Mental Health in Crisis
Updated: Mar 2, 2021
This is a transcript of a 2/28/21 talk as part of an ongoing talk/discussion series on the history of radical change in the field of mental health called "Mental Health in Crisis." This is intended as an introduction to popular critical and radical approaches to mental health history and change. Future talks will be focused on specific projects or moments in psychiatric history. A guiding assumption behind these talks is that the question of mental health, or, even more broadly, health and care are not secondary questions or auxiliary questions to a primary question of social and political organization. The specific purpose of these talks is 1. to introduce interested people to these lesser-known projects, groups, and events that politicized and radicalized mental health care without having to do a great deal of reading or study, 2. to have discussions about what is relevant today in their theories and practices, and 3. to try out ideas and concepts to be developed into a limited-run journal on the theme of psychiatry and radical transformation tentatively titled "Folly." The slides are available at the bottom. Information on future talks can be found most easily on the Of Unsound Mind Facebook page (https://www.facebook.com/ofunsound) or by following me on Twitter (https://twitter.com/SashaDurakov). If you are interested in participating in the journal, join one of these talk/discussions or email me at firstname.lastname@example.org.
The image below is a famous 1878 painting by Tony Robert-Fleury called Pinel at the Salpêtriére in French and Pinel Freeing the Insane in English. Robert-Fleury was already a famous painter of epic historical scenes when the French state commissioned him for a painting commemorating the fifty year anniversary of Pinel’s death. Left of center, you can see Phillipe Pinel, one hand holding a cane, the other being kissed in supplication by an inmate of the Salpêtriére hospital in Paris. The painting memorializes what has become the most famous event in modern psychiatric history when the young physician, in the wake of the French Revolution, was recently assigned to the women-only Salpêtriére and freed the patients from their chains. The fully-clothed benevolent doctors seem to arrive on the scene already endowed with the spirit of the Revolution and the Rights of Man, approaching the frenzied and half-naked madwomen with a mix of objective observation represented by the figure examining the woman’s arm in the center and humanist recognition of the plight of the unfortunate. While his peers succumbed to a therapeutic nihilism and chained the mad to walls to contain a threat, which, if not curable, could at least be kept at a comfortable distance from an already disorderly society, Pinel introduced an empirical approach to the study of madness, producing a systematic nosology that redrew the lines between types of madness using scientific observation and rational deduction. In this story, Pinel serves as Atlas, single-handedly carrying the weight of a new era of psychiatry regulated by the scientific spirit, humanism, and increasingly medical norms on his republican shoulders.
Of course, none of it is true. The original “removing the chains” event took place at the men’s Bicetre hospital where Pinel worked prior to transferring to the Salpêtriére. And the chain removal probably happened after he left and was performed by his assistant Pussin. Robert-Fleury likely moved the scene to the Salpêtriére to satisfy the contemorary taste for delicate and sultry female figures. Pinel was also far from the first to try to medicalize psychiatry: Thomas Willis already connected psychological disturbance to the functions in “the Brain and Nervous Stock” in 1672, while William Battie broke with the medical nihilism of John Monro at Bethlem when he medicalized his diagnostic system as director of St. Luke’s hospital in 1751. Nor was Pinel’s, or rather Pussin’s, act of removing chains the decisive break with tradition it has come to represent: when Pinel removed the chains of patients at the Salpêtriére, he did it with a select group under strict surveillance and as a test rather than a principle; the non-restraint movement found more success at the Quaker Retreat in England and didn’t become a widespread trend until the German neuro-psychiatric or somatic turn beginning with Wilhelm Griesinger in Germany in the 1860s, closer to the time Robert-Fleury was painting.
A contemporary of Robert-Fleury, Pierre Aristide André Brouillet made a painting in 1887 called A Clinical Lesson at the Salpêtrière that distils and intensifies some of the themes of the first. Here, the objective observation of a woman’s body in the same institution–this time by the new star of the Salpêtrière, Jean-Martin Charcot– is again the dominant theme, but the masculine observers have multiplied and the object of study has been reduced to just one. The scene is no longer set outside with its attendant distractions, but in an enclosed and controllable observation theater. Charcot is in a heroic position demanding the attention of his colleagues, but he is not the central figure; the central figure is not a person at all, but a reflex hammer and an electrotherapy device on a table, present to demonstrate that the institution’s medical gaze has become increasingly quantitative, empirical, and scientific. Behind the main figure in Robert-Fleury's scene, a woman writhes on the ground in a classic but anachronistic hysterical pose that is more suited to this later era of Charcot than to Pinel’s time. In this way, we can see how Robert-Fleury was not really trying to portray a historical event at all; rather, he was projecting an ideal back onto the past that led naturally into his rational and correct present. The kernel of truth in Pinel’s act has matured into a fully formed approach that naturally culminates with what already exists in the present. The past here serves above all to justify and exalt the present.
