Therapists Are Cops: A Critique of Sanist Reason[1]
On the Management of Bare Life: Psychiatric Hegemony as Post-Political Bio-Politics
On August 23, 2023, during the early stages of the Republican primaries, Presidential hopeful Vivek Ramaswamy (at this time in third place lagging behind Ron Desantis and the frontrunner, Donald Trump) tweeted the following:
“Don’t remove guns from law-abiding citizens. Remove violent, psychiatrically deranged people from their communities and be willing to involuntarily commit them. Revive mental health institutions: less reliance on pharmaceuticals, more reliance on faith-based approaches that restore purpose to people’s lives. We know from the 1990s how to stop violent crime. The real question is if we have the spine to do it. I do – and I’ll use the power of the purse to accomplish it just as Reagan did in the 1980s.” (Ramaswamy, 2023)
On a first glance, anybody can recognize the deeply paranoid and authoritarian sentiment underlying Ramaswamy’s remarks. Even liberal media outlets condemned Ramaswamy for his callousness at the time, rightly pointing out that he has repeatedly perpetuated the claim that to be transgender is to have a mental illness; So that if you connect the dots between his statements one very quickly comes to the realization that Ramaswamy is proposing the mass incarceration of “criminals” and transgender people alongside a loosening of regulations around treatment plans to include more “faith based” interventions, that he is calling for the rebirth of involuntary psychiatric incarceration as a broadly institutionalized practice in response to crime and (what he views as) sexual degeneracy. Ramaswamy, like many Republican politicians, is a fascist populist. That is to say that there is nothing surprising or new about the sort of ideas he is advancing.
The immense tragedy of our modern situation is that this rhetoric is neither new nor confined to the fringes of far-right fascist ideology in Neoliberal capitalist society. So often today, the fight against “mental illness’ is a bipartisan moral crusade in the U.S. advanced with just as much fervor by liberal Democrats as by fundamentalist conservatives.
What is properly within the realm of serious discussion among the U.S. corporate and political class today is not so much the need for and admissibility of involuntary psychiatric incarceration, but rather, its relative extent when compared alongside the archipelago of alternative marketized “treatment” options. Options from the use of psychopharmaceutical interventions, to intensive outpatient care, and even decentralized online counseling and therapy programs have all helped to bring about a more humane, more modern, more egalitarian mode of psychiatric management – or so the story goes. In this way, the institutionalized management of human beings by sanist systems of psychiatric control has never ceased since the “de-institutionalization” (marketization) of the pervasive U.S. Asylum system in the mid 20th century, but has transformed into more profitable, more legally defensible, and more ubiquitous forms by tying the functioning and administration of psychiatric institutions to the market.
This “apolitical”, technocratic approach to the management of populations – of their organic,psychological, and social constitutions – is what the Slovenian philosopher Slavoj Zizek refers to under the term “Post-political Bio-politics”. For Zizek and other critical theorists, the term “post-political” indicates a politics which claims to leave behind old ideological struggles in favor of an emphasis on expert management and administration, while “bio-politics” designates the regulation of the security and welfare of human lives as its primary goal. As Zizek puts it in the second chapter of his 2008 text “Violence”: It is clear how these two dimensions overlap: once one renounces big ideological causes, what remains is only the efficient administration of life . . .almost only that” (Zizek, 2008 : 40). This almost is important because once politics is merely confined to the efficient management of everyday life, to “scientific governance” of minds and bodies, the only way to sufficiently impassion and motivate is through substantial fear of an Other who is supposed to be harmful to the social fabric and wellbeing of the community (the homeless, the mad, immigrants, criminals, pedophiles, and “groomers” to use a few contemporary examples). This perceived harm then justifies moral and legal campaigns to neutralize the “threat” in question by institutional means, whether its a “Crime wave”, “Migrant invasion”, or a “mental health epidemic”. There are no politics here, only problems to be solved and the best means to solve them. This reduces the autonomy of subjects to supposedly “apolitical” institutional interventions to a sort of non-factor, purposefully disregarded for the management of what is considered bare life.
I can not stress enough that this kind of “post-political” administration of populations is a bipartisan ideological phenomena within modern capitalism. Perhaps no U.S. politician reflects this fact better than the governor of California, Gavin Newsom, a “progressive” liberal if ever there was one, who has nonetheless proudly expanded the state of California’s capacity in terms of beds in psychiatric facilities while simultaneously cutting funding to outpatient services, crisis response services, and early intervention programs. The agency “Disability Rights California” (DRC) has made the case that ”The loss of mental health services act (MHSA) funding will deprioritize our historically underserved, unserved, and inappropriately served BIPOC and LGBTQIA+ communities by dramatically reducing funding for much-needed mental health services (Peer advocates mobilizing, 2023).
What is truly remarkable about this development is that Gavin Newsom has used the threat of a “mental health epidemic” and a homelessness crisis to justify the reduction of alternative sources of “treatment” for mad and disabled people, all while increasing the state’s capacity for psychiatric incarceration! Ironically, the text of the bill under discussion (California Senate Bill 326, 2023-2024 session) decries the incarceration of the mentally ill within the Prison Industrial complex as “economically inefficient”, and leading to recidivism as compared to the alternative of psychiatric treatment. The bill also expands county reporting and record keeping requirements across the state of california, to be anonymously studied by an advisory board of mental health professionals for treatment and program optimization. We can clearly see, then, that the underlying drive for the passage of this bill is NOT care for psychiatric service users and survivors, but the efficient administration of the “mentally ill” at the minimal necessary cost to the state.
Whether you are Vivek Ramaswamy or Gavin Newsom, a Trumpian populist or a progressive liberal, the bipartisan consensus regarding mental illness and the “mental health epidemic” today is that it should be up to the representatives of the state, private and public partners, and professional researchers to decide what to do with psychiatric service users. This determination “cannot” be made by mad people and service users themselves, because how do “they” know what is best for them? “They” are in need of professional help after all… No, it is much better that “we”, the sane, the “stable”, the “healthy”, the “experts”, help them to become more like “us” and return to society with the ability to cope with the way things are.
To look at things a bit more two-sidedly, we might consider the motivation for this popular deference towards psychiatric institutions and the professionals who staff them. Psychology and Psychiatry, as the argument goes, are forms of modern empirical science. The proponents of these fields have finally cracked the code of the human brain, of human wellbeing, and thus are considered some of the only proper scientific managers for human beings experiencing psychological and emotional distress. Of course it is cruel to throw the homeless, the disabled, and the mentally ill into prisons, where they are likely to be abused and to be drawn back into the system through a lack of opportunity and care – progressive liberals readily admit this. Police officers and security guards do not care for human beings in need!
