NEITHER PSYCHIATRY NOR ANTI-PSYCHIATRY, BUT MENTAL HEALTH AS RADICAL POLITICS

Tad Tietze Historical Materialism, London 10 November 2013

ABSTRACT
When working as a clinical psychologist in the NHS, Peter Sedgwick

pursued a sustained critical engagement with the ideas of thinkers associated with the anti-psychiatric movements of the 1960s and 1970s Erving Goffman, Thomas Szasz, R.D. Laing, and Michel Foucault. He welcomed their critique of scientific positivism while rejecting a tendency to annex psychiatric problems from health and illness in general. He also laid the basis for a political economic critique of the health industry by dissecting the distorting impact of medical individualism. Sedgwick's work only hinted at the increasing centrality of diagnosis to the legitimacy of mainstream psychiatry. However, his theoretical innovations provide a powerful framework for understanding controversies surrounding the newly released psychiatric diagnostic bible, the DSM-5 and for strategically orienting radical political projects in relation to such struggles over the boundaries of normality.

OUTLINE OF PAPER
Sedgwick & anti-psychiatry last time
Goffman / Laing / Szasz / Foucault

Sedgwick on health & illness

Critique of positivism Health & illness as socially constructed

DSM-5 & new critical perspectives

Example of bereavement exclusion in Major Depressive Disorder De-medicalising misery versus politicising medical goals

SEDGWICK'S LEGACY
Psychologist working in the NHS

Marxist intervention in the debates over psychiatry via a sustained

engagement with the ideas key thinkers associated with antipsychiatry

Early argument (1972) for more and better mental hospitals, more

and better doctors and nurses at the expense of armaments and the profits of the rich
Controversial because he refused to simply condemn psychiatry,

and even praised the beneficial effects of medications and ECT at a time the NLR was publishing Laing's writings uncritically

CHALLENGE OF ANTI-PSYCHIATRY
In the 1960s & 1970s anti-psychiatric critiques & movements

seemed to have mainstream psychiatry on the ropes

Heterogeneous but 3 basic themes: 1. 2.

Low quality of science of psychiatry when compared with medicine Repressive nature of practice, robbing patients of individual rights through mechanisms such as detention & forcible treatment Value-laden nature of psychiatric diagnosis that turned deviancy from mainstream norms into an undefinable entity called mental illness

3.

ERVING GOFFMAN
(Critical) US functionalist

sociologist
Asylums (1961), Stigma

(1963)
Trenchant ethnographic

examination of psychiatric hospitals, with their often brutal & ineffective treatments and tendency to render patients dull and inconspicuous

SEDGWICK ON GOFFMAN
Represents only a small break from dominant functionalism
Stigma/oppression and rebellion happen, but only as they fit within a broader

functioning social order

Focus on oppressive aspects of micro-systems of social

interaction masks general defence of the social status quo

Political radicals seen in same terms as mad people

Goffman has no room for sense of the historical contingencies of

social institutions. This deficiency makes it absolutely impossible for him to use his insights, either into particular local settings or into the general quality of everyday life, in any way which is critical: which issues, i.e., a demand for change in a definite direction. [S 1974]

R.D. LAING
Scottish psychiatrist &

psychotherapist The Divided Self (1960), The Self and Others (1961), Sanity, Madness and the Family (with A. Esterson, 1964), The Politics of Experience and the Bird of Paradise (1967) Argued schizophrenia resulted from impossible binds people were put in by their families and society it was really society (at the family level) & not the patient that was pathological

SEDGWICK ON LAING
Starts from conflict between two personal realities psychotic

and normal in a crazy world; he cannot provide a way to have a standpoint on the irrationality of the totality that is not merely from within these two views
Because he favours the psychotic, and by privileging the mad experiences of

the psychotic patient as somehow positive, he falls into mysticism

Studies of families limited by lack of normal controls unclear if

he is describing relationships specific to schizophrenogenesis

Even in most anti-systemic phase moves without mediation

between small-scale pathologies & social pathologies (e.g. imperialism)

THOMAS SZASZ
Hungarian-American psychiatrist The Myth of Mental Illness:

