The Dream of the Outside: Deinstitutionalization, Anti-psychiatry, and the Move Into the "Community"
Updated: May 6
This is part of a series of presentations on the history of radical mental health projects called Mental Health in Crisis. Find recordings at unsoundmind.org/blog and the landing page for the series with notes, slideshows (with many more images), and info for how to follow the series at https://www.unsoundmind.org/post/mhic-presentation-series.
What is madness? We’ve been talking about madness and psychiatric history for weeks now, but it seems we are not any closer to having even a basic idea of what the object of all these interventions is.
The history of madness could be told as a history of acts of delineation, of decisions which established lines of belonging and exclusion, inside and outside, normal and abnormal that separate the lunatics from the sane. Michel Foucault’s History of Madness is the most comprehensive attempt at producing such a history to date, though it is, despite its title, not really a history of madness per se–something which remains a dubious prospect– so much as a history of the spaces reason has assigned to it under differing systems of production and knowledge, what he calls a “history of limits” and an “archeology of silence.” (xxviii-xxix) In an earlier age, Foucault claims, madness was characterized as a possible limit experience nevertheless internal to the subject: death and madness were the great nothingnesses one confronted within themselves and, in this confrontation with the great mysteries of knowledge and life, discovered deeper meanings and truths, however esoteric they may have seemed. Like the figurations of hell and the end-times, madness seemed to reveal essential truths and possibilities of the human experience and the order of the world. In this representation, or in similar ones where madness also appeared as the tragic truth of the world, madness was in dialogue with reason, cloaked though it may have been in the habit of Antichrist and Death.
In the 16th century, Europe’s relation to madness began to shift: madness and reason become locked in a reciprocal relation of exclusion as the former begins to appear principally as unreason and the mad become in-sane (28). Perhaps more clearly, reason’s silencing of madness took the form of material and juridical containment in special hospitals and almshouses, a shift Foucault refers to as “the Great Confinement” (55). Klaus Dörner, in his book Madmen and the Bourgeoisie, argues along these lines that madmen first became stable visible subjects within reason’s regime of visibility once the category of “insane pauper” (37) become a public cause for concern necessitating incarcerating and removal. It was through social exclusion that madness came to be recognized and treated as a tangible problem. Whether madness is conceived of as an outside or as an experience at the limit of intelligibility, it is also paradoxically under persistent surveillance and constant illumination under floodlights of reason. Human zoos are the historical precondition for psychiatric classificatory systems. Fewer places is this clearer than in the courts. Prior to the infamous M’Naughten case that established the first modern insanity defense, the courts of Europe and the colonial US made use of the “wild beast test,” which excluded the furiosi, the raving lunatics, from legal culpability, considering them to be of the same mental level as beasts. The legal test corresponding to this figure was of a zoological order: English general physician Richard Mead warned that such a madman was likely to “attack his fellow creatures with fury like a wild beast” (Quoted in Scull, 58). The court’s rationale for exculpating the mad could be summed up in the phrase “‘furiosus solo furore punitur,’ a lunatic is punished by his madness alone” (Polsky, 509). Subsequent tests and criteria remained wed to the basic principle that madness and legal culpability were irreconcilable, even as knowledge of and the characterization of madness shifted.
In the 19th century, madness was no longer principally negatively defined in relation to reason in the shape of unreason, but appeared positively in the form of disease as “mental illness.” Increasingly, insanity, the foil to reason, ceded to taxonomies of observable and classifiable medical entities. Mirroring this domestication by science, the courts, beginning with the M’Naughten test in England, integrated more sensitive tests that registered momentary lapses of judgement and losses of reason connected to specific medical symptoms. Subsequent tests became even more subtle: the Model Penal Code of 1962 exempts the lawbreaker who “lacks substantial capacity to appreciate the criminality of his conduct or to conform his behavior to the requirements of the law.” The addition of the word “substantial” and substituting “appreciate” for “know” establishes a spectrum of the understanding that includes one’s emotional state and interpretative capacity on top of simple understanding. Despite these substantial changes in the representation and “place” of madness, the act of exempting a person from the punishments determined by law on account of unreason —though rare— remains a litmus test for the boundary separating the legal citizen from the insane. The fact that, among all the various contingencies and accidents of life, insanity has consistently appeared as a special category warranting tests and operational procedures probably explains why insanity defense trials have long aroused great interest in the public, which is equally horrified and fascinated by the deeds of insane criminals and their eventual fate.
Dissolving Lunacy in Law
Perhaps this legal continuity and popular wonderment serves to explain why someone like Thomas Szasz became and remains to this day one of the key figures of what is commonly called “anti-psychiatry.” Thomas Szasz was born in Hungary, but moved in 1938 to escape the Nazi’s eastward encroachment and to find new opportunities in the United States. Here, he studied psychiatry and, even early on during his residency in Chicago, adopted a principled and unwavering stance against coercion in his field. His stance, over time, grew into a single-minded crusade. Szasz’ critique of the concept of mental illness and his strong focus on legal categories have made such indelible stamps on the antipsychiatry movement, on psychiatric survivor groups, and rights-based organizations that I would say the Szaszian understanding of psychiatry has become the baseline for opposition in the United States and Canada and the main point of entry for those seeking out a critique. I would not be surprised if his books The Myth of Mental Illness and The Manufacture of Madness were the most cited in Anglophone radical or anti-psychiatry texts.