If you want to improve the health and wellbeing of an animal you go to a veterinarian, if you want to improve the quality of a building you call an architect or a contractor, and when considering who to go to for personal improvement or the alleviation of psychological and emotional distress you go to a therapist – or a psychiatrist – or a social worker. Whoever you go to, you normally go to the psy-professions.[2] Only they know how to help. They are the experts and so are invested with a minimal level of institutional and epistemic authority that is not granted to service users and survivors, whose autonomy is regarded variously as secondary or negligible, even by many service-users themselves.
At an individual level, this manifests in an implicit trust for “mental health professionals”. Their expertise functions like a radiant golden crown on the head of a king or queen indicating God-given authority, except that rather than being the presumed carriers of God’s favor, psy-professionals are the presumed carriers of privileged knowledge and expertise. The radiant authority of the natural sciences pulls in those experiencing distress, trauma, hopelessness, and pain with the hope of self-improvement or the alleviation of their ills. Each of us is tasked with the responsibility of finding our personal therapist and/or mental health team, doing the work of subjecting ourselves to a master who can look over our thoughts, behaviors, and wellbeing for us. Happiness, neurobiology, growth, child development, self-realization, all become the expert domain of the psy-professions.
In this frame of logic, both the views of Ramaswamy and Newsom can be accounted for. In the face of so many threats to the prevailing social order and its stability (homelessness, wealth inequality, domestic extremism and terrorism, ecological collapse due to anthropogenic climate change) the political representatives of our capitalist ruling class feel the need to employ psychiatric expertise in stabilizing the prevailing social order. They need a managerial bureaucracy to keep the system going, and this is exactly what the psy-professions do. Do you have an epidemic of crime and sexual degeneracy? Well, these things must be the result of a “mental health epidemic”, you need to incarcerate the perpetrators so that they can “get better”. Does your state suffer from a homelessness crisis? The easiest way to hide homeless people from tourists is to throw them behind locked doors until such time as they can be “reformed”. No matter what the problem is, the psy-professions or some subgroup among them are invariously ready to put themselves forward as a listening ear, a scientific administrator, or a wise sage for personal solutions to the problem in question.
This situation where the psy-professions take on a more and more prominent role in the administration of society such that this intervention becomes practically invisible to us on a day to day basis is the result of a long process whereby scientific ideas on mental pathology and human wellbeing have seeped outwards from within psychiatric institutions towards the public sphere, where these scientific ideas have assumed the form of a Hegemonic Ideology identified by Marxist Sociologist Bruce Cohen as “Psychiatric Hegemony”.[3] Cohen openly acknowledges that “The mental health system has always had ideological dimensions, yet the recent demands of neoliberal capital have necessitated the expansion of the psychiatric discourse to the point where it has become hegemonic and totalising. Our behaviour, our personalities, our lifestyles, our relationships, and even our shopping trips are now closely observed and judged under this psychiatric hegemony, and we have in turn come to monitor and understand ourselves through this discourse” (Cohen 2016 : 70)
Over the course of his 2016 text of the same name, Cohen expands upon this concept of Psychiatric Hegemony through an in-depth analysis of the history and development of psychiatric institutions in the United States and Western Europe, making the case that we must understand how the nature of the psy-professions and psychiatric institutions arise from the specific politico-economic dynamics of the Capitalist Mode of Production in these societies. For instance, how the social organization and provisioning of care on the basis of its commodification in turn results in significant inequalities in who receives institutional intervention and what the nature of this institutional intervention is within our medical and “mental health” systems:
“These patterns within medicine mirror and reproduce oppressive features of the wider society as well.” Marxist scholars of medicine have theorised this replication of the wider class struggle within the health system in a number of ways. First, the priorities of the institution favour those of capitalism and the ruling class. For example, the modern system of health care emerged out of the need for a healthier and more reliable industrial workforce (Waitzkin 2000 :48); concern for the health of the working classes has tended to peak when there are imperialist wars to be fought, while the majority of current medical research prioritizes lifestyle and “me too” cosmetic treatments for the global market rather than research on life-saving treatments for cancer and infectious diseases (see, e.g., Rapaport 2015 ). Second, the exploitative work relations within capitalist societies are replicated within the rigid hierarchy of medicine, with high-waged, upper middle-class consultants holding a great amount of decision-making power at the top, the lower middle-class nursing managers administering consultants’ needs in the middle, and—holding no power whatsoever and subject to the whims of health managers—the low-earning working-class orderlies and auxiliary staff at the bottom of the pyramid. Navarro (1976 : 446) also notes the tendency of the medical profession to maintain and reinforce these class relations through “both the distribution of skills and knowledge and the control of technology” within the health service.Third, the health system functions as an institution of social control. That is, it reinforces the dominant values and norms of capitalism through its surveillance and labelling practices. In the words of Freidson (1988 :252), medicine acts as a “moral entrepreneur” to the extent that illness is viewed negatively and as something to be “eradicated or contained.” (Cohen 2016 : 32)
“These patterns within medicine” and within the Psy-professions more specifically, are the symptomatic expression of the underlying capitalist economic base in which psychiatric institutions function. But equally and simultaneously, they are the symptomatic expressions of sanism, its objectification within the rhetoric and practices of psy-professionals themselves. These Objective forms of violence burst into the lives of persons and impose themselves upon service users and survivors as a world of rules and meanings not our own.
Psychiatry as “Objective” (Systemic and Symbolic) Violence
Therapists and other psy-professionals are cops, the law, agents of social control. Whether individual persons in these fields personally want to take on this institutional role is of little consequence to the machines of which they are an operative part. These institutional machines process large amounts of people each year, generating outputs in the form of documents, diagnoses, prescriptions, insurance claims, and so on – generating interventions (and thus experiences) in the lives of persons.
In bearing witness to the broader systemic conditions that in turn give rise to or facilitate particular experiences of harm by psy-professionals, my goal is to grasp the objective historical basis for the lived experience of persons; lived experiences of harm generated within the particular institutional structures, practices, motivating incentives, and the discourses that constitute the praxis of the psy-professions themselves. Few people would argue that psychiatric institutions are free from exploitation, discrimination, and violence – such a case is clearly wrong from the jump, and proven wrong by the mere existence of so many psychiatric survivors, Mad activists, and scholars telling their stories to this day (Moore; Russo & Sweeney 2016; Mason). Rather, modern day defenders of psychology and psychiatry do so on the basis that it is not as bad as it used to be – the story goes that there are less people being forcibly committed to psychiatric wards today, fewer modern day examples of experimental psycho-surgeries like lobotomies being used in treatment, less stigma around mental health conditions, access to trauma-informed care is improving, the science around different conditions and treatments is constantly improving, and so on. The formal prohibition of the kinds of brutal treatment that generally characterized the European and U.S. asylum systems during the 19th and 20th centuries is taken as evidence of modernization, and so most tend to look away from what we know about how the psy-professions still operate on a broader level.