Even if Fleury’s take on the event is inaccurate, the image is ubiquitous in the field. It would not have been uncommon to see this image in the superintendents’ or chief psychiatrist’s office in an asylum, as for instance in this image of the superintendent's office at the Central State Hospital in Indianapolis. It probably adorns the walls of many clinics today. Why has this image, and the scene it represents, proved to be such a persistent one in the history of psychiatry? What does positing Pinel’s removal of the chains as the inaugural event of modern psychiatry communicate about the history of the profession? First of all that it emerged as a force of humanitarian goodwill in a barbaric age. Over time, one can say, the heroic spark of enlightenment has steadily grown brighter and now shines in the hearts and minds of the American Psychiatric Association and the National Institute of Mental Health, which, despite the occasional scandal or two, are fundamentally oriented towards healing and liberating people from suffering. This is what I would call the developmental or evolutionary conception of medical history whose central apostle today is probably the historian Edward Shorter. This position suggests that psychiatrists today can symbolically and practically trace their practice directly back to Pinel’s original act and that, over time, practices, diagnostic tools, and treatments that appeared in primitive form in his time have developed to become an altogether greater and more advanced whole.
An image by the Canadian psychiatric patient William Kurelek offers a very different conception of history. We see a skull, cut in half with some pieces broken off. Within the skull, we see a number of scenes that don’t flow from one into the next, but are contained and juxtaposed violently against one-another. Violent domestic scenes stand next to decay and rot and predation in the natural world. In the bottom, the gang of medical doctors stand in tight claustrophobic circles around a naked man and poke and prod at him with pens and tools. Though the body is a framing device and some ribbons evoking torn nerve fibers hang here and there like drapery at a theater, the organic explains nothing. It may appear that the scenes remain inaccessible to one-another, but notice how there are still similarities between the various scenes: the crow eating a lizard resembles the doctors prodding at the man; nature, war, domesticity, medicine, and art all exist side-by-side in this skull, which is furthermore permeable to the outside world, since the walls are open on our side. My own interpretation is that they contain walls to emphasize that the events explode into the present only to pass, in a moment of crisis, into another. Reality–and more specifically medicine–in this world is not the smooth development of an original idea towards perfection, but the irruption of contradictions that break with the norm and alter our perception of the image as a whole from moment to moment. The past does not run fluidly into the present, but bursts forward in particular moments of clarity and association. To me, this image is representative of the view of history as a series of ruptures and crises.
What is a crisis? The term comes to us from Greek and it’s especially appropriate for my purposes because it was originally a medical term: krises means “to distinguish” or “to judge” and it referred to the moment when a physician was forced to make a decision. At certain points in a treatment, the physician recognizes a kairos, an opportunity or an opening, at which point he must decide how to act, for instance whether to bleed or purge a patient in a high fever. The crisis was the point after which the patient could change from an acute to chronic phase, be healed, or die, depending on how the doctor chooses to act. Walter Benjamin opposes a crisis model of historical change to the evolutionary and historicist view and lays out, perhaps somewhat obliquely, what it offers. In his Theses on the Concept of History, he wrote that “To articulate the past historically does not mean to recognize it 'the way it really was' (Ranke). It means to seize hold of a memory as it flashes up at a moment of danger…Only that historian will have the gift of fanning the spark of hope in the past who is firmly convinced that even the dead will not be safe from the enemy if he wins. And this enemy has not ceased to be victorious.” The stakes here have shifted: this is a formulation of historical memory in the service of partisan transformation and redemption; it is not the past frozen in books that is at stake, but our capacity to respond to the crises of the times and foster hope for the future.
So just what are these “crises'' in the field of psychiatry? That question will be a major focal point of these talks and discussions. Preliminarily I will assert that what appears in retrospect as a single “crisis” is often the result of overlapping dynamic crises. I don’t want to suggest that a major event, like a war, breaks out and mechanically causes changes in psychiatry. Instead, certain contradictions emerge and create an opening (the kairos I mentioned before), which can be seized upon to reroute or dramatically transform medicine, or, I should emphasize, to do nothing or very little and maintain it in its present condition regardless of how inappropriate they may be in new circumstances. Looked at in this way, something fundamental did happen during the French Revolution that changed madness and psychiatry forever: the medicalization of madness occurred as an effect of the rationalizing of the state, and specifically the Constituent Assembly’s 1790 abolishing of what were called lettres du cachet, essentially royal letters that in many cases facilitated arbitrary imprisonment. The end of arbitrary punishment brought with it a desire for rational and democratic treatment before the law: this entailed a clear dividing line between the insane and criminals, demarcating the specific legal processes each must undergo to be imprisoned, creating a legal "patient" status for the mad person, and prescribing roles for state actors in medical affairs. In these broad transformations that turned the mad person into a patient and railed against arbitrary punishment now associated with the despised royals, Pinel was less a Hercules and more likely a man ready and well-positioned to step into an opening made by the revolution.