Foundations of a Theory of Personal Conduct (1961), The Therapeutic State: Psychiatry in the Mirror of Current Events (1975), Psychiatric Slavery (1977) Mental illness a myth because unlike physical illness no anatomical & genetic contexts to judge someone ill, only social & ethical ones Psychiatrists deprived people of liberties by bestowing spurious diagnoses

SEDGWICK ON SZASZ
Uses positivist standard (pathological lesions) to separate

medicine from psychiatry, but in fact this is untenable

Uses extreme examples of repression by psychiatry to make

general case c.f. rest of medicine but then has nothing to say about illiberal aspects of medicine in general
Extreme right-wing libertarianism poses itself as being anti-

authority but is in fact mostly against collectivism

Ultimately glories in contractual aspects of medical individualism

disconnects medicine from its place in capitalist social relations

MICHEL FOUCAULT
Histoire de la folie l'ge

classique - Folie et draison (1961; translated & abridged as Madness & Civilisation, 1965), Naissance de la clinique - une archologie du regard mdical (1963; translated as The Birth of the Clinic) Concepts of mental health & illness were purely social-historical constructs
Shifted & changed over time but

always played the same role in upholding power relations

The asylum & the analysts couch

were equally parts of systems of repression & control of the victory of reason over unreason

SEDGWICK ON FOUCAULT
Vital corrective to liberal teleological picture of ever-improving,

ever more benevolent scientific advances in psychiatry

But puts too much store in the irrational rationalism of modern

medical approaches to insanity as unique to the current era. He therefore cannot relate psychiatry to social change adequately
Reason/unreason is effectively the driver of history Cannot account for shifts back & forth to & from holistic & mechanistic

approaches

PSYCHIATRIC POSITIVISM
The critique of psychiatric positivism unites the anti-psychiatric

thinkers & is their strongest card

What we do have is a consistent and convergent tendency of

opposition directed against positivist method in the study of abnormal human behaviour. Positivism, for the present discussion, may be taken to refer to an approach towards the investigation of human pathology which, modelling itself upon antecedents which it believes to be characteristic of the natural sciences, (a) postulates a radical separation between facts and values (declaring only the former to be the subject-matter of the professional investigator) and (b) suppresses the interactive relationship between the investigator and the facts on which he works. [S 1972]

LIMITS OF THE CRITIQUE

Sedgwick: Critique of positivism must be extended to all of

medicine
It appears to me that none of [the critics] have begun by asking

the question: What is illness? Only in the light of an answer to this question could we determine our answer to the question: Is mental illness really illness in the medical sense? [S 1972]
The difference so forcefully argued by anti-psychiatric theorists,

between the biological norms to which physical medicine appeals and the social norms which back up psychiatry, dissipates into nonsense as soon as we are brought to see that the medical enterprise is from its inception value-loaded; it is not simply an applied biology, but a biology applied in accordance with the dictates of social interest. [S 1974]

SOCIAL CONSTRUCTION OF HEALTH

It may prove possible to reduce the distance between psychiatry

and other streams of medicine not by annexing psychopathology to the technical instrumentation of the natural sciences but by revealing the character of all illness and disease, health and treatment, as social constructions
Outside the significances that we voluntarily attach to certain

conditions, there are no illnesses or diseases in nature [S 1982]

ILLNESS AS SOCIAL DEVIANCY

All sickness is essentially deviancy from social norms, which

themselves must be understood in terms of conflicts over ideas & practices within a given society
BUT: Not all deviancy is illness!

Not a relativism: Definitions of health & sickness always product

of specific, historical social processes meaning can only be judged if one has a critique of social structure and change
However illness is specified from culture to culture, the attribution

of illness appears to include a quest for explanation. [S 1972]

Illness arises historically alongside practice of treatment & tied up with it

DSM-5 & BEREAVEMENT

DSM-5 (2013) has deepened the crisis of psychiatric authority Debate over diagnostic categories has focused on issues such as

inappropriate medicalisation, disease mongering, etc.