This cynical tendency to downplay ongoing systemic abuses against mad and disabled people within psychiatric settings by reducing them to the actions of uniquely evil individuals, generally not reflective of the idealized progress of clinical science illustrates perfectly why Slavoj Zizek argues that we must not fall prey to the spectacle of subjective violence, “of violence enacted by social agents, evil individuals, disciplined repressive apparatuses, fanatical crowds” (Zizek, 2008 : 11). When we identify violence only with the cruel individual, act or phrase, only with explicit harm committed by identifiable agents, we render opaque – invisible – those Objective forms of Systematic and Symbolic violence that in turn condition and give rise to the very conditions of possibility for Subjective (individual, personified) violence. Rather than assuming that a background zero-level of non-violence is the norm in psychiatric institutions, with psychiatric abuse, neglect, and incarceration being rare exceptions to the smooth functioning of the clinical machine, we can and should identify how psychiatric abuse, neglect, and incarceration arise as the symptomatic expression of this smooth functioning itself – how it is actually constitutive of what the psy-professions are as a form of institutionalized social control.
Systemic violence is, strictly speaking, objective, anonymous, and therefore not as often attributable to particular social agents who can be identified as responsible for committing wrong. Zizek uses the evocative example of the infamous imperialist King Leopold II, arguing:
“The fact that the Belgian king Leopold II who presided over the Congo holocaust was a great humanitarian and proclaimed a saint by the Pope cannot be dismissed as a mere case of ideological hypocrisy and cynicism. Subjectively, he may well have been a sincere humanitarian, even modestly counteracting the catastrophic consequences of the vast economic project which was the ruthless exploitation of the natural resources of the Congo over which he presided. The country was his personal fiefdom! The ultimate irony is that even most of the profits from this endeavor were for the benefit of the Belgian people, for public works, museums, and so on”. (Ibid : 14-15)
This is important to keep in mind – no matter who Leopold II was as an individual, his personality, ethical code, religion and so on; none of these things had the power to modify his objective position as the colonial occupier of the Congo nor the monstrous violence he enacted upon its people, and none of these things changed the profitability of rubber, copper, or cobalt, or the demand for these raw materials in Europe for further production and sale. This is the very essence of systemic violence: it takes the form of catastrophes which arise from the smooth day-to-day functioning of established economic and political systems. The systematic drive of profit-making within a capitalist mode of production takes on a reality as real as any raw material. The relationships, “agreements”, and monetary contracts formed between various capitalists, state actors, workers, peasants, and so on, are all Objective social relations in this sense. Zizek argues that “the intricate relationship between subjective and systemic violence is that violence is not a direct property of some acts, but is distributed between acts and their contexts, between activity and inactivity” (Ibid. : 213). In this sense, the behaviors and significations of subjective actors are shaped and over-determined by the objective systematic context that they occupy, such that their personal thoughts and feelings often matter less than the actual actions, forms of inaction, and overall function they undertake in their objective social positions.
The objective social position of psy-professionals as petit-bourgeois professionals and as agents of epistemic and institutional authority similarly shapes the thoughts, actions, feelings, and social functions that they reproduce in their particular personhoods. In this way, it is less important what particular therapists, psychiatrists, social workers, and so on intend or believe they are doing in the course of their work. As individuals – much like King Leopold II – they can be progressive, kind, charitable, and sincerely concerned for the wellbeing and happiness of service-users and survivors. Their objective position relative to service users and survivors does not change as a result, the presumed institutional and legal authority of psy-professionals over the bodies and minds of mad and disabled people is not altered by the moral excellence or lackthereof within the psy-professions as a whole. The role that psy-professionals play in studying, categorizing, diagnosing, determining treatment plans for, and producing documents about their particular patient-objects is essentially that of bio-political and ideological control.
This is why I argue that Therapists and the whole caste of psy-professionals are essentially Cops in their objective social function: their role is constituted by the policing of boundaries – boundaries between reason and unreason, boundaries between sanity and madness, boundaries between civil society and those deemed “a risk to themselves and others”, between a productive happy life and misery… psy-professionals are a special kind of Master-figure much like the figure of the cop, except that instead of wielding the sanctity of the law like an ideological bludgeon, they prefer the weapon of scientific and professional authority. This tool helps them to define away the agency of mad people and those labeled with psychiatric diagnoses, explicitly equating madness with irrationality in a way that grants clinical psy-professionals and other agents of the state direct institutional control over service-users deemed insufficiently worthy of autonomy.
This brings us to the second major kind of objective violence identified by Slavoj Zizek: Symbolic violence, which he describes as being “embodied in language and its forms, what Heidegger would call ‘our house of being.’ As we shall see later, this violence is not only at work in the obvious – and extensively studied – cases of incitement and of the relations of social domination reproduced in our habitual speech forms: there is a more fundamental form of violence still that pertains to language as such, to its imposition of a certain universe of meaning” (Ibid. : 1-2). This is the immense power that resides in what Zizek (drawing from Lacan) calls “The Symbolic Order”, a theoretical term for the proverbial “rules of the game” governing our day to day social and linguistic interactions:
What, then, is this symbolic order composed of? When we speak (or listen, for that matter), we never merely interact with others; our speech activity is grounded on our accepting and relying on a complex network of rules and other kinds of presuppositions. First there are the grammatical rules that I have to master – blindly and spontaneously: if I were to bear these rules in mind all the time, my speech would break down. Then there is the background of participating in the same life-world that enables me and my partner in conversation to understand each other. The rules that I follow are marked by a deep divide: there are rules (and meanings) that I follow blindly, out of habit, but of which, if I reflect, I can become at least partially aware (such as common grammatical rules); and there are rules that I follow, meanings that haunt me, in ignorance(such as unconscious prohibitions) (Zizek, 2006 : 9).
It is important that we understand what Zizek means when he refers to this deeper kind of symbolic violence, realized in the imposition of an intersubjective universe of meaning upon persons’ through their integration into a symbolic order which provides for them a certain Weltanschauung, or worldview to live by, through which to interpret their own lived experience and place in the world. For our purposes here, in seeking to critique psychiatry as an institution of bio-political and Ideological control, our goal is to identify those specific ways in which psy-professionals have imposed a certain professional worldview (weltanschauung) upon service users and survivors, and how this worldview functions to represent the psy-professions, mental health symptoms, and service users/survivors as the objects of a hegemonic discourse.
