8 February 2020
Whilst socialists broadly show solidarity for, or are members of disabled struggle, current structural critiques around mental health often only focus on austerity rather than the framework within which disability is placed. As such, left campaigns rarely push for more than funding for psychological treatment. Current socialist mental health discourse fails to engage with for instance, the radical roots of the Frankfurt school, revolutionary France and the Black Panther Party and tacitly accepts the Medical Model. Far from a niche issue in the movement, a failure to engage with the critical issues surrounding mental health and psychiatry risks leaving us as active participants in reproducing systematic oppression. If socialists ignore psychology because of its history of individualism, we might leave behind an integral part of working-class history and ignore possibilities for its future.
Assuming that liberation for those with mental health problems is all that a Mad Revolution could entail shows how little is known about the extent of the tyranny of institutional psychiatry. Instead, mad liberation should free all workers from coercive, normalising power of the state and its institutions. Mental health awareness is largely useless, unless it is used to shed a critical light on medicalised psychiatry and the alternative, ‘Social Model’ of mental health, bringing it to the fore of socialist awareness and presenting an alternative vision for progressive mental health work and radical policy changes.
Psychiatry as the servant of capitalism, patriarchy, and white supremacy
If you build the world on workers’ backs, how can you blame the worker when her back breaks
For nearly 200 years, psychiatrists have been attempting to determine a biological cause of mental health problems to no avail. Despite the fact that ‘faulty biology’ is commonly assumed to be a cause of psychosis and other mental health problems, childhood trauma is as much a predictor of a lifetime diagnosis of schizophrenia as smoking is of lung cancer. The small amount of weak correlational evidence that suggests mental health is due to genetics or ‘bad wiring’ in the brain is blown out of the water by recent advancements in epigenetics theory. Yet, this narrative, also known as the ‘Medical Model’ of mental health is rolled out by mental health awareness campaigners in what they claim is an attempt to destigmatise mental ‘illness’. However, not only has the Medical Model been continually discredited with a lack of evidence, but it’s individualistic and biological explanation of psychological distress has been shown to increase the stigma of those experiencing distress, worry, or psychosis in recent research
Touting the biological narrative despite its lack of evidence, whereby ‘disorder’ is genetically inherent, has many benefits for capitalists but there are three main elements that motivate the capitalist capture of psychology. Outlining them sheds light on how the Nature arm of the Nature vs Nurture debate functions as a political tool, these are:
The ability to legitimise the castigation of women, BAME, queer people and other members of marginalised communities that threaten imperialism, colonialism, patriarchy, and capitalism with collective action by assigning ‘saneness’, or lack thereof, as a substitute for moral categorisatio
The means with which to deny systematic trauma is being dealt to the working class and thus avoid associated criticism.
To prop up the psychopharmacological industry and thus shore up commitment to Capitalist Realis
As part of a long history of political people being branded ‘insane’ and subjected to imprisonment and coercion masqueraded as clinical intervention. Individuals who deviate from normality are pathologised via the Medical Model, which rests on distress as a signal of ‘difference’ or ‘deviance’ from the norm. The concept of a ‘norm’ here is key as ‘the norm’ is changeable and socially constructed, shifting frequently throughout history. For example, feudalism was a socio-economic norm until around the 15th century, though most would now view owning land in exchange only for the ability to work for a master as undesirable. But, if you’d expressed that view in 1381 you’d have been aiding and abetting the Peasant’s Revolt.
Placing boundaries on norms is politically effective, because it determines what is and isn’t acceptable in the political, economic, and social world. In one example, the Othering of queerness is politically beneficial in that heteronormative families are favoured; ensuring reproduction of the labour force and upholding gendered working roles. Resultantly, all benefit capitalist modes of production and stifle collective organising. As such, queerness is almost always pathologised as a part of its Otherness, despite the historically and geographically prevalent acknowledgement, acceptance, and integration of multiple sexualities and genders across non-capitalist, pre-modern, and non-Western cultures. Though, even the conceptualisation of sexualities and genders in the terms we find readily understandable has roots in Western European traditions. Specifically, heteronormativity is predominantly a White imperial invention, spread through colonialism to the global south. The history of European imperialism at home and abroad carries with it a pattern of pathologising all Others; suffragettes deemed ‘hysterical’ and tortured, runaway Black chattel slaves framed as suffering ‘drapetomania’, and women who were openly sexual or performed early abortion practices considered Witches with psychic powers and burnt or outcast. Turning to more recent cases, diagnosis of homosexuality as a psychological disorder was only withdrawn from the DSM, the de-facto diagnostic bible of psychiatry, 46 years ago; while Gender Dysphoria still remains, elements of which cast transgender people as merely ‘ill’ rather than inevitably and reasonably reacting to socially enforced cisnormativity. Imprisoning enemies of convention might leave the established order open to revolt, but creating covert social norms leaving some vulnerable to subjugation causes people to police themselves. The marginalisation of members of society and their subsequent disproportionate pathologisation, such as women or BAME people, functions as a means to divide and conquer through an invisible force that has been described as ‘Normalising Power’.