Let’s move away from mythical origins and look at the United States and what will be one of the major themes of the series: the transformations that attend capitalism, particularly in the settler-colonial state. What role does psychiatry play in a colonial system, slavery, and capitalism? There’s multiple ways to approach this problem. Let’s look at some of the dominant ideas. One position has been to view psychiatry as a neoliberal tool for molding psychiatric subjectivity through guiding individuals stressed out and anxious from the instability of the economy or the climate into medical consumerism under the guise of “treatment.” Very few characterize psychiatry solely in this way, but surely there are some economic reductionists out there. From this angle, one of the main drivers of psychiatric theory and practice is the market, specifically the market in psychiatric drugs since the rise of psychopharmacology in the 1950s with the introduction of the antipsychotic Thorazine.
In this view, psychiatric diagnoses are a type of subjectivity that is essentially wed to the drug market; the rapid proliferation of new diagnoses (each with an variable assortment of potential drug regimens) is tied to the neoliberal notion that certain market decisions can shape one’s identity and solve (or mitigate) personal crises and traumas. This is perhaps best seen in the way that psychiatric language has so thoroughly permeated the broader public’s way of discussing everyday problems, the ubiquity of anti-stigma campaigns, the growth of the drug industry, and the shift in mental patient status from being overwhelmingly involuntary to largely voluntary. In other words, there has been a rise in a democratic, common psychiatrization of increasingly granular states that would, in times past, not have come into the radar of psychiatrists except perhaps for wealthy patients. Such developments are actually very recent and certainly don’t reflect the majority of psychiatric history: through most of its history, most psychiatric hospitalizations were involuntary, and, even when this started to shift in the 1960s, it remained at around 20% until just the last few decades. In the past, most people who became regular users of psychopharmaceuticals did so following the experience of being hospitalized. It wasn’t until the late 1990s that the FDA decided to allow drug companies to market directly to consumers, which dramatically increased the number of people going to their doctors asking to receive certain diagnoses and medications. These are new processes, but they are dramatic: the market in psychiatric medications is expected to become a $40 billion industry by 2025 (nearly double its current size) in response to the expected rise in patients due to the coronavirus pandemic. This certainly suggests that the mental health field today is strongly tied to the production and expansion of a consumer market.
Without suggesting they reduce psychiatry to this function, Ethan Watters and China Mills have written about psychiatric subjectivity being exported to the Global South often with funding and advertising by pharmaceutical companies, and Bonnie Burstow about the business of psychiatric drugs in North America. While plenty of people are certainly making a lot of money off of psychiatric research and treatment, particularly in the largely unregulated private facilities in the United States and the anti-stigma campaigns largely driven by the drug industry in countries without a Western psychiatric system, I would argue that the profit motive is not the dominant driver of change and adaptation in psychiatry. I think we miss a lot by viewing psychiatry as solely a producer of mental health treatment commodities and anti-stigma advertisements geared toward acquiring new customers (though there is truth to these statements as well). Categories of mental illness can’t be reduced to consumer profiles, even if that is a significant, and perhaps increasingly significant, part of what they are.
One popular term used to describe psychiatry’s role under capitalism is “social control.” It’s a term with an odd history since in the 1920s and 30s, it referred mainly to what were called “soft powers” like the church and the family to subtly change or mold individuals, in contradistinction with the “hard powers” of the military or the police who force people to do things. The problem with “soft power” is its enormous range and abnormal flexibility as a concept; after WWII, usage reversed and from then on, it mainly referred to what could broadly be called the “police power” of psychiatry, the power to defend society from threats or to mold and manipulate individuals for some political or economic end. The addition of a social control theory allows for a more complex understanding of the economic function of psychiatry beyond conceiving of the patient as either a willing or unwilling consumer of psychopharmaceuticals. I want to briefly draw attention to two processes here. First is the ubiquity of forced labor and peonage in mental institutions from the late 19th century on. In some institutions, up to 90% of patients were working without pay or for starvation wages. Add to this that those on disability live in conditions of enforced poverty, insofar as they cannot earn above a certain amount without losing state benefits. Some, like Marta Russel, have connected these facts with the Marxist concept of a “reserve army of labor,” a mass of people who can be preserved by the state at minimal cost until the time when they are needed to fill in the gaps in production or undercut wage increases by performing menial labor for free or at extremely low wages. Most of this forced labor was reproductive and helped cut costs to the state’s welfare budget, but in some cases it was also profitable. Today, sheltered workshops and “adult activity centers” around the country still pay subminimum wages to disabled people and people with psychiatric diagnoses while prisoners still toil for cents on the hour to produce things like furniture, clothing, and labels for cans.
