideological levels. As Brown (1974 : 17–18, emphases original) remarks, a Marxist approach to the psy-professions helps us make sense of “the manifestation, on a huge, technological basis, of capitalist economic relations,” so we can then “understand the role of psychology and psychiatry as mediating the economic-class structure and the personal emotional structure.” Psychiatry’s claims to “scientific practice,” remarks Scull (1993: 392–393), means it has “great potential value in legitimizing and depoliticizing efforts to regulate social life and to keep the recalcitrant and socially disruptive in line.” However, this medicalisation of deviance by the mental health experts should not be treated as fundamentally distinct and separate from the economic base that 34 Psychiatric Hegemony determines the specific form—as well as the groups—who are regulated under such regimes of power. As Parker (2014: 167) states of psychotherapy, a Marxist analysis allows us to understand the profession within capitalism “as an apparatus that not only participates in the production of value but also ... [becomes] more important to the production, circulation and management, in both the State and civil society, of subjectivity.” In this manner, the following section will analyse a range of examples from the history of psychiatry, highlighting both their specific techniques for managing subjectivity as agents of social control and the production of economic value from their operations.
Industrialisation and the Mad Doctors
Official historians of psychiatry see Philippe Pinel’s unchaining of the mad in Paris in 1793 as a highly symbolic moment when the insane were, for the first time, recognised as human beings in need of therapeutic intervention rather than imprisonment and mistreatment (see, e.g., Lieberman 2015: 35–36). It is the formal beginning of the psychiatric profession, a new group of medical experts whose vocation will be to care for and treat the mentally ill as opposed to punish them. Pinel’s traitement moral (known in the Anglo-American world as “moral treatment” or “moral therapy”) was hailed as a truly humanitarian approach to the management of the mad which reflected the rationalism of the new industrial world. Rather than forwarding an organic aetiology for madness, patient case studies suggested to Pinel that particular life events or trauma was at the root of their disturbed behaviour. It was felt that “moral” means could correct the actions of the insane through a more understanding response involving listening to patient complaints, reasoning with them, and showing kindness (Porter 2002: 104). Pinel’s philosophy placed an emphasis on the humane care of the insane with the goal of returning them to “rationality” and good health through respectful, therapeutic discourse. His own commentaries on moral treatment, however, cautioned that “successful treatment depended on the employment of psychological terror and fear to gain the compliance of the insane” (Kirk et al. 2013: 45). This importance placed on threats, compliance, and the reform of character found at the very birth of psychiatric practice is something that we continue to see in the “therapeutic” setting today. Fundamental here is the emergence of new understandings of madness which closely align with the changing forces of production and the management of social deviance. Psychiatry’s success is dependent on the profession’s usefulness in serving the industrial order, including the demands of the bourgeoisie for a highly regulated and compliant workforce. It is more than coincidence that the profession remains—without any trace of irony—insistent on aligning their earliest developments with the appropriately named system of “moral treatment.”
Following Pinel, William Tuke and his fellow Quakers implemented the principles of moral treatment at their York Retreat in England. At this rural residence patients were to be treated humanely and with dignity; a minimum of physical restraint was utilised, instead the custodians encouraged various forms of behavioural adjustment. However, transgressions from acceptable standards of “normal” and proper conduct would not be tolerated. Rather than be idle, patients were expected to take up work and hobbies, adhere to good manners at all times, to dress appropriately, and be considerate in social interactions with staff, other patients, and visitors to the Retreat (Foucault 1988a: 241–278). With a ratio of one staff member to every three patients, Tuke claimed a 70 per cent recovery rate among patients at the establishment (Whitaker 2010b: 24).
Contemporary commentators continue to see moral treatment and the practices at the York Retreat as examples of what good mental health care should be (see, e.g., Borthwick et al. 2001). Its underlying philosophy, however, reflected wider puritanical responses of Victorian society to the socially deviant. A reform of character under industrial capitalism was not only desirable but also necessary; by force of will, the irrational citizen would now be made rational again. As Foucault (1988a: 241–278) has discussed, moral treatment was a shift in the management of those labelled as “mad” in as much as the new disciplinary apparatus enforced a closer surveillance of personal conduct, so as to instil obedience to authority in a new set of societal relations. Kirk et al. (2013: 45) have noted of the Retreat that it was still an institution that confined people against their will and utilised a system of rewards and punishments to enforce “psychological and physical conformity.” Making progress in this system of moral treatment, state Kirk et al. (2013: 45),
required obedience and proper behavior by the patients. Failure to follow the rules dramatically undermined the patient’s social status, institutional privileges, and personal wellbeing by the forced transfer to more remote and less respectable and comfortable wards. Total control by the alienists/ moral managers over the physical and social environment of the inmates was the mechanism that imposed discipline.
This moral management of social deviance was appropriated and replicated by the medical attendants/mad doctors in the larger asylum system over the course of the nineteenth century. Mass incarceration in such facilities effectively facilitated, “sweeping from the streets the poor, the indigent, the mad and the homeless, [and] unsightly beggars” (Breggin 1993: 145), yet at the same time offered a philosophy of care and treatment which emphasised humanitarianism and the potential for recovery. Effectively, the mad doctors succeeded in gaining jurisdiction over the mentally ill through a convincing medical rhetoric on mental disease, even though, as Abbott (cited in Kirk et al. 2013: 9) notes, “[o]f its treatments, only incarceration had any effect, and that made the psychiatrists little different from the jailers they had replaced, despite their reference to the medical model of science, treatment and cure.”
The custodians of the emerging asylum system offered a more sophisticated form of social control consistent with the complexities of the industrial order. It is interesting in this respect that the early proponents of moral treatment were religious orders from whom the mad doctors/alienists appropriated their methods—a move from religion to psychiatry as the moral authority for the scientific age. As Abbott (1988: 298) further comments, the early success of the profession is based on its promise to adjust individuals to the new social order. “From its first interest in prevention and indeed from the moral therapy era,” he writes (Abbott 1988: 298, emphasis added),
psychiatry had been fascinated by the relation of the individual to society. The psychiatric concept of prevention attributed nervous and mental disease to failure of adjustment between individual and society, and assumed successful adjustment would prevent disease. Adjustment underlay every application of psychiatry to social control; young people must be adjusted to the orderly world, soldiers must be adjusted to trench warfare, workers must be adjusted to factories.
Foucault (1988b: 180) reiterates Abbott’s point when he states that “[f ] rom the outset, psychiatry has had as its project to be a function of social order.” The mad doctors’ control of jurisdiction over those labelled as “insane” was only possible through constructing a medical narrative which reflected and responded to the social and economic concerns of the ruling elites. This is further stressed by Foucault (1988b : 180–181, emphasis original) when he puts himself in the shoes of the alienist/psychiatric profession as they emerge in the nineteenth century;
everywhere society is meeting a mass of problems, in the street, at work, in the family, etc. – and we psychiatrists are the functionaries of social order. It is up to us to make good these disorders. We have a function in public hygiene. That is the true vocation of psychiatry. And that is its true context, its destiny.
A useful example of psychiatry’s expanding moral role with industrial society can be seen in Fig. 2.1 which shows an original record of incarceration for the Trans-Allegheny Lunatic Asylum (in the city of Weston, West Virginia), from when it opened in 1864 until 1889. Reasons for admission include “bad whiskey,” “desertion by husband,” “immoral life,” “laziness,” “novel reading,” “politics,” and “uterine derangement”.
Fig. 2.1 Reasons for Admission to the Trans-Allegheny Lunatic Asylum, 1864–1889
In the name of “public hygiene,” behaviour considered as deviant or threatening to the industrial elites was pathologised by the mad doctors. This included what Szasz (2000: 35) refers to as one of “the most commonly diagnosed and most enthusiastically treated mental disease[s] in the history of medicine,” namely masturbatory insanity. As the label suggests, the profession theorised that masturbation was not only an unhygienic and deviant behaviour but one which led to insanity and even suicide (Szasz 2000: 36). Still being offered for the “sufferer” as late as the 1930s, treatment options included “restraining devices and mechanical appliances, circumcision, cautery of the genitals, clitoridectomy, and castration” (Szasz 2000: 36). Widely recognised as the founder of British psychiatry, Henry Maudsley was particularly vocal in his disdain for those engaging in such behaviour; “[t]he sooner [the masturbator] sinks to his degraded rest,” opined Maudsley (cited in Szasz 2000: 36), “the better for the world which is well rid of him.” This example allows us to identify specific economic and ideological concerns of the ruling classes embedded in the construction of the mental illness. As Szasz (2000: 35) has noted, masturbation was useful to psychiatric expansionism insofar as the “disorder” could be potentially applied to the entire population. Children and adults, males and females could all be caught in the masturbatory insanity net; the classification was a clear case of the mad doctors medicalising deviant behaviour. It was also a good example of the expansion of psychiatric jurisdiction through the medicalisation of sex and sexualities.
Further, it is possible to discern here more specific needs to reinforce the family unit as well as productivity within the labour force. As White (2009: 20–21) has outlined, the claimed physical manifestations of masturbatory insanity (including baldness, stammering, blindness, and skin disease) were used as “a means of social control over the activities of men” (White 2009: 21). Sexual activity was to be confined to reproduction; masturbation was associated with an idleness that would not be tolerated in industrial society. Additionally, the burgeoning of ideas on eugenics—avidly taken up by psychiatry (Chap. 7)—suggested that the alleged greater susceptibility of the working classes to insanity was the result of an evolutionary trend which would continue unless abated by compulsory sterilisation of the “mad.” Castration for masturbatory insanity was therefore theorised as “hygienic” in halting the reproduction of “inferior stock.” For example, the well-known Pennsylvanian gynaecologist, William Goodell, was of the opinion in 1882 that “sound policy” in the future would be “to stamp out insanity by castrating all the insane men and spaying all the insane women,” a view shared by the editor of the Texas Medical Journal who also believed that the “treatment” would have the additional benefit of stopping insane men from masturbating (cited in Whitaker 2010b: 57–58).
Women who deviated from their primary roles as wives, mothers, and homemakers were a particular target for the masturbatory insanity label. In the second half of the nineteenth century, the profession began specialising in female “mental illnesses” such as hysteria and nymphomania. The prerogatives of industrial capitalism dictated that a woman’s place was in the home, and psychiatry reinforced these patriarchal norms through the social control of women who deviated from the prescribed gender role (Chap. 5). Isaac Baker Brown of the Obstetrical Society of London, for example, was a firm believer that female madness was primary caused by masturbation, suggesting that symptoms could be detected in those women who desired work and were indifferent to their domestic obligations (Showalter 1980: 176–177). From 1859, he performed clitoridectomies on women and girls (as young as ten years old) for a variety of deviations including a 20-year old who disobeyed her mother and was a serious reader, a woman who was “forward and open” with men and had never had an offer of marriage, and a unmarried dressmaker with digestive problems (Showalter 1980: 177). Brown’s surgical mutilations were particularly recommended for uncooperative wives, with Showalter (1980: 177) noting that he “urged clitoridectomy for women seeking divorce and believed that the operation would make them more contented, and certainly more manageable, wives.” It is recorded that this specific surgical intervention did not vanish from asylums until the 1950s (Whitaker 2010b : 79).
In another ironic twist in the history of mental illness, at the same time as psychiatry was utilising radical interventions to stop disobedient women from masturbating and gaining sexual pleasure outside of the confines of heterosexual marriage, there were colleagues in private practice who—in the name of psychiatric treatment and advances in medicine—were masturbating their “frigid” and matrimonially unsatisfied “hysterical” patients to orgasm. As Maines (1999 ) has outlined, the “treatment” of middle-class women labelled as “hysterical” was highly profitable for the profession and one which was assisted at the end of the nineteenth century by the introduction of a new “medical aid” and future sex toy, the vibrator. Though seemingly contradictory, both practices can be understood as part of the various attempts by psychiatry to pathologise and control the female body through preserving the status quo of family, marriage, and the industrial division of labour (Chap. 6).
Biological Theory and Physical Treatments
As with prisons and workhouses, institutions for those labelled as “mentally ill” expanded considerably over the course of the nineteenth century in the United Kingdom and the United States. Private clinics and practices for middle-class clients grew and diversified as the century progressed, while large publically funded asylums were built and filled with the working classes. In 1850, there were only 7140 people (4.03 per 10,000 of population) in public asylums in the UK, yet by 1954 there were 148,000 (33.45 per 10,000 of population) (Scull 1984: 67). Similar increases were witnessed in the United States, with over 550,000 people incarcerated in psychiatric institutions by 1955 (Lieberman 2015 : 154). In the mid-nineteenth century, the poor for the first time outnumbered 2 Marxist Theory and Mental Illness: A Critique of Political... 41 the rich as psychiatric patients (Burstow 2015: 38). Private practice individualised social problems of industrial society as various forms of “neuroses”—especially useful in reinforcing the restricted roles of middle-class women. In contrast, the asylum system utilised various physical “treatments” on groups considered as deviant, problematic, or “unfit” to be let loose in wider society. As Scull (1989: 243) notes, with the introduction of state provision, lower-class families were particularly prone to committing troublesome and decrepit family members to the asylum due to the lack of “resources for coping with the dependant and economically unproductive.” Thus, as industrial society progressed in the nineteenth century, so business and prestige for the emerging mental health profession flourished.
However, then as now, there remained problems for the alienists/psychiatrists in constructing a valid knowledge base with which to legitimate and justify such expansion to other branches of medicine (as well as the general public). Another major paradox from the history of psychiatry, highlighted by Scull (1989: 239–249), is that as the numbers of the “insane”—measured by the rates of psychiatric incarceration— increased throughout the nineteenth and into the twentieth century, “curability” rates—measured by the numbers discharged from such facilitates—declined. Between the 1870s and the 1920s, the “recovery” rate in England dropped from 40 to 31 per cent (Shorter 1997: 191). Many inmates were incarcerated in such facilities for the entirety of their lives, with Scull (1989) acknowledging that, by the 1950s, the average stay in a US state psychiatric hospital was over 20 years. During the hundred years of growth in the business of private and public psychiatry between 1850 and 1950, colleagues in other branches of medicine had made considerable advances in their knowledge base. In comparison, the mental health experts had made no noticeable progress. This was in spite of psychiatry developing a wide range of biomedical, physically based treatments for mental disorder, some of which will now be discussed.
From the end of the eighteenth century, western medicine made specific advances in their activities due to the appropriation of the language and techniques of scientific enquiry. Impressionistic theories of disease that had been based on the idea of “humoral balance” (Scull 2015 : 28) were no longer acceptable in a society built on rationalism and science. This was encapsulated in Rudolf Virchow’s development of the medical “gold standard” for discovering and accurately classifying disease. As Burstow (2015 : 36, emphasis original) outlines,
According to this new understanding, pain or discomfort per se no longer sufficed for something to qualify as a disease. Real lesion, real cellular pathology observable directly or by tests was to be the standard. While disease might be hypothesized and temporarily entertained in the absence of pathology, to be clear, it was discoveries of pathology alone which confirmed them.
Attempts by the alienist/psychiatric professionals to similarly legitimise their ideas and practices following Virchow’s gold standard of medicine are encapsulated in the observational and classificatory work of the German psychiatrist Emil Kraepelin—considered as the “father of modern psychiatry” (Cohen 2014a: 440)—in the latter half of the nineteenth century. Kraepelin’s close observations and recording of life histories of over a thousand incarcerated asylum patients led him to theorise that mental disease was caused by discrete, physical entities that incapacitated the normal working of the brain. He developed successive editions of the Textbook of Psychiatry (Lehrbuch der Psychiatrie) which outlined his findings and delineated different varieties of mental disorder, including his original descriptions of praecox (later relabelled as schizophrenia) and manic-depression (Cohen 2014a: 440–441). Thus, Kraepelin’s work was a successful attempt to promote the idea of a “scientific psychiatry”—that is, a branch of medicine which followed the scientific method and biological theory of their colleagues in other sub-disciplines. As a result of his work, mental disease was firmly established as a disease of the brain, and various treatments aimed at this human organ were progressed under a scientific ethos of hypothesis testing, experimentation, and evaluation. Only one omission from Virchow’s gold standard continued to haunt the psychiatric profession, and that was the absence of the discovery of any definite physical pathology. Theories could be entertained, according to Virchow, but not confirmed without real evidence of mental disease. As with those who followed him, Burstow (2015: 43) notes that Kraepelin’s ideas on mental pathology hung on assumptions—rather than definite proof—of linkage “between symptoms, etiology, and prognosis.” This did not, however, stop psychiatry experimenting on the bodies of those incarcerated in the hope of, retrospectively, proving aetiology.
The physician Benjamin Rush (a signatory to the US Declaration of Independence) was an early believer in the physical aetiology of mental illness. In the 1890s, the man who would become known as “the father of American psychiatry” (his face still appears on the APA emblem) announced his latest cure for madness, the “tranquilizer chair.” Whitaker (2010b: 16) explains the workings of this invention,
Once strapped into the chair, lunatics could not move at all—their arms were bound, their wrists immobilized, their feet clamped together—and their sight was blocked by a wooden contraption confining the head. A bucket was placed beneath the seat for defecation, as patients would be restrained for long periods at a time.
Rush was a man of science, he believed that insanity was caused by the irregular flow of blood vessels in the brain. Thus, he argued that the tranquilizer chair calmed and steadied the blood supply of the insane. The device “binds and confines every part of the body,” stated Rush (cited in Whitaker 2010b : 16),
By keeping the trunk erect, it lessens the impetus of blood toward the brain ... [the tranquilizer chair’s] effects have been truly delightful to me. It acts as a sedative to the tongue and temper as well as to the blood vessels.
Along with the bloodletting, cold baths and spinning devices that were then popular in “calming” and “curing” the mad (see Whitaker 2010b: 1–38), Rush’s new invention was popular back in the asylums of Europe where the attendants were particularly impressed at how the tranquilizer chair could make the most stubborn of inmates “gentle and submissive” following only one or two days of chair therapy (Whitaker 2010b: 16). These early examples of torture disguised as “treatment” by psychiatry developed further in the early part of the twentieth century as they appropriated physically invasive techniques from other branches of medicine.
As the “curability” rates continued to drop and scientific psychiatry faced mounting challenges from Freud’s “dynamic psychiatry”—which appeared to offer more potential for positive mental health outcomes (see Shorter 1997: 145–189)—the desire of the public mental health system for credibility intensified in the first few decades of the twentieth century. At this time, public psychiatry adopted the veneer of general medicine by strategic name changing (“asylums” became “hospitals,” “alienists” became “psychiatrists”, and so on) as well as appropriating physical apparatus (e.g., ambulances and morgues) and interventions (such as drugs and surgery) from other parts of medicine. As Whitaker (2010b: 73–74) has noted, the new psychiatric treatments were different from previous alienist interventions in that they actually “worked”—through permanently damaging the brain. Indeed, Walter Freeman who popularized the transorbital lobotomy in the United States advocated for the procedure as a part of what he called “brain-damaging therapeutics” (Burstow 2015: 52).
Before thorazine appeared on the market in the 1950s (see discussion below), biomedical psychiatry experimented on the socially deviant with a variety of dangerous drug “treatments.” These included various poisons such as camphor and metrazol, as well as insulin administered at very high dosages to invoke seizures and comas in the patient (Whitaker 2010b: 91–96). Purposely taking the patient “to the doors of death” (as one physician put it (Whitaker 2010b: 91)), such treatments were considered a success and carried out widely in the psychiatric institutions of the 1930s and 1940s. The hospital staff observed that the inmates became quieter and more obedient following such “treatment,” while the patients themselves lived in palpable terror of further interventions of this nature (Whitaker 2010b: 91). The “treatments” remained dangerous, causing not only brain damage for many but also occasionally death. Meanwhile, some psychiatrists remained concerned that these interventions were less than permanent and did not signify a long-term cure for chronic mental illness.