This sort of ubiquitous, intersubjectively-imposed universe of meaning is precisely what the Marxist Sociologist Bruce Cohen has in mind when he uses the term “Psychiatric Hegemony” to describe the ideological role of the Psy-Professions within capitalist society today. Psychiatric Hegemony is Symbolic violence par excellence, with its power to negate and transform living, breathing, dynamic human beings into biological machines, perhaps affected by their social environment, even changed by it, but ultimately an organic machine nonetheless – whose parts can be dissected, categorized, and understood in the context of the overall physiology of the whole organism. The symbolic violence of this interpretive act lies precisely in the analysis of the particular diagnoses, symptoms, experiences, and personality of the patient-object from without, so that psy-professions function as the privileged interpreters of psychological phenomena, armed so often in the 21st century with the dominant tools of biomedical psychiatry and the disease model.
Objective (Systemic and Symbolic) violence thus constitutes the hard underlying kernel at the center of each instance of Subjective violence, experienced at first as a random exceptional outburst or the act of a uniquely evil person, until it is properly systematically contextualized in terms of what brought about the outburst of subjective violence in the first place. In developing a philosophical and political critique of psychiatric hegemony and sanism, a central task for any sufficiently critical or systematic analysis is to identify the particular historical and institutional factors that have led the psy-professions to take on such an increasingly significant role as agents of social and ideological control – to understand how these functions of social control arise directly from the social position occupied by and the history of the Psy-Professions..
For scholars who are proponents of the sciences of dialectical and historical materialism, this is synonymous with the task of identifying how the oppressive features of modern psychiatric institutions have historically developed out of capitalism’s need to create institutions for the categorization, exploitation, reform, and even the disposal of unproductive, intransigent, or otherwise “useless” persons from the perspective of the ruling class within capitalist society. This is not some conspiracy-theory set in a smokey backroom where a handful of powerful people can be identified as responsible, but a story of decentralized decision makers, a gradual process whereby the converging interests of politicians, psy-professionals, insurance and pharmaceutical corporations, and so on, all culminated in order to expand the available machinery for the control and modification of thoughts and behaviors at the disposal of state, market, and institutional authorities. Going forward, we will explain how these systematic tendencies within capitalism as a system significantly influenced the course of development of the Psy-Professions in the U.S. since the end of the Second World War and the long period of psychiatric “deinstitutionalization” (marketization) that followed.
The Drug “Revolution” and the Early Years of Psychiatric Deinstitutionalization (Marketization)
In seeking to explain the particular course that the Psy-professions have taken in the mid to late 20th century, Bruce Cohen takes us back to the period of psychiatric “deinstitutionalization” which can generally be used to describe trends beginning just after the end of World War 2 in the 1950’s, with tendencies towards marketized outpatient and psychopharmaceutical interventions intensifying to a state of professional dominance in the 1970’s and 1980’s in the U.S..
It was around the end of World War 2 that over 500,000 Americans were being held within the U.S. Asylum system, with these overwhelmingly being members of poor, working class, and marginalized communities interned against their will for being deemed too deviant, disordered, or otherwise problematic for the outside world (Cohen, 2016. : 41-42). We must keep in mind that this was a truly massive carceral enterprise, that the American Asylum system in the 1950s’ was twice as large as the prison system at that time, and that the scale of the U.S. prison industrial complex would not surpass the heights in incarcerated population already achieved under the Asylum system until the early 1980’s under the Reagan administration. (United States – World Prison Brief).
This, in turn, led to a gradual but significant rise in funding and resources allocated by state governments for the maintenance and staffing of public psychiatric institutions during the period, which was consequently registered in state coffers as a budget-expense like any other large-scale social program. Yet, the Asylum system was not like other existing social programs of its time because of the specific Ideological function it played within the institutional era of psychiatry. It was perhaps the Ideological trash bin of the era, used to throw away those who were deemed too abnormal or deviant for civil society – to categorize and sort them in accordance with the particular kind of “dysfunction” or “illness” specific to them, and to use this category-label as the basis upon which to justify confinement, regulation, medication, and even psycho-surgical intervention – a relatively common practice at the time in hospitals all over the country (Whitaker, 2001 ; 121-127).
Shortly after the end of World War 2, in the year 1954, something incredible happened: the pharmaceutical company Smith, Kline & French introduced chlorpromazine into the U.S. market, selling it as Thorazine and marketing it as the very first antipsychotic psychopharmaceutical medication to be proven therapeutically effective in clinical settings. Psychopharmaceuticals had been employed in the Asylum system well before this, and as early as the 1920’s sections of the American Bourgeoisie were beginning to invest heavily in psychiatric and pharmaceutical research (Whitaker 2001 : 63, 128-129), but it is generally agreed among the scholars that I’ve read that it was Thorazine that kicked off “The Drug Revolution” in Psychiatry. Within a year, as many as two-million Americans were taking the drug, and its perceived effectiveness and safety was taken as a very important piece of new proof of the biological causation of mental illness within biomedical psychiatry (Cohen 2016 : 55).
I say “perceived effectiveness” because, as Cohen points out, psychiatric professionals in the Asylum system already knew about Thorazine and had been experimenting with it during the late 1940’s/early 1950’s, and their findings revealed that Thorazine was primarily useful as a chemical restraint in psychiatric wards, quite similar in its effects to a lobotomy, but without the permanent brain damage (Ibid. : 56-57). Within a year of launching the drug, Smith, Kline and French were reporting a total yearly sales increase of over a third. This grates against the conventional narrative of the Drug Revolution advanced by institutional psychiatry, where de-institutionalization was brought on by a greater public access to outpatient services and effective psychopharmaceutical medications like Thorazine, but many American psychiatric wards began depopulating prior to the widespread implementation of Thorazine in the 1950’s, and most European countries wouldn’t see a reduction in patient figures until the 1970’s – well after the widespread implementation of the drug (Ibid. : 58). The conventional narrative, then, is clearly untenable as a historical hypothesis.