Perhaps more significantly, in terms of its reach, psychiatry has acted as a disciplinary power for “training” or normalizing inadequate or problematic workers and codifying the domestic reproductive role of women, particularly in eras of increased social disorder and large scale migrations of people. Bruce Cohen’s Psychiatric Hegemony: A Marxist Theory of Mental Illness is a good example of this approach. He writes: “From moral treatment to drug treatment, psychiatry’s project remains unchanged: their goal is the moral management and behavioral adjustment of populations considered socially deviant, whether unemployed, underproductive, or politically suspect [...] As a part of the superstructure, the mental health system has aided the economic base through the naturalization of the fundamental inequalities of capitalist society.” This comes out very clearly in the early “moral therapy” regimens of Pinel, the Quakers, and Benjamin Rush who characterized success by how well a patient could be reintegrated into productive, that is, either domestic or working life. Cohen also draws attention to the rise in workplace specific phrases and work-related words in the Diagnostic and Statistical Manual throughout the 20th century, from just 10 in the DSM-1 in 1952 to 387 in the DSM-5 in 2013.
This question of “normalization” is the central theme of Georges Canguilhem’s seminal book The Normal and the Pathological from 1941. Although Canguilhem was primarily discussing physiological disease, and to some extent physical disability, normalization became a key concept in the critique of psychiatry, so permit me a short and very crude aside. To put it simply, Canguilhem argues (I think very persuasively) that there is no norm in medicine that is not imbued with (moral, ethical, aesthetic) value. The norm is what is imagined to be good. This can take a variety of forms: normal weight can simply be whatever the average weight is, for example. Here, it is assumed that “normality” can be deduced through quantitative measurement and that what is most common is normal, good, natural, etc. Most often, the standard used to establish the norm is posited as value-neutral, objective, or purely observed, but Canguilhem rightly points out that these are already indicative of a prior valuation: observation or quantitative analysis is good or better than qualitative valuation, for example. He writes: “The concept of norm is an original concept which, in physiology more than elsewhere, cannot be reduced to an objective concept determinable by scientific methods. Strictly speaking then, there is no biological science of the normal. There is a science of biological situations and conditions called normal. That science is physiology.” Normalization names those processes or acts that orient what is towards what they ought to be, towards the norm. In no way is Canguihem arguing for some kind of medical relativism, but he’s drawing our attention here to the normative basis of medicine, which it cannot escape. This move shifts the terrain on which medicine stands: living beings, and in our case political speaking beings, are normative creatures; we should not fool ourselves that the norms we set are “natural.” A disease or a virus are also perfectly natural and could be said to have their own norms and normal ways of acting within a body. In this call that we recognize how medicine deals not so much with natural, objective norms, but values, Canguilhem entreats us to think about how our norms are set and why. This opens a door to consider how doctors (in our case psychiatrists), but also teachers, corrections officers, nurses, scientists, etc presume a set of norms and establish practices to normalize their objects of study or care. Others have taken this mode of analysis further than Canguilhem, as for instance his student Michel Foucault, who draws at length from this mode of analysis to historicize the ways in which unreason has been progressively relegated to silence in The History of Madness and the 19th century shift to a disciplinary mode of normalization in psychiatry in his lectures Psychiatric Power.
Such methods of approach (social control and normalization) have proved to be very powerful tools in studies of psychiatry with an eye to gender, sexual, and racial oppression. For many of these thinkers, psychiatry is not just a naturalizer of social divisions, gendered inequalities, and racism, but is a crucial part of the ensemble that produces these things in the first place and oftentimes an active force of normalization and discipline. It doesn’t just defend or naturalize race, for example, it was involved in its scientific codification and institutional implementation, in other words in its effective production. In the colonial situation analyzed by Frantz Fanon, this naturalization of racial hierarchy and racial difference was barely veiled with “Native” patients (often political prisoners) simply locked to walls and European ones receiving modern treatment. Psychiatry was a key discipline, furthermore, in the 19th century project of grounding the naturality of slavery in science beginning with Samual Morton’s massive Crania Americana, which was an attempt to ground racial difference in phrenology, or observable physical differences in skull/brain size. Psychiatry was also, of course, one of the key disciplines of the eugenics movement in the US and in Germany where psychiatrists first adopted the concepts of “worthless eaters” and “lives not worthy of living.” Schizophrenic patients were also the first to be murdered by gas in Saxony, but I’ll save that discussion for a later session.
A deeper look at psychiatry’s consecration of race in the US can help demonstrate how complex this involvement can be. One of the most blunt mechanisms at its disposal is to pathologize the resistance of slaves and colonized peoples. This can be a straightforward maneuver or a more subtle one, but I would argue the subtle variety has had much wider influence: whenever mental illness becomes more closely aligned with the concept of danger, there is a noted increase in the labeling of non-white people as insane. Jonathan Metzl’s The Protest Psychosis is one of the most compelling narratives of this type: he traces the way the diagnosis of schizophrenia changed from describing a condition of docility and alienation to one of aggression and violence in the 1960s during the Black Power movement. Subsequently, the stereotypical image of the schizophrenic shifted from listless white wives to militant young Black men who were then hospitalized and committed at significantly higher rates. Anne Parsons’ From Asylum to Prison: Deinstitutionalization and the Rise of Mass Incarceration After 1945 provides support to this thesis in her writing about changes in involuntary hospitalization demographics in the late 20th century. A number of court cases intended to protect patients in the 60s through the 80s increasingly made psychiatric commitments an agonistic process to be worked out at least partially in the courtroom. A heavier onus was placed on the state to prove either that a patient was a danger to themself or others or that they are incapable of caring for themself. Wherever the transfer to the courts and the emphasis on danger and incapacity took place, Black men specifically were again committed at higher rates. Between 1960 and 1980, the rate of psychiatric hospitalization for Black Americans rose by 7 percent and a study of six states found that the increase was highest among men with prior arrests on record. Similar figures are quoted for states that implemented these legal changes around the country.