Two forms of “physical therapy” on the brain that tended to produce more permanent effects (we might say damage) were ECT (more commonly known as “electroshock treatment”) and lobotomy. Along with drug treatments, both of these interventions in modified forms are still in use today. Crucial here in understanding the perceived “effectiveness” 2 Marxist Theory and Mental Illness: A Critique of Political... 45 of these treatments—despite a lack of any evidence for the biological aetiology of mental disease—is to highlight the ways in which they successfully adjusted the behaviour of the socially deviant in a way which allowed for discharge back to the family and even a return to work. The treatments are not an advance in psychiatric medicine, but nevertheless useful in modifying inappropriate behaviour in a more permanent manner, in turn aiding capitalist prerogatives for productivity in the family and the labour force. Both “treatments” would eventually take a back seat to “antipsychotic” drugs, which some scholars argue perform essentially the same task as ECT and psychosurgery in damaging the brain, yet do so in a cheaper and seemingly more effective manner (see, e.g., Breggin 1991; Breggin and Cohen 1999 ; Moncrieff 2009; Whitaker 2010a).
To understand these physical interventions as forms of social control of deviant groups, it is useful to consider those who were first forced to have the treatments, and the groups who have been subsequently prioritised for them. ECT was first performed in 1938 on an Italian homeless man rounded up by the police in Rome. The inspiration for placing electrodes on the forehead of psychiatric inmates and giving them electric shocks was Italian psychiatrist Ugo Cerletti’s visit to a local slaughterhouse where he observed pigs being stunned with electric jolts, making them more manageable for butchers to kill. After being shocked with 110 volts through the brain, Cerletti’s first human guinea pig experienced a seizure and subsequently pleaded with the psychiatrist not to inflict the “treatment” on him again (by this point the vagrant was under the—not too surprising—impression that the psychiatrist was going to kill him); Cerletti announced ECT a triumph (Whitaker 2010b: 96–98). Then as now, the procedure produces a convulsion or grand mal seizure (van Daalen-Smith et al. 2014: 206) which appears to “calm” the patient and inhibit the behaviour conceptualised by mental health workers as various forms of “psychoses” or “autism.” The psychiatric profession remains baffled as to how ECT works on the body, yet a recent review of the available evidence stated that the only known effects are permanent brain dysfunction and a higher risk of death (Read and Bentall 2010 ).
As with the drug treatments that preceded it, ECT has been a nonetoo-subtle method of psychiatric torture which demands conformity from psychiatric inmates, either by threat or as a result of the intervention itself; as Burstow (2015: 55) reminds us, the Nazi doctors were early adopters of ECT for use on concentration camp inmates. From the earliest experimentations with ECT, it appears that psychiatry was quite aware that electroshock resulted in brain trauma, generally feeling that this was no bad thing. ECT-inflicted patients were observed as experiencing amnesia, being disorientated, lethargic, and apathetic; some noted that their whole intellect was lowered by the “treatment” (Whitaker 2010b: 98). This was all seen as helpful for the patient, for as one physician (cited in Whitaker 2010b: 99) noted, “the greater the damage [to the brain], the more likely the remission of psychotic symptoms.”
It was the perceived intellect of the inmate population that particularly marked them out for ECT. Noted pioneer, Dr Abraham Myerson (cited in Burstow 2015 : 55), bluntly stated of candidates for ECT that
[t]hese people have ... more intelligence than they can handle, and the reduction of intelligence is an important factor in the curative process. I say this without cynicism. The fact is that some of the very best cures that one gets are in those individuals whom one reduces almost to amentia [simple-mindedness].
ECT has experienced a recent resurgence, with psychiatrists now keen to target deviant young people labelled as “depressed” or “autistic” for shock treatment if they “fail to respond” to drug interventions (Breggin and Breggin 1998: 195; see also Tomazin 2015 ; van Daalen-Smith et al. 2014). Leonard Roy Frank (cited in Mills 2014: 93), a survivor of ECT, rhetorically asks, “[w]hy is it that 10 volts of electricity applied to a political prisoner’s private parts [genitalia] is seen as torture while 10 or 15 times that amount applied to the brain is called ‘treatment’?” Because, I would argue, the threat of ECT is effective in policing those who fail to perform their family, school, work, or consumer roles in western society. Yet, even for some of those in the profession, the treatment remained imprecise as a biomedical intervention and it soon appeared that ECT would be superseded by Egas Moniz’s Nobel Prize-winning “miracle cure” of the lobotomy (Whitaker 2010b : 107–108).
Inspired by observations of World War I veterans who had suffered prefrontal brain damage, neurosurgeons suggested that operating on the brains of those labelled as mentally ill could dull the emotions and reduce the intellectual capacity in a more permanent and specific way than ECT had been able to. Egas Moniz theorised that pathological thoughts were “fixed” in the “celluloconnective systems” in the prefrontal lobes of the brain, thus the “cure” for mental disorder was to “destroy” these connections through psychosurgical interventions (Whitaker 2010b : 107–108). Like the majority of subsequent lobotomies, Moniz’s first procedure was carried out on a woman (in this case, a former prostitute). As Whitaker (2010b: 113) describes the operation, Moniz “drilled holes into her skull, used a syringe to squirt absolute alcohol onto the exposed white fibers, which killed tissue through dehydration, and then sewed her back up.” The woman was subsequently returned to the asylum, where the psychiatrists reported that she remained in a calm state. Following this “successful” operation, further prefrontal operations on the incarcerated population were performed, and by 1936, Moniz was advertising his drilling procedure as demonstrating marked improvements in all of the operated patients (including the observation that post-operative manicdepressives had become “less emotional”) (Whitaker 2010b : 114).
During the 1940s and 1950s, Moniz’s psychosurgery was made popular in America through the refinements made by Walter Freeman and his neurosurgeon assistant James Watts. Their first patient was again female—a 63-year-old woman who Freeman felt dominated her husband and who he described as a “master of bitching” (cited in Whitaker 2010b : 115). Freeman and Watts were pleased with the results of the operation, writing in the Southern Medical Journal that the woman was now able to carry out household chores and appeared to her husband, “more normal than she had ever been” (cited in Whitaker 2010b: 116). By the end of 1936, the physicians had operated on a further 16 women and 3 men (Whitaker 2010b: 116). Post-operative evaluations of patient behaviour were almost exclusively carried out by staff at the psychiatric facilities where the procedures had been performed, focusing on the social norms of “appearance, work, and activity levels” (Getz 2009: 145). Not surprisingly, the results were considered overwhelming positive. Freeman (cited in Getz 2009: 145) himself was especially proud that, as with ECT, intellect and creative functioning was permanently curtailed by the surgical procedure, declaring that “[n]one of our patients has written a book, designed a house, composed a piece of music or invented a salable gadget.” The particular targets for lobotomy were the black community as well as uncooperative women. This issue is highlighted in Freeman’s own recollections (cited in Burstow 2015: 53–54) of lobotomising a black woman who had been confined in a padded cell at the psychiatric hospital for some years: “when it came time to transfer her ... for operation,” he recalls,
five attendants had to restrain her while the nurse gave her the hypodermic [injection]. The operation was successful in that there were no further outbreaks ... From that day after ... (and we demonstrated this repeatedly to the ward personnel), we could grab [the patient] by the throat, twist her arm, tickle her in the ribs and slap her behind without eliciting anything more than a wide grin and hoarse chuckle
As with all of psychiatry’s physical interventions, the lobotomy “worked” for capitalism in as far as they pacified troublesome groups for good. The left-wing filmmaker and actor Frances Farmer was but one of many political victims of Freeman’s psychosurgery. As Ussher (2011: 71; see also Getz 2009 : 146) has recounted, Farmer was originally committed to Washington State Hospital by her mother in 1944 for “drinking, smoking, swearing and having sex with men,” she was eventually lobotomised and returned home in 1950. The same fate was visited on John F. Kennedy’s older sister, Rosemary Kennedy, by her father in 1941, following his concerns for her aggressive behaviour and the fear that she might become pregnant (Getz: 2009 : 146; see also Burstow 2015 : 54).
Whitaker (2010b: 123) notes that the majority of lobotomised patients were able to leave the hospital, leading to the phrase “lobotomy gets ‘em home” becoming popular in the media as news of the “miracle cure” spread. The surgery was increasingly argued to be useful for not only psychotic conditions such as schizophrenia and manic-depression but an ever-widening variety of mental disorders (including anxiety and depression) as well as for dealing with “criminals, psychopaths, and sexual perverts” (Valenstein 1980: 96). The operation was even recommended to American housewives who were finding the tedium of homemaking and childrearing too boring to cope with. As late as 1980, Valenstein (1980 : 2 Marxist Theory and Mental Illness: A Critique of Political... 49 90) was suggesting that such women remained appropriate cases for psychosurgery. He states of one typical case for the procedure:
Household chores such as washing-up or polishing a table were completely impossible for her, as they took so long and caused her such distress. Her husband and mother were, therefore, forced into running her home and, on medical advice, her two children were at boarding school.
ECT, antidepressants, and psychotherapy all had a limited effect on this woman’s behaviour—each time she “relapsed” after a few weeks—and Valenstein (1980: 90–91) suggested that in such “hard to reach” cases, psychosurgery would still make sense as a part of modern psychiatric treatment. Here we see the continuation of physical therapies as forms of social control; the appropriate gender role for women as mothers and wives being reinforced through the “scientific” psychiatric discourse and “treatment” technologies of the mental health system (Chap. 6).
Freeman eventually became frustrated with the amount of time the Moniz-designed brain-drilling operations took and his reliance on an assistant to anesthetise the patient. Instead he devised a simpler, cheaper and less time-consuming operation which he boasted could be done in 20 minutes (Whitaker 2010b: 133). The procedure required no anaesthetic—instead he used three successive shocks of ECT to pacify the patient—and could be administered by any psychiatrist after only a few hours of training. Freeman’s infamous “transorbital lobotomy” innovation has been described by Whitaker (2010b : 133) as follows:
Freeman attacked the frontal lobes through the eye sockets. He would use an ice pick to poke a hole in the bony orbit above each eye and then insert it seven centimeters deep into the brain. At that point, he would move behind the patient’s head and pull up on the ice pick to destroy the frontal lobe nerve fibers.
Freeman (cited in Whitaker 2010b: 133) even felt it unnecessary to sterilise the ice pick and thereby “waste time with that ‘germ crap.’”
Consequently, Burstow (2015: 53) notes that Freeman’s innovation further increased medical interest in the procedure, due to its ability to maximise “doctor’s profits, [reduce] hospital expenses, and dramatically 50 Psychiatric Hegemony [increase] the number ‘served.’” Thanks to the claims of high “curability” attributed to the transorbital lobotomy by the media and medical journals at the time, over 20,000 social deviants in America alone were lobotomised in the 1950s (Whitaker 2010b: 132). Research articles followed the lobotomists’ claims in suggesting that the procedure was a painless, minor, low-risk operation which brought about significant improvement in the patient’s behaviour. Over time, however, it became clear that what this implied was that the lobotomy made the inmate more manageable for hospital staff. As Burstow (2015: 52) comments on the subjective judgements made of the lobotomised victim, “behaviour presenting less problems for staff [qualified] as ‘improvement.’ Indeed, people who could once write poetry and now could do little but giggle were being declared better.” Whitaker (2010b: 131) agrees, stating that “any change in behavior [of the lobotomised inmate] that resulted in the patients’ becoming more manageable (or less of a bother), could be judged as an improvement.” It is unsurprising then that, as Getz (2009: 145) remarks, under such conditions the procedure was increasingly used as a form of punishment by psychiatric staff for unruly behaviour or for those who had not been appropriately pacified by doses of ECT. In fact, Freeman was personally convinced that the more the patient resisted his ice-pick therapy, the more necessary it was that they should receive it (Whitaker 2010b: 133).
Similar to the current expansion of drug treatments for ever-younger groups of deviant, Freeman’s evangelical zeal for the lobotomy led him to operate on 11 young people in the 1950s, including one just four years old (Whitaker 2010b: 135). Explaining his rational for lobotomising children, he admitted it was simply an easier and more efficient method of behaviour modification. “It is easier,” Freeman (cited in Whitaker 2010b: 136) argued, “to smash the world of fantasy, to cut down upon the emotional interest that the child pays to his inner experiences, than it is to redirect his behavior into socially acceptable channels.” It was by this point a typical statement of psychiatric arrogance that subsequently left 2 of the 11 lobotomised young people dead (Whitaker 2010b : 136). Eventually, Freeman—a psychiatrist with no formal surgical training or qualifications—had killed too many patients for the medical establishment to accept and was banned from performing any further lobotomies in the late 1960s. It is estimated that over 40,000 psychiatric patients were victims of psychosurgery while it was fashionable in mid-twentiethcentury America (Getz 2009: 147). Subsequently, the “curability” claims made by psychiatry were, once again, found to be groundless. An example is offered by Whitaker (2010b: 135) in describing the reasons for the popularity of the procedure at the Stockton State Hospital in California; the lobotomy could turn “resistive, destructive” inmates into “passive” ones (Braslow, cited in Whitaker 2010b: 135). While a useful method of social control, it was no miracle cure for mental illness; it is estimated that 12 per cent of those lobotomised at the hospital died from the procedure (usually through bleeding in the brain), many more were left severely and permanently disabled, and only 23 per cent ever left the hospital (Whitaker 2010b: 135).
As with ECT, the brutality of the lobotomy has not stopped subsequent attempts by the profession to make it popular again. In the political turmoil of the 1970s, psychiatrists suggested that black people should be targeted for psychosurgery (Burstow 2015 : 54), while practitioners in the 1980s considered that the intervention might be of benefit for those suffering from anorexia nervosa, ADHD, and autism (Getz 2009 : 148). The latest version of psychosurgery is called “neuromodulation” or “deep brain stimulation,” and is recommended for those labelled with depression or obsessive-compulsive disorder (Getz 2009 : 147).
While the physical treatments outlined above attempted to offer psychiatry a veneer of biomedical progress to legitimate their activities, they can be more accurately understood as instruments of torture and oppression to more efficiently control those considered as problematic and troublesome to capitalist society. Yet Whitaker (2010b: 127–130) also notes that there were important economic motives for the state and the psychiatric profession to continue experimenting on inmates in search of a more efficient way of managing deviant populations. This included the need for a cheaper form of “care” that could be performed outside the hospital system—an intervention which would address the mounting fiscal crisis caused by the continued funding of large psychiatric hospitals. Mythologised as yet another miracle cure for those labelled as “mentally ill,” this would eventuate in the popular promotion of drugs (or “psychopharmaceuticals”) within the mental health system, which will be discussed in the next section.
The Drugs “Revolution”
Through the maximisation of profits for pharmaceutical corporations, the contemporary popularity for prescribing drugs is perhaps the most obvious and salient example of psychiatry serving the economic base of capitalism. However, this phenomenon can also be understood as the profession performing its ideological role as a part of the superstructure of capitalism, through the continued individualisation of political discontent and management of the population through chemical agents. The past few decades have witnessed a substantial increase in the consumption of psychiatric drugs across western society. For example, in America, the number of children medicated with ADHD-related drugs (chiefly Ritalin) grew from 150,000 at the end of the 1970s to 3.5 million in 2012 (Whitaker and Cosgrove 2015: 91–92). Similarly in the UK, Moncrieff (2009: 3) notes that the prescriptions for antidepressants increased “by 243 % in the ten years up to 2002.” The explosion in profits for pharmaceutical companies over this period has been summated by Whitaker (2010a: 320–321):
In 1985, outpatient sales of antidepressants and antipsychotics in the United States amounted to $503 million. Twenty-three years later, U.S. sales of antidepressants and antipsychotics reached $24.2 billion, nearly a fiftyfold increase. Antipsychotics—a class of drugs previously seen as extremely problematic in kind, useful only in severely ill patients—were the top revenue-producing class of drugs in 2008, ahead even of the cholesterol-lowering agents. Total sales of all psychotropic drugs in 2008 topped $40 billion. Today—and this shows how crowded the drugstore has become—one in every eight Americans takes a psychiatric drug on a regular basis.
As a result of what Burstow (2015: 167) has termed psychiatry’s “march to Pharmageddon,” there have been concerns from scholars both inside and outside the psy-professions that drug prescribing is getting out of hand. Specific critiques have suggested that mental health experts may be medicalising evermore aspects of our everyday behaviour as mental illnesses (e.g., our “hoarding,” drinking, gaming, grieving, gambling, and so on) so as to prescribe us more drugs; that the professional bodies are far too cosy with pharmaceutical companies and have consequently lost sight of their duty of care to their clients; that the potential health harms of long-term drug taking have been neglected in the hype around the latest “miracle pill” appearing on the market (e.g., Whitaker (2010a: 354) notes that those labelled as “mentally ill” are “now dying twenty-five years earlier than their peers”); and that other therapies are being ignored in favour of the quick-fix chemical cure.
This section demythologises the idea of the “chemical cure” for mental illness by concentrating on the changing economic and political goals of capitalism since the mid-twentieth century. This analysis demonstrates that there can never be a “magic bullet” for mental disorder when aetiology has not been established, thus we have to understand drug treatments as a continuation of the biomedical technologies of control I have discussed so far in this chapter. As with other physical interventions, psychopharmaceuticals can also be understood as a further attempt to legitimise the psychiatric profession as a relevant branch of medicine. A critical evaluation of psychotropic interventions then should not focus on their effectiveness in “treating” or “curing” mental disorders, but rather analyse how this metaphorical placebo aids the survival and expansion of the psychiatric profession beyond the asylum walls. This discussion will break with much of the previous scholarship in the area by arguing that the profit-making ventures of biomedical psychiatry—as reflected in the growth of the new psycho-drugs culture—are in fact secondary to capitalism’s desire for the closer surveillance, monitoring, and moral management of the general population in neoliberal society, a function that the psy-professions are most suited for.
Official historians of psychiatry view the introduction of the drug chlorpromazine (marketed as thorazine in America) in the 1950s as a turning point of revolutionary proportions in the treatment and care of the mentally ill. Shorter (1997: 246) calls it “the first drug that worked,” while in a chapter titled—in the now familiar irony-free fashion of such writers—“Mother’s Little Helper: Medicine At Last,” Lieberman (2015 : 175, emphasis original) argues that chlorpromazine was “the first psychopharmaceutical ... a drug providing true therapeutic benefits for a troubled mind.” According to such scholars, this is a breakthrough in psychiatric medicine which can be equated “to the introduction of penicillin in general medicine” (Shorter 1997 : 255). It is the beginning of “the era of psychopharmacology” (Shorter 1997: 255) which, as biomedical knowledge on the workings of the brain has progressed, we continue to reap the rewards of today. For Lieberman (2015: 178), chlorpromazine is the first drug to specially target and reduce the symptoms of psychoses (such as hallucinations and disorganised thinking). As he explains, the effect of the drug on institutionalised patients was dramatic and lasting: “[n]ow they could return home,” he states, “and incredibly, begin to live stable and even purposeful lives. They had a chance to work, to love, and—possibly—to have a family” (Lieberman 2015 : 180). Chlorpromazine was also a significant improvement on previous physical therapies (such as ECT and lobotomy) in terms of being “much less dangerous, and easily tolerated by the patients.” Just over a year after the drug was approved by the US Food and Drug Administration (FDA) in 1954, Scull (2015: 367) notes that two million people were taking chlorpromazine in America alone. On this basis, the official history of psychiatry suggests that the introduction of chlorpromazine leads to the slow but inevitable end of the asylum era. In the words of Lieberman (2015 : 180), “[i]t is no coincidence that the asylum population began to decline from its peak in the United States in the same year Thorazine was released.” For Shorter (1997), the triumph of chlorpromazine as the first “antipsychotic” drug represents a breakthrough for the psychiatric profession as important as Pinel unchaining the mad 150 years before—it was proof of the biological causation of mental disease and, just as importantly, a safe treatment modularity with which to control, if not cure, the symptoms of severe mental disorder.