Sharp debate over the bereavement exclusion (BE) in Major

Depressive Disorder (MDD) DSM-5 workgroup claimed BE was invalid

Argument is that BE doesnt differentiate between two different types

of problem (i.e. between illness & not-illness)

Normal grief often meets criteria (5 symptoms over >2 weeks) for

MDD e.g. sadness, difficulty sleeping, decreased appetite, fatigue, diminished interest or pleasure in usual activities, and difficulty concentrating on usual tasks PLUS clinically significant distress or role impairment

 Zisook (2012): Depression can and does occur in the wake of

bereavement, it can be severe and debilitating, and calling it by any other name is doing a disservice to people who may require more careful attention Wakefield & First (2012) found the evidence wanting:
Kendler & Zisook (2007 x 2): Looked at MDD v BE patients, but confusing

methodology
Treatment response no different But should this make a difference? Suicide risk driving need to diagnose? BE accounts for this, so irrelevant No more likely to have recurrent MDD than people who have never been

depressed

The Lancet (2012): Grief is not an illness; it is more usefully

thought of as part of being human and a normal response to death of a loved one.

CAUGHT IN A TRAP?
Development of medical practice within capitalist social relations

increasingly technical-physical definition of illness

Psychiatry under pressure to prove its illnesses are (reductively)

physical or to accept they lie outside the bounds of medicine

Some progressives line up with latter want to de-medicalise

misery
Resisting the psychiatrization and psychologization of almost every aspect of

human experience, and finding a way to place what are, frequently, essentially moral and political not medical matters back at the centre of our understanding of human suffering is a massive and multifaceted task. [Moncrieff Chap 1]
Psychiatry provides analgesia at the expense of understanding [Jureidini

2012]

A false counter-position if we see all illness as socially

constructed

SEDGWICK ON BEREAVEMENT
The example [of a bereavement causing symptoms] is revealing

in several ways. A doctor may prescribe some form of minor tranquilliser to relieve some of the effects of a bereavement, even though depression of activity and feeling following the death of a close relative would scarcely be regarded as constituting a mental illness. Bereavement has, however, also been reported as a significant precipitating event in the onset of actual psychiatric illnesses The line of division between a bereavement and a psychiatric illness following bereavement would seem to depend on our culturally-derived expectations about how to mourn properly. [S1974]

POLITICISING GOALS (1)

Greatest advances in combatting illness have come through

social and political measures

The point is not to deny the illness-ness of illness (to de-

medicalise) , nor to technologise it further

The alternative is to politicise medical goals Mental illness, like mental health, is a fundamentally critical

concept: or can be made into one provided that those who use it are prepared to place demands and pressures on the existing organisation of society. [S 1972]

LIBERTY VS. COLLECTIVE PROVISION

Capitalism creates antagonism between medicine/psychiatry as

legally-inspired, contractual & individualistic on one hand, and collectivist on the other
Complicated by double meaning to collective: (1) due to

collective political struggles from below and (2) provided by state & its social agencies from above
Warned RCPsych [in S 1983] that Rights libertarian critique of

psychiatric authority was a way of breaking down collective provision without challenging state/ruling class authority

POLITICISING GOALS (2)

Just as the revolutionary exposes and pressurises Parliamentary

democracy by demanding consistent democracy; just as he exposes and fights the courts of bourgeois justice by demanding consistent justice: so he must and combat the evils of our antitherapeutic institutions of 'psychiatry' by demanding consistent psychiatry. [S1972]
That is, more and better psychiatrybut not more of the same.

 I myself am perfectly happy to see as many mentally-ill persons as

possible treated, fully and effectively, in this society; for no matter how many maladjustments may become adjusted through expert techniques, the workings of capitalism will ever create newer and larger discontents, infinitely more dangerous to the system than any number of individual neuroses or manias. [S1972]

BIBLIOGRAPHY
S 1971 PS, R. D. Laing: Self, Symptom and Society,

Salmagundi
S 1972 PS, Mental illness is illness, Salmagundi S 1974 PS, Goffman's Anti-Psychiatry, Salmagundi S 1982 PS, Psychopolitics, Pluto Press

S 1983 PS, The Fate of Psychiatry in the New Populism, BJP

M 2011 Rapley, Moncrieff & Dillon, Carving Nature at its Joints?

DSM and the Medicalization of Everyday Life in Rapley, Moncrieff & Dillon (eds), De-Medicalizing Misery: Psychiatry, Psychology and the Human Condition, Palgrave Macmillan