It’s not hard to understand why: Szasz offers a very simple, appealingly schematic, understanding of modern psychiatry and its categories. Mental illness, he says, does not exist, at least not in the same way cancer and diabetes do. What does it mean for an illness to exist? According to Szasz, an illness is something quite clear: a disease is a histopathological lesion, or, in layman’s terms, tissue damage. Because mental illnesses cannot be traced to clearly observable cellular or molecular pathology, the “illness” in “mental illness” is better described as a metaphor for “problems of life” than as an observable somatic entity or process. Psychiatry’s original sin is in having construed behavioral patterns as symptoms of an underlying disease entity the psychiatrist presumes exists where none presented itself. Being essentially “problems of life,” there’s nothing inherently wrong with seeking help to deal with issues normally classified as psychiatric, the problem is that contemporary psychiatry forces patients to undergo treatment. Hence the entire problem of psychiatry can be reduced to the question of coercion, and Szasz correspondingly divides psychiatry into two types: Institutional Psychiatry, which is characterized by the use of forced treatment it justifies with the assumption of a mythical disease entity, and Contractual Psychiatry, which is voluntary and ideally discusses its clients’ problems in a mutually agreed-upon manner. The word “contractual” is the key to understanding Szasz’ political worldview, based as it is on the abstractions of classical liberalism. Szasz has never claimed to be against coercion tout court; like Hobbes, Szasz believes humans to be essentially evil, “beasts” that must be tamed by the law. Unlike the ambiguous, discretionary power exercised by the medical police making up what Szasz calls a “Therapeutic State,” the real police hold citizens accountable to clearly defined laws in exchange for protection from the brutality of natural law. If this sounds familiar, it’s likely because it’s the basic abstract position of the American libertarian tradition, to which Szasz doubtlessly belongs.
Szasz’ underlying political positions and personal conduct makes him an odd bedfellow with the many feminist, antiracist, and anticapitalist groups and authors that have made use of his work. In the wake of the Minneapolis uprising following the murder of George Floyd, speaking to you from a city currently occupied by police following yet another state-sanctioned murder of a black man, Daunte Wright, I find strict adherence to a Szaszian form of anti-psychiatry to be antithetical to any radical orientation aspiring to a communal future based in principles of collective care and material transformation. Without suggesting he is personally responsible, the centrality of Szasz’ positions in US-based anti-psychiatry currents betrays (if not actively bolsters) two popular tendencies in the US antithetical to collective rebellion: first is an overly simplistic concept of the body and its diseases that ultimately gives credence to non-psychiatric medical hegemony, and second is an individualistic rights-based approach to political organizing I would characterize as a kind of legal formalism.
The central claim that mental illness is not an illness like any other because it lacks a localized cellular or molecular lesion is in no way an uncontroversial or simple claim. For even the assumption of a “simple” and “purely physical” disease is still a normative posture. As Peter Sedgwick puts it in Psycho Politics, there are no diseases in nature, which is to say that all demarcations of health and disease contain value-statements and therefore cannot be understood without social determinations of normal and abnormal. This is not to say that all breakdown and pain is "socially constructed." But it does imply, as George Canguilhem argued at greater length and with greater subtlety in The Normal and the Pathological, that we possess no means by which to understand physiological or natural processes without a social valuation and framework. By making an unfavorable comparison between psychiatry and medicine the central pillar of the anti-psychiatric position, its adherents lose sight of how other branches of medicine manipulate people and space, often in cooperation with state agents or the police: the histories of anatomists stealing the corpses of slaves to conduct medical research, or university researchers performing experimental treatments on the poor, or epidemiologists letting diseases run their course in black or native communities recounted for instance in Medical Apartheid by Harriet Washington appear as just individual ethical failures as opposed to expressions of underlying rationales or power relations. Among anti-psychiatry critics, the propensity of psychiatry to progressively “discover'' new mental illnesses of an increasingly molecular nature is evidence of its arbitrary and theological foundation. It is true that psychiatric diagnoses objectify and pathologize human behavior and alienate us from an understanding of our environment and relations and provide convenient rationales for intrusive police or carceral operations, but, as medicine increasingly directs itself towards smaller and smaller genetic, neurological, and cellular abnormalities, the very same could be said about our approach to health in general. Didier Fassin, in his article “Public health as culture” discusses a case in France when professionals modulated the amount of lead they considered constitutive of lead poisoning, which at times justified state intervention into some peoples’ houses and at other times excused the state from having to take action to remove sources of lead (Fassin, 171). Today, writers like Nikolas Rose or Lorraine Daston and Peter Galison in their book Objectivity are tracing new histories of the so-called “hard” scientific categories and diagnoses that show them to be just as wed to aesthetic assumptions, political presuppositions, and normative stances as psychiatry. Psychiatry as Szasz characterizes it is not exceptional among medical specialties for being grounded in normative assumptions and practiced as a form of power and manipulation; if anything, it is exemplary of the medical field as a whole.