Unfortunately, the above picture of the psychopharmaceutical “revolution” does not stand up to closer scrutiny. The available evidence demonstrates that the drugs were—and continue to be—no more useful than previous physical treatments, either in the sense of proving an underlying biological aetiology for mental illness or in terms of the potential harm posed to patients (see, e.g., Breggin and Cohen 1999 ; Burstow 2015; Davies 2013; Kirsch 2009 ; Moncrieff 2009 ; Whitaker 2010a). As Moncrieff (2009 : 1) has outlined,
there is no real demarcation between previous eras’ psychiatric treatments, and the theories that justified them, and our own; that the need to believe in a cure for psychiatric conditions that drove and sustained people’s faith in insulin coma therapy, ECT, radical surgery, sex hormone therapy and many other bizarre interventions is the strongest impetus behind the use of modern-day psychiatric drugs.
I argue here that the drugs revolution can be understood as a significant success for welfare capitalism, where institutional costs are transformed into profits for pharmaceutical corporations. At the same time, the decline of the welfare state and rise of neoliberalism in the 1970s eventuate in chemical forms of social control largely replacing the institution and other forms of physical constraint as the more subtle and preferred technology for managing deviance in capitalist society. Initially suspicious of drug therapy, the evidence also suggests that psychiatric professionals in fact remained for some time wedded to the institution as their traditional power base and only belatedly turned to drugs as a technique of legitimating their expansion beyond the asylum walls. Thus, the idea of a “drugs revolution” in the twentieth century can be understood as a myth used to retrospectively legitimate the current, dominant treatment modality within the mental health system and the continuance of the psychiatric profession as the dominant group of experts responsible for defining and “treating” mental illness.
Contrary to psychiatric mythology, the introduction of chlorpromazine to the mental health system happened by accident rather than design, the term “antipsychotic” being later added by pharmaceutical companies to more effectively market the drug to institutional psychiatry and state authorities. Hypothesised as a beneficial anaesthetic for major operations, the drug was originally used by Henri Laborit, a French naval surgeon, for its antihistaminic properties in 1949. The surgeon (cited in Whitaker 2010a: 48) noted that the results of the drug appeared positive in that the patient “felt no pain, no anxiety, and often did not remember his operation.” Thus, Laborit felt chlorpromazine offered a potential improvement on barbiturates and morphine, popularly used as pre-operation anaesthetics at the time. At a medical conference in 1951, he further stated that the drug appeared to produce “a veritable medicinal lobotomy,” and for this reason might also be of use to psychiatry (Laborit, cited in Whitaker 2010a: 49). The following year, Jean Delay and Pierre Deniker, two prominent French psychiatrists, put the drug to the test on patients they had labelled as “psychotic” at St. Anne’s Hospital in Paris (Whitaker 2010a: 49–50). The first patient to be given the drug was a 57-year-old male labourer who had been admitted for “making improvised political speeches in cafes, becoming involved in fights with strangers, and for ... walking around the street with a pot of flowers on his head preaching his love of liberty” (Delay, cited in Shorter 1997: 250). After three weeks of chlorpromazine the psychiatrists discharged the patient, observing a new calmness within him. The authorities were impressed with the results of the drug on the asylum population; while still conscious and responsive to the ward staff, the inmates were much more subdued and quiet. As with ECT and pre-frontal lobotomy, the drug produced a more manageable and compliant patient. The psychiatrists wrote triumphantly of the chlorpromazine-drugged patient in 1952 that “he rarely takes the initiative of asking a question” and, further, “does not express his preoccupations, desires, or preference” (Delay and Deniker, cited in Whitaker 2010a: 50).
As a quick and cheap substitute for lobotomy, the drug quickly became popular across asylums in Europe. Hans Lehmann, the physician who is often cited as responsible for the introduction of chlorpromazine to North America, admitted he was intrigued by the claim of the research papers and drugs marketing literature that the drug acted “like a chemical lobotomy” (Shorter 1997 : 252). After the implementation of the drug regimen at his Verdun Hospital in Montreal, Lehmann felt chlorpromazine achieved roughly the same results as insulin treatment and ECT but was an improvement on psychosurgery (of which he was an avid supporter) (Moncrieff 2009 : 45). The drug, announced Lehmann, was most useful in managing the psychiatric patient in that it produced an “emotional indifference” in the inmate (cited in Breggin 1991: 55). As Breggin (1991: 55) notes, chlorpromazine was not conceptualised by the profession and business promoters as a cure for mental illness or even an alleviator of symptoms, but rather a pacifier of one’s character. “We have to remember,” stated the psychiatrist E. H. Parsons (cited in Whitaker 2010a: 50–51) in 1955, “that we are not treating diseases with this drug ... We are using a neuropharmacologic agent to produce a specific effect.” That effect has been summated by Breggin (1991: 55, emphasis original) as, “[p]atient’s don’t lose their symptoms, they lose interest in them.”
Thus, chlorpromazine’s success in sedating patients on the ward was hardly a “revolution” in psychiatric practice. Prior to the 1950s, notes Moncrieff (2009 : 41), other psychotropics were used extensively by the profession both inside and outside the institution; “[i]npatients were frequently prescribed several different drugs simultaneously,” she comments, “and outpatients were also frequently prescribed drugs, mostly barbiturates and stimulants.” Unlike today, this drugging of patients was viewed by the profession as something of an embarrassment; psychiatry was all too aware that such chemical interventions were a form of physical control rather than anything that could be considered as “therapeutic” (Moncrieff 2009: 41). At the time, drugs were not seen by the majority of psychiatrists as central to the future of their practice. For this reason, psychiatrists in America remained, for a time, reticent to use chlorpromazine in their institutions for the simple reason that they already had other physical and chemical treatments which acted in roughly the same manner. Further proof that the drug was no “miracle” pill for mental disorder (as the New York Times would go on to describe it in the mid1950s) (Whitaker 2010a: 58) is provided by Scull (2015: 367–368), who observes both that the numbers of patients in asylums were falling in many parts of America prior to the introduction of chlorpromazine in the 1950s and that many European countries witnessed no such reductions in patient numbers until the 1970s—many years after the drug had been introduced there. The impreciseness of the correlation between chlorpromazine and deinstitutionalisation has led Scull and other commentators (see, e.g., Whitaker 2010a: 206–207) to a different conclusion—that fiscal considerations of state legislatures took precedent over any claims to effective treatment or the “curability” of those labelled as mentally disordered. The psychiatric institution was no longer economically viable as a holding place for problematic populations, so the hype created around new “neuroleptic” drugs such as chlorpromazine and the possibility of returning patients to “the community” were used in a way which “allowed governments to save money while simultaneously giving their policy a humanitarian gloss” (Scull 1984: 139). As Lieberman (2015: 179) notes, the American success of chlorpromazine was achieved by the pharmaceutical company Smith, Kline & French, who focused their efforts on state governments through the fiscal arguments of “health economics” and “cost-cutting,” rather than promising psychiatry a miraculous cure for mental illness. Together with a successful media campaign (see Whitaker 2010a: 58–61) claiming that chlorpromazine symbolised a “new era of psychiatry,” this tactic worked; within a year of launching the drug, Smith, Kline & French’s total sales increased by over a third (Moncrieff 2009 : 42).
The success of chlorpromazine was therefore not the result of scientific endeavour and the development of ever-more sophisticated psychiatric practice, but instead social and economic forces beyond the profession— namely, institutions as economically unviable forms of social control, the marketing of drugs by pharmaceutical companies, and the eventual need for the expansion of psychiatry as moral managers of the general population. The success was economic not therapeutic; while no disease had been identified or treated with chlorpromazine, pharmaceutical companies recognised that, with deinstitutionalisation, there was now substantial rewards to be made from the business of community-based mental health care. Meanwhile, governments could justify cuts and closures of the asylums and instead fund outpatients and drug treatments as both cheaper and more “effective” public health interventions. In time, the crisis of deinstitutionalisation facilitated the psychiatric profession’s increased commitment to the biomedical model and the use of drugs as a primary source of medical legitimation for their continued practice and expansion into other arenas of economic and social life. Drugs aided the professional legitimation of mental health work outside the institution (Moncrieff 2009: 49), and a revised history of the “drugs revolution” was constructed to suggest the natural progression of psychiatry as a branch of scientific medicine.
At first, the post-war expansion of outpatient clinics and community-based mental health teams (often comprising of a variety of social and medical practitioners) appeared to threaten psychiatry’s natural position as the ultimate authority on mental illness. Yet the post-institutional turn to biomedicine and drugs became a useful justification for reinforcing the power of the psychiatrists in these new settings. Only the psychiatrist had the power to prescribe and alter the medications of the patient, and with the growing mythology that the drugs were actually effective, it meant that all other treatment options were given secondary importance, subservient to chemical interventions in the community (for an example of this dynamic, see Samson 1995 ). Thus, Moncrieff (2009: 44) suggests that by the mid-twentieth century psychiatry had become a “sitting duck” for a new treatment with which they could legitimately justify a disengagement from the asylum and an expansion into the world outside. Drugs provided that justification and fitted well with the popular view from other branches of medicine. As Breggin (1991: 55) states of the benefits of drug interventions for psychiatrists,
the dose could be “titrated”—that is, it could be raised and lowered to obtain the desired effect. As an ostensibly more humane intervention, drug therapy both salved the consciences of psychiatrists and made them feel more like legitimate doctors.
With the development of successive generations of neuroleptics and selective serotonin reuptake inhibitors (SSRIs) such as Prozac, Zoloft, and Paxil, sales have skyrocketed as psychiatric practice has expanded into new arenas of public and private life. The evidence, however, has repeatedly shown that the drugs do not work. For example, an extensive review of both the published and unpublished clinical trials of the “wonder drug” Prozac by the clinical psychologist Irving Kirsch (2009 ) concluded that it was no more effective than placebo (i.e., dummy pills with no active ingredients) (see also Whitaker 2010a; Whitaker and Cosgrove 2015). Similar findings have been outlined by Moncrieff (2009) in a review of research on various antidepressants and stimulants. “[P]sychiatric drug treatment,” she concludes, “is currently administered on the basis of a huge collective myth; the myth that psychiatric drugs act by correcting the biological basis of psychiatric symptoms or diseases” (Moncrieff 2009: 237). It is therefore an impressive success for biomedical psychiatry that, despite the lack of evidence, the idea of “chemical imbalances” in the brains of those diagnosed as “mentally ill”—and psychopharmaceuticals as the “chemical cure”—has gained such traction in both popular and scientific discourse. In the words of Breggin and Cohen (1999 : 35), “[n]o psychiatric drug has ever been tailored to a known biochemical derangement,” and, “no biochemical imbalances have ever been documented with certainty in association with any psychiatric diagnosis.” This is something that psychiatrists have only recently owned up to, with Ronald Pies (cited in Whitaker and Cosgrove 2015: 186), editor-in-chief of the Psychiatric Times, admitting in 2011 that “[i]n truth, the ‘chemical imbalance’ notion was always a kind of urban legend—never a theory seriously propounded by well-informed psychiatrists.” An urban legend may be, but nevertheless a biomedical rhetoric that can justify psychiatric intervention and drug treatment as valid medical practice. The psychiatrist Daniel Carlat has freely acknowledged that using the language of “chemical imbalances” at least suggests to patients that psychiatrists know what they are doing. In 2010, Carlat (cited in Whitaker and Cosgrove 2015: 187, emphasis added) declared,
I say that [“chemical imbalances in the brain”] not because I really believe it, because I know that the evidence isn’t really there for us to understand the mechanism. I think I say that because patients want to know something, and they want to know that we as physicians have some basic understanding of what we’re doing when we’re prescribing medications. And they certainly don’t want to hear that a psychiatrist essentially has no idea how these medications work.
Whitaker and Cosgrove (2015: 87) have discussed the significant benefits for both big pharma and the psychiatric profession in promoting drug use in the current mental health system. For the drug companies, psychiatry can medically legitimate their products as well as facilitate the expansion of the potential population for their products. In turn, the drug companies legitimate the institution of psychiatry as a “real” (meaning biomedically-based) part of medicine and facilitate the expansion of its areas of research and expertise through various funding and revenue streams. The outcome of this relationship has been fairly predictable—both parties have benefited enormously over time. Pharmaceutical companies continue to maximise their profits while psychiatry’s (and, by extension, other psy-professionals’) power—as signified by the proliferation of its discourse among the general population—has significantly expanded over the past 35 years.
That said, the expansion of the psy-professions in general and the proliferation of the psychiatric discourse to hegemonic status in neoliberal society cannot be explained by the success of the drug industry alone. This requires further analysis of the ideological role of psy-disciplines, which will be outlined in the next chapter. Suffice here to say that a Marxist analysis of psychiatric power always needs to consider the benefits to capitalism inferred by their changing discourse and practices. And while every part of civil society can serve the economic base, it is the value of such institutions as part of the superstructure which distinguishes them as ultimately relevant and useful to the ruling classes. So whereas we may think of the drugs issue only in terms of the economic prerogatives of capitalism, it is in fact their value as a means of social and ideological control of the population which should be given particular importance here. As Moncrieff (2009: 238) has rightly stated of the dominant biomedical view of psychopharmaceutical interventions as effective treatment for mental illnesses,
this knowledge has itself become an instrument of psychiatric power. It has facilitated the particular form of social control that is embodied in psychiatric practice, by construing psychiatric constraint as the medical cure of mental disease. It has helped to disperse psychiatric power throughout the population by concealing the moral nature of psychiatric judgements
From moral treatment to drug treatment, psychiatry’s project remains unchanged: their goal is the moral management and behavioural adjustment of populations considered socially deviant, whether unemployed, underproductive, or politically suspect. The intervention of pharmaceutical companies in the process of psychiatric medicalisation needs to be understood as a rather insignificant factor in the general production of the psychiatric discourse. As Horwitz and Wakefield (2007: 182, emphasis original) have commented on biomedical psychiatry’s takeover of the DSM in the 1970s, “[t]here is no evidence that pharmaceutical companies had a role in developing DSM-III diagnostic criteria.” While this statement might be challenged by the DSM-III research of Lane (2007 ) and others, it is still accurate to conclude that pharmaceutical companies have never been the originators of diagnostic categories; this has remained the responsibility of psychiatry (regardless of how far the profession may sometimes appear to be in big pharma’s pockets). Thus, while SSRIs and other contemporary psychoactive drugs can be seen as interventions of social control performed by mental health workers, “to restrain individuals from behavior and experience that are not complementary to the requirements of the dominant value system” (Lennard, cited in Conrad 1975: 19), the specific form of behaviour and experience which is considered in need of reform or restraint is still dictated by the psychiatric profession.
Utilising Marx’s theory of historical materialism, it has been argued in this chapter that the modern mental health system is constituted and framed by the social and economic forces of industrial capitalism. Trough a socio-historical survey of the practices and philosophies of the mental health experts from moral treatment to psychopharmaceutical interventions, I have demonstrated that the success of the psychiatric professionals is predicated on their knowledge claims aligning with the goals of the ruling classes for subservient and compliant workers. As a part of the superstructure, the mental health system has aided the economic base through the naturalisation of the fundamental inequalities of capitalist society. Tis ideological role of the psychiatric system works to depoliticise and individualise the realities of existence within the current social order through medicalising deviance and enforcing conformity on suspect groups. Yet as will be discussed in the following chapter, in neoliberal society the ideological role has been extended, resulting in the psychiatric discourse becoming hegemonic. As Burstow (2015: 70) has summated of this expansion,
Incomparably more people are intruded on, with that number multiplying with every passing day. Surveillance of anyone who has ever seemed in trouble, surveillance of our children, of seniors is now routine. If once upon a time, one would have to appear “deviant” or to exhibit “unusual behaviour” to fall under the auspices of the “system,” now normal childhood qualifies as a disease. Moreover, the intrusion reaches significantly deeper than the shackles of yesteryear, into the inner recesses of the brain. It is as if psychiatry had removed the fetters from the body of the “lunatic” subject only to place more durable ones on everyone’s mind.
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3: Psychiatric Hegemony: Mental Illness in Neoliberal Society
The previous chapter outlined a critique of the political economy of mental illness, focusing on the psy-professionals’ support of the economic base from the development of moral treatment and the asylum system in the nineteenth century to the current profiteering from an expanding drugs market. Demonstrating Marx and Engels’ (1965: 37) statement that capitalism “must nestle everywhere, settle everywhere, establish connections everywhere,” I have shown that the mental health system generates an increasing range of products and services for the market, mirrors the wider division of labour through exploitative work practices, and functions as an institution of social control, policing deviance, and reinforcing exploitative relations within capitalist society as “normal” and common sense.
This chapter, however, gives special attention to the expanding ideological power of the psychiatric discourse within neoliberal society. I present here my core rationale for taking a Gramscian approach to understanding this discourse as “hegemonic,” that is, an all-encompassing form of knowledge which works to naturalise and reinforce the norms and values of capital through professional claims-making. As was highlighted in the last chapter, the mental health system has always had ideological dimensions, yet the recent demands of neoliberal capital have necessitated the expansion of the psychiatric discourse to the point where it has become hegemonic and totalising. Our behaviour, our personalities, our lifestyles, our relationships, and even our shopping trips are now closely observed and judged under this psychiatric hegemony, and we have in turn come to monitor and understand ourselves through this discourse. As Whitaker (2010a: 10, emphasis original) rightly states of these changes,
Over the past twenty-five years, psychiatry has profoundly reshaped our society. Through its Diagnostic and Statistical Manual [the DSM], psychiatry draws a line between what is “normal” and what is not. Our societal understanding of the human mind, which in the past arose from a medley of sources (great works of fiction, scientific investigations, and philosophical and religious writings), is now filtered through the DSM.
The chapter begins by describing the ideological purpose of professional groups such as psychiatry within advanced capitalist societies. In doing so, I draw on the theoretical work of Gramsci, Althusser, and Habermas in conceptualising how such groups within civil society legitimise ruling class ideology through their practices and constructed discourse. This is followed by a discussion of how this ideological critique can be applied to medicine and psychiatry, as well as a review of the processes through which the psychiatric discourse—that is, the totality of ideas (including the language, practices, and treatments) on “mental illness” and “mental health” that psychiatric and allied professions have circulated to the public over the past 200 years—became hegemonic following the “crisis” of psychiatry in the mid-1970s, the construction of the DSM-III in 1980, and the wider development of neoliberal policies. The final part of the chapter discusses some of the contemporary issues which inform the recent increase in “mental illness” self-surveillance and self-labelling behaviour, a situation, I argue, that further demonstrates the existence of psychiatric hegemony.
Hegemony, Ideology, and Professional Power
Given the oppressive economic conditions that workers endure under western capitalism, Marx (1971) prophesied the proletariat revolution as inevitable. This certainly appeared likely with the European and American financial crises of the 1920s and 1930s and, consequently, a rise in political and class consciousness. It was, however, a catastrophic period which western capitalism survived. In this context of failed revolutions, theorising on the superstructure of capital (Chap. 2) became increasingly important to Marxist writers in addressing the “inevitability” question (Heiner 2006: 10-11). Gramsci’s (1971) answer to this question was that the ruling classes ultimately survived threats to their authority not through direct “domination” and coercion of the masses but rather by demonstrating “intellectual and moral leadership.” It was the latter type of supremacy that constituted what he termed “hegemony,” a form of “internal control” which Femia (1981: 24) outlines as “an order in which a common social-moral language is spoken, in which one concept of reality is dominant, informing with its spirit all modes of thought and behaviour.” Or as Kellner (2005: 158) has succinctly defined hegemonic power, the “domination by ideas and cultural forms that induce consent to the rule of the leading groups in society.” Gramsci argued that the coercive powers of the state (e.g., the army, police, and the judicial system) were comparatively ineffective and fragile in ultimately halting the revolution; instead the capitalist classes had secured a greater chance of survival through hegemonic power—the rule of the bourgeoisie by induced consent. As Crossley (2005: 114) has articulated this idea,
The bourgeoisie must win the hearts and minds of the people, persuading them (without even seeming to do so or to need to do so) that the status quo is natural and inevitable, beneficial for all, and inducing them to identify with it.