The most famous and comparatively blunt example of the pathologization of racial difference and rebellion is the work of Samual Cartwright. Cartwright claimed that slaves that ran away suffered from a disease he called “drapetomania” (or “runaway slave disease”) and “Dysaesthesia aethiopica” or “black laziness.” Much has been made over Cartwright’s classifications, but it’s important to note that he did not actually recommend psychiatric treatment in a clinic or hospital, but “treatments” which would be administered on the plantation. These so-called treatments, like whipping and social isolation, were entirely indistinguishable from normal discipline on the plantation. This may have been a pathologization of rebellion, but without even the veneer of a medical response. On the whole, Cartwright’s influence is likely overstated, as psychiatric incarceration was not a widespread form of social control in the antebellum south where more blunt means were available and few psychiatric hospitals or clinics even existed. The Civil War further stunted the growth of asylums in the South and concentrated it in a few congested hospitals like the Milledgeville Asylum in Georgia, historically the most crowded in the US. Psychiatry was practically of little use to slave owners in the South; instead, as slavery was enshrined in law and sanctified in religion, these psychiatrists joined the chorus of scientists embedding slavery into natural order.
A second approach, which in some variations supports and in others contradicts the first, is one that characterizes civilization as pathogenic. According to this theory, Black and Native peoples in their “natural states” do not go mad because their primitive minds are too simple and undeveloped. The early 19th century Scottish psychiatrist Andew Halliday, for example, wrote “We seldom meet with insanity among the savage tribes of men... Among the slaves in the West Indies it very rarely occurs.” This is a pro-slavery psychiatry that theoretically operates as a depsychiatrization of non-white peoples. In 1840, the national census workers were required to ascertain whether citizens were “idiots'' or “insane.” One reason was because social reformers were interested in lobbying the state for funds to build new asylums. But what these census takers found was that free Black people were insane and idiotic at numbers far above that of white people; more astoundingly, insanity was about ten times more common for free Black people than for slaves. This suggested that it was exposure to civilization and freedom driving these Black people–who are “naturally primitive”– insane. Of course, the numbers were totally falsified and impossible, but the census became a useful tool of propaganda: citing this census, Edward Jarvis wrote “Slavery has a wonderful influence upon the development of moral faculties and the intellectual powers.” I don’t want to lead anyone astray and give you the idea that these two strategies are opposed, despite any noted contradictions. Their contradictory interplay should clue you in on how complex these strategies actually are: in one case, psychiatry pathologized difference and rebellion but without proscribing treatment; in another, involuntary treatments of Black patients rose once psychiatrists shifted a diagnosis towards the description of violence and the space for commitment determinations to the courts all of which is associated in the US with the fear of Black aggression; and in the last case, psychiatrists depathologized the so-called “natural state” in the service of preserving slavery and the racial hierarchy. I will discuss all these questions in more detail in the session on Frantz Fanon’s antiracist psychiatric work.
To return to the methodological questions I started with, I would argue that an analysis of the social control function of psychiatry is incomplete, that it has the potential to flatten and simplify the contradictions intrinsic to psychiatry. It’s not hard to come up with examples of when psychiatrists characterized their labor as a complex defense mechanism of society or of genetic purity, as in the widespread use of sterilization in mental institutions in the 20th century or their justification of incarceration by emphasizing the future “danger” of patients. On the other hand, throughout history, many psychiatrists have imagined they were agents of healing in the world, however much that contradicted their daily practice. Although mainstream psychiatry’s goals align with those of the state in many cases, the social control theory at times makes it sound as if psychiatry is being organized and directed in a top-down way and exists as a weapon in the hands of the state with more-or-less clear underlying goals. This, I believe, is not true.
Ever since President Pierce vetoed the madhouse reformer Dorothy Dix’s proposal for a federal psychiatric policy in 1854, the organization of the field has been decentralized and unequally organized and developed across the country. It’s undeniably true that psychiatry has broad and significant policing functions, that some of its agents are endowed with the police power even in the strict legal sense as in when they forcibly hospitalize an individual with a security justification, but I don’t think social control can stand as either an adequate cause for the creation or development of psychiatry, nor does it explain transformation in the field on its own. A forensic psychiatrist working in the courts has a different function than the psychiatrist at the early psychosis clinic in a university who is different from the psychiatrist working in the busy downtown psychiatric ward or the one working in the psychiatric wing of the maximum security prison. Their languages, practices, models, diagnostic tools, and treatment methods are sometimes at fundamental odds with one-another, so much so that it probably isn’t right to speak of “psychiatry” but of many psychiatries. Anne Lovell, Francois Castel, and Robert Castel have detailed these differing “psychiatries” in the US in great detail in their under-read book The Psychiatric Society, which I think is one of the best for understanding the complexities of US psychiatry.