Also in the modern context, 70% of people diagnosed with Borderline Personality Disorder (BPD) are women. Since the advent of the disorder, some practitioners have been concerned that diagnosing someone with a personality disorder was at best insensitive and deeply coercive at worst. Critical psychologists have argued that what is perceived as a ‘personality disorder’ is merely a collection of behaviours developed as a coping mechanism for the emotional effects of trauma, and some form of trauma is almost a guaranteed antecedent to a diagnosis of BPD/EUPD, including experiences of miscarriage, sexual assault, incest, child abuse, racist harassment and intimate partner violence. It should be noted that much of the outlined traumas are resultant of patriarchy and White supremacy and the mutually reinforcing activity of both. However, ‘trouble with the law’ and broadly-construed ‘social deviance’ are themselves part of the DSM definition of personality disorders – a vicious cycle where protesting validity of BPD as a diagnosis either for oneself or in general can be regarded as evidence for a diagnosis.
The above paragraph covers comparatively rare diagnoses, but the same charges can be levelled at anxiety and depression – notable, now, for their high and rising rates of diagnosis. It is wrong to argue that the distress, sadness, and worry – symptoms that those diagnosed with anxiety and depression experience – are a ‘myth’: they are extremely real, painful, and in some cases deadly. But in contrast to the Medical Model, the Social Model of mental health argues that the feelings attached to the diagnoses of anxiety and depression are an entirely normal reaction to a very sick society, or perhaps a small amount of sanity in an insane world. To be alienated from ones labour, to be made to experience the pain of racial segregation, to feel the destruction of social bonds through annihilation of public spaces, to always have to fear sexual assault, to experience the threat or reality of violence when dancing in the ‘gay quarter’, to be poor, unfulfilled, and unequal will always be hurtful. To experience that hurt is not the symptom of a nebulous Anxiety Disorder or omnipotent Major Depressive Disorder, it is a reasonable reaction to threat, to powerlessness, and to a life that you always know will never truly be yours. Thus, the individual is perversely diagnosed with a ‘disorder’ as if something was wrong with them – with us – and not reflective of the institutions of the state and the failure of its economic systems
Should we fund the services that harm us?
Unless we destroy it, the normalising power of the institution will forever stretch beyond its walls
In the UK in 2018, MIND reported that 40% of GP appointments are related to mental health, with 1 in 4 people reporting symptoms such as distress, worry, sadness, or psychosis (i.e. hallucinations, voice hearing) in any one year. Therefore, it becomes difficult to argue that the ’abnormalities’ the Medical Model purports to define in the DSM are by any definition ‘abnormal’ at all. In this way, it is important to examine and critique how clinicians, whether mental health specialists or otherwise, treat those presenting with such symptoms. Whether clinicians take an approach that recognises the ubiquity of the problems as an individual or social problem, and whether they are given the tools to adequately solve these problems, is crucial in our analysis. Though it is obvious that excellent mental health services are possible, some mental health services are excellent, and one of the ways through which they can be improved is funding; simply throwing money at services that are unsuitable, coercive or actively detrimental to the wellbeing of service users is not an argument socialists – or anyone – should be making.
People reporting to their GP that they are experiencing common symptoms of anxiety, stress, grief, depression, or other such problems are usually offered psychoactive drugs and sometimes, a referral to the IAPT (Improving Access to Psychological Therapies) programme. In their present form, IAPT are almost entirely limited to offering cognitive behavioural therapy (CBT). CBT is reliant on the idea that the problem lies in the individual, that the individual’s ‘thinking patterns’ are faulty, and resultantly that their behaviours reinforce negative emotions. Beck, one of the initial proponents of cognitive therapy, believed that every patient he came in contact with similarly experienced faulty thinking patterns that needed to be altered to make way for their recovery. It is easy to believe that an underweight young woman who obsesses over her weight to an extent at which her life becomes marred by low-confidence might benefit from a change in thinking. But, can we in all honesty suggest that the very crux of her issue is herself and her faulty thought patterns, which can be cured by altering her behaviour and beliefs about herself in an isolated therapy room? Or, would it be better to change patriarchal bodily expectations, cultural ascription of moral value to food, violence against women and other such predictors of disordered eating behaviours
Like the diagnostic systems outlined in the first part of this piece, CBT takes an intrinsically individualised approach that encourages the patient and those around them to see the self as the source of the problem as opposed to the oppressive conditions in which they live. My own experience of cognitive behavioural therapy for disordered eating included me being actively discouraged from talking about my concerns about the wider world and its impact because it ‘was not relevant, but how I thought about them was’. Equally, when a fellow activist expressed to her CB therapist that the poverty she faced was a cause of her distress, she was told that such ‘black and white thinking’ was indicative of her disorder. While therapists can’t wave a magic wand and create a utopia, the institution of psychiatry they work within must be seen as an active participant in quelling dissent and preventing the success of struggle if it deters service-users and patients from seeing the root of their distress as being structural, rather than personal.