Gramsci located the intellectual and moral leadership won by the ruling classes as residing in civil society rather than the state. By “civil society” he meant institutions such as religion, education, the media, and the family, to which Marxist scholars such as Navarro (1986) and Waitzkin (2000) have added the institution of health as a further site of hegemonic power. These civic institutions are much more effective than direct, repressive organs of the state in manipulating the masses due to their perceived detachment from elite control. Hegemonic power is conducted under the guise of objective and neutral institutional practice, though it is in reality nothing of the sort. Instead, intellectuals and professionals are responsible for the legitimation of ruling class ideas within the public sphere, articulating such values as seemingly natural and taken-for-granted knowledge about the world. Tus, Fontana (1993: 140-141) comments that
the function of intellectuals is not only to create a particular way of life and a particular conception of the world, but also to translate the interests and values of a specific social group into general, “common” values and interests.
What we understand as “normal” and common sense is in fact dominant, capitalist ideas imparted through professional discourse, an issue summated in the famous quote from Marx and Engels that “the ideas of the ruling class are in every epoch the ruling ideas” (cited in Navarro 1980: 196). Althusser (2005: 114) commented that the concept of hegemony offered “a theoretical solution in outline to the problems of the interpenetration of the economic and the political.” In other words, it was an effective explanatory device for understanding the survival of the economic base of capitalism despite significant political struggles against the bourgeoisie in every epoch.
Althusser himself extended Gramsci’s conceptions of hegemony by developing a specific theory of ideology. Rather than being directly shaped by the economic base, Althusser suggested that institutions of civil society had a degree of autonomy from it that is “neither totally shaped by the economy nor totally autonomous” (Crossley 2005: 150). This can explain why not every decision, behaviour, or practice of an organisation appears to be traceable back to the economic prerogatives of capitalism. This subtlety within Althusser’s analysis highlights that hegemonic power is a form of negotiated power in which professional groups and institutions can act in semi-autonomous and sometimes oppositional directions to capital. Each institution has its own set of professional priorities, interests, and values to protect from other competing groups, and sometimes this may bring about conflict with the objectives of the ruling elites. In such situations, compromise is necessary so as not to threaten the fundamental economic base and current social order (Freidson 1988; Williams 1977). Discussing the institution of medicine as part of hegemonic relations, Navarro (1989: 198) summarises this issue of professional autonomy as follows:
Medical knowledge is not produced and reproduced in the abstract but through agents and relations which are bearers of power relations of which class is a determinant one. To say this is not to say that medical and scientific knowledge does not have an autonomy of its own, but that autonomy takes place within a set of power relations which determines not only how medical knowledge is used … but also what knowledge is produced and how that knowledge is produced.
With industrial societies becoming more complex, Althusser emphasised the increasing significance of such institutions in imposing capitalistic ideology on the working classes, referring to them as ideological state apparatuses (ISAs). ISAs, he argued, were much more effective in securing the consent of the masses (Crossley 2005: 152), reproducing the goals of capitalism as normal and inevitable, or as Crossley (2005: 152) conceptualises them,
[S]ites of practice where human subjects or agents are, in effect, shaped as compliant and willing members of (capitalist) society. That is, they are the sites of practices which form us as human agents, making us what we are and, more importantly, making us “in the image” of capitalist society.
To summarise, a Marxist ideological critique which follows the ideas of Gramsci and Althusser investigates
the subtle “ideological hegemony” by which institutions of civil society … promulgate ideas and beliefs that support the established order … the “ideological apparatuses” that the capitalist class use to preserve state power … and the ideological features of modern science that legitimate social policy decisions made by “experts” in the interests of the dominant class. (Waitzkin 1978: 270)
Effectively, hegemony functions to pacify revolutionary protest through making certain limited concessions to the working classes (e.g., by introducing and extending parliamentary democracy), while the ISAs become increasingly important in reinforcing the norms and values of the ruling classes as a consensual and widely shared view of social reality.
Of all the areas of civil society, Habermas argued that the sciences offered the greatest potential for acting as ISAs. Tis was due to the rhetorical language of the sciences which promoted its various disciplines as fundamentally objective and value-free. According to Habermas, scientific ideology was increasingly working on technical solutions to social and political problems within capitalist society. In this manner, states Waitzkin (2000: 122), “science tends to depoliticize these issues by removing them from critical scrutiny.” Of great pertinence to understanding psychiatric discourse as hegemonic in neoliberal society, Habermas (cited in Waitzkin 2000: 122) was already claiming in 1971 that, “today’s dominant, rather glassy background ideology, which makes a fetish of science, is more irresistible and far-reaching than ideologies of the old type.” Increasingly, the different branches of science are responsible for legitimating fundamental inequalities in advanced capitalist societies as “normal,” “inevitable,” and “natural.” For example, Navarro (1986: 40-41, emphasis original) states of the health system that it serves “a very high legitimization function” for capital in this regard,
[I]t creates false consciousness that what is basically a collective and, therefore, political problem, determined by the manner of control over the process of production and consumption in capitalist societies, can be solved by individual therapeutic intervention. In this way, medicine depoliticizes what is intrinsically a political problem. Tus, what requires a collective answer is presented as an individual problem, demanding an individual response. This is a main ideological function of medicine, the legitimization of class relations in our society.
There are a number of specific interventions relevant to psychiatric practice which Waitzkin (2000: 124) has detailed as part of this legitimation process—these include the increasing medicalisation of social problems, “the transmission of ideological messages” within professional-client interactions, “the management of potentially troublesome emotions” by the discipline, and the reproduction of the “class structure and the relations of capitalist production.” Following Freidson’s (1988) work on medical dominance, Waitzkin (2000: 123) hypothesises that
doctors may be more effective in enforcing societal norms than other social control agents; doctors are less accountable to the public and therefore freer to inject class and professional biases into their relationships with clients.
Medical social control thus has extended to economic production, the family and other major institutions. As a part of this medical social control, how and why the psychiatric discourse has become hegemonic within neoliberal society will be discussed in the following sections.
The “Public Language” of the DSM-III
Speaking at the annual meeting of the American Psychiatric Association in 1965, Mike Gorman (at the time, executive director of the National Committee Against Mental Illness) called for the psychiatric profession to develop new skills, procedures, and practices to confront the challenges posed by deinstitutionalisation and the mounting critics of the current mental health system (Chap. 1). Fundamentally, psychiatry was not speaking to the people. The middle class “worried well” spent years in private therapy hoping to learn what was really going in their unconscious, while the working classes still faced a largely coercive system of public psychiatry in institutions or outpatient facilities. It was time, Gorman argued, for psychiatry to justify itself to an increasingly cynical public who often felt that whatever “mental illness” was, it was someone else’s problem. Reflecting the disenchantment of many within the APA, Gorman (cited in Harris 1995: xv, emphasis added) stated that
psychiatry must develop a “public” language, decontaminated of technical jargon and suited to the discussion of universal problems of our society … As difficult as this task is, it must be done if psychiatry is to be heard in the civic halls of our nation.
Fast-forward 50 years and it is clear that the profession has succeeded in this aim, so much so that we now often articulate the behaviour and emotions of ourselves and others using the “public language” that the psy-professionals have honed over this period. Generally, when we make assessments of character, we are now reiterating the dominant psychiatric code—for example, “your kid’s a bit hyperactive,” “those guys in the IT department are all on the [autistic] spectrum,” “she’s obviously experiencing mental health issues today,” “I’ve just got a compulsive personality,” “he’s totally addicted to gaming,” “you sound clinically depressed,” and so on. It is perhaps hard to remember that it was not always like this. Before the 1980s a different language was used to articulate our feelings and emotions—we were perhaps “down” or sad sometimes, overjoyed or elated at other times, but seldom “manic,” “clinically depressed,” or indeed “bipolar.” As Furedi (2004: 84) similarly notes of the rise of “therapeutic culture” in the west, “[b]efore the 1980s, terms like syndrome, self-esteem, PTSD, sex addiction and counselling had not yet entered the public vocabulary.” And few desired access to labels of mental disorder either (which, at the time, involved a high risk of being hospitalised). When mental illnesses were identified in public discourse, it was typically limited to highly stigmatised categories such as schizophrenia or manic-depression. Tis has obviously changed. Here I locate the fundamental reason for this as due to the decline of social welfarism and the rise of neoliberalism in the 1970s; this change facilitates the expansion of the psy-disciplines into many new areas of social and economic life. The institution of psychiatry emerges as an ISA because the psychiatric discourse becomes increasingly important in reinforcing the dominant goals of neoliberalism, focusing on the self—rather than the group, community, organisation, or society—as the appropriate site for change and (using the language of neoliberalism) “growth.”
As was outlined in Chap. 1, western psychiatry was in a state of professional and epistemological crisis in the 1970s (see, e.g., Decker 2007; Mayes and Horwitz 2005; Wilson 1993), a situation which was only averted with the publication of the DSM-III in 1980. Despite the failure to in any way improve the actual “science” of psychiatry, the hype that the DSM-III task force and the APA leadership created around the manual as scientifically more rigorous than ever before worked as an excellent public relations exercise for the profession. The DSM-III was also a decisive victory for biomedical psychiatry, a return to the descriptive “scientific psychiatry” of the early twentieth century. Tus, the DSM-III can also be seen as an attempt at internal legitimation, to align their activities and practices more closely to other branches of medicine. As a result of this return to biomedicine, the DSM-III was primarily promoting drug solutions to the mental disorders catalogued therein, a situation that has led many commentators to highlight the strong financial linkage between task force members and pharmaceutical companies (see, e.g., Cosgrove and Wheeler 2013). The rapid growth in the total number of mental disorders from DSM-II to DSM-III (from 182 to 265, the largest single expansion to date) also suggested a move by psychiatry to increasingly (bio)medicalise aspects of life which had previously fallen outside of the profession’s domain, a process to further expand their areas of jurisdiction. Due to the success of the DSM-III, Samson (1995: 79) states that the manual has become “the most important source of professional legitimation worldwide,” and one which has had serious consequences outside of psychiatry itself. As Mayes and Horwitz (2005: 265) have since summarised of the effects of the DSM-III,
The direct and indirect institutional change the new manual produced extended far beyond psychiatry, because the DSM is used by clinicians, the courts, researchers, insurance companies, managed care organizations, and the government (NIMH, FDA, Medicaid, Medicare). As a classificatory scheme, it categorizes people as normal or disabled, healthy or sick. And as the definitive manual for measuring and defining illness and disorders, it operates as mental health care’s official language for clinical research, financial reimbursement, and professional expertise. Few professional documents compare to the DSM in terms of affecting the welfare of so many people.
While critical assessments of the DSM-III which expose the document as an important example of professional retrenchment and jurisdictional expansion—in other words, a fundamentally political rather than scientific project (Armstrong, in Caplan 1995: ix)—have validity, not enough attention has been paid to the wider societal processes effecting the institution during the period when the DSM-III was constructed and produced (in fact, neo-Foucauldian scholars such as Nikolas Rose (1996, 1999) are probably the only ones to make the connection between the emerging “advanced liberal” conditions and the expansion of psydiscourse and services). In the 1970s, western society is in a period of serious social and economic upheaval. Tese issues cannot be separated from the crisis within psychiatry in the 1970s, nor the solution offered by the DSM-III in 1980. Instead, the development of the DSM-III can be better understood as a part of the structural changes informed by the decline of the social state and the emergence of neoliberal ideology.
Fundamentally, the DSM-III began to speak the “public language” that Gorman had advocated 15 years earlier. Such adaptation of professional knowledge to more consumer-friendly terminology was not unique to psychiatry but witnessed across a range of professions. For instance, Oppenheimer made the observation in the mid-1970s that professionals were increasing called upon “to systematize their knowledge and thereby make it potentially accessible to lay members of society” (Macdonald 1995: 4). Whereas the DSM-I and the DSM-II were primarily developed for use by doctors in the hospital system, Decker (2013: xvii, emphasises added) explains that the DSM-III “was meant instead for psychiatrists in private practice, mainly seeing patients one to one, and for research psychiatrists in academic institutions, carrying out a host of studies on many patients at a time.” Consequently, the language and phrasing of mental disorders in the DSM-III was simplified and made more intelligible to the lay community. For consultations with clients and for research (e.g., the increasing use of mass-survey data collection, which developed with the DSM-III field trials and continues today), simple articulations as opposed to jargon-laden typologies of disease were required. The DSM-III offered an example of Althusser’s (2005) concept of “interpellation”—people began to recognise their own behaviour in the descriptions of mental pathology in the manual, lists of “symptoms” that could be easily utilised in quantifiable researcher checklists as well as self-report studies which encouraged people to begin diagnosing themselves with such disorders. For the first time, each disorder in the DSMIII was presented with a handy list of specific diagnostic criteria, which spoke simultaneously to everyone as well as in such a vague manner as to facilitate the stretching of the psychiatric net much wider than before. For instance, the diagnostic criteria for overanxious disorder included “unrealistic worry about future events,” “preoccupation with the appropriateness of the individual’s behaviour in the past,” “overconcern about competence in a variety of areas,” “excessive need for reassurance about a variety of worries,” “marked self-consciousness or susceptibility to embarrassment or humiliation,” and “marked feelings of tension or inability to relax” (American Psychiatric Association, 1980: 56-57).
More generally, however, the psychiatric discourse witnessed in the DSM-III (as well as subsequent DSMs) reflects the emergence of neoliberal obsessions with efficiency, productivity, and consumption (Chaps. 4–7). So when we conceptualise psychiatry as speaking a “public language” in the DSM, it must be recognised that this language is not neutral and value-free but rather reflects a dominant ideological rhetoric of the specific epoch, in this case the crisis in welfarism and the emergence of neoliberalism. The priorities and proclivities of western psychiatry cannot be seen as motivated primarily by professional interest or by economic motives of the pharmaceutical industry but instead as framed by prevailing norms and values of the social order. As a political document, the discourse articulated in the DSM-III reflects the changing nature of late capitalism. Table 3.1 gives a straightforward example of this, highlighting the increased use of phrasings attached to work, home, and school with each edition of the DSM. Whereas the DSM-I and the DSM-II make hardly any reference to such arenas of life, the DSM-III dramatically increases such phrasing—a trend which continues as neoliberalism progresses. It is also interesting to note that there was a significant increase in the use of the “work” and “school” phrasings between the DSM-IV-TR (in 2000) and the DSM-5 (in 2013), despite the manuals being of almost equal length.<super>a</super>See Appendix A for methodology Like every profession, psychiatry has a degree of autonomy in their research and practices, yet they are ultimately shaped by current power relations. The priorities of the profession, therefore, tend to mirror the priorities of capitalism. To illustrate this point with another example, Lane (2007) has profiled how shyness became the new mental disorder of social phobia (since relabelled as social anxiety disorder) in the DSM- III (Chap. 4). With no validity for such a diagnosis, a number of parties are implicated in this case of medicalisation including the Pfizer pharmaceutical corporation (who funded a number of task force meetings at the time) and Robert Spitzer’s fight with the psychoanalysts for control of diagnostic constructions. However, these issues are predated by the profession’s own research focus on shyness which can be traced back to the mid-1960s, with a small number of patients showing symptoms of anxiety around social situations such as visiting the office canteen, attending parties, or being involved in public speaking (Lane 2007: 71). As would progress further under the neoliberalist doctrine, the development of new classifications such as social phobia would appear to the profession to originate in some sort of “evidence base” (which are actually people’s problems in adjusting to changing arrangements of capital in arenas such as work, home, and the school). Psychiatry then does in fact maintain a key role in setting the agenda for what potentially ends up in the DSM; however, the origins of that agenda are external to the profession, dictated by wider social and economic forces. By the time of the DSM-5, psychiatric diagnoses are blatantly mirroring neoliberal ideology in relating mental illness to underperformance. With the diagnostic criteria for premenstrual dysphoric disorder (PMDD), for example, the manual (American Psychiatric Association 2013: 172, emphasis added) states that “[t]he symptoms are associated with clinically significant distress or interference with work, school, usual social activities, or relationships with others (e.g., avoidance of social activities; decreased productivity and efficiency at work, school, or home).” Tus, the prevailing ideological values of our time—for instance, to be productive and efficient in all aspects of our lives—is conceived through psychiatric discourse as a common sense mental health message. Are you failing within neoliberal society? Ten you might have a mental illness. As Conrad and Potter (2000: 561-562) have summated of psychiatry’s diagnostic project here, the process is necessarily historically and culturally contingent: “[c]ertain diagnostic categories appear and disappear over time, reflecting and reinforcing particular ideologies within the ‘diagnostic project’ (the professional legitimization of diagnoses), as well as within the larger social order.” Beginning with the success of the DSM-III, this section has mapped how the psychiatric discourse reflects and reproduces the dominant ideology of late capitalism. The reason for its progression to a state of hegemonic authority on the self requires discussion of the main tenets of neoliberal philosophy. Tese will be examined in the following section.
The Rise of Neoliberalism and Hegemonic Psychiatry
The post-war period of social welfarism and popular state intervention in many spheres of social and economic activity (including state provision of health and welfare services, public housing, nationalised industries, and a highly regulated labour market) effectively came to an end in the 1970s with high levels of inflation and unemployment (conceptualised by contemporary commentators as “stagflation”) (Schrecker and Bambra 2015: 13). In this climate there was a popular response from the economic elites—and then the electorates—to the “neoliberal” ideas of economic philosophers such as Hayek (1976) and Friedman (1982) who argued that the well-being of the individual was predicated on the autonomy and freedom of the market in capitalist societies. According to these commentators, the crisis in contemporary economic and social conditions was due to the over-regulation and control of the market by the state. Centralised planning and over-bureaucratisation of the marketplace had been a detriment to the competition and potential growth of western economies (Rose 1996: 153). Under such conditions, neoliberal thinkers argued that individuals could not reach their full potential, achieve substantial success, and consequently maximise their own happiness. Neoliberal philosophy then framed old laissez faire economic arguments in a new conception of personal emancipation; it appeared simultaneously as a “pragmatic” response to changing global processes and as a popular “freeing” of the people from the constraints of central governments. As Harvey (2005: 40) has noted of this selling of the neoliberal project to the masses,
An open project around the restoration of economic power to a small elite would probably not gain much popular support. But a programmatic attempt to advance the cause of individual freedoms could appeal to a mass base and so disguise the drive to restore class power. Furthermore, once the state apparatus made the neoliberal turn it could use its powers of persuasion, co-optation, bribery, and threat to maintain the climate of consent necessary to perpetuate its power.
Schrecker and Bambra (2015: 13) have commented that neoliberalism can be best understood as having multiple dimensions, “including concrete policy programs and innovations (e.g., welfare state retrenchment and ‘workfare’), more general reorganization of state institutions (e.g., privatization and contracting out), and an ideology.” In the first instance, neoliberalism is an economic theory which seeks to free capital from government regulation and restraint in the belief that this is the most successful and efficient means of achieving wealth and happiness for the greatest number. Or as Harvey (2005: 2) states of the idea, it proposes “that human well-being can best be advanced by liberating individual entrepreneurial freedoms and skills within an institutional framework characterized by strong private property rights, free markets, and free trade.” The popularity of this political philosophy crystallised in the late 1970s with the electoral successes of the Tatcher and Reagan governments in the United Kingdom and United States, respectively. Backed by international financial institutions such as the International Monetary Fund and the World Bank, “liberalisation” policies were quickly introduced which “freed” local markets from state interference and saw a massive redistribution of resources from the public to the private sector, including the selling-off of state industries and assets (Moncrieff 2008: 237-238). At the same time, these neoconservative governments cut public spending in such areas as health, housing, education, social services, and welfare. As devastating as the neoliberal economic policies of the 1970s and 1980s were to the working classes, it was the ideological aspects of the
3 Psychiatric Hegemony: Mental Illness in Neoliberal Society 83 philosophy which had the greater and longer lasting impact on western society. In Moncrieff’s (2008: 241) words, what accompanied the economic polices was “an evolving cultural and moral ethos, which is best summed up by a change from broad acceptance of collective virtues such as equality and solidarity to the individual and intertwined values of competition and consumerism.” As with the “freeing” of capital from state intervention, neoliberal philosophy argued that the individual must also be “freed” from the state. To “aid” or “encourage” the individual to be competitive and maximise their potential within this society, neoliberal governments made radical cuts in spending on social services and welfare provision, instead channelling resources into training and workfare programmes, nominally aimed at encouraging entrepreneurship and proactive citizens into employment and business opportunities. Fundamentally, this brought about a seismic shift in the popular perception of the state from being a provider of care and services to the population to one aimed at facilitating (both market and individual) competition. The move from “welfare capitalism” to “workfare capitalism” has been summated by Schrecker and Bambra (2015: 16) as a move to “decentralization and welfare pluralism (with a strong role for the private sector), the promotion of labour market flexibility, supply-side economics, the subordination of social policy to the demands of the market and a desire to minimize social expenditure.”