Szasz’ faith in a theoretically pure legal system of rules and punishments also explains his continuous preoccupation with forensic psychiatry, which introduces vague categories where there should be simple rules and discretion where there should be clear sentencing procedures. Szasz is at his most naive here. So far as the criminal is concerned, according to Szasz, the only question “is whether or not the person committed the act and whether he committed it within the definition of what constitutes a criminal act” (Szasz and Turkel). But that is not how policing or courts work. The police and courts have an enormous amount of discretion; the ascription of criminality onto their victims is in no way clearer or better defined than that of mental illness. In Minnesota, where I live, Philando Castile is dead because the police have the discretion to shoot people when they feel scared. Cops like Mark Riggenberg and Dustin Schwarze were able to execute the handcuffed 25 year old Jamar Clark and face no charges because they were acting within their discretion. Meanwhile youth who threw stones or destroyed property during rebellions against these state-sanctioned murders potentially face decades of incarceration. The determination of “criminal” is plastic, and does not in reality have a definite relation to any specific law: the powerful and the rich can break many laws without being punished, and the marginalized can be punished without breaking any.
Szasz's position is ultimately identical to that of capitalism itself: pay up according to the terms of a contract or suffer the consequences. Szasz eliminates madness’ exteriority by claiming that no one is outside the law and the contract-forms of capitalist society. Everyone is granted access to adequate social services to aid them with interpersonal or social problems, so long as they can pay for them. Forget how social positions are established, how wealth is distributed, how resources are gained or stolen; rich and poor alike theoretically have access to the same services. Give me my rights, my property, my family, and stay out of my business; in the libertarian tradition of the US, the poor, made poor by expropriation and exploitation, are as free as everyone else to starve to death, rot in a prison cell for stealing goods, or be shot dead in the street by the police.
This dual emphasis on medical knowledge and a rights-based legal formalism in the United States expresses itself in our domestic social movements’ focus on affecting changes in large professional associations and the law. When I critique Szasz here, I am not only critiquing his influence on these movements, but also the underlying tendencies he represents most clearly. This is in part due to the essentially decentralized development of US psychiatry. In the 1840s, Dorothy Dix conducted a nation-wide investigation of the conditions of asylums culminating in a failed attempt to lobby the legislature and president Pierce to put in place a federal psychiatric policy in 1854 that would have secured regulated conditions and a unified strategy. Nevertheless, this combination of scandal and policy work marks the beginning of a strategy common among much of the critical, reformist, and anti-psychiatric traditions going forward: a consistent thread can be traced from Elizabeth Packard in Illinois decrying her incarceration at the hands of her husband and successfully lobbying for stricter commitment criteria to the writings of Albert Deutch, Albert Q. Maisel, Mary Jane Ward, Nellie Bly, and Kate Millett decrying the conditions of American hospitals. To this could be added a number of popular films that cast mental institutions and psychiatrists in a negative light like One Flew Over the Cuckoo’s Nest and The Snake Pit.
Judicial activism was even more pronounced from the 1960s on when a number of high-profile Supreme Court cases followed one-another around the country, issuing major challenges to asylum administration, at times hastening the closure of institutions that couldn’t meet the new standards or sustain themselves without patient labor. An early and exemplary case was Rouse v. Cameron in 1966. In 1960, Charles Rouse was found not guilty by reason of insanity in a weapons possession case and was placed in a security hospital where he spent the next six years with only nominal treatment. Judge David Bazelon held that patients committed have a "right to treatment" and cannot be indefinitely held in psychiatric facilities for the purposes of simple removal. Some years later, in the early 1970s, Wyatt v. Stickney reaffirmed that patients are entitled to more than custodial care, but went further in establishing baseline standards for quality of food, environmental conditions, and more at asylums. Though far from the last significant case, the last one I will mention is Souder v. Brennan, which held that patients could no longer be expected to perform institutional peonage and amended the Fair Labor Standards Act (FLSA) in 1986 to protect institutional laborers and secure them at least a partial wage. Later cases established a right to refuse treatment, increased judicial oversight of civil commitments, the requirement to seek out less restrictive alternatives to institutionalization, and more.
A number of paradoxes attend this kind of judicial activism. The central paradox is simple: when we appeal to the law to help us improve conditions or acquire protection from harm, psychiatric law scholar Bruce Arrigo points out, it is largely the law itself from which we are asking for protection (Arrigo, 39). After New York passed the Care Act in 1890 that made the confinement of the insane in mental hospitals compulsory, it has been the legislature that provided the funds for the hospital system, the courts that established the necessity of forced treatment, and their collaboration that made the conditions for the possibility of custodial care and forced treatments. When we seek legal remedies to protect us or guarantee us a certain standard of treatment, we also strengthen the power of the law to act in our lives. This leads us to the second paradox: judicial activists sometimes talk of rights gained as if they were positive entities in the world. Once created, it is often implied, they envelop the vulnerable like an invisible shield. I would contend that rights do not exist. I mean this in multiple senses: first is that rights must, in each and every situation, be claimed and seized before a receptive audience. One may always say “this violates my right,” but this statement must meet certain conditions in order to have a real effect in the world. If one says “I have rights” while detained in solitary confinement, the right does not effectively exist, or, put another way, has no possibility of actualization, regardless of whether one believes it does or not. One can nominally have the right to happiness, to protection, or to privacy, but what good are any of these latent rights if the police can enter your home for a welfare check and shoot you on your own couch? The declaration of a right must in other words be heard by another who can and will respond to this call. Furthermore, the declaration of right often happens after the supposed right has already been violated; in that sense, rights are, for the most part, remedial and not protective. In this sense, rights are more like weapons one uses in hopes of transcending the purely affective and emotive plane of pity for one's conditions to gain access into a court or office where something more substantial can take place to end an ongoing injury or remediate an old one.