There is usually a substantial gap between ‘low-need’ services such as IAPT and inpatient or day-patient stays, so many who are burdened with extremely long waits to be seen by a psychologist may find themselves waiting so long with a worsening condition, that they are eventually deemed to require hospitalisation. Those in inpatient psychiatric care are extremely vulnerable and frequently cannot access the full spectrum of their human rights, and those rights are often abrogated without due regard for balancing the rights of the patient against the harms that psychiatric care is meant to prevent or mitigate. Even the new ‘rights-compliant’ Mental Health Act as amended in 2007 has been shown to be largely ineffective in ensuring that nobody is deprived of their rights unless absolutely necessary, with inpatients often reporting imprisonment within the facility, forced psychopharmacological intervention and a total lack of privacy. Refusal of elements of treatment often results in patients being restrained, administered tranquillisers, force-fed or given immediate release with next to no community care, heightening risk of suicide and self-harm. The illusion of choice is present, but in practice, patients’ consent is rarely freely given.
Almost all movements and events in an inpatient care setting are immediately recorded and later interpreted by a multidisciplinary mental health team. The interpretation of these after-the-fact records has long been criticised as post-hoc and fatally influenced by the diagnosis the patient received, or is being given. Consequently, non-problematic behaviours are sometimes problematized and written down as evidence – or lack thereof – of a presenting ‘disorder’. Furthermore, some behaviours that are reactions to the oppressive atmosphere within the facility are considered a symptom of the diagnosis the patient is given. Of course, this disconnect between peer norms and diagnosis norms is driven by what is considered culturally normal for the diagnosing professional and the institution of psychology as a whole. This immediately excludes behaviours which are distinct from typical gender norms, heteronormativity, or White British culture: for example, female patients have reported that not shaving their body hair is taken as an example of failing to take care of oneself and thus indicative of a depressive episode.
As it is often highly difficult to leave even voluntary inpatient psychiatric care, patients are ultimately subject to a regime of coercive conformity: to be discharged, the patient must conform not to the norms of their own culture, class, or identity, but to those imposed by their caregivers, and ultimately to those of a psychiatric establishment which is Whiter, more male, more capitalist, and more hetero- and cis-normative than the context which a patient may be arriving from and returning to.
Perhaps just as bad is the consensus that all inpatients are simply ‘mad’, the mad do not have any connection to reality, and clinical staff are always both right and patient-centred. This black-and-whiteism presents acute moral problems because it legitimises coercive therapy, including forced psychopharmacological treatment, and potentially coercion into nominally ‘consent-only’ treatments like ECT. Additionally, castigating such components as ‘madness’ frequently acts as a metaphorical stand-in for a moral judgement, limiting the power the Mad themselves have to react or complain.
The role of the psychopharmacological industry in systemic problems with mental health services should not be underestimated – and the modern psychiatric establishment has already begun to push back against a few of the grossest excesses, although without acknowledging the structural and ideological problems that have led to the problem. The clinical benefits of antidepressants are subject to intense debates, with low estimates for effectiveness at only 11%, and placebo and non-pharmaceutical effects thought to play a significant role in the supposed effectiveness of this sort of routine prescription. Whilst it is extremely difficult to provide an adequately nuanced critique of psychopharmacology without amassing a great deal more pages of text, it should be said that although psychoactive medication such as antidepressants and antipsychotics may bear benefits, we do not yet understand why or how. Because of the medical model’s need to reinforce its monopoly on mental health discourse, pharmaceuticals are still used widely, but if the problem is social – as I argue – then pharmaceuticals can only temporarily ease pain but are being used as a cure-all. More frighteningly, longitudinal studies have not yet uncovered the effects of such wide-spread, long-term use of antidepressants.
The argument that I have laid out is not that psychiatric treatment only has the propensity to harm. Unequivocally it can be argued that therapies, psychopharmacological treatment, and sometimes sections under the mental health act has saved lives and increased the wellbeing of many in extreme states of distress. However, the navigation of the coercive tactics outlined above should not be the bare minimum we accept for people to find the support they need: one of the basic demands of a modern psychological movement should be that it treats patients equitably rather than merely equally. We need to learn to develop a more expansive imagination when it comes to mental health and socialism, including a wider critique of the power held by institutions is needed, including that which they exert on service users and public life. An intersectional analytical approach should be taken in which we understand that some people will benefit more from on-the-ground psychiatric intervention as it stands, simply because of the nature of the institutions of psychiatric medicine themselves. For example, a heterosexual White man is not going to have to face the institutional racism, sexism, or queerphobia of psychiatric services, though this is not to say there are not class-based oppressions that he faces within the service. The services we demand as patients and as participants in society should be equally suitable for and deliver equal benefit to the most marginalised people and the most privileged, or they are not fit for purpose. The bare minimum is not one-size-fits-most where the stakes are the health, wellbeing, and happiness of those driven to the margins – the bare minimum is appropriate, individualised care which reflects the patient, and which does not conflate treatment with conformity to the institution’s norms.