With this being said, if we view the Drug Revolution primarily as a commercial and ideological revolution, keeping in mind that Thorazine was specifically marketed to state legislatures through fiscal arguments surrounding “health economics” and “cost cutting”, the historical picture begins to make a little more sense. Fiscally conservative politicians had every incentive and desire to cut welfare and public spending and to reduce the “burden” that psychiatric institutions imposed on state budgets. As far as many psy-professionals at the time were concerned, psychiatry was in the process of entering a new era: a scientific era, where biomedical psychiatry and the Drug Revolution were rapidly uncovering the etiology, therapies, and even cures for various kinds of mental distress, and where the abuses of U.S. mental asylums would finally be consigned to history on the path to progress. This emerging generation of scientifically-minded psy-professionals was bolstered by the epistemological and professional authority derived from Biomedical psychiatry and the perceived effectiveness of psychopharmaceuticals’. The Journalist Robert Whitaker describes some of the ideological and discursive work driving this early process of deinstitutionalization in his book Mad in America (Whitaker, 2001), citing a 1963 speech by President John F. Kennedy as an informative example:
“In early 1963, President John Kennedy unveiled his plan for reforming the nation’s care of the mentally ill. The state hospitals, relics from a shameful past, would be replaced by a matrix of community care, anchored by neighborhood clinics. At the heart of this vision, the medical advance that made it possible, were neuroleptics. Two years earlier, Kennedy had received the recommendations of the Joint Commission on Mental Illness and Mental Health, and in that report the drugs had been described as having “delivered the greatest blow for patient freedom, in terms of non restraint, since Pinel struck off the chains of the lunatics in the Paris asylum 168 years ago . . . In the surprising, pleasant effects they produce on patient-staff relationships, the drugs might be described as moral treatment in pill form.” (Whitaker, 2001 : 155-156)
We must understand that this program of reforms which came to characterize these early phases of “deinstitutionalization” – gradually clearing the U.S. asylum system for alternative methods of psychopharmaceutical and in-community outpatient interventions – was also, simultaneously, a political project of marketization and austerity. The move towards community care, outpatient clinics, and psychopharmaceutical intervention as primary care-pathways was driven by a confluence of intersecting interests among state officials, psy-professionals, pharmaceutical companies, and insurance agencies who all had something or other to gain from the process of reducing populations in state-run hospitals and asylums and expanding outpatient care, pharmaceutical, and insurance markets.
Yet, we should not use these financial and professional incentives to imply that the process of psychiatric “deinstitutionalization” (marketization) was done cynically, merely for the purposes of profit, control, and professional clout. It is generally unwise in my opinion to replace systematic analysis with a blind hermeneutics of suspicion, imagining psychiatrists, psychologists, insurance agents, lobbyists, and politicians sitting in a dark backroom, undertaking a formal conspiracy to make themselves richer and more ideologically powerful.
Rather, we must grasp how the objective institutional and economic positionality of different particular historical actors during this period incentivized a gradual process of reducing the population in state-run inpatient programs, increasing private and public investment in the development of outpatient programs while also increasing reliance on the use of psychopharmaceuticals as a means of symptom-regulation. The Psy-Professions at this time were at a stage in which they had to metaphorically “shed their old skin”, emerging not as the butchers of the late 19th and early 20th centuries, but as scientifically minded medical professionals who could be trusted to know what they were doing because of their privileged knowledge regarding the human mind and its wellbeing.
This battle for professional and epistemic legitimacy was made only more protracted by controversies within and surrounding the American Psychological association in the 1970’s. These included insurgent social movements – including movements led by psychiatric service users and survivors AGAINST the arbitrary authority of Psy-professionals, as well as internal struggles within the APA over the status of homosexuality, which had been designated as a mental illness in the DSM-I and DSM-II (Cohen 2016 : 13). These serious challenges to the authority of the APA and the Psy-professions as a whole constituted both a scientific and political crisis that necessitated some kind of legitimizing response by the field(s). This began in an embryonic form with the so-called “Drug Revolution” – the knowledge of and power to prescribe drugs gave the Psy-professions a legitimizing veneer through a common set of practices and discourses shared by them with other bodies of medical professionals.[4]
The actions of Psy-Professionals during the mid-20th century should be placed in this context, as motivated by the need for a renewed sense of epistemic and professional authority, facilitated by the perceived successes of “the Drug Revolution” and the early phases of “deinstitutionalization” (marketization) of psychiatry. In the face of ever-proliferating critiques by scholars, activists, and psychiatric survivors, this was seen as a necessary defense by the psy-professions of their scientific legitimacy and privileged position as highly educated middle-class professionals.
In 1965, during the annual meeting of the American Psychiatric Association (APA), Mike Gorman (then the executive director of the national committee against mental illness) declared that psy-professionals urgently needed to develop new skills and terms in order to deal with the problems of deinstitutionalization and the ever-growing mass of critics and psychiatric survivors in opposition to the mental health system. As Cohen puts it:
“Fundamentally, psychiatry was not speaking to the people. The middle class ‘worried well’ spent years in private therapy hoping to learn what was really going in their unconscious, while the working classes still faced a largely coercive system of public psychiatry in institutions or outpatient facilities. It was time, Gorman argued, for psychiatry to justify itself to an increasingly cynical public who often felt that whatever ‘mental illness’ was, it was someone else’s problem. Reflecting the disenchantment of many within the APA. Gorman stated that: ‘Psychiatry must develop a public language, decontaminated of technical jargon and suited to the discussion of universal problems of our society … as difficult as this task is, it must be done if psychiatry is to be heard in the civic halls of our nation’ (Cohen, 2016 : 75).
Looking back on this quote almost 60 years later, it is easy to take for granted how successful this professional project of constructing a “public language” has been. So often we find ourselves articulating our emotions, behaviors, and experiences through the very public language that the psy-professions’ have developed over the past six decades. So often we refer to our own experiences of anguish with the clinical terms of depression and anxiety, we refer to unruly children as “hyperactive” or as “definitely having ADHD”, faux-diagnose our friends based on their particular characteristics in the form of a joke, and we can do this playfully or in all seriousness. Likewise, the weaponization of “mental health” as a catch-all explanation and boogeyman by our political class – similar to the terms criminal and immigrant- reflects an underlying and purposefully manufactured disdain for the mad expressed through the professional language of the psy-professions. Whether we really buy into this ‘public language’ or just use it isn’t the point. The point is that, on a broad scale, our very terminological lexicon and framing devices for normal behavior, mental health, and distress have been territorialized, taken over by the psy-professions. Therapists and Psychiatrists speak through our mouths, we articulate ourselves from within their discourse, make ourselves intelligible as a patient-object to be processed through the system, so that all they ultimately hear are echoes of their own voices.
This is the fundamental violence of Psychiatric hegemony, that it is not merely effective in the realm of abstract ideas, but is objectified in the form of discourses, institutional arrangements between service users and psy-professionals, jokes about mental illness, interpersonal and institutional discrimination, media depicting mad people and those labeled mentally ill as murderous or unstable, undeserving of agency – all of this perpetuates and popularizes a sanist Weltanschauung (Worldview) which then functions to govern day to day social relations through its practical reification in action and in thought.
This sanist worldviewhas taken its most obvious forms in the resurgence and popularization of Bio-psychiatry and the disease model in and just before the 1970’s, but it has also been perpetuated more generally by all those with something to gain from a program of individually-oriented marketized social control of working class and oppressed people. The capitalists benefit because the boss gets disciplined and economically productive workers more focused on individual solutions to their problems than collective or political solutions that might challenge the bosses social position. Corporations directly involved in the production and patenting of medical technology, psycho-pharmaceuticals, novel therapies, and other “treatments” benefit insofar as they rake massive profits in from their alliance with the Psy-professions and maintain a stable social order to do their business in.