This leads us to our last paradox: the demands for the legal recognition of rights, especially for the so-called “gravely disabled” or “severely mentally ill” can only be adequately acted upon by an advocate with political capital or institutional power. In this sense, an effective act of honoring rights simultaneously disempowers the rights-claimer since they cannot in reality act in their own name or in their own interest or the interest of a collective they belong to. This by no means suggests that judicial activism is pointless or that negative rights have not substantially improved many peoples’ lives and provided a means of remedial corrective action where none existed. What it does mean is that, if the goal is communal empowerment or liberation, legal goals ought to be pursued in terms of their instrumental usefulness to a social movement that can use them. The real goal, in this view, is to create and foster a social movement powerful enough to enact political transformations without the intermediate role of the legal advocate or the state, especially since the latter can and will change its relation to those rights depending on external economic or political conditions. Ruthie-Marie Beckwith’s study Disability Servitude has provided sufficient evidence to Martha Russel’s thesis that states and institutions will do everything in their power to skirt the laws when facing a crisis like a labor shortage where masses of disabled peoples’ subminimally or uncompensated labor suddenly becomes more essential. Rights, in the final account, apply only to full citizens and in the eyes of the state, when in crisis, threats don’t have rights, nor do the “severely disabled,” the “vulnerable,” or those with “extreme mental illness” who can be warehoused or killed with impunity given a sufficient rationale.
Fleeing and fighting diagnoses
In part due to the excessive and tangled mess that constitutes the legal production around psychiatry and the status of the mentally ill, those looking for a coherent picture of the state of American psychiatry or a more streamlined means to affect change often turn to large professional groups like the American Psychiatric Association. In addition to their influential medical journals, they also publish the Diagnostic and Statistical Manual, or DSM, at its core a descriptive handbook of psychiatric nomenclature for professionals, taken by the public and activists alike to represent the most contemporary and accurate reflection of the field’s epistemological understanding of problems in the field. The origins of the DSM lie in the VA’s creation of a technical manual used to aid in the classification and management of masses of complex psychiatric cases during World War II–when over 40% of medical discharges were due to psychiatric conditions–called the Medical 203. In 1952, an APA committee was tasked with producing a manual to standardize psychiatric nomenclature for American professionals directly modeled on the Medical 203. From being a relatively marginal statistical tool like the census and an optional diagnostic aid for professionals, the DSM has grown into a multimillion dollar publication that serves as the standard for statistical research and drug trials and the gatekeeper for social aid, school resources, housing options, and the possibility of medical or therapeutic interventions for patients.
The 1960s and 70s were marked by the rise in social movements formed around marginalized subjectivities like black power, feminism, gay power, and the psychiatric survivor movement. While the first two DSMs were steeped in the psychodynamic theories that still betrayed a strong psychoanalytic influence in the 1950s, the APA’s approach to mental disorders took on increasingly medical pretensions as these new protest movements grew. The APA–and US psychiatry in general–was in a crisis of legitimacy, facing attacks from many sides at once, and pursued medicalization as a way to position themselves as the arbiters and gatekeepers of what constitutes a disease or syndrome worthy of intervention and what is a normal behavioral divergence from the norm. So far as their relationship to psychiatry is concerned, activist groups, in turn, began to direct their efforts towards demanding alterations, additions, or deletions of diagnostic categories or a change in treatment regimens in addition to securing negative legal rights, and affecting policy decisions. Among the more famous and successful examples is the campaign to remove homosexuality from the Diagnostic and Statistical Manual in the early 1970s. Until 1973, homosexuality was widely classified as a mental disorder, specifically as a personality disorder. Naturally not every gay person was subject to treatments for their supposed “illness,” but generally we can say that characterizing sexual orientation in terms of illness is an underhanded way to recast a social inhibition as a medical problem, and this was something everyone had to come to terms with. For the individual gay person, they were asked to believe that their desire itself was pathological while many were either convinced or forced to participate in extreme aversion therapies like those that administered electroshocks when excited by the wrong imagery or therapies of a more subtle variety that sought to exploit the gay person’s guilt to break down their defenses and create a personality crisis from which a new, straight, person could emerge (Castel and Lovell, 241-2). Gay prisoners fared even worse: at the Vacaville prison in California, inmates received intensive psychotherapy, experimental drug treatments (including chemical castration), and even psychosurgery (Ibid, 185).