Another way to approach this problem has been to view the ways in which psychiatry, and medicine in general, is constituted by basic contradictions under capitalism. This is the method of the Socialist Patients Collective (SPK) in Germany, Democratic Psychiatry in Italy, and, in a different way, Institutional Psychotherapy in France, all of whom I will discuss in future sessions. The SPK’s approach was to say: look, capitalism forces you to work for a wage for as long as necessary and in dangerous and unhygienic environs if need be in order to survive; thus, the law of competition forces many into positions that are degrading and pathogenic. Of course, people get ill in every economic system, but capitalism’s power of uprooting people from their traditional means of subsistence and healing, irreversibly transforming and poisoning ecosystems, and forcing people to work to their physical and mental limit basically guarantees illness and breakdown that could theoretically be preventable. Furthermore, capitalism individualizes care of these collective illnesses and has discovered means of commodifying this care, tying the promise of health itself right back into a pathogenic capitalist relation.
The SPK write: “Illness is the essential condition, the presupposition and the result of this capitalist process of production. The capitalist production process is at the same time a process that destroys life. It continuously destroys life and produces capital. Capitalism is dominated by capital’s primary need of accumulation. Illness is the expression of the life-destroying power of capital. Illness is collectively produced: that is, insofar as the worker creates capital in the work process, which encounters him as an alien force, he collectively produces his own isolation. It’s therefore only logical that healthcare produced by capitalism perpetuates this isolation in that it doesn’t treat these symptoms as collective but rather treats them as individual bad luck, fault, and failure. However, capitalism produces, in the form of illness, the most dangerous threat to itself. Therefore it has to fight against the progressive moment in illness with its heaviest weapons: the healthcare system, the legal system, the police.” Illness is Janus-faced, that is, it looks forwards and backwards; it is potentially both a beginning and an end. What SPK calls its “negative moment” consists of its debilitating and destructive effects in the human body and mind. Its “progressive” or “positive” moment lies in the capacity of the sick person to organize on the basis of their bodily decomposition, to recognize at this point the hostage situation they are really in and to reject this relationship. What are we to make of these ideas while living through an extended surreality in which 500,000 people in the US are dead, so many of whom were forced to work in positions that put them at high risk of contracting COVID-19 or were living in nursing homes or other facilities designed to manage the ill, old, and debilitated, when it’s still a question of when people at risk of homelessness will receive already reduced stimulus checks, when people are freezing to death in their own homes in Texas, and yet the Mall of America is open for business and schools are expected to open so parents can go to work? Our bodily and mental integrity is being held hostage by this way of relating to the world. For that reason, our illness is indeed cause for concern for capitalist accumulation. But this relationship is still robust and flexible: we can see how the state rationalizes eugenic measures about who is worth sacrificing in the name of the market and the ways in which a kind of bare minimum of care must be doled out to preserve the workforce. There are elements here of a social control theory, but with a fold: psychiatry and medicine no longer appear as independent subjects in history nor as moldable tools in the hands of a defined ruling class, but as an effect of the ecological, physical, and social disintegration wrought by capital accumulation and a diverse set of responses to it.
Let’s look at the spread of psychiatric facilities in the US to better illustrate some of these themes. American psychiatry didn’t really get off the ground until the 1820s. Prior to that, the largest practices were based in the wealthier cities of long-settled states on the east coast like Massachusetts and Virginia. In the 18th century, psychiatry was primarily private and available mainly to people of means. Very few general hospitals had psychiatric wards and only Virginia had a dedicated public mental hospital. So what happened in the early 19th century? Throughout the 18th century, and particularly towards the end, the population continued to grow fairly rapidly. But more importantly than simple population growth, after the revolution, urban cores became densely populated, factories began to pop up all over the east coast, and increasing enfranchisement of a broader swathe of the white male population gave us Andrew Jackson and the gospel of Western expansion with its bloodthirsty annihilation of the Native people who lived there. This rapid growth and expansion along with a general atmosphere of upheaval and violence led to immense anxiety, particularly among social reformers, about the spread of crime and disorder arising from dislocations, mass migrations, and the overwhelming sense of transformation. An apocalyptic spirit was in the air and the social world appeared rife with chaos, crime, poverty, and lunacy.