The withdrawal of the state from many areas of social and community activity and the refocusing instead on the individual as the site of responsibility and transformation begins to explain how the psy-disciplines came to expand their areas of jurisdiction with neoliberalism. Rose (1996: 150-151) eloquently refers to the populace in this new set of political and social relations as “enterprising individuals,” that is, subjects embedded with the core values of neoliberalism. Tis includes the very language we now use to speak of and understand ourselves—as autonomous individuals seemingly free to choose, yet personally responsible for non-achievement. As Harvey (2005: 65-66) suggests of the neoliberal self,
While personal and individual freedom in the marketplace is guaranteed, each individual is held responsible and accountable for his or her own actions and well-being … Individual success or failure are interpreted in terms of entrepreneurial virtues or personal failings (such as not investing significantly enough in one’s own human capital through education) rather than being attributed to any systemic property (such as the class exclusions usually attributed to capitalism).
Popular consent for such a conception of the self has been achieved through “[p]owerful ideological influences circulated through the corporations, the media, and the numerous institutions that constitute civil society—such as the universities, schools, churches, and professional associations” (Harvey 2005: 40). Here we can obviously add the psyprofessions as a part of civil society responsible for promoting such neoliberal values. Harvey (2005: 3) concludes that neoliberalism “as a mode of discourse” has become hegemonic. How we understand ourselves and the world is both shaped by and relies on the dominant language of the “enterprise culture.” In other words, the discourse traditionally associated with business and economics (e.g., “efficiency,” “productivity,” and so on) is now also used to refer to our own experiences, emotions, and behaviour. In neoliberal ideology, the self has replaced the group, the community, or wider society as the site for reform and change. Tis emphasis on the individual has seen the depoliticisation of social and economic inequalities to the point where, in the words of Ulrich Beck (1992: 100, emphasis original), they have been redefined “in terms of an individualization of social risks.” Most pertinent to our understanding of the psy-professions in neoliberal society is that “social problems are increasingly perceived in terms of psychological dispositions: as personal inadequacies, guilt feelings, anxieties, conflicts, and neuroses” (Beck 1992: 100). In this “risk society,” “expert” groups such as psychiatrists and psychologists become increasingly important to capitalism in their attempts to scientifically speak to the “risky” behaviour of the individual. Tis rise of “expert knowledge and expert opinion” in neoliberal society, remarks Turner (1995: 221), means that such discourse is “highly politicized.” Tus, as the social state has fallen away with the expansion of neoliberal ideology, the psy-disciplines have come to play a key role in promoting and perpetuating the focus on the risky subject, increasing their moral authority into new areas of jurisdiction, with every individual within a population redefined under a hegemonic psychiatric discourse as “in a permanent condition of vulnerability” (Furedi 2004: 130) to “mental illness.”
Through an understanding of the rise of neoliberalism, it is therefore possible to comprehend the recent expansion of the psychiatric discourse. For Rose (1999: vii), the psy-professions have played “a very significant role in contemporary forms of political power,” so much so, that the disciplines “make it possible to govern human beings in ways that are compatible with the principles of liberalism and democracy.” Tis is due to their professional focus on character reform and self-realization, values which have a high degree of symmetry with the neoliberal project. As has been discussed, in 1980 the DSM-III expanded the APA’s range of mental disorders and made the diagnoses more user-friendly. It began to speak the language of neoliberalism, highlighting everyday issues in settings beyond the institution. Rather than only disability and illness, recovery and growth were now also promoted as possible. Moskowitz gives an example of this change in emphasis with the introduction of the diagnosis of identity disorder in the 1980s, the DSM stating that potential sufferers had
uncertainty about a variety of issues relating to identity, including long-term goals, career choice, friendship patterns, sexual orientation, and behaviour, religious identification, moral value systems and group loyalties … Frequently, the disturbance is epitomized by the person asking “Who am I?” (American Psychiatric Association, cited in Moskowitz 2001: 246)
Previously dominated by the negative institutional classifications of schizophrenia and manic-depression, the expanding range of personality, identity, and anxiety disorders from the DSM-III onwards has initiated a more “positive” discourse of day-to-day concerns, inadequacies, and traumas. In the post-institutional climate, acute and severe mental disorders have been replaced with the now “common disorders” of ADHD, post-traumatic stress disorder (PTSD), general anxiety disorder, BPD, and autism, for which the prescribed treatment is much more likely to be drugs or therapy rather than committal. The impressive results of this neoliberal shift in the psychiatric discourse towards the idea of “positive” mental health can be seen in the countless “awareness campaigns” invoking the risk of mental illness within the general population (“it’s everyone’s problem”), as well as the mass screenings and “early intervention” programmes in schools to “catch” the early phases of mental illness in children and thereby “prevent” a more serious disorder in adulthood. Further examples include the expanding number of epidemiological studies which claim to highlight yet more cases of mental pathology which have gone undetected and/or untreated in the community, the grassroots movements campaigning for further aspects of behaviour or personality to also be classified as an official mental disorder, and the general high levels of self-labelling within the population.
Similarly, it is more than coincidence that the 1980s and 1990s saw the rise of self-help culture (Ehrenreich 2009; Moskowitz 2001) and the turn of psychological and counselling professionals towards “positive psychology” and “positive thinking” (Cederström and Spicer 2015: 62-63). Laid thick with the values of neoliberalism, the discourse of “positive mental health” no longer focuses primarily on bringing the “insane” back to some state of normality but rather on the self-improvement of the individual. It is no longer enough to be “sane” or “normal”; one has to be constantly striving to be more positive and happier in life. Tis is a therapeutic quest which perfectly aligns with the neoliberal philosophy of personal responsibility and the need to constantly improve the self. It is a hegemonic discourse, thinly veiled as a therapeutic and medical expertise on the mind which promotes the values and goals of neoliberal capital. As Ehrenreich (2009: 8-9) has stated of the “positive thinking” revolution in late capitalism, it promotes a model of deficit focused entirely on the individual:
If optimism is the key to material success, and if you can achieve an optimistic outlook through the discipline of positive thinking, then there is no excuse for failure. The flip side of positivity is thus a harsh insistence on personal responsibility: if your business fails or your job is eliminated, it must [be] because you didn’t try hard enough, didn’t believe firmly enough in the inevitability of your success. As the economy has brought more layoffs and financial turbulence to the middle class, the promoters of positive thinking have increasingly emphasized this negative judgment: to be disappointed, resentful, or downcast is to be a “victim” and a “whiner.”
In the same way, psychiatric labels have come to focus on deficits and failings in character which threaten the productivity and consumption activities of the individual in many social and economic arenas of life. Thus, the psychiatric discourse seeks to both depoliticise the fundamental inequalities and structural failings of capitalism as individual coping problems while reinforcing the values of competition and self- improvement as common sense and taken for granted. Speaking similarly of psychotherapy, Parker (2014: 171) states that the individual’s
“adaptation” to capitalism requires psychotherapists not merely to ameliorate the worst excesses of the system, but to ensure that this adaptation is geared to inciting and channelling the critical reflexive energy of citizens so that the very critique that they make of the economy serves to fine-tune it … Tus psychotherapy becomes crucial to the state health apparatus as a practice devoted to the balance of dissatisfaction and yearning requisite for consumption and production.
To explain more fully how we have come to self-regulate ourselves under a hegemonic psychiatric discourse in neoliberal society, the next section draws on Foucault’s theory of bio-power, a subtle form of regulatory power focused on the body.
Bio-Power, Governance, and Psychiatric Hegemony
To counter the claim that psychiatry acts as an agent of social control, such professionals commonly point to the many clients who now voluntary approach them demanding a psychiatric label (and often specify the medication which they see as the solution to their chosen disorder). Tey also highlight the many grassroots organisations which have sprung up to support the “reality” of various mental disorders (e.g., Autism Speaks, Children and Adults with Attention-Deficit/Hyperactivity Disorder, and the Depression and Bipolar Support Alliance) with anti-stigma campaigns and calls to “normalise” these a ictions in line with a growing disabilities discourse (Conrad 2007: 87). Further, professionals can cite the global flow of biomedical ideas on mental illness which people are increasingly communicating through social media without any direct intervention from the experts (as an example, I was recently forwarded an image from a “friend” on Facebook showing brain scans of four “normal” people and four suffering from ADHD, PTSD, bipolar disorder, and depression--cue the conclusion that different coloured blobs in the head are the cause of different mental illnesses--“just because you can’t see it,” read the accompanying statement, “doesn’t mean someone’s not battling it”). Reflecting on these acts of self-monitoring and promotion of the psychiatric discourse from the behavioural and happiness sciences, Davies (2015: 258) notes that the greatest success of such knowledge claims occurs “when individuals come to interpret and narrate their own lives according to this body of expertise.”
For Foucault, the emergence of industrial society marked a transformation in the exercise of power from the right to take life to power over life (Smart 1983: 90). This was a change in the nature of sovereign power towards a focus on the biological; the body becomes an increasingly important site for the surveillance and governance of the individual. Under the developing system of production, populations are to be supervised and managed through more subtle systems of regulation and social control, with health and social services being particularly significant to the emergence and expansion of bio-power. As Smart (1983: 90) explains,
[T]he well-being of the population or the social body was the object of techniques of power, the focus of their exercise being the conditions affecting the biological processes of life (e.g. reproduction, mortality, health, etc.). The emergence of these respective techniques for subjugating bodies and for regulating populations has been identified by Foucault as marking the beginning of an era of bio-power.
Bio-power is thus the merging of the biological with the political. Under new expert authorities in industrial society, the body becomes an object of knowledge to be monitored, coerced, and controlled in increasingly complex ways. Trough these techniques the body is made “docile” so as to be “subjected, used, transformed, and improved” (Foucault, cited in Gastaldo 1997: 114). Expert forms of knowledge on the body such as those produced by the psy-professionals become increasingly important in advanced liberal societies as they can regulate individuals beyond the traditional sites of state intervention. Tis general process of regulation of the population beyond the direct, overt apparatus of the state has been referred to in a Foucauldian sense as modes of “governance.” “Governmentality” was defined by Foucault (cited in Rose et al. 2006: 83) as “techniques and procedures for directing human behaviour.” In Rose’s (1996: 155, emphasis original) words,
Governing in a liberal-democratic way means governing through the freedom and aspirations of subjects rather than in spite of them. The possibility of imposing “liberal” limits on the extent and scope of “political” rule has thus been provided by a proliferation of discourses, practices, and techniques through which self-governing capabilities can be installed in free individuals in order to bring their own ways of conducting and evaluating themselves into alignment with political objectives.
Rose would disagree, but I believe that these political objectives are to reinforce class rule and facilitate the maximisation of profits for the elites. As the social state has declined, the governance of individuals through neoliberal health and wellness discourses—including psychiatric ideology—has allowed for a more subtle form of social control to emerge, one that governs bodies “at a distance” through the extension of bio-politics. This is the expansion of ruling class hegemony through the spread of psychiatric myths into previously untouched areas of social and economic life. It is a most profound form of social control, as it appears in daily life as if we have consented to this expansion of psychiatric authority. After all, no one forced us to recognise our own unproductiveness because we spend too much time at the computer playing solitaire; rather, we now seem to be proactive in realising we have a “problem”—anything from attention-deficit and work avoidance behaviour to gaming addiction and obsessive behaviour—and require “help.” Tus, an important part of bio-politics in neoliberal society is self-surveillance, with Rose (1999: 11, emphasis added) noting that,
Through self-inspection, self-problematization, self-monitoring, and confession, we evaluate ourselves according to the criteria provided for us by others. Through self-reformation, therapy, techniques of body alteration, and calculated reshaping of speech and emotion, we adjust ourselves by means of the techniques propounded by the experts of the soul [meaning, the psy-professionals].
For neo-Foucauldian scholars, this governance at a distance is not necessarily a negative thing. Instead, it can empower individuals in negotiating their many public and personal responsibilities, and in understanding the limits of their actions and behaviour in society. Yet at its heart, notes Furedi, this “therapeutic governance” has a weak conception of individual capacity. It remains a top-down view of the individual which “represents scepticism towards the ability of people to act as responsible citizens, without the support of professionals who knows [sic] best what is in their interest” (Furedi 2004: 196). Instead, it can be more accurately hypothesised that the current popularity of mental health self-surveillance and mental illness self-labelling results from psychiatric hegemony and its imbued neoliberal ideology of risk and personal responsivity. As Clarke et al. (2003: 171-172) have stated of this focus on medical surveillance in neoliberal society,
[H]ealth becomes an individual goal, a social and moral responsibility, and a site for routine biomedical intervention … the focus is no longer on illness, disability, and disease as matters of fate, but on health as a matter [of ] ongoing moral self-transformation.
Through psychiatric hegemony, then, we are all implicated as “at risk” of mental illness and must constantly self-monitor for potential signs of disorder (as many professional associations and drug adverts advise us). Clarke (2013: 418) has summated the importance of this mental health self-governance in neoliberal society with reference to the rise of disorders such as ADHD. She states,
The parent has successfully sought help and aided the medicalisation of the child’s deviant behaviour (Chap. 5). Tis is a neoliberal process of social control which is so successful that Norris and Lloyd (cited in Adams 2008: 119) have noticed that the mental illness diagnosis often comes as a relief to the parent
Neo-liberal governance is typified by its emphasis on citizen involvement as individuals take independent action and become enterprises (or entrepreneurs) unto themselves and in a sense police themselves by internalising and enacting prevailing truths about the identification and management of risks … Neo-liberalism depends on self-governance (or in the case of children, governance by parents and similar authorities). For instance, mothers increasingly turn to … individualising children’s (mis)behaviour as disordered through mental illness discourse, of which attention deficit disorder (ADD)/Attention deficit hyperactivity disorder (ADHD) is the most prevalent around the globe today.
first, because they have located the “cause” of their child’s distress, and secondly, because they, as parents, are not to blame … Their child’s “abnormal” behaviour is, in this account, a medical issue to be rectified through medication that makes “normal” their child’s brain dysfunction.
What is also evident here is that the biomedical model is crucial to promoting neoliberal solutions focused on the individual. This successfully depoliticises the non-conformity of the child through suggesting that “chemical imbalances” in the brain are the problem. As a frontline psychiatrist herself, Moncrieff (2008: 243) has recognised that the rise of biomedical psychiatry and neoliberalism are intrinsically linked: “the chemical imbalance idea of psychiatric problems facilitates the neoliberal project,” she argues, and “features of neoliberalism in turn strengthen the chemical balance theory and biopsychiatry more generally.” The increasing social and economic disparities in neoliberal society are individualised through biomedical ideology. Moncrieff (2008: 248-249) states that this represents
a clear instance of the medicalization of political discontent. But this situation is not overtly coercive. Tis view has not been imposed on people by direct force. People themselves have come to see their problems as individual problems, emanating from their brain chemistry.
Thus, biomedical ideology as a part of psychiatric hegemony has become the dominant “solution” to what are social and economic conditions of late capitalism. Biomedicine promises a range of corrections in line with neoliberal conduct, such as improved productivity and marketability as well as “recovery” and the “normalisation” of mental disorders for those who are at risk of deviating from their expected roles as workers, consumers, students, homemakers, and reproducers of the future workforce. Yet psychiatric hegemony encompasses more than the dominant biomedical rhetoric, and can also be detected in social models of the psy-professions. Feminist therapists, for example, argue that a legitimate response to a climate of anti-feminism is now to work on the self-esteem of their clients. “Hence,” remarks Dubrofsky (2007: 266), “social, political, and economic problems are turned into personal problems that can be solved by an individual who is willing to work on him- or herself.” It is but one example of an all-encompassing psychiatric discourse that denies the social and political realities of late capitalism and has successfully placed the focus back on the individual as the site of change.
Tirty-five years ago, Ingelby (1980: 54) predicted an expansion of psychiatric ideology into the public sphere when he stated that psychiatric ideas were being “incorporated within ‘common sense’ itself.” No longer was the mental patient to be subject to overt forms of oppression within the psychiatric institution; rather, the patient would come to embody psychiatric discourse on a more voluntary basis. “For as the mental hospitals are phased out,” remarked Ingelby (1980: 54),
more and more treatment takes place in the doctor’s surgery and the general hospital; but the mental patient is still just as effectively incarcerated within his role. Moreover, this role is internalized within the patient’s own thinking and that of the people around him or her, and it guides everybody’s self-interpretations, whether or not they ever become patients.
As the neoliberal project has developed, we have all become implicated as subjects at risk of mental disorder. Tis is not, however, due to any advancement in the knowledge on real pathology but rather an expansion of the psychiatric discourse to the point where it has taken on hegemonic status. It is more than coincidence then that, as Davies (2015: 177) has observed, “[t]he entanglement of psychic maximization and profit maximization has grown more explicit over the course of the neoliberal era.” As I have argued in this chapter, neoliberalism requires a compliant and competitive population focused on correcting and improving their emotions, behaviour, and social capacities. Tis has been aided by the expansion of the psy-professions in governing populations “at a distance”; psychiatric hegemony has depoliticised fundamental inequalities of capitalism while proliferating neoliberal values through its classifications and philosophies on “treatment.” The pretext of scientific authority on the mind has allowed the psy-professions to enforce ruling class values and norms as consensual and taken-for-granted assumptions of human behaviour. Tis has happened to such an extent that individuals are now involved in acts of self-surveillance, seeking the solution to the structural failings of neoliberal society through individual DSM symptoms of “mental illness.”
The psychiatric profession has always been a site of social control for policing the working classes within industrial society, yet their ideological role has never been as significant as it currently is. Over the chapters that follow, I will systematically demonstrate the development of this psychiatric hegemony by drawing on the evidence of psy-expansionism into the world of work and employment, through exploring youth deviance and the education system, through investigating the social control of women and the reinforcement of the division of labour, and with the continued pathologisation of social and political dissent.
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4: Work: Enforcing Compliance
In this chapter, I profile the increasing encroachment of psychiatry and the psychological sciences upon the world of work. I argue that such expansionism has served a number of key goals for the profession and for capitalism, including professional legitimation and the expansion of expertise, increased profit and the consumption of goods and services and, most importantly, the naturalisation of unequal and exploitative relations in the workplace. I will demonstrate here that it is more than coincidence that the conceptualisation of work as a form of treatment or “therapy” by psychiatrists coincided with the development of industrial capitalism in the nineteenth century. “Work therapy” continues today, yet I will show that psychiatry’s role has moved from that of the social control and punishment of the unemployed and the non-able bodied in the asylums to a more subtle focus on reinforcing compliant work regimes and permanent “self-growth” ideologies on the precarious worker in neoliberal society. This exploration of dominant notions of work and unemployment therefore gives special attention to the emerging hegemonic role played by the mental health experts within the neoliberal workplace. This can be demonstrated through changes within professional practices and the psychiatric discourse embedded in the categories of “mental illness” given in successive DSMs since 1980. Te discussion will show that psychiatry and allied psychological sciences have expanded their areas of jurisdiction into the workplace of the white-collar worker at the behest of capitalist enterprise, where self-surveillance and a continual working on the self has become a part of the increased need for an efficient, flexible, and mobile labour force.