Declassification activists used disruption and theatrics as part of a public awareness strategy intended to pressure the APA into making changes. They weren’t alone nor the first to pursue this method. In 1965, a Black Caucus of the APA formed, which was soon followed by the creation of the Black Psychiatrists of America group (Harrington). In 1969, some of the black psychiatrists in these groups and a new “radical caucus” of the American Psychiatric Association directly inspired by them disrupted the APA conference in Miami, Florida, accusing their colleagues of pacifying righteous anger and not taking a principled stance on domestic anti-black racism and the war in Vietnam (Richert). They alleged that psychiatrists were excusing and normalizing racism, pacifying dissent in the cities, and stabilizing soldiers to continue to fight unjust wars. In 1970, a group of feminists–among them Phylis Chesler of Women and Madness fame–disrupted the American Psychological Association's annual conference, demanding one-million dollars in reparations to support deinstitutionalizing women locked in mental hospitals among other things. Borrowing from this tactical repertoire, gay activists began disrupting APA conferences beginning in 1970. At the first handful of conferences, activists would enter and heckle speakers who were known to espouse homophobic positions, shouting them down or storming the stage and stealing the microphone to speak. By 1972, through extended pressure and a successful media campaign, some gay activists were featured on panels and shifted the emphasis from raucous militancy to trying to gain access into the war room. The climax of this new strategy was at the APA conference in Dallas. The activists had secured a panel slot entitled “Psychiatry: Friend or Foe to Homosexuals (a Dialogue)” during which a heavily disguised gay psychiatrist named John Fryer recounted a life of fear and loathing in the midst of intolerant colleagues.
Differences soon came out between more conservative participants who assured the public and professionals that what gays really wanted was to be given the opportunity to live according to societal norms and the radicals who, as scholar Abram Lewis puts it, either viewed “psychic injury as a systemic effect of racism, sexism, and homophobia” as did the Combahee River Collective (106) or embraced “unreason as an antidote to liberal paradigms of social and subjective stability” (109). The move to demedicalize homosexuality is also exemplary for some of the unintended consequences that can attend such movements. Though championed by many anti-psychiatry critics as a progressive move to demedicalize and depsychiatrize a form of deviance, it is worth noting that psychiatrists too celebrate the declassification as a major turning point for the domination of the biomedical framing of mental disorder and the public revaluation of the field as a medical discipline. Psychiatry’s prospective scientists seized upon the controversy as an opportunity to dissociate their field from the vagaries and endless depths of the psyche, hoping to replace Freudian couches with laboratories as the avant-guard of mind-doctoring (Ibid, 86). As it turns out, the removal of homosexuality in the DSM-III was accompanied by a general rise in the total number of sexual perversions and deviations as well as a section on gender identity disorders for the first time. Abram Lewis suggests that “[r]ather than ‘depathologizing’ sexuality, as the revision is often memorialized today, the campaign might instead be read as facilitating a more nuanced psychiatrization of sexual and gender difference.” (98).
Is there a beautiful world outside?
With all of these groups, one could say that there were always tendencies among those on the outside to demand entry into “normal society” or into the rooms where decisions are made, and others who saw the inside itself as the problem. If the desire to be folded into the soothing flow of normal time and space was in the air, various radical therapies simultaneously offered acceptance of marginality and otherness as a source of empowerment against said flows (see, for instance, the journal The Radical Therapist). Few became as famous or as representative of the movements for counter-cultural therapeutics in the New Left as R.D. Laing and David Cooper in England. Despite being assigned the same catch-all label of anti-psychiatry and lumped together with the legal formalists in the US, these two not only opposed the subordination of madness under a typical legal subject, but even asked at times to what extent the latter can truly be considered a superior state. Laing and Cooper had the clarity of mind to ask: what the hell was so normal about the organization of the social world in its typical form? Weren’t the most powerful states in the world arming themselves for mutual destruction? It certainly wasn’t schizophrenics going abroad to bomb Viatnamese villages, so why is normality a state the schizophrenic has to adjust to?
Interestingly, some of the positions widely associated with the more famous R.D. Laing are probably better suited to his comparatively obscure comrade David Cooper. Cooper was a South African born communist who fought against the Apartheid regime. After coming to England to study, he opened Villa 21 in 1962, a therapeutic community at a hospital in Hertfordshire that stretched the model to its limits by scrapping all outward semblances of power inequalities, besides the keys to the prescription drawer. Like the Basaglias and others in Gorizia, he discovered there were hard limits to how much one can radicalize an institutional space and gave up the project in 1966. Cooper lived and continues to live, however, in the shadow of R.D. Laing. Laing was a Scottish-born psychiatrist whose wonderful book The Divided Self used existential and phenomenological theories of experience to render the seemingly alien speech and experience of “psychotics” comprehensible. He claimed that much of what we stigmatize as psychotic is only made incomprehensible by our tendency to abstract it from context and alienate it from its networks of communication and imminent relations. Psychosis was reframed as a defensive strategy taken up by a person in a crisis of ontological insecurity, itself often the result of familial irrationalities.
By making use of cybernetic theories of communication and Sartre’s existential theories of group relations, the dialectical critique of family relations was scaled up as an analytic tool for unmasking the hidden contradictions and relations of domination in institutions and “society” to varying levels of success. Prior to this milieu, Wilhelm Reich notably understood the patriarchal family as a material and economic unit whose dynamics and dysfunctions are imminently productive of social activity like fascist formations. Reich viewed compulsive heterosexual marriage as the result of prevailing “economic constellations” and not their cause; at the same time, forming a kind of circle, the family is “prerequisite [...] of the authoritarian state and of authoritarian society” (Reich, 71). Between the two, Cooper is the more faithful torchbearer of this theme, with an added emphasis on the psychedelic fads and New Left Freudo-Marxism of his time and less attention paid to sexual pedagogy and morality.