Psy-professionals themselves, occupy a definite social position within modern capitalism, corresponding to a definite mode of day to day life where the categorization, quantification, regulation, and restriction of living human beings in accordance with established cultural, legal, and professional-psychological norms is their job. It’s how they make their living, how they achieve personal and professional prestige, how they support themselves and their families – in other words, even self-critical reformers are heavily invested in existing social arrangements due to their position as highly educated professional bureaucrats privileged by those arrangements. This alignment of interests among many divergent parties has led to the formation of a symbiotic relationship between them, where each legitimizes and strengthens the reach and authority of the others through their combined projects and influence.
When Mike Gorman called for the psy-professions to adopt a “public language” in 1965 so that civilians and public institutions alike might take these fields more seriously and employ their help more often, he surely could not have imagined that his suggestion would be as heavily institutionalized as it was from 1980 onward, nor could he have predicted just how ubiquitous that “public language” would become in popular culture. Yet, this was surely a major goal of Gorman in particular and of the psy-professions more generally, to redeem themselves as scientific medical professionals, masters of the human mind and of care for its well-being in a similar way that physicians can be considered masters of the human body and its well-being.
This is actually an excellent example of a Hegelian concept known as the “Cunning of Reason” which will help us avoid the sort of blind hermeneutics of suspicion that I mentioned earlier as a possible approach to criticizing the psy-professions and Sanism; Such a limited approach ultimately only leads us back to an acknowledgment of subjective violence and its horrors, never reaching the depths from which that subjective violence erupts. The “Cunning of Reason” describes a process whereby a historical actor, in their particular individuality (their personality, passions, objectives, and actions) bring into being more Universal, world-historical consequences by unintentionally triggering the necessary conditions for such a transformation to come into being. In this way the particular subjective will of the historical actor is overdetermined by the material, institutional, and socio-symbolic conditions which they inhabit, reducing their intention to a sort of non-factor which simultaneously and contradictorily brings about a rupture in prevailing conditions . The individual, in their finite personhood, becomes an agent of History.
I would argue that the historical development of the Psy-professions from the very early phases of deinstitutionalization in the 1950’s to now can be understood in the terms of this “Cunning of Reason”, more particularly in the Cunning of Sanist Reason itself as a broader historical phenomena objectified in psychiatric institutions of all sorts. In their finite individualities, various psy-professionals sought a more modern and scientific version of their profession which could stand alongside physicians as representatives of modern bio-medicine. Others found themselves more attracted to psychodynamic and humanistic accounts of the human mind and its wellbeing, others made themselves reformers for trauma-informed care, destigmatization, or for addressing inequalities faced by marginalized communities in the “mental health system”. Most all of these figures, regardless of their intentions, morals, personalities, or philosophies contributed to the proliferation of the system that is sanism and the Ideological phenomena which is Psychiatric Hegemony, not because they willed it or because they are necessarily “bad people”, but because the very Sanist logic inherent in the “mental health system” itself was objectified in their actions, words, and selective inactions as agents of that system.
We should carry this knowledge forward in our analysis of the epistemic/professional crisis of Western psychiatry in the 1970’s and the eventual publication of the DSM-III in 1980, which was a direct response to that crisis. This new version of the DSM was written in simple english, helped to solidify bio-psychiatry as a dominant mode of psychiatric discourse, and helped expand diagnostic categories in terms of the sheer number of diagnoses available and the criteria that were used to apply them as labels to patient-objects.Like the drug revolution then, the turn to bio-psychiatry and the disease model that came as a response to the crisis of the 1970’s was a sort of false revolution in psychiatric thought and practice which retroactively became a true Ideological revolution in the public sphere. The virtual invisibility of psychiatric hegemony today, its seemingly “non-political” and scientific character, is a direct result of this Ideological revolution and a reflection of its near-totalizing success at constructing and perpetuating a Sanist Weltanschauung fit to our contemporary era of Neoliberal capitalism.
The Crisis of the 1970’s and the Rise of Bio-Psychiatry
It would be wise to begin with a more in-depth exploration of the context that created the crisis of Western Psychiatry in the 1970’s if we are going to understand why particular actors took the steps that they did in legitimizing the psy-professions as a response to this crisis.
During this period “Institutional Psychiatry”, another name for the massive state-run U.S. Asylum system was already in a state of significant decline in terms of its prestige, funding, and overall interned population (Harcourt 2011: 42). As was stated earlier, this was facilitated by the perceived success of the “Drug Revolution” at developing effective psycho-pharmaceuticals and an increasing emphasis by politicians on cutting costs and reintegrating service users back into their communities through outpatient care programs. At the same time, the frequent abuses and neglect committed against psychiatric survivors in these institutions, their tendency to pathologize everyone who walked through their doors as carrying the tell-tale signs of “Mental Illness”, and an ever-proliferating series of Exposé’s and personal accounts revealing these systematic abuses and oversights, all led to a decline in the public reputation of the psy-professions. Even if you didn’t know that much about Psychology or Psychiatry at the time, it was common knowledge that you didn’t want to be thrown into the Asylum system. For one, you couldn’t possibly know when you would be released, and secondly you had no idea and no power over what could be done to you once you were involuntarily admitted.
This popular sentiment, backed up by the horror stories of friends, family members, acquaintances and even strangers was only further bolstered by a sizable and growing ethnographic literature based in U.S. psychiatric institutions during the 1960’s and 1970’s. As Cohen points out in Psychiatric Hegemony (2016), these included studies by Irving Goffman in 1961, by Thomas Scheff in 1966, and most importantly in terms of its impact on public opinion, a 1973 study by U.S. Psychologist David Rosenhan titled “On Being Sane in Insane Places” (12). In this study, Rosenhan sent several “pseudo-patients” (students and researchers not diagnosed with any kind of psychiatric label) into different psychiatric hospitals, all with the same goal: get labeled with Bipolar disorder or Schizophrenia and get admitted into the hospital in order to record what happens there. All of the participants were admitted and given such a label, all of them were held for at least a week, and all of them found that their behaviors – even the note taking they were required to do for the study – were pathologized by the doctors staffing the hospital as evidence of their “disorders”. The results of the paper and the claims advanced by Rosenhan’s work as a whole were outright scandalous for the Psy-professions. Rosenhan was claiming that Psy-professionals at every hospital he sent malingerers to literally could not tell the difference between the “real” and his “pseudo” patients. This only lent further credence to the idea (already propounded by Scheff in 1966) that the diagnostic categories being used by the Psy-professions were more or less socially constructed labels, applied to persons deemed deviant or insufficient in some manner by high-status professionals given the authority to police normal behavior and personalities.