Psychiatry has always been a conservative vocation which seeks to reinforce and maintain the status quo, where the dominant norms and values of society are normalised and deviations from them are pathologised. This is clearly evidenced when exploring psychiatric interventions in the world of work. The nature of work has changed dramatically over the last two centuries with the relations of production having grown increasingly complex; the serfs have been emancipated and replaced by an increasingly flexible and precarious pool of labour required for global growth. At the same time, what has not changed is the intervention of the psychiatric discourse to justify oppressive labour relations as normal and inevitable through the depoliticising and individualising of economic hardships in the workplace. To take but one example, I woke up one afternoon recently to find that the 2014 Noble Prize winners in psychology were suggesting that my tendency to stay up late rather than get up early was a sign of “Machiavellianism, secondary psychopathy, and exploitive narcissism” (Jonason et al. 2013: 538). Obviously, some of psychiatry’s little helpers had been getting up very early in the morning to grapple with the theories of evolutionary psychology and the problem of vampires. Te authors did at least admit that a limitation of their study could be the predominance of students in their sample; “night-time preferences may be strongest in college-students,” state Jonason et al. (2013: 540), “because of the freedom a orded to stay up late and lessened need to work relative to adults.” Behind the wackiness of such research lies a serious moral message informed by the needs of liberal democratic societies for good citizens and workers to rise early and go to bed at a reasonable time. A point summarised more generally by Phil Brown (1974: 47-48) when he states that “[a]s guardians of morality, the psychiatric-psychological establishment must put into the textbooks the definitions of mental illness that best reflect the dominant social values of the bourgeoisie.”
Moral Treatment and the Work Ethic
As was discussed in Chap. 2, crucial to the early formation of the asylum attendants—later to be renamed as “alienists” and then “psychiatrists”— as a legitimate group to manage the insane was the appropriation of the “humanist” philosophy of “moral treatment” from Pinel and Tuke. In line with the dominant values of early industrial society, the exposure to and reinforcement of appropriate behaviour could correct deviant character. In theory, the “mad” would no longer be chained, tortured, and warehoused by society, instead they would be taught how to behave and act appropriately without fear of punishment. In turn, good behaviour would be rewarded with humane care and the potential to re-join the world outside the institution. Te stick had been replaced by the carrot; as long as the patient could learn the rules and behaviour of this new society, they had nothing to fear.
As with the prison and workhouse, one of the primary features of moral treatment at the York Retreat was the importance of work in the daily regime of the inmates and, equally, a distain for idleness. Even if the work was of little value in itself, it reinforced a moral imperative in the mind of the deviant. As Foucault (1988a: 247) reflected,
Work comes first in “moral treatment” as practiced at the Retreat. In itself,
work possesses a constraining power superior to all forms of physical coercion, in that the regularity of the hours, the requirements of attention, the obligation to produce a result detach the su erer from a liberty of mind
that would be fatal and engage him in a system of responsibilities.
Samuel Tuke was of the opinion that “of all the modes by which patients may be induced to restrain themselves, regular employment is perhaps the most generally efficacious” (cited in Scull 1989: 90). Under such a “treatment” regime, work had a moral value in self-regulating the behaviour of the deviant. Tis was a new form of moral surveillance in industrial society and one which was as applicable to the prisoner, the poor, and the mad as it was to the factory worker. It is this moral authority of such management and daily regimes as found in wider capitalist society which psychiatry progressed with the expansion of institutions for the insane throughout Europe and America in the nineteenth century. Te key to psychiatrists successfully establishing themselves as the “experts on the mind” was their appropriation of moral treatment as a “scientific” system of care for the management of the insane which—more that coincidentally—conformed to the values of the dominant social order. As Pollard has noted, industrial capitalism demanded “a reform of ‘character’ on the part of every single workman, since the previous character did not fit the new industrial system” (cited in Scull 1989: 91). A new set of competitive norms had to be taught and internalised through the new institutions by disciplinary techniques rather than coercion, and this applied as much to those labelled as “mad” as to the rest of society. Tus, the appearance and success of moral treatment can only be fully understood within the wider social and economic context in which it emerged, a point reinforced by Scull (1989: 92) when he notes,
The insistence on the importance of the internalization of norms, the conception of how this was to be done, and even the nature of the norms that were to be internalized—in all these respects we can now see how the emerging attitude toward the insane paralleled contemporaneous shifts in the treatment of other deviants and of the normal.
Following the philosophy of moral treatment, regimes of work were established in institutions for the insane so that the chances for idleness among these deviant populations would be minimised and the work ethic could be reinforced as part of the new, dominant approach to “care.” Farms were to be attached to asylums to o er the opportunity for “the kind of regular employment which greatly helped to restore men’s minds” (Scull 1993: 150). However, while still stressing the therapeutic benefits of moral treatment, as the asylums grew in size, the work undertaken by patients became more orientated to the goals of the facility. Similar to prisons, inmates of asylums could be found “employed” in the asylum laundries, as farm labourers, and for undertaking other menial tasks within the institution (Scull 1993: 288-289). Tus, “work therapy” became an excuse for patients to be used as cheap labour for the smooth running of the institution. Tis would be a constant of inpatient existence until such establishments were phased out in the latter half of the twentieth century, with Brown (1974: 51, emphasis original) commenting on psychiatric institutions in the 1970s that
[h]ard work, faith in one’s superiors and rule-following are taught, backed up with the wide range of threats available to hospital sta . Everything done to the patients is seen as something for the patients—“work therapy,” “recreational therapy,” etc. Thus cheap labor on the wards and in “occupational therapy” is obtained in the guise of help.
The “Humanisation” of Work
The impact of the psychological sciences on the work environment outside the institution was not felt until after World War II. Te post-war economic boom created an environment of labour shortages and low retention, and under these circumstances economic elites became increasingly interested in the “psychology” of the “productive worker.” “Business managers, beset by high rates of absenteeism and job turnover,” reiterates Napoli (cited in Cautin et al. 2013: 43) of the situation in America,
took unprecedented interest in hiring the right worker and keeping him contented on the job. Management turned to psychologists … and the amount of psychological testing quickly increased. Surveys show that in 1939 only 14 % of businesses were using such tests; in 1947 the proportion rose to 50 %, and in 1952, 75%.
From finding and retaining the “right worker” through psychological testing developed the associated idea of the “happy worker”—an employee who, through positive reinforcements, could increase rates of productivity and, consequently, profits. Work was no longer seen only as a necessity for survival within capitalist society but a place of improvement, importantly a place to improve oneself. As Rose (1999: 56) has summarised of this so-called “humanization” of work, “correctly organized, productive work itself can satisfy the worker; the activity of working itself can provide rewarding personal and social relations for those engaged in it; good work can be a means to self-fulfilment.” Te psychological sciences had a significant role to play in the development of new techniques for the selection, management, and improvement of the workforce (Rose 1999: 82), and the branches of occupational and industrial psychology expanded significantly during this period.
Changes in the industrial base of capitalism in the 1970s only served to expand psy-professional practice still further. As the manufacturing sector was replaced in economic significance by growth in the service industries, changing skills were required within the labour force. Traditional manual labour was declining while there was a burgeoning skills gap within white collar occupations. Tus, the labour force was put under increasing pressure to “adapt” and “upskill” to meet the needs of the changing marketplace. Te new aptitudes required by employers included social skills, problem-solving skills, independent and team working, a flexible approach to work, as well as workers ready to further upskill. In the future, people would have to demonstrate high levels of “employability” within their jobs and what Elraz (2013: 810) calls a “sellable self ” which will be, “associated with the constant expectation to perform, manage-impression, self-promote and ‘sell’ oneself as an attractive product: with no ‘faults’, ‘weaknesses’ or ‘limitations’, always ready to be, and do ‘more’.” Tis “new subjectivity of work” (Rose 1999: 106) has meant that the individual worker has become a key site for psyprofessional intervention in neoliberal society. I experienced one example of this intervention at first-hand when I was employed at a Training and Enterprise Council in England in the early 1990s. Both employees and our unemployed “clients” were o ered the chance to undertake taxpayer- funded neurolinguistic programming, a business-orientated form of neurocognitive therapy. Te presence of this “training initiative” is a small demonstration of the successful creep of the psychological sciences into the work environment over this period—those to be re-skilled learnt in these sessions that the way to real, long-lasting, and personally satisfying success was to examine their own weaknesses and confront their personal barriers to achieving a job. Te discourse of neurolinguistic programming fitted perfectly with the dominant notions of the sellable self, where success in employment was intrinsically tied to the self-actualisation of the person; an increasing need within neoliberal capitalism to “work on the ego of the worker” (Rose 1999: 113).
The idea of “positive thinking” and the opportunity for “personal growth” brought about by the expansion of the psy-professions into the world of work has been indoctrinated on the employed and unemployed alike. Ehrenreich (2009: 45) recounts the experience of laid-o white- collar workers as follows:
At the networking groups, boot camps, and motivational sessions available to the unemployed, I found unanimous advice to abjure anger and “negativity” in favor of an upbeat, even grateful approach to one’s immediate crisis. People who had been laid off from their jobs and were spiraling down toward poverty were told to see their condition as an “opportunity” to be embraced … [T]he promised outcome was a kind of “cure”: by being positive, a person might not only feel better during his or her job search, but actually bring it to a faster, happier conclusion.
I would argue that what is taken by employers, managers, benefit officers, work counsellors, and occupational psychologists as “negative thinking” is the continued ability of people to think critically about their situation and consider it in a wider political context. Tis is the antithesis of the required compliant employed or unemployed citizen in neoliberal society, and the psy-professions have sought to depoliticise and individualise such thinking through their expansion of hegemonic notions of “happiness,” “positive thinking,” and “positive mental health.” As psychotherapist Richard Brouillette (2016) recently admitted, a concentration on individual narratives by the profession means that “therapy could easily become an arm of the state, seeking to ‘cure’ listlessness or a reluctance to work, potentially limiting social and political awareness among those it is intended to serve.”
Rose (1999: 114) has noted that a focus on positive mental health in the workplace has included management policies aimed at “richness of self, self-acceptance, growth motivation, investment in living, unified outlook on life, regulation from within, independence, and adequacy of interpersonal relations.” In contrast, mental illness in the workplace can broadly be conceived as the opposite; for example, those who are perceived as having poor interpersonal relations, who show a lack of independence, and have “negative” personality traits which limit their “growth” potential (e.g., introversion, shyness, melancholia, and pessimism).
The current prevalence of mental illness in the labour force is estimated to be one in every four workers. Te Partnership for Workplace Mental Health (2006: 6) estimates that the indirect annual costs of mental illness to American employers may be as high as $100 billion. Whereas a straight Marxist analysis would suggest that the increased alienation of workers in neoliberalism leads to greater levels of sickness including mental disorder (see, e.g., Robinson 1997; Rosenthal 2010; Rosenthal and Campbell 2016), there is a need to consider the interventions of the mental health system in the world of work as increasingly useful in ideological terms, justifying the precarious conditions that we currently work under as natural and inevitable. I argue here that mental illness designations are increasingly focused on the world of work and serve an important role in depoliticising employment relations; instead of recognising power disparities in the work environment, new and/or changing diagnostic categories of mental illness encourage workers to problematise the self rather than the organisation or wider society.
Table 4.1 shows the quantity of work-related terminology used in each edition of the DSM. Te number of such phrasings has significantly increased over time, from a count of 10 in the DSM-I to 387 in the DSM-5. References to “work,” “working,” or “worker” are particularly evident in mental disorders from 1980 onwards and, despite being a similar sized manual to the previous edition, the DSM-5 increased the use of such phrasings by almost a third (it is worth noting that part of this increase is due to the introduction of the workplace to the previously
|DSM-I DSM-II III III-R DSM-IV IV-TR DSM-5|
|Flexible/ility||0||0||0||1||7||4||14||Loss of job/employment/||0||0||8||1||9||10||16||:job loss||Under/unproductive/ity||0||0||10||2||11||8||12|
aSee Appendix A for methodology.
school-defined ADHD diagnosis, a classification which Conrad (2007: 139) has referred to as representing “the medicalization of underperformance”). As expected, the DSM-III in 1980 shows a large increase in the references to workplace terminology. Following the construction of DSM-III, a number of mental illness classifications have appeared which have specifically sought to pathologise behaviour and personality traits which are seen to limit the desired skills and roles of workers in the neoliberal workplace; these include disinhibited social engagement disorder and social anxiety disorder. To illustrate my argument for the workplace as a site of psychiatric hegemony I will now outline the latter diagnosis as an appropriate case study.
Case Study: Social Anxiety Disorder
First classified in the DSM-III (American Psychiatric Association 1980: 227-228) as social phobia under the notoriously vague—yet increasingly useful—lexicon of anxiety disorders, the primary symptom of social anxiety disorder (SAD) was a “persistent, irrational fear of, and compelling desire to avoid, situations in which the individual may be exposed to scrutiny by others” (American Psychiatric Association 1980: 227). As acknowledged by Lane (2007: 72-75), the development of this diagnosis by the DSM-III committee had little to do with any scientific study on the topic and much more to do with acquiring a set of descriptive, inclusionary behavioural criteria under the watchful eyes of pharmaceutical patrons such as Upjohn. By the 1990s, social phobia was being named “the disorder of the decade” (Aho 2010: 191); this situation was significantly aided—not for the last time—by a loosening in diagnostic criteria with the deletion of the phrase “compelling desire to avoid” in the revised edition of the DSM-III (American Psychiatric Association 1987: 241). With only the mental disorders of alcohol dependence and major depressive disorder a ecting more people, those who currently suffer from SAD in the United States are estimated to represent at least 13 per cent of the population (Aho 2010: 191).
If there really was originally an attempt to exclude “normal” behaviour from the criteria for SAD, this appears to have completely vanished by the time of the release of the DSM-5 (American Psychiatric Association 2013: 202), where the first symptom of the disorder is now a,
Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech).
Readers may be reflecting on whether they have also shown similar anxieties in such social situations, arguably many of us have. Is this normal behaviour—an irritating if perhaps necessary fallibility of something which maybe makes us who we are—or is it a pathology, an illness which requires treatment? Critics have argued that the APA’s invention of SAD represents the successful medicalisation of shyness, a natural human emotion (Lane 2007; Scott 2006). Tus, the diagnosis can be conceptualised as a label given to those deviating from dominant neoliberal norms of the model citizen and worker who should now be assertive, gregarious, and an aggressive go-getter. As Scott (2006: 134) saliently comments, thanks to the development of the SAD label, the psy-professionals now assert that “being shy is a barrier not only to personal relationships but also to career advancement and civil interaction with strangers, acquaintances and friends.”
There are a number of key reasons that have been given by scholars for the “discovery” and expansion of SAD. Tese include the influence of pharmaceutical companies on such “diagnostic creep,” the potential for jurisdictional expansion by psychiatrists and allied professions, and the promotion of shyness as a medical problem by advocacy groups and research institutions (see, e.g., Conrad 2007; Lane 2007; Moynihan and Cassels 2005; Scott 2006). However, while there is plenty of evidence to suggest that these factors have had a significant impact on the expansion of SAD throughout western society, they do not explain psychiatry’s original focus on shyness towards its initial appearance in the DSM-III. Such an analysis involves a wider socio-historical analysis of psychiatry’s primary function within western society. Aho (2010: 201) has been one to offer such a critique of those who forward the political economic view of medicalisation as simply, “a product of recent capitalist collusion between the pharmaceutical industry, managed care organizations … and advocates of the new DSM.” Instead, he states that “before medical professionals and pharmaceutical conglomerates can profit from pathologizing certain behaviors, a web of historical meanings is already in place, working behind our backs to determine what will count as normal and abnormal” (Aho 2010: 201).
As I have outlined earlier in this book, the institution of psychiatry does not work in a vacuum, somehow above the everyday norms and values of wider society; rather, they are a profession with a particular conservative zeal for upholding the current social order through their work. When behaviour becomes unacceptable to the needs of capitalism, the profession seeks to pathologise such deviance. Tis process does not happen overnight but through a progression of debate, research, and movement towards a collective focus on such areas. In this case, the research on shyness from Philip Zimbardo (1977)—the former president of the American Psychological Association—is seen as key towards the development of social phobia as a category of mental illness. Significantly, his research did not suggest that shyness was a mental illness, but rather noted a concern that people with such characteristics were likely to be seriously disadvantaged as society began to change. Zimbardo (1977: 5, emphasis added) commented on the “condition,”
Shyness is an insidious personal problem that is reaching such endemic proportions as to be justifiably called a social disease. Trends in our society suggest it will get worse in the coming years as social forces increase our isolation, competition, and loneliness. Unless we begin to do something soon, many of our children and grandchildren will become prisoners of their own shyness.
The traits of shyness—including timidity, mistrust of others, and a lack of self-assertion (Zimbardo 1977: 13)—were conceptualised as increasingly problematic within contemporary society and therefore a justifiable focus for psychiatric activity. Tis is tacit acceptance that such behaviour has not been found to be a mental disorder as a result of rigorous testing but rather is socially dictated and culturally relative; shyness becomes a “social disease” (i.e., a social deviance) in need of treatment. Thus, “the rise of social phobia,” states Cottle (1999: 25),
offers a glimpse not so much at the anatomy of a specific illness as at the still inherently subjective nature of psychiatric medicine and the cultural forces that help draw the boundary between what we are told to think of as normal and what we are told to consider pathological.
Concerned with the need for workers to conform to the desired norms and values necessary to “succeed” in neoliberal society, the psy-professions have stigmatised and “othered” those once considered only shy, introverted, or reticent co-workers. Tis process of psychiatrists labelling the shy as mentally ill has also been previously highlighted by Scott (2004: 133) who acknowledges that, in comparison, the non-shy self,
embodies the cultural values of contemporary Western societies: ambition, assertiveness, competitiveness and individualism. Tis dominant ideal can be used to stigmatize those who fail to live up to such expectations, whose difference is attributed to individual pathologies rather than to an unrealistic cultural ideology.
The success of psychiatric hegemony here is that since the original construction of social phobia in 1980, workers have become more inclined to self-label and entertain the possibility of therapy and drug treatment for their failure to be more sociable and assertive at their place of work. Tis situation has further legitimated the extension of the psy-professions in the areas of unemployment, job training, and work, reinforcing the neoliberal focus on the self as the site of change, while simultaneously depoliticising the increasingly alienating work environment and constant pressures on employees to upskill and be “more employable” in the jobs market (see Elraz 2013). Trough the pathologisation of such “non-sellable” traits, Lane (2007: 208) argues that what counts as acceptable behaviour within the population has been narrowed to such an extent that “we now tend to believe that active membership in community activities, the cultivation of social skills (becoming a ‘people person’), and the development of group consciousness are natural, universal, and obligatory aims.”
As Roberts (2015: 24) has pointed out of the recent increase in the use of the “autism” label by the psy-professions, the pathologisation of shyness reflects neoliberal capital’s desire for “emotional labour” within the work force. “It is no longer enough just to shift product,” states Roberts (2015: 24), “one must now do it with a smile, with ‘sincerity,’ with a friendly touch.” In this chapter I have discussed the psy-professionals' involvement in the area of work from utilising it as a form of “therapy” for idleness in the nineteenth century to encompassing dominant neoliberal ideals of employability and productivity in the current DSM. Reinforcing the ideological prerogatives for workers to concentrate on their individual failings rather than the social reality of their collective exploitation under capitalism has allowed the experts of the mind to expand their areas of jurisdiction into the office, factory, home, and—as we shall see in the next chapter—the school.
In 2014, the Bureau of Labor Statistics ranked industrial-organisational psychologists as the fastest-growing occupation in the United States, with Farnham (2014) noting of the profession that “their expertise results in better hires, increased productivity, reduced turnover, and lower labor costs.” Meanwhile, the UK government’s Department for Work and Pensions has recently been considering compulsory mental health counselling for the unemployed and possible sanctions for those who refuse such “treatment” (Gayle 2015). Again we witness here the expansion of psy-professions as they align their “expertise” and “science” with the needs of capitalism. Contrary to what our managers are telling us, the infiltration of psychiatry and allied professions into our work lives is not a progressive step in the health field, rather it signals the closer surveillance and social control of labour under neoliberal conditions. Te following chapter moves on to discuss how the future workers have also become victims of this psychiatric hegemony through the closer monitoring of their behaviour in the education system.