One of their emphases, at least early on, was on the subjective possibilities of the experience of madness as a process of discovery and learning. This is why they were both attracted to the passages in Foucault’s work on the Renaissance treatment of madness, sensing therein a possibility for communion with the madness that lurks in the heart of reason. How each pursued this communion gave rise to mounting tensions through the 1960s that resulted in the proponents of existential (anti)psychiatry becoming increasingly divergent through the 1970s. Hitherto subterranean conflicts erupted onto the surface at the 1967 Dialectics of Liberation conference organized by Laing and Cooper with two other radical psychiatrists to discuss the question of destruction and the paths to liberation. The conference featured lectures by then-famous figureheads of the New Left, among them Herbert Marcuse, Stokely Carmichael (later Kwame Ture), Allen Ginsberg, and Gregory Bateson. Some of the contradictions and shortcomings were readily apparent: there were almost no women invited to speak at the conference. Others emerged once the delicate thread uniting various “counter-cultural” forces was torn up by conflicting presuppositions about the problem at hand. Laing offered a fumbled attempt to scale up his familial theory of schizophrenia: “One moves [...] from the apparent irrationality of the single ‘psychotic’ individual to the intelligibility of that irrationality within the context of the family. The irrationality of the family in its turn must be placed within the context of its encompassing networks” (Laing in Cooper et al., 11). We scale up, Laing says, from the micro-units into what he calls the “total social context” which is “dangerously out of control” (Ibid, 12).
The line of thinking that begins with the question “who is really crazy in a crazy world” has been immensely productive of challenges, further questions, reframings, and contextualizations. It can and should always be asked. At the same time, it does not really say anything concrete about the world if it does not account for real material networks rather than just their irrational logics or psychological underpinnings. Even though Laing did hold that individual violence must be understood within a context, his notion of “context” rarely goes beyond decrying the division of groups into “us versus them” binaries. The scene shifted as soon as Kwame Ture took to the stage. Abstract binaries were moot and bizarre to this man who lost his notes for the speech because he had recently gotten arrested and the cops stole them (117). All the talk of individuals and getting over personal complexes and prejudices sounded to him like a “cop out;” instead, he brought Fanon into the debate and said that if black people are alienated, its not due to some vague notion of society or familial dysfunction, but due to the everyday functioning of a white supremacist, capitalist mode of production. At a panel talk with Alan Ginzberg, Ture becomes irate with the mainly white, liberal audience who talk of violence in the abstract, who view it as a philosophical possibility one can take up or refuse as opposed to the air one breathes or the environment one lives in. One audience member even accosts him and the wider black power movement for failing to assuage white liberals’ fears and goes so far as to accuse him of being a totalitarian using fascist methods (Anatomy of Violence). The failure to account for the material differences between people living under racial capitalism in critical psychiatric literature helps to account for Thomas Szasz' absurd proclamation that psychiatry is a contemporary iteration of the institution of slavery, or the fact that Goffman does not mention that St. Elizabeth’s was a segregated institution in his analysis of Total Institutions, or Ginzberg’s call for a “calm, peaceful, tranquil equilibrium” as a response to Ture’s acceptance of counter-violence in the face of thievery and brutality.
If anything binds Szasz, Laing, and Cooper, it is the belief that we must look outside of conventional, coercive psychiatry to discover a humane approach to forms of distress or difference labeled “mad.” Szasz located the problem in coercion rooted in medical self-deception, and therefore opposed his Contractual Psychiatry to the Institutional form, which would ideally incorporate madness into the interior of law. Laing and Cooper on the other hand sought to carve out physical spaces “outside” the system where one could go mad safely and freely. This led to Laing opening up Kingsley Hall, where the mad could travel through their experience of madness in a supportive environment. But is there really an “outside” to the system? Is this not a convenient illusion that allows one to ignore the fact that, for instance, the majority of the Kingsley Hall residents were middle-class student Laingian converts who therefore already had far more social and material support than the average “psychotic” in a mental hospital? His and others’ search for an “outside” in the East sometimes presented itself as a kind of Orientalism that exalted acupuncture, Taoism, herbal treatments, Buddhism, and much else mashed together and cleaved off from their real context and historical development, as if they could pick and choose which practices and theories appealed to them and simply claim them as elements of a general counter-culture against Western chauvinism. In an interview with Asylum magazine in 1986, Laing contended that psychiatry ought to remain completely apolitical (Bigwood and Laing, 16). Laing was unable to see that there is no escaping politics by simply declaring something apolitical. To be apolitical is only to take the side of the present system; to declare oneself “outside” without taking the whole social context into account is to reproduce that context in miniature.
The "Real" Outside: Community Psychiatry
Anti-psychiatry is normally used to name either any force that opposes psychiatry–its categories, status as a medical field, or its treatments–at any level, which is a rather vague concept, or it is used to describe any project that directs itself at behavioral abnormalities or distress in a radically different way–"outside the system,” one often says. But is anti-psychiatry, in the popular forms I’ve outlined, really “outside” psychiatry proper? If so, what is exteriorizing about their knowledge or practices? Franco Basaglia critiqued this belief in an interview with Laing: “In reality,” he said “outside the system doesn't exist, and there is a continuum between outside and inside” (196). Insofar as it still recognizes and centers on psychical and behavioral differences or distress, even if it valorizes them as superior to or natural consequences of the norm, the drive for an anti-psychiatry conceived of as an “outside” space or “outside” response could also be described as the drive for a new, enlightened, psychiatry.