These three factors alone (fiscally conservative politicians attempting to cut the budgets of state psychiatric facilities, a growing population of journalists and psychiatric survivors educating the public about the systemic abuses of “Institutional Psychiatry”, and an expanding body of ethnographic literature calling into question the practices, authority, and basic knowledge-base of the Psy-professions), would have been enough to constitute an epistemic and professional crisis for Western Psychiatry on their own. And speaking very generally, these were the central issues that made the crisis of the 1970’s such a crisis. There was a substantial portion of the population, whether laymen or highly educated, that had very good reason to reject the practices, terminology, knowledge-base, and even the very legitimacy of the Psy-Professions as a whole.
But these aren’t the only reasons that this period would become known as the Crisis of the 1970’s, otherwise we could just as easily refer to it as the crisis of the 1960’s given that most of the factors that I’ve described thus far were already in place during that decade, and all of them worked to significantly undercut the perceived legitimacy of the Psy-professions going forward. Yet, these “external” factors, having to do with how the public and other groups of educated professionals (negatively) perceived the Psy-professions, were amplified by the “internal” factor of ruthless struggle within the American Psychological Association over the future direction of the Psy-professions and the publication of the DSM-III (which took place between the years 1974 and 1980). This is what makes the 1970’s so important in my view, it’s a time when Psychoanalysts, proponents of Bio-psychiatry, humanists, and reformers all waged professional warfare against each other to determine the future of their shared discipline, so that when the smoke clears with the publication of the DSM-III in 1980 there are definite winners and losers who emerge from the conflict.
Chief among matters of internal dispute within the APA at this time was the status of Homosexuality as a “mental illness” as it had appeared in the DSM-I and DSM-II. It would be comforting to say that the controversy over whether homosexuality could be considered a “mental illness” was brought about due to concerns with whether such a diagnosis had any scientific validity in the first place. It would be even more comforting if members of the APA simply realized that the people arguing for homosexuality to be considered a “mental illness” were bigots, imposing their own particular values upon human beings who were simply divergent from the cis-heterosexual norms perpetuated by such a stigmatized designation. But neither of these were the real reason for the controversy, even though there certainly were more reform-minded Psy-professionals working and rising through the ranks of the APA at the time who had scientific and moral concerns over the validity of homosexuality as a diagnostic category. Instead, it was the efforts and planning of gay and lesbian rights activists that would eventually lead to homosexuality being declassified as a mental illness in 1973, between the publication of the DSM-II and DSM-III.
It was the year 1970 at the annual conference of the American Psychological Association in San Francisco when gay and lesbian activists, led by Frank Kameny and Barbara Gittings, picketed the conference. There, they demanded of the APA that homosexuality be declassified as a mental illness and insisted that they would not stop organizing demonstrations against the Association until their demands were met. According to CBS news correspondent Mo Racca, they didn’t stop there, they came back the next year and infiltrated the conference directly in 1971. Kameny (who was fired from the army in 1957 for being caught by police in a gay mens club) took the microphone from a speaker giving a public lecture at the conference and declared “Psychiatry is the enemy incarnate. Psychiatry has waged a relentless war of extermination against us. You may take this as a declaration of war against you” (Racca 2019). That same year, Gittings (founder of the New York branch of the lesbian civil rights group “daughters of Bilitis”) went on public television with David Susskind and said to him that “Your attitudes toward us are the problem. There’s nothing wrong with homosexuality. The only thing wrong with it is that you people are upset about it. Why are you upset?” (Ibid.). Gittings made a clear case that it was the bigoted attitudes of the public and the Psy-professions posing as scientific authorities on homosexuality that needed to be interrogated, not the mental wellbeing and humanity of gays and lesbians.
This concerted and militant effort on the part of these activists won them an audience with the APA, with sympathetic members of the association helping to arrange a panel for them at the 1972 conference in Dallas titled: “Psychiatry: Friend or Foe to the Homosexual?”. Charitable sentiment on the part of reform-minded sections of the APA wasn’t the only motivating factor for inviting the disruptive activists to speak, though. At least not according to the Canadian Anti-Psychiatrist Bonnie Burstow, who claims in the third chapter of her 2015 text “Psychiatry and the Business of Madness” that “Among other things, psychiatrists wanted the disruption stopped. What was likewise a factor, it is largely psychoanalysts who made their reputation by “treating” homosexuality, and the battle between the neo-Kraepelinians and the analysts was beginning to gather momentum. Here was a way for the neo-Kraepelinians to at once marginalize the psychoanalysts, put an end to the embarrassment, and position themselves strategically” (Burstow, 2015 : 80). We can see then, that the faction Burstow identifies as “neo-Kraepelian”, a rising force in Psy-professions relative to the strength of the psychoanalysts, had every reason to support the cause of declassifying homosexuality as a mental illness.[5]
What Kameny and Gittings could not know when they were invited to the APA conference of 1972, was that they were reinforcements in a factional war within the APA that would help to turn the tides in the battle against the authority of the psychoanalysts. Though the objective of these activists was chiefly gay and lesbian liberation and certainly not to bolster the professional authority of more bio-deterministic trends in psychiatry, this is exactly what they ended up inadvertently doing through their loose alliance with the internal reformers of the APA.
In light of this narrow opportunity for declassification in 1972, Gittings and Kameny came to the conclusion that they needed a psychiatrist on the panel to give them a degree of legitimacy to the people who would be voting on whether or not to declassify homosexuality as a mental illness. So Gittings invited a gay psychiatrist organizing quietly on the outskirts of the APA named John E. Fryer to attend and speak at the panel.
Fryer had previously been forcibly expelled from his job at the University of Pennsylvania because it was found out that he was gay, so he knew what it was like to be discriminated against for his sexuality, and he was very afraid of speaking at the panel for fear that he might lose his career. Still, he decided that he had to share his story as a gay psychiatrist and came up with a solution to the possibility of his testimony affecting his career: Fryer would don a disguise. Wearing a wig, a baggy tuxedo, and a mask, and speaking through a voice modulator, Fryer addressed a ballroom full of his peers in Dallas Texas under the pseudonym “Dr. Anonymous” (Racca 2019). Fryer told his colleagues about his experiences hiding who he was, how it forced him to live a double life in order to keep his job, how it was perfectly possible to be a homosexual and to be “healthy”. According to Racca, “He [Fryer] pressed his fellow psychiatrists to help others become more open-minded: “We must use our skills and wisdom to help them—and us—grow to be comfortable with that little piece of humanity called homosexuality” (Ibid.).