Revolutions, wars, and, as in this case, broad social transformation and crisis, have a special relationship to madness. Madness always enjoys some level of conceptual fluidity in everyday speech and culture: we call lots of things crazy, many people or ideas insane or psychotic. Politicians are narcissistic or psychopathic. Some people get more granular and refer to women they don’t like as “borderline” or “hysterical.” In periods of insurrection, madness is less like a river with contained tributaries flowing out into culture or language and more like a bomb throwing shrapnel all over the place. During the Paris Commune, the figure of the petroleuse, the pyromaniac women who savagely burned the city, became a commonplace representation in the popular press virtually overnight. Across the Atlantic, images of American Revolutionaries with syphilitic madness spreading the gospel of democracy and anarchy were published and distributed in the major cities. The founding father of American psychiatry, Benjamin Rush, warned during the Revolutionary War that some people may be stricken with “liberty-mania,” “land-mania,” “negro-mania” (here, he’s talking about the accumulation of slaves, not an obsession of Blackness), “republican-mania,” or “monarchical-mania.” So, it wasn’t just the popular press, but the most respected psychiatrists: Pinel, too, during the French Revolution, traded in this kind of discourse, asking in his diagnostic writings to what extent revolution either causes insanity or itself is the product of some sort of insanity. Laure Murat’s The Man Who Thought He Was Napoleon is a wonderful book on this increased fluidity in revolutionary and chaotic times, particularly in France. The barrier between sanity and madness, between the normal and the deviant, becomes thinner and more fluid as the social world is rapidly transformed and the bases for making such determinations (Calvinist religion, for example) are uprooted and destroyed. Through this polemical intensification, psychiatry’s general political power and relation to political norms most clearly appears.
So what was the cause of madness for the social reformers in the early urban US? The family, poverty, ill health, or civilization–an ill-defined term that could stand for virtually anything. They believed that an environmental or social theory of madness would save psychiatry from the superstition and chains supposedly characteristic of religious townships. If civilization’s speed and intensity and the density and stress of the city were causing people to go mad, the first step was to swiftly and decisively remove them from this noxious environment, to sever their relations to everything to avoid any pathogenic residue and ensure a clean slate for recovery. For that reason, commitment laws were very lax; after all, once the patient was inevitably cured, they would be returned post haste. So where do they go for their tranquil retreat? Thomas Kirkbride, one of the members of the US’ first professional medical association, the Association of Medical Superintendents of American Institutions for the Insane, designed a widely adopted architectural model that rationally incorporated the principles and ideals of the reformers. A central administrative tower fanned out into long wings with rooms regularly spaced out throughout. The patient was to begin in the farthest section and move towards the front doors to symbolize their progression towards freedom. Plentiful windows maximized sunlight and, if one looked out, one would’ve seen a quaint, peaceful country scene away from the hustle and bustle of the inner-city. Labor was regimented and disciplined and therapeutic in itself. A well-ordered asylum was a hard-working asylum. Through holistic reform of the person and their world, cure was all but inevitable. Many associate asylums and prisons with cramped, overcrowded, disease-ridden places for segregating the unseemly; it’s important to remember that, to their creators, they were architectural marvels, designed to normalize movements and activities in a rational whole and prepare deviants for the outside world. They were considered progressive, even utopian, laboratories for individual growth and social change.
By the 1870s, asylums and prisons lost all veneer of being for rehab and the fervent optimism of the reformers decayed into an all-encompassing pessimism. The purpose shifted then to simply remove the mad and criminal to defend society. The corridors of Kirkbride asylums once tread by patients on the progressive path to liberation were filled to the brim with beds. The sunlight streaming in from the windows cast the shadow of iron bars on the stale interior. The ascent to recovery symbolized by the long winding hallways became a hellish circle to nowhere. Patient labor, as I discussed earlier, became pervasive, but the idea that it was helping anyone was just window-dressing; its main purpose was to ensure that the institution could crawl once more into the next miserable day. All the same, it can’t accurately be said that these realities betrayed the original intentions of the reformers: progressives emphasized discipline, removal from society, and regimented labor as reformatory. The reasoning changed but the structures and practices stayed the same; therapeutics, under quantitative intensification and pessimism, tipped seamlessly into segregation for its own sake, drudgery, and brutality.
What does it mean for us who want change that the penitentiary, the asylum, and the almshouse appeared at a time of great clamor for change and positioned themselves as the avant guard of social reform. It is vital we keep this fact in mind when we discuss the history of radical change: many of the forms we rebel against or look back at in horror were once utopian ideals and tectonic shifts in thinking and practice. We are in a transitional phase between a biomedical reductionist dominant model and something that might be called a "bio-psycho-social" one. It would be a mistake to see a "paradigm shift" in psychiatry as sufficient. Similar stories of an optimistic, apparently progressive, push shifting into pessimism, custodialism, and abuse could be told with Pinel's revolution, the neuropsychiatric revolution in late 19th century Europe, the hubris of colonial Christians "saving" people in China or South Africa by building asylums, or with the formulation of "reactive neuroses" following WWI. Opposing theoretical formulations, each claiming to be a progressive reform or even a revolutionary measure to save psychiatry from barbarism descended into old forms and horrid conditions. The great cathedrals of healing are periodically revealed to be nothing but cages painted in gold every few years by the next generation of reformers.