Putting aside this question of whether anti-psychiatry is truly outside the system, the official US psychiatric establishment itself began to accelerate a transition to outside its traditional hospitals sometime around World War II. A common story holds that, around 1950, or, in some iterations, in the 60s, 70s, or even 80s, a singular event called “deinstitutionalization” occurred in which hundreds of thousands exited the asylums and either went home, went to prison and nursing homes, or were abandoned on the street. Each of these three narratives has a corresponding historical turning point: for deinstitutionalization, Kennedy’s 1963 Community Mental Health Act, which provided grants for Community Mental Health Centers where people would theoretically receive diversified aid outside the hospital; for transinstitutionalization, the 1965 amendments to social security that shifted the burden of cost especially for the elderly onto the federal government and incentivized transfers into nursing homes and other institutions at the same time as the rapid proliferation of prison infrastructure; for abandonment, Reagan’s 1981 gutting of mental health budgets, first in California and then nationally, undercutting the community mental health movement. The event called "deinstitutionalization" is, in reality, a confusing tangle of contradictory events and actors (See Lovell, Ben-Moshe, and Parsons).
I believe this confusion is related to a more general confusion around the way we historicize psychiatry. Since Dix’s failed attempt to secure a federal psychiatric policy, US psychiatry has been marked by uneven development and local implementation. We talk about historical junctures and shifts, but psychiatry can be defined at all times as being combinatory. It has always had “harder,” carceral and violent, and “softer,” outpatient and manipulative, mechanisms at its disposal. These do not oppose one-another as alternative forms, but constitute a broad fabric, what Anne Lovell and Nancy Scheper-Hughes call its “circuit of control” (“Deinstitutionalization,” 366). Psychiatry is a many-headed beast. Anne Lovell describes it well:
The wider the range of available programs —and it is constantly expanding— the greater the likelihood that any problem identified as being of concern to society will match up with some program ready to take charge of a new segment of the population. It is this constantly shifting clientele that constitutes the jurisdiction of the mental health system. The unity of the system really lies in the diversity of the services it undertakes to provide” (Psychiatric Society, xxi).
Psychiatry, in other words, is neither a simple tool to be picked up and used by a political or economic class, nor is it a unified system with clear directives and shared understanding. It is not purely vertical (i.e. from the psychiatrist down to the patient), nor is it entirely horizontal; “its connotations are both general and specific” (Lovell and Scheper-Hughes, “Deinstitutionalization,” 380); and its language is everywhere. For instance, psychiatry is not simply an auxiliary discourse in the criminal law: cops use the figure of the madman to justify shootings, while “excited delirium” can let them off the hook for clear-cut murder. Psychotic means dangerous, criminal means partly psychotic. Nonprofits and welfare groups, too, have become increasingly psychiatrized. Much of their attention is now centered around the invented category of “homeless and vulnerable mentally ill” as if this were a natural construction. Liat Ben-Moshe, in Decarcerating Disability, is one contemporary scholar working to denaturalize this concept: what ties “homeless” to “vulnerable” to “mentally ill?” Are there actually real causal links between these attributes, or does the term describe the invented object of a managerial logic of populations? Rachel Jane Liebert has pointed out that psychiatry proper is progressively moving into the realm of future securitization comprising a tendency she ingeniously calls psycurity: chief among these new interests is the figure of the “prodromal psychotic,” i.e. those who show signs of being potentially psychotic in the future as a site for intervention. Everywhere we look, psychiatric logic is in operation: schools, in their search for deviants and problem-children; social work, since the early 20th century, has included “a reinterpretation of the problems of welfare assistance in psychological terms;” and eugenics has been given new life by genetic-manipulation technology and the sacrificial public health directives of the state.
Along these lines, it should be asked: to what extent was the most progressive of these options, so-called “community psychiatry,” ever even attempted here? Where is this so-called “community?” As Lovell, Scheper-Hughes, and, more recently Liat Ben-Moshe have stressed, it is not immediately clear what “community” refers to. Is it simply the place one finds oneself? Well, then the institution is surely a community. Is it belonging to a religious, ethnic, or racial group? Again, this is completely possible in a prison or psychiatric hospital. More often than not, “community” is simply a negative term meaning “not in the mental institution or prison.” A group home located in an isolated area outside city limits with locks on the bedroom doors is, according to this logic, “in the community,” but in reality it translates the carceral, exclusionary logic of the asylum into a micro-institutional domestic environment. Community treatment sounds nice, but it doesn't equate to adequate housing, access to resources, the absence of coercion, or even permission to access the public spaces we often think of as community spaces.