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Jonason, P. K., Jones, A., and Lyons, M. (2013) ‘Creatures of the Night: Chronotypes and the Dark Triad Traits’, Personality and Individual Differences, 55(5): 538-541. Lane, C. (2007) Shyness: How Normal Behavior Became a Sickness. New Haven: Yale University Press. Moynihan, R., and Cassels, A. (2005) Selling Sickness: How Drug Companies are Turning Us All into Patients. Crows Nest: Allen and Unwin. Partnership for Workplace Mental Health. (2006) A Mentally HealthyWorkforce— It’s Good for Business. Arlington, VA: Partnership for Workplace Mental Health. Roberts, R. (2015) Psychology and Capitalism: Te Manipulation of Mind. Alresford: Zero Books. Robinson, J. (1997) Te Failure of Psychiatry: A Marxist Critique. London: Index Books. Rose, N. (1999) Governing the Soul: Te Shaping of the Private Self (2nd ed.). London: Free Association Books. Rosenthal, S. (2010) Sick and Sicker: Essays on Class, Health and Health Care. Hamilton, ON: J.H. French & Company. Rosenthal, S., and Campbell, P. (2016) Marxism and Psychology. Toronto: ReMarx Publishing. Scott, S. (2004) ‘Te Shell, the Stranger and the Competent Other: Towards a Sociology of Shyness’, Sociology, 38(1): 121-37. Scott, S. (2006) ‘Te Medicalization of Shyness: From Social Misfits to Social Fitness’, Sociology of Health and Illness, 28(2): 133-153. Scull, A. (1989) Social Order/Mental Disorder: Anglo-American Psychiatry in Historical Perspective. Berkeley: University of California Press. Scull, A. (1993) Te Most Solitary of A ictions: Madness and Society in Britain, 1700-1900. New Haven: Yale University Press. Zimbardo, P. G. (1977) Shyness: What It is, What To Do About It. Reading, MA: Addison-Wesley.
5: Youth: Medicalising Deviance
This chapter considers the key economic and ideological factors within capitalist society that have precipitated what might be described as the relatively recent psychiatric and therapeutic “gold rush” of diagnosing young people with ever greater varieties of mental illness. As regimes of work have changed throughout the twentieth century and the demand for the workforce to possess higher and more complex skills has become greater, it will be shown that a focus on compulsory schooling justifies the closer surveillance and control of youth behaviour by psychiatric and associated professions. In forwarding the central argument of this book, a socio-historical analysis is performed on the diagnosis of ADHD, currently the most popular mental illness label given to school-aged children and young adults. While considering the issues of deinstitutionalisation, psy-professional struggles over jurisdiction, and the encroaching power of the pharmaceutical industry, the ADHD case study, along with textual analyses of consecutive DSMs, will show that the increasing infiltration of the psychiatric discourse into the education system serves a significant function for capitalism in enforcing dominant moral codes and economic prerogatives while pathologising any deviation or resistance to these patterns of authority.
Wilkinson and Pickett (2010: 63) estimate that a million children in Britain are currently mentally ill, including one in ten of those aged between five and sixteen. Understanding these figures in the context of the education system, the scholars note that “in any secondary school with 1000 students, 50 will be severely depressed, 100 will be distressed, 10-20 will be suffering from obsessive-compulsive disorder and between 5-10 girls will have an eating disorder” (Wilkinson and Pickett 2010: 63). And the numbers appear to be growing. For example, in the case of attention-deficit/hyperactivity disorder (ADHD), three to five per cent of young people in the US were diagnosed with the disorder in 1970s (Conrad 2006: xi) whereas the current estimate is between seven and nine per cent of the youth population (Bowden 2014: 423). Recent studies from the US Centers for Disease Control and Prevention suggests an even higher rate of 11 per cent of school-age children, including 20 per cent of the male population (Saul 2014: 16). This represents a growth in ADHD in the US of 41 per cent in the last ten years (Saul 2014: 16). Whitaker and Cosgrove (2015: 92) estimate that 3.5 million young people in America are now being prescribed ADHD medication, which is “nearly six times the number in 1990.”
As will be detailed later in this chapter, my analysis suggests that the range of mental disorders that can be associated with young people is currently 47 from a total of 374 classified in the DSM-5. Fifty years ago, in the first edition of the DSM, the figure was just eight. This impressive picture of the current “epidemic” of child mental illness can be contrasted with the knowledge that just a hundred years ago cases of mental disorder in children was considered most rare, with there being no specific pathology that psychiatry believed affected young people in particular (Timimi 2008: 166). How can we explain the increase in the rates and numbers of mental illnesses said to be afflicting young people across western society, especially over the past 35 years? Critical scholars have pointed to a number of factors including the consideration of psychiatrists as “moral entrepreneurs” responsible for the increased medicalisation of childhood, the need for a continual expansion of psy-professional activity into new areas of public and private life, and the role of pharmaceutical companies in distorting notions of “mental illness” to increase the profits from drug consumption (Rose 2006: 476-479). While the increasing medicalisation of deviant behaviour is a common theme within much of this scholarship, writers are cautious as to the seemingly complex dynamics whereby a specific aspect of young peoples’ behaviour becomes categorised as a new mental illness by psychiatry (though pharmaceutical companies are often seen as a key agent here). Rose (2006: 480), however, has suggested that this medicalisation thesis should be tempered by a more “subtle” and less deterministic approach through which we can understand how both individuals and their doctors discursively code experience “in relation to a cultural norm of the active, responsible, choosing self, realizing his or her potential in the world through shaping a lifestyle.”
The argument I develop here is much simpler than either Rose’s or the medicalisation scholars, less subtle maybe, but certainly more straightforward: rates of mental illness for young people have increased because of capitalism’s need to mould the moral character of the individual at an earlier age than previously. As the last chapter documented, neoliberalism has seen the progressive creep of psychiatry and associated professions into the workplace, training centres, and welfare and unemployment offices to enforce self-surveillance and progress “character building” in the interests of capitalism. Likewise, such regimes depoliticise and pathologise resistance through re-framing the systemic problems of an alienating and unfulfilling work environment as symptoms of “mental illness” and, thus, part of an individual’s own failings. With the requirement for more compliant, competitive, and skilled citizens needed for the neoliberal marketplace, the psy-professionals have also intensified their focus on youth; this has particularly been achieved through the compulsory education system as the primary site for surveillance and, consequently, diagnostic expansion. This chapter begins by outlining the social construction of “children” and “young people,” and the subsequent concern for their moral obligations by welfare agencies. It will then focus on the introduction of compulsory schooling as well as the development of child psychology and child psychiatric services which emerge from the education factories. Discussion of the post-war struggle for professional jurisdiction of disturbed and disabled children will be given, followed lastly by a detailed analysis of psychiatry’s increasing focus on young people in neoliberal society.
The Social Construction of Childhood
At the end of the twentieth century, Rose (1999: 123) stated that childhood had become “the most intensively governed sector of personal existence.” This includes the surveillance of the home and the school by health, welfare, and education services. It was not always this way; in fact, “childhood” as a separate and distinct phase of the life cycle only emerges with the Enlightenment and then develops further with industrial society (Aires 1962; Conrad and Schneider 1992: 145). Before this period, little attention was shown to these smaller versions of adults who were afforded the same rights and obligations as the rest of the population. Specifically, the nineteenth century saw key changes in this view, as birth and the first years of a person’s life were reconceptualised as a period of significance to industrial citizens’ future physical and moral health. The early years were reshaped as a time of “innocence” where the child needed special attention and guidance from authorities (Conrad and Schneider 1992: 146).
Consequently, this period witnessed a growing concern for the younger population from the media, politicians, charities, and the public, which resulted in the emergence of professional groups and organisations specifically focused on childhood as a new “social issue.” The construction and subsequent problematisation of young people in the nineteenth century can be succinctly understood as informed by two necessary conditions for the expansion of industrial capital at this time: firstly, the economic requirement for the labour force to be physically healthier, better skilled, better organised, and generally more conditioned to industrial work regimes prior to entering the factories and the mills. And secondly, the ideological requirement for the working classes to conform to the new industrial environment, embracing the dominant norms and values of capitalism without dissent (these ideas often being framed by religious groups, the media, and politicians as a concern for the “future morality” of society). As a result, there is an increase in the surveillance of the emerging nuclear family (Chap. 6). However, it is with the establishment of compulsory schooling in the latter decades of the nineteenth century that these economic and ideological prerogatives are given their clearest and most enduring form.
The establishment of compulsory education addressed the need for a more literate and higher skilled workforce (Timimi 2008: 165), while at the same time allaying the fears of the ruling classes as to the perceived threat of an increasingly organised and politicised working class population. The new public schools system therefore performed a secondary socialisation function, instilling dominant codes in the future labour force and acting as a site where authority and moral obligation of the new citizens could be enforced. Similar to the factory, the asylum, and the prison, the school established another institution of social control in industrial society where obedience to the social order could be reinforced, primarily through surveillance by moral authorities rather than through physical punishment. Citing John Locke’s philosophy on education which informed this state apparatus, Scull (1993: 108) notes that “[t]he child needed to be taught to be ‘his own slave driver’” through rewarding “appropriate” behaviour and shaming deviant actions. Joined by an emergent teaching profession, the psychological sciences would come to take a decisive role in enforcing this ideological function of the education system. Following the enactment of legislation in the 1830s to outlaw child labour in Britain (Duffin 2000: 330), the increased visibility on the streets along with public concern as to the potential delinquency of the young working class population led to demands that greater attention be paid to child welfare. Informed by Christian and nationalist doctrines as well as burgeoning psychological, educational, and philosophical approaches to “child development” (Timimi 2008: 165), many “child-saving” charities and philanthropic groups emerged during this period to campaign for greater social and medical interventions in early life, with a particular focus on the family and the school. As Conrad and Schneider (1992: 146) recount, “[t]hese reformers, including moralists, educators, and clergy, supported child-rearing philosophies that emphasized psychological control and moral solicitude, in the name of benefiting the child.” For such reformers, a great deal of momentum was gained from the introduction of compulsory schooling—this led to what Timimi (2008: 165) calls “a prolonged and unprecedented public discussion about the physical and mental condition of children.” This concern for the psychological well-being and development of the young citizen also paralleled the more general growth of public medicine in Victorian Britain. As Porter (1997: 633-634) has outlined of the guiding principles,
medicine (it was argued) had to become a positive and systematic enterprise, undertaking planned surveillance of apparently healthy, normal people as well as the sick, tracing groups from infancy to old age, logging the incidence of chronic, inherited and constitutional conditions, correlating ill health against variables like income, education, class, diet and housing.
By the end of the nineteenth century, the medical gaze had expanded to incorporate “the entire psycho-social economy” of society (Porter 1997: 634), including a growing interest in education. Within the school environment, the concern for the “morality” of the future workers shown earlier by child-saving groups became a focus for the scientific surveillance and management of young people by the psychological sciences under the auspices of identifying learning difficulties and behavioural problems. In the new century, psychiatrists and psychologists began to observe, monitor, and evaluate the classroom, not for mental pathologies within the child but for behaviour that differentiated them from the “normal” and the expected. Tus the psy-professionals’ interventions in schools were, from the beginning, moral rather than scientific judgements of appropriate behaviour, holding within them the aim of enforcing dominant and desired notions of “normality” on the young. As Rose (1999: 133) has summarised,
It is around pathological children—the troublesome, the recalcitrant, the delinquent—that conceptions of normality have taken shape. It is not that a knowledge of the normal course of development of the child has enabled experts to become more skilled at identifying those unfortunate children who are in some way abnormal. Rather, expert notions of normality are extrapolated from our attention to those children who worry the courts, teachers, doctors, and parents. Normality is not an observation but a valuation. It contains not only a judgment about what is desirable, but an injunction as to the goal to be achieved. In so doing, the very notion of “the normal” today awards power to scientific truth and expert authority.
Before the advent of compulsory schooling it had been rare for children to be conceptualised as suffering from a “mental illness,” though Timimi (2008: 166) notes that there were occasional youth admittances to asylums throughout the nineteenth century. However, the concern for the welfare of the child and the general “mental hygiene” of the population in the early part of the twentieth century changed this view and saw the emergence of medical and social disciplines and professional bodies that, for the first time, specialised in child and adolescent health, including the establishment of paediatrics as a sub-discipline of medicine (Duffin 2000: 317). Similarly, early development psychology and child psychiatry were also established (Timimi 2008: 166), the latter notably helped by the foundation in England of the Tavistock Square Clinic in 1920 which boasted a children’s department responsible for promoting “awareness” of childhood mental disorders (Porter 1997: 645).
In the previous chapter I discussed the development of an increasingly complex work environment throughout the twentieth century; at the same time, the psychological sciences expanded its areas of jurisdiction to facilitate skills diversification and “personal development,” increase the productivity and efficiency of the workforce, and enforce conformity to the dominant values of capital by pathologising and depoliticising worker resistance. The primary site for enforcing such structures of discipline on the future workforce, however, would come to be the school—this was where the psychological sciences would first make a significant claim to expertise beyond the psychiatric institution and the analyst’s couch. Rose (1999: 135) recounts that, as with the factory or the parade ground, school brought children together in a single space where they could be observed and judged en masse. Individual differences between children were made visible by the school system, and the institution, “sought to discipline [children] according to institutional criteria and objectives” (Rose 1999: 140). However, there were those who would not or could not adapt to the desired moral codes for behaviour and performance at school. These young people—who came to be labelled as “educational imbeciles or the feeble-minded” (Rose 1999: 140)—were a problem for the authorities.
Inspired by the eugenicists’ obsession for marking and testing biological and mental differences within the general population (Chap. 7), psychologists developed the intelligence quotient (IQ) test to measure the academic performance of school children and separate the able from the less-abled students. This is the beginning of psychometric and associated testing which has since expanded across many areas of economic and social life. Commenting on the significance of the “intelligence” test, Rose (1999: 143) states that,
The technique of the test was the most important contribution of the psychological sciences to the human technologies of the first half of the twentieth century. The test routinizes the complex ensemble of social judgement
on individual variability into an automatic device that makes difference
visible and notable.
Thus, the intelligence test can be seen as a moral technology used specifically for the social judgement of school children by psychologists under the guise of “science” (see also Roberts 2015: 12-13). The inventor of the test, Alfred Binet, had developed it to identify the “feeble-minded” to be sent to special schools. Significant for contextualising later mass testings and screenings of school children for intelligence, abnormalities, and mental disorders, Rose (1999: 142, emphasis added) notes, "Binet’s test used criteria that were directly educational and behavioural. They were direct assessments of the degree of adaptation of individual children to the expectation that others had of them." The key to the success of Binet’s test was not the ability to accurately measure “intelligence”—which he felt was impossible to predict through such time-restricted tests—but its administrative usefulness in identifying problematic individuals (Rose 1999: 142). By the 1960s, the “science” of testing school children had expanded to such an extent that it was enshrined in the United States under the federal Medicare package, where children could be screened for a whole host of physical and behavioural disorders. With mass-screening programmes administered through schools, Conrad and Schneider (1992: 155) state that it had become, “possible to establish diagnosis and intervention with deviant children to an extent beyond the dreams of the 19th-century child-savers.” Under the pretext of “health care” for school children, these moral technologies aided the expansion of the psy- professionals into the education system over the course of the twentieth century, and with it an increased focus on childhood deviance and the use of psychiatric labels to neutralise such threats to authority.
The Rise of the Risky Kid
An analysis of successive editions of the DSM for youth-related diagnoses demonstrates three key issues to support my argument for the development of psychiatric hegemony here. Firstly, psychiatry has linked childhood mental illness to unwanted behaviour and conduct in the classroom from the very first edition. For example, the DSM-I introduced “learning disturbance” as a category of “special symptoms/reaction” (American Psychiatric Association 1952: 39), as well as the mental disorder of conduct disorder/disturbance (American Psychiatric Association 1952: 41) which included the example of truancy as symptomatic behaviour (in an updated form, the latter remains in the DSM-5) (see Appendix B for the full diagnostic list identified in each DSM). Secondly, the pathologisation of youth behaviour and the experiences/events of childhood and adolescence have increased exponentially, from eight diagnostic categories in the DSM-I to 47 in the DSM-5 (see Table 5.1). Young people have been a market of serious growth for the mental health industry, and psychiatry (along with pharmaceutical companies and other vested parties) has been successful in grabbing a significant piece of that pie over the years. From my analysis of the DSMs, the classifications and discourse on youth have grown considerably, divorcing all other areas of specific
Table 5.1 Number of youth-related diagnostic categories in the DSM, 1952-2013a
aSee Appendix B for full diagnostic list.
psychiatric expansion. Tirdly, the growth in youth-related mental illness classifications and discourse is uneven, with the most pronounced increase evidenced in 1980 with the publication of the DSM-III. At the end of institutionalisation and the beginning of neoliberalism, the number of mental disorders aimed at young people and adolescents doubled from 18 in the DSM-II to 37 in the DSM-III. It is here, for example, that the behaviours of stuttering and being mute become mental illnesses (the former remains in the DSM-5 as childhood-onset uency disorder (American Psychiatric Association 2013: 45-47)), while learning disabilities, social ineptitude, and (especially) boys’ unruly behaviour are medicalised under labels such as autism and ADHD. In previous DSMs, references to “school” were rare (the word was mentioned only four times in the diagnostic categories in the DSM-I and twice in the DSM-II), yet in the DSM-III the word was liberally scattered across many diagnoses as both examples and the focus for a site of disorder, with the phrase being used a total of 91 times. Many new words and phrases associated with youth, education, and leisure were introduced under classifications and symptomologies in the DSM-III, and these have usually increased with each successive edition of the manual (see Table 5.2).
To fully understand the growth in the psychiatric surveillance of young people during the post-war period, it is necessary to consider the expan- sion of the welfare state in western societies, the struggle for control of
Table 5.2 Number of youth-related words/phrases in the DSM, 1952-2013a
aSee Appendix A for methodology.
expertise over the areas of youth mental health and “mental retardation” between psychologists, psychiatrists, psychoanalysts, educationalists and social workers, societal concerns over the morality of young people, and the perceived increases in teenage delinquency and crime at the time. The expansion of intelligence testing to increasingly younger populations allowed for the detection of ever greater numbers of those considered “feeble-minded” or “morons.” Confined to institutions for the “mentally retarded” or in “special schools,” Eyal et al. (2010: 78-79) note that these “socially incapable” individuals were inevitably from working class and minority backgrounds, with professional judgements made on the basis of prevailing ideas of “feeble-mindedness” as related to delinquency and crime. The number of young people admitted to institutions for the mentally deficient increased dramatically between the 1940s and the 1960s, with Eyal et al. (2010: 114) recording a figure for America of 108,500 pupils in 1948 but 540,000 students by 1966 (the general school-age population in the country less than doubled over the same period). This period of intense institutionalisation of large numbers of young people represents the attempt of psy-professionals to exert social control over deviant groups who could be diverted from the public schools system into spaces of moral management and confinement. Being “mentally deficient” was a useful metaphor for deviant and troublesome individuals in the education system, as Eyal et al. (2010: 79) remarks, “[t]ruancy, delinquency, epilepsy, alcoholism, sexual promiscuity, even masturbation, all served as pretexts for commitment as mentally deficient, and the category of ‘defective delinquent’ was the main prism through which the problem of feeble-mindedness was viewed.” Such moral failings of the post-war juvenile delinquent were conceptualised by child psychiatrists as evidence of a serious mental disorder (most often utilising the label of “childhood schizophrenia”) for which they typically recommended psychiatric institutionalisation and a course of 20 ECT treatments (Eyal et al. 2010: 134).
As has been previously discussed in Chap. 3, deinstitutionalisation led to a significant change in the diagnostic focus of psychiatry from “severe and acute” mental illnesses—which typically called for an institutional response—to less severe pathologies which expanded their areas of expertise and locus of operations. By the mid-1970s there was a similar decline in the use of institutions for the “mentally retarded”—children were “mainstreamed” back into the public schools system and, consequently, a greater surveillance of young people within the education system by psychiatry and related professions unfolded. By the time of the publication of the DSM-III in 1980, youth-related mental illnesses had mysteriously doubled and delinquent behaviour such as pyromania, kleptomania, and other “conduct disorders” had been given their own DSM classifications. Tus, the DSM-III and the growing focus on youth mental illness can be understood as a consequence of the deinstitutionalisation of deviant youth from special education facilities. As with the move towards “milder” mental disorders in the community, the integration of children and young people once labelled as suffering from “learning disturbances” into mainstream schools called for the greater surveillance and control of youth behaviour in the wider education system. The increase in the psychiatric labelling of groups of young people with diagnoses such as oppositional defiant disorder, ADHD, conduct disorder, and autism is a consequence of the change in the site of psy-professional operations which, in the latter case, is supported by Eyal et al. (2010) who argue that the recent autism “epidemic” in western society is a result of the diagnostic substitution of the term “mentally retarded” for the more recent psychiatric label.