There have been many times when thoughtful and delicate models and codes of ethics drawn up by caring minds and offered to the public –or, just as often, to politicians– in hopes of a paradigm shift have ended up in the hands of wardens and cops. Veritable trauma-factories like prisons have unironically imported the language of “trauma-informed care” and some forensic psychiatrists today use the language of “psycho-social disability.” In the 1970s, one of the central demands of the antipsychiatry and psychiatric survivor movement was that any mental health care practice must integrate the experience and expertise of the patient or sufferer. This has roots in the disability movement’s demand for “nothing about us without us.” At various times and places, this is in itself a radical political demand that fundamentally challenges the way knowledge is formed and practice is legitimated. At the same time, the incorporation of mental health service users does not in itself guarantee fundamental or radical transformations: many clinical and institutional workplaces now employ peer-support specialists, researchers of all stripes have increasingly made strides to incorporate accounts from patients and service users in their studies (however superficially), and some psychiatrists and social workers often have no qualms referring patients to peer-run alternative support groups like a Hearing Voices Group so long as it doesn’t disrupt their own work.
What does this suggest? First that no model and language is universally applicable and will not have the same effect in every locality or with every group of people under so massive an umbrella as “psychiatric patients.” A practice or group style can be capable of rupturing a paradigm or power dynamic in one place and serve the interests of an institution in another. Second, it signals that we must be wary of the risk of confusing the production of novel ethical principles (like the centrality of peer voices or the modification of language) or prefigurative models for change for the transformation itself. In a future session, I intend to compare the way peer groups have instantiated and defined themselves and how they intervened in standard psychiatric practice in the US, Chile, and Greece to work out some of these differences. One of the goals of this series should be to recognize the ways in which radical models of care respond to local needs and desires. Care is polycentric because life and struggle are polycentric; models are useful insofar as they help us get back up, keep living (or, even better, living well) and fight in concrete struggles for a better life and a better relationship to one another.
So what are we to do? Much of our imagination around what’s possible has been limited by what exists and how overwhelming it feels. Going forward we’ll be looking at times in the past when theory coincided with concrete practices around the world: Democratic Psychiatry in Italy, the anti-asylum movement in Brazil, anti-colonial psychiatry in North Africa, Institutional Psychotherapy in France, organizing in university psychiatric clinics in Germany, peer support networks in the US and around the world. “Psychiatry in and at War” was the subtitle for this event and I am aware I have barely mentioned any wars. I ended up approaching this from a more metaphorical angle of how conflict transforms psychiatry. But I will say here that perhaps no other event works as quickly and as intensely as an accelerant for change as war in the history of psychiatry. Virtually all of the projects I plan to discuss in the future were touched in some way by World War II: some radicals spent time in concentration camps and fascist prisons; governments, facing up to hundreds of thousands of psychically wounded soldiers, green lit experimental projects and approaches; psychiatric associations dramatically altered their diagnostic manuals to account for rapid changes in behavior; material constraints forced some to resort to creative means of solving architectural or treatment problems that later became hegemonic.
Briefly, I want to suggest that what tied these experiments together beyond the experience of war was a relationship to contradiction and negativity, an antagonistic or even insurrectionary drive, if you like, on the one hand, and a commitment to creativity, collective production, and experimentation on the other. Furthermore, they did so without sacrificing a basic ethical orientation. Franca Ongara Basaglia, reflecting back on her experience in the Democratic Psychiatry movement in Italy, said “it all began with a ‘no.’” The projects I want to discuss never lost sight of that ability to say no. Most of them, upon discovering that their projects were being exported as a prefabricated blueprint for ethical care, jumped ship and preferred to flounder a bit in isolation until finding bearings somewhere else and with a new orientation later. These projects could be viewed as what Nick Crossley has referred to as “Concrete” or “Working Utopias,” practical laboratories where new ideas could be tried out and tested as well as central locations where interested parties could meet and spread ideas. How does a "working utopia" relate to the world? Does it hermetically seal itself off in order to stay true to a higher code of ethics? Does it situate itself as a meeting place for radical movements? How does it balance sustainability and antagonism?
To conclude, I want to return to the notion of crisis. To quote Walter Benjamin once more: “The tradition of the oppressed teaches us that the 'state of emergency' in which we live is not the exception but the rule. We must attain to a conception of history that is in keeping with this insight. Then we shall clearly realize that it is our task to bring about a real state of emergency.” Today we face crisis after crisis in an interminable cycle. Where are the crises today? In mental healthcare, but also in the wider political and economic order? The tradition of radical psychiatry asks: what kind of therapeutic practice opposes pathogenic forces, particularly when they seem to be essentially embedded in the order of the world? Can some manner of healing prefigure a different world or at least prepare us to fight? Lastly, is there a type of healing that is also, in itself, a kind of fighting? In this period of reactionary cuts to alternative facilities across the world –from Sao Paulo to Thessaloniki– and a further enmeshment and confusion of carceral and psychiatric governing logics, a radical psychiatry must regain a real power of saying "no," not just to inadequate means of healing our wounds, but also to a morbid and failing capitalist hegemony.
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