Given that broad privatization of public space coincided with the supposed movement “into the community,” it must be stated that for many people in the atomized US, the word "community" evokes little more than the people we work with or our immediate family. The sane, normal citizens offered the gift of access to this impoverished community to the disabled and mad, but they themselves do not know what it is or where to find it. If the lunatic takes a seat on the steps of these welcoming peoples’ homes, the citizen calls the police; when they step into the lobby of a building, they are met with security; fine, they’ll go to the parks, and then find that locals act indignant “as if the homeless were violating their own living rooms when they pass time in public” (Lovell and Scheper-Hughes, 353). The United States has obliterated the commons, and surveils its ruins with a psychiatric-policing gaze: the poor are forced to trade symptoms for aid as the “vulnerable, homeless mentally ill” or on condition of an Involuntary Outpatient Treatment order, but, at the same time, we don’t want the crazy criminals on our doorstep. The assumption of a psychiatric narrative is the passport into the community, which then excludes them on account of their dangerous insanity or unsightly disability. It doesn’t occur to those who now fight for looser commitment laws and the reproduction of insane asylums, which never actually disappeared, to fight instead for housing, access to food, or the establishment of real public spaces. That being said, policy changes from above will not deliver us from this circuit of control. As Franco Basaglia commented when visiting a Community Mental Health Center in New York:
We must remember that these psychiatric units have not arisen from the necessity on the part of those who work in the traditional mental hospitals to turn the institution upside down (that is, they are not born as an immediate answer to an immediate need), but are the direct expression of a new legislation which tends to resolve technically the contradictions of the reality in which it operates. (128)
Psychiatry, in its carceral and community forms, is chiefly related to this matter of the technical resolution of contradictions. The circuit of control is supported by a circle of justifications facilitated by psychiatric statistics: psychiatric status is used to define a population’s needs so that psychiatric treatment becomes the goal. It is forgotten that homelessness or violence are not mechanical outcomes of psychiatric conditions, but the definite outcomes of particular political and economic networks and decisions. If community is to mean anything in this country, it will be a meaning seized in struggle against these conditions and against this exclusionary logic: community can only be made by subverting the logics of institutions, seizing space from owner-thieves, and creating real alternatives through a struggle for existence and joy. In other words, if we don’t want to merely reproduce it in a new form, the rejection of institutional logic in the struggle for simple places to be must be an anti-capitalist struggle.
These debates were at the heart of the Young Lords’ 1970 occupation of the Lincoln Mental Health Center in the Bronx, when they, along with some Black Panthers, paraprofessionals, locals, and some patients decried the disconnection of the mostly affluent white staff to their clientele and the fatal consequences of medical care based on efficiency and profit. They demanded destigmatized drug treatments, non-carceral and consensual care-relations, and propagandized about the political nature of health. Despite major conflicts with the police, they actually won funding for their People’s Program they used to fund methadone therapy, acupuncture, and lead testing, and offered some diagnostic services with a mobile chest x-ray vehicle they seized from the city until they were permanently booted from the hospital by the police in 1978 (Blanchard). The Lincoln Hospital occupation is a rejoinder to the fadism so popular in the US that offers thousands of new, hip combinations of ancient psychological insights with new technological innovations, a fraction of which are available to the poor who continue to languish in confinement and custodial care; the occupiers remind us that the only route to health “for the people” in a world colonized by capital is through political struggle.
When we fight for legal rights or for professional adjustments, we fight in the language of the law or of medicine. Is the movement to politicize madness or empower mad people a legal movement? Is it a medical and health movement? Is it a movement at all? Perhaps it is just a general name used to describe incommensurable tendencies, languages, and practices. Perhaps Foucault was right when he called anti-psychiatry the force that strives to depsychiatrize and demedicalize problems, ripping them from the doctor’s hands and placing them back into the political arena. I think another goal must be to preserve forms of non-psychiatry, a concept I am borrowing from David Cooper. To illustrate what I mean by this, consider the response of a contributer to a small feminist journal in Michigan to the declassification of homosexuality: “My reaction to this piece of news might be compared to that of a woman who has treated her broken leg with her own and her friends’ home remedies, and who emerges at last from her front door, limping slightly, only to meet the family doctor bustling up the front walk with a jar of aspirin and a few well meant words of comfort” (in Abram, 84). I would not call this form of queer care “anti-psychiatry.” It is not directed at demedicalizing or depsychiatrizing anything. I would, maybe rather clumsily, call that sort of care non-psychiatry. Psychiatry is a particular way of framing human problems; by definition, it frames them in the context of the mind or behavior. Anti-psychiatry is thus positioned in relation to that framing, in such a way that it tries to break it down, decenter it, and destabilize it. But what about forms of care that bear no negative relation to psychiatry, and that do not characterize problems in the same way at all?
In her book on the Hiawatha Asylum for Insane Indians, Vanished in Hiawatha, Carla Joinson claims that “Native Americans had long recognized mental problems such as hysteria and depression in their people. They called these alienated states ‘soul loss’ or ‘being lost to oneself.’” Not even mentioning the vague “Native American” non-subject here, I think it is a mistake to so readily translate concepts from a cosmology rooted to a relation to land stolen by settlers into the latter’s language of health; Native people did not “discover” the same diagnoses. Their concepts are not simply equivalent alternatives, but contain their own non-fungible specificity. It may be the case that in the struggle for autonomy, a non-psychiatric practice becomes an anti-psychiatric one, but one of our tasks in anti-psychiatry is to know the difference between the struggle to depsychiatrize and when to respect autonomy. David Cooper said of non-psychiatry that it “erodes itself as one writes it.” It responds, in addition to the need for food, company, and shelter, to the impossible need for autonomous expression (67). To always want to know, to plumb the depths, to have a ready-made response to an anguished or frenzied call in one’s own language is perhaps part of our problem. To depsychiatrize the social world means in part to learn to respect our own limits and the boundaries of the understanding or spaces we inhabit. We must learn when to fight, but perhaps we must also learn to know when it is necessary to be silent and simply respect that which we cannot know.
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