Education Factories and the Surveillance of the Future Workforce
In the mid-1970s my own primary school introduced a rule banning a popular lunchtime activity of inserting baked beans into bread rolls. We were instructed to eat rolls with butter only; the baked beans had to remain on the plate, outside the roll at all times. One day, a friend of mine disobeyed this rule and was caught by a teacher at our lunch table. The teacher was most put out by this open display of beans-in-roll pleasure. I was ten years old but even then curious about how the world worked, so I asked the teacher why this activity was forbidden. This was a mistake. The response was very loud and a bit scary. The lesson we learned that day was if there is something worse than blatantly disobeying school rules it was questioning them; students who question orders are by extension questioning authority. As outlined earlier in this chapter, compulsory education serves both an economic and an ideological function in capitalist society. Students learn a range of literacy and numeracy skills which will benefit the market in due course and, at the same time, they learn to conform, obey, and take for granted the norms and values of capitalist society as inscribed through the formal and informal processes of schooling. As neoliberalism has impacted compulsory schooling over the past 35 years, the latter ideological function has become increasingly important, with noted scholar and school teacher John Taylor Gatto (2002: 21) bluntly stating that “[n]o one believes that scientists are trained in science classes or politicians in civics classes or poets in English classes. The truth is that schools don’t really teach anything except how to obey orders.”
Schools manage the ideological reproduction of the future labour force. Youth dissent and resistance must be neutralised in the interests of enforcing the ideals of the ruling classes upon all young citizens. Rather than an array of free-thinking individuals, schools use techniques of scientific management on young people to produce “formulaic human beings whose behavior can be predicted and controlled” (Gatto 2002: 23). Difference or digressions from the expected behaviour are signs of deviance and can be consequently labelled as “learning difficulties” and signs of pathology. In western society, explains Adams (2008: 114), the education system rewards cohesion and cooperation with teachers, school rules, and the prescribed tasks of the classroom. Yet—as with the rules of my own primary school—the judging of the behaviour of pupils and how far they are “cooperating” or otherwise with teachers’ expectations are context specific rather than universal. Instead of considering reactions to behaviour considered as inappropriate and incorrect as a product of the professional expectations of teachers alone, Adams (2008: 114) argues we need to place them in their broader socio-political and cultural context. The current ideal type among teachers for the conforming and non-confrontational pupil needs to be seen as a result and reinforcement of this wider context. Tus, “inappropriate” behaviour does not necessarily re ect impairment but rather “socio-cultural and political actions” of the wider policy environment. “Dominant political positions,” states Adams (2008: 114), “contribute to the creation of categories such as ‘deviant’ through their description of appropriate and inappropriate. This duly positions professional response that in turn can and does further legitimate policy.” The psychological sciences have become increasingly useful for teachers and the schools system in supporting the exclusion of troublesome pupils and labelling non-conformist students as mentally disturbed. Szasz has previously highlighted the absurd vagueness of diagnostic symptomology which allows any aspect of child behaviour in the classroom to be understood as a potential mental disorder. This he does by citing a journal article from 1962 which argued for more psychiatric services in the education system, identifying the following symptoms which suggested underlying pathologies in school children:
1. Academic problems—under-achievement, over-achievement, erratic, uneven performance. 2. Social problems with siblings, peers—such as the aggressive child, the submissive child, the show-off. 3. Relations with parental and other authority figures, such as defiant behavior, submissive behavior, ingratiation. 4. Overt behavioral manifestations, such as tics, nail-biting, thumb-sucking … [and] interests more befitting to the opposite sex (such as tom-boy girl and effeminate boy). (Radin, cited in Szasz 1997: 35).
As signalled by the recent construction of mental illness categories explicitly focused on student behaviour in school (such as losing homework and failing to pay attention in class), psy-professionals’ role in the public education system has become more pronounced over the past few decades. Just as profound, however, has been the heightened concentration in the post-welfare era on the school as a site of economic competition, with market forces more directly in uencing school management, teaching processes, and ultimately the pressures placed on young people to acquire greater numbers of qualifications and skills than previously. Adams (2008: 115) has described how neoliberal education policies have subordinated the needs of individual students to the wider economy, arguing that “in effect, ‘learner’ became ‘worker in waiting’ with the knowledge and skills deemed as worthwhile to gleam from school as those required and celebrated in the commercial world.” As a result, commentators have noted how schools have become far more demanding social environments which involve greater levels of self-regulation of young people (Timimi 2009: 139). As western governments have demanded greater numbers of students continue in education and reorientate themselves to a future as white-collar workers, the qualities of school pupils once considered appropriate (such as exuberance, curiosity, and energy) have been replaced by more on-task academic learning and seat-work (Graham 2008: 24). As a result of the pressures on teachers and pupils in this neoliberal environment, there has been a need for a closer surveillance of behaviour in school and, more readily, a desire to discipline the defiant child through the application of various mental illness labels. As the Department for Education and Skills for England and Wales stated in 2005, “better discipline … [in schools will] enable teachers to teach and learners to learn” (cited in Adams 2008: 115). To further illustrate how psychiatric hegemony has been achieved as a result of the needs of capital to ideologically control young citizens, the following section profiles the origins and development of ADHD, the most popular label of mental disorder currently applied to young people.
Case Study: Attention-Deficit/Hyperactivity Disorder
As noted at the beginning of the chapter, up to 11 per cent of school-age children in the United States are currently diagnosed with ADHD (Saul 2014: 16). Granted, these figures are considerably higher than those for other western countries. For example, Zwi et al. (in Conrad 2006: xii) suggest that the United States has a diagnosis rate for ADHD some 10-30 times higher than that for the UK. However, one trend which unites all western societies is the increased use of the label for problematic children over time—particularly since the 1990s (Conrad 2006: xii)—and the increased use of stimulant medications as a treatment option. The dominant biomedical view states that ADHD is a neurological dysfunction of the brain. This is despite a lack of any evidence for the biological causation of the disorder (Christian 1997: 34; DeGrandpre 2000: 9). A brief overview of the symptoms for the mental disorder in the DSM-5 highlights the obvious psychiatric construction of ADHD as a set of education markers—to which has been added workplace markers (Chap. 4)—of deviance and failure within the schooling system. The symptomologies given by the American Psychiatric Association (2013: 59) for the “inattention” markers of ADHD are,
- Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate).
- Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).
- Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).
- Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).
- Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).
- Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).
- Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
- Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).
- Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).
As a general marker of productivity, changes to the ADHD diagnosis between DSM-IV (1994) and DSM-5 (2013) have focused on expanding the diagnosis to adults by introducing aspects of work and home life as additional realms for symptomologies. Similarly, the symptoms from the American Psychiatric Association (2013: 60) for the “hyperactivity and impulsivity” component of ADHD are,
- Often fidgets with or taps hands or feet or squirms in seat.
- Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place).
- Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.)
- Often unable to play or engage in leisure activities quietly.
- Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to
- or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with).
- Often talks excessively.
- Often blurts out an answer before a question has been completed (e.g., completes people’s sentences; cannot wait for turn in conversation).
- Often has difficulty waiting his or her turn (e.g., while waiting in line).
- Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).
Clear within the phraseology and the “symptoms” of ADHD is the concern to medicalise the behaviour of unruly children in the classroom; it is a question of children refusing to conform to the required order of school life and, therefore, the APA developing the label of ADHD as a device of social control (rather than a product of scientific enquiry). As Graham (2008: 23) has correctly remarked of these symptomologies, “most of the behaviours listed are connected to (and one could even argue contingent upon) the demands of schooling.” The contradiction between the espousal of biological aetiology and treatment of increasing numbers of young people, and the obvious place of compulsory education in the construction of the ADHD label has been further highlighted by Christian (1997: 34) when he states that “[s]chool classrooms have had and still have an intimate connection to the origination and the diagnosis of ADHD; and yet, little attention is given to the school setting in the causal explanation of the disorder.” Rafalovich (2004: 21-34) has sought to partially address this situation by performing a socio-historical analysis of pre-ADHD labels, in the process detailing psychiatry’s increased focus on the “morality” of young people’s behaviour in school at the end of the nineteenth century.
The growing medical concern for the “moral imbecile” was specifically contemplated by the physician George Still at the beginning of the twentieth century when he gave a series of lectures at the Royal College of Physicians in London, arguing for the increased scientific investigation of “the occurrence of defective moral control as a morbid condition in children” (cited in Rafalovich 2004: 27). Still believed morality to have a biological base, so pathology could be suspected if it appeared that children were not developing in the way society had designated (i.e., if it appeared that the appropriate moral controls on the child’s behaviour were absent). However, he argued that such children should not to be confused with the “retarded” or “idiot” child. Following his own observations, he stated that these young people were just as intelligent as those who showed moral control and thus demonstrated a degree of agency in their immorality. Symptoms of these defective young people included “passionateness,” “lawlessness,” and “wanton mischievousness-destructiveness” (cited in Rafalovich 2004: 28). Too young for prison and too smart to be considered an imbecile, Still argued that this was a hereto under-investigated and under-theorised group of juvenile delinquents who offered a potential threat to the future of society. Despite the clear linkage between medical science and dominant views on morality within Still’s work, official historians of psychiatry continue to see the physician as a scientific visionary, responsible for the original research on children which would eventually lead to the modern classification of ADHD. In contrast, Rafalovich (2004) identifies the growing concern for deviant and unruly youth by the medical profession as the origins of the current DSM label.
Significant to Rafalovich’s (2004: 29-34) socio-historical analysis is the diagnosis of encephalitis lethargica (EL)—commonly known as “sleepy sickness”—which concerned medicine in the 1920s. Admittedly a poorly defined illness, EL can be understood as an early explanation for delinquency, including as it did the symptoms of “emotional instability, irritability, … lying, thieving, impaired memory and attention, personal untidiness, tics, … poor motor control, and general hyperactivity” (Kessler, cited in Rafalovich 2004: 30). Similar to Still, the physician Roger Kennedy utilised case studies to argue that the young people suffering from EL were in fact, “moral rather than mental imbeciles. Some of them appear dull and drowsy, but in their antics and behaviour they display a cunning that is not commensurate with greatly impaired mental faculties” (cited in Rafalovich 2004: 32). As Rafalovich (2004: 30) argues, such statements exemplify a crucial point in the construction of the ADHD diagnosis, where child psychiatry begins to use specific diagnoses such as EL to claim that “persistently defiant childhood behaviour represented physiological pathology.”
Such claims as to the biological aetiology of the child’s immoral character appeared to be confirmed during the 1930s when the synthesising and marketing of new psychoactive drugs saw an expansion—especially in the United States—in the scope and in uence of pharmaceutical industries on the psychological sciences and the general public (Conrad 1975: 14). In 1937, Charles Bradley presented the results of a drugs study on school children with learning disabilities. His research appeared to show that amphetamines, paradoxically, calmed many of his participants and allowed them to complete study tasks with less disruption. Now an often cited study in the development of drug treatments for ADHD, at the time it was treated as no more than a curiosity. Bradley’s study was performed on children already attending special institutions and diagnosed with “learning disabilities,” thus the results of the research appeared from the outside as if it was only relevant to a small cohort of young people who had already been excluded from mainstream schooling. Yet, an interest in improving student “discipline” in schools by the psychological sciences and pharmaceutical researchers—under the guise of helping those with “learning difficulties”—slowly progressed over the following decades. In the 1950s, the first edition of DSM named a number of mental disorders which directly referred to young people’s deviant behaviour at school (such as conduct disturbance, see American Psychiatric Association 1952: 41) and the drug Ritalin appeared on the US market for the first time. Following the development of Laufer et al.’s new diagnostic category of hyperkinetic impulse disorder in 1957 (Conrad 1975: 14), the turbulence of the 1960s led to an increase in disruptive and resistant young people being labelled as hyperactive. In 1968, the APA more than doubled their diagnostic categories for young people with the publication of the DSM-II, including a dedicated section on “behavior disorders of childhood and adolescence” (American Psychiatric Association 1968: 49-51). Among the new disorders was hyperkinetic reaction of childhood (or adolescence), which the APA described as characterised by “overactivity, restlessness, distractibility, and short attention span” (American Psychiatric Association 1968: 50). With the help of “moral entrepreneurs” such as pharmaceutical companies and the Association for Children with Learning Disabilities (Conrad 1975: 16), by the mid-1970s hyperkinesis had become “the most common child psychiatric problem” in the United States (Conrad 1975: 14).
As has been noted earlier in this chapter, a significant shift occurred with the production of the DSM-III in 1980. While deinstitutionalisation was a threat to public psychiatry, the relatively small field of child psychiatry offered opportunities for the expansion of the medical discipline into new areas of work and expertise. With the mainstreaming of deviant children who were once confined to “special schools” and the increasing requirement for adolescents to upskill and study beyond the end of compulsory schooling, the interests of the state in managing and controlling youth within the education system coincides with the specific interests of the psy-professionals to expand their areas of influence beyond one institution and into another.
Reflecting on the DSM-III committee’s desire to open up the possibility of mental disorders to a much broader population—some might say everyone—a whole chapter of the manual is devoted to “disorders usually first evident in infancy, childhood, or adolescence” (American Psychiatric Association 1980: 35, emphasis added). Taking up five pages of this chapter was the new diagnosis of attention deficit disorder (ADD) which, under the two subtypes of ADD with hyperactivity and ADD without hyperactivity, brought together numerous previous labels given to troublesome children (including hyperkinesis and minimal brain dysfunction). Significant here was the growing emphasis placed upon the inattentiveness of the school child (examples in the DSM-III included that the child, “often fails to finish things,” “often doesn’t seem to listen,” is “easily distracted,” and “has difficulty concentrating on schoolwork” (American Psychiatric Association 1980: 43)), a focus that should not only be seen in the cynical context of diagnostic expansion—a move from explicitly disruptive behaviour to simple levels of concentration at school—but also in terms of the changing needs of the classroom towards more studious and attentive pupils. Reflecting this change, ADD became the now familiar classification of ADHD in the revised edition of the DSM-III seven years later (American Psychiatric Association 1987: 50-53). Following his extensive research on ADHD with clinicians, parents, teachers, and pupils, Rafalovich (2004: 131) finds that key to “discovering” behaviour that will consequently be defined by authorities as ADHD is the child’s school. Such behaviour, he states, is “articulated in one of two ways: as academic struggles, denoting an inability to competently engage in the achievement of classroom assignments, and as social struggles, denoting interpersonal con icts with other students and/or teachers” (Rafalovich 2004: 131). These two sites of struggle at school are then re ected in the symptomology constructed by psychiatry within the ADHD diagnosis, as Rafalovich (2004: 131) concludes, “the disorder’s inattention component can be seen in academic failure, and its hyperactivity component can be witnessed in children’s overt behavioral problems.”
With the construction and expansion of the ADHD category to greater numbers of young people, the emphasis is changing from overt disruption to student inattention. This can be seen as reflecting the changing educational priorities in neoliberalism from the social control of deviant working class youth to the ideological enforcement of a dominant morality on the broader population of school children. The move towards consideration of simple inattention as pathology has also had the interesting by-product of slowly closing the gender gap of this still male-dominated mental disorder (DeGrandpre 2000: 147). Following prescribed gender behaviour, boys have been more likely to be labelled as loud, aggressive troublemakers in class, while girls have been considered by teachers as more passive and introspective. Tus, Rafalovich (2004: 125, emphasis added) rightly summates that “[t]he issue at the core of why there is such a huge gender discrepancy in instances of ADHD has more to do with behavioral visibility than with the actual existence of the condition.” The diagnosing of boys with ADHD has been estimated as three to five times higher than for girls (DeGrandpre 2000: 147), a situation that led the New York Times in 1994 to conclude that boyhood was in danger of becoming a “state of proto-disease” (cited in DeGrandpre 2000: 147).
Increasing the focus on inattention in subsequent editions of the DSM has been a useful way in which the APA can attempt to address the above gender bias in the application of the ADHD label. In his book Saving Normal, the chair of the DSM-IV task force, Allen Frances (2013: 142), freely admits of the classification that “[w]e changed a few words so that the definition [of ADHD] would be more female friendly—taking into account that girls are more likely to be inattentive ‘space cadets’ and less likely than boys to be hyperactive.” Apart from glimpsing another picture of the impressive manner in which the DSM task forces undertake their work (i.e., a reliance on dominant, common sense notions of “appropriate” gender roles rather than any scientific evidence), Frances’ statement highlights the blatant intention of the APA to expand the classification outwards to groups currently under-represented in the profile of ADHD.
In conclusion, this socio-historical analysis of ADHD has demonstrated that the diagnosis emerged from the closer focus of the psy-professions on the morality of young people in the twentieth century and the concern for controlling and correcting deviant behaviour. The expansion of ADHD from a rare disorder to a popular disease among young people over the past 35 years can be understood as a result of capitalism’s need to enforce discipline, compliance, and authority on the future workforce at a younger age. The redefined standards of normality in the neoliberal classroom are therefore designated under the lexicon of psychiatric hegemony as a concern for the control, correction, and treatment of deviant groups of children. ADHD as a classic example of the medicalisation of deviant behaviour is perhaps best summed up by a special education teacher cited in Rafalovich’s (2004: 111) research who, without irony, states that “[t]he last thing someone with untreated ADHD wants to do is go to school.”
Rose (1999: 123) has commented on the importance of young people to industrial society that “the child—as an idea and a target—has become inextricably connected to the aspirations of authorities.” Over time, psychiatric authorities have medicalised more and more aspects of the experiences and behaviour of children. From intelligence testing and the institutionalisation of “mentally deficient” children to DSM-III and the demands of the current education system, this chapter has explored the expansion of psy-professionals’ focus on children and adolescents over the past hundred years. Trough socio-historical investigation, analysis of consecutive DSMs as well as utilising the case study of ADHD, I have demonstrated how the supposed “experts on the mind” have served to reinforce the economic and ideological prerogatives of the capitalist class. For youth, this primarily takes place through compulsory schooling as secondary socialisers of the future workforce. Throughout the development of industrial capitalism it has been demonstrated that the psy-professionals has been concerned with the perceived immorality of working class youth. The psychiatric discourse previously pathologised such deviant behaviour through incarcerating such groups in “special schools” and then, more recently, through the construction of an increasing range of mental disorders aimed specifically at youth and schooling. As Rafalovich (2004: 64) has concluded, from the diagnosis of EL nearly a hundred years ago to ADHD currently, the institutional location has been a key variable in understanding the construction of childhood mental illness. He states that “problems in school have been historically seen as indicative of severe social maladjustment, and improvement in school performance is equated to ‘appropriate’ social behaviour” (Rafalovich 2004: 64). As framed by the neoliberal focus on the individual as the site of change, the institutional requirements of the school for conformity and compliance means that now more than ever teachers are aided by the mental health system. The focus of teachers on the notion of the “individual deficit” of young people, comments Adams (2008: 123), should now be seen as having “become even more political rather than psychological.”
Speaking more generally to the drivers of the medicalisation of deviant behaviour in his classic study of hyperactive children, Conrad (2006: 98) states that “[t]he greater the benefit to established institutions, the greater the likelihood of medicalization.” While the changing demands of capitalism brought about the relatively recent expansion in psy-professional activity focused on young people, the discussion in the next chapter investigates an institution of industrial society which has experienced psy-professional intervention for a more sustained length of time, namely the family. It will be demonstrated that the reconstituted nuclear family system in capitalist society has served to confine and oppress women for specific economic reasons, and that this system of patriarchal relations has been constantly reinforced by psy-professional practice over time.
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