Fryer’s words, and the panel as a whole, made a significant enough dent in the debate to have a committee formed for the investigation of the “question” of whether homosexuality was a mental illness or not. The committee, of course, could find no scientific evidence in the positive for the classification of homosexuality as a mental illness, but to be frank this wasn’t really the point of the committee in the first place. In the face of disruptive protests by activists, more and more widespread public questioning of Psy-professional authority, petitions from members within the APA for declassification, and an internal struggle between the Psychoanalysts and Bio-medically oriented Psychiatrists, the formation of this committee was more like professional damage control that allowed the APA to save face to the public and its members while changing its official policies in order to slow the bleeding of the crisis of the 1970’s (which was, at this point, in full swing). As Cohen puts it in Psychiatric Hegemony “The end result was a decision based not on research evidence but rather a simple postal vote of APA members [In 1973]” (Cohen 2016 : 13).
In this way, the fight for the declassification of homosexuality became the particular occasion for a power-struggle between competing factions of the APA. However, the true essence of this power-struggle was not to be found in the particular issue of whether or not to declassify homosexuality, although this issue did occasion the intensification of the struggle. Instead, the traumatic kernel at the heart of the professional warfare being waged within the APA was the crisis of the 1970’s itself. In a very simple sense, this can be taken to mean that the battle lines were set by the differing orientations of opposing factions within the APA to the crisis of public legitimacy. Psychoanalysts wanted to keep treating homosexuality as a kind of defect to be sorted out by talk-therapy. The forces of reform and bio-medical psychiatry saw, however, that these efforts by the Analysts to maintain their authority was scientifically arbitrary and hurt the legitimacy of the psy-professions as a whole.
At a deeper level though, the “external” crisis of public legitimacy, which seems to have shaped the orientation of particular factions of the APA to the question of declassification, was a secondary byproduct of the “internal” crisis of epistemology. During the decades preceding the crisis of the 1970’s Psychoanalysts, Bio-psychiatrists, Humanists, and reformers all found themselves on a roughly equal professional footing vis a vis control of the APA. As far as I can tell, no faction within the association during this period was able to achieve a majority which would guarantee that the policies and documents produced by the APA would reflect the opinions, biases, frameworks, and techniques of their faction.
This only really begins to change and then accelerate beginning in the years 1973 and 1974. In the former, the postal vote declassifying homosexuality as a mental illness took place, the next year, this decision was ratified by the full membership of the APA (Racca, 2019). Bio-psychiatry, as a rising force at the time, had many young professional proponents moving up through the ranks of the APA, so that when the construction of the DSM-III began in the year 1974, they were the only faction in an advantageous enough position to direct the construction of the new Diagnostic Statistical Manual into reflecting their factional preference for viewing psychiatric categories as scientific descriptors for discrete “mental illnesses” which could be used for purposes of research and diagnosis. The publication of the DSM-III in 1980 was a massive victory for this section of the APA, as Cohen describes at length:
“The DSM-III was also a decisive victory for biomedical psychiatry, a return to the descriptive “scientific psychiatry” of the early twentieth century. Thus, the DSM-III can also be seen as an attempt at internal legitimation, to align their activities and practices more closely to other branches of medicine. As a result of this return to biomedicine, the DSM-III was primarily promoting drug solutions to the mental disorders catalogued therein, a situation that has led many commentators to highlight the strong financial linkage between task force members and pharmaceutical companies . The rapid growth in the total number of mental disorders from DSM-II to DSM-III (from 182 to 265, the largest single expansion to date) also suggested a move by psychiatry to increasingly (bio)medicalise aspects of life which had previously fallen outside of the profession’s domain, a process to further expand their areas of jurisdiction. (Cohen 2016 : 77)
Cohen continues by making the case that we can not separate this professional victory for Bio-psychiatry from the social, economic, and political context of the actors involved. Particularly, we can not separate the publication of the DSM-III and the broader turn by the psy-professions toward Bio-psychiatry from the attack that was being led by conservative politicians on welfare and collective institutions like unions at the time. Nor can we properly separate the rise of Bio-psychiatry from the rise of new ideas regarding individuality and personhood developed by Neoliberal ideologists like Friedrich Hayek and Milton Friedman. Cohen argues that the psychiatric discourse of the DSM-III is a direct reflection of these contemporary concerns around efficiency, productivity, consumption, and individuality, so that “when we conceptualise psychiatry as speaking a ‘public language’ in the DSM, it must be recognised that this language is not neutral and value-free but rather reflects a dominant ideological rhetoric of the specific epoch, in this case the crisis in welfarism and the emergence of neoliberalism” (Cohen 2016 : 79).
What Neoliberalism and Bio-psychiatry have in common, other than their rising to a hegemonic status at almost the exact same time as one another, is their over-emphasis and problematization of the individual as the primary site of social and psychological intervention, so that if there is a change to be made, it is to be made at the level of the individual.
Neoliberalism is more explicit about this, neoliberal ideology conceptualizes persons primarily as autonomous entrepreneurial individuals and it posits that the freedom and self-realization of individuals can only be achieved by unleashing market-institutions from state control and oversight, which might otherwise hamper the possible extent of personal freedom and lead to state-driven “inefficiencies” for profit-makers. Although the economic policies that are associated with this Ideological framework have been an utter catastrophe for poor, working class, and oppressed people here in the U.S. this series of systematized catastrophes for the masses of people was actually the greater point of the turn to increased corporate power and the destruction of the welfare state that neoliberalism represented.
This ruling class counter-revolution at the level of ideology and state policy helped the U.S. capitalist class and their political representatives claw back the concessions won by their domestic working classes over the last few decades, helping to steadily increase the rate of labor-exploitation at home while also advancing a rhetoric of individual freedom and personal responsibility that could obfuscate the role of ruling class interests and institutions in creating conditions of unfreedom for the masses of people. In this context, it became very useful for members of the ruling strata to argue that self-improvement was the domain of rational, autonomous individuals and not really matters of public or state concern. This withdrawal of the state from public institutions and welfare was simultaneously the opening of new ideological grounds for the psy-professions, who could characterize dissatisfaction, laziness, inattentiveness, or unhappiness at work as signs either of individual failure and the need for self-improvement (or) of a discrete, biologically rooted, “mental illness”. These institutional changes co-accompanied trends of mass incarceration during the mid to late 20th century, so that the repressive functions of the asylum system, its capacity to regulate, throw away, and “train” people in violation of established norms and rules remained to the fullest extent (inside AND outside of the Asylum system itself).
As moral entrepreneurs granted a massive amount of epistemic and professional authority, this made psy-professionals incredibly useful mouthpieces for the ruling norms and values of the time. These norms and values took on a Symbolic efficacy all of their own, looping together with professional incentives and close ties to pharmaceutical corporations in a complex of Systemic and Symbolic violence that effectively became self-perpetuating in its internal unity. This is what makes the massive increase in references to work, homework, and school from the DSM-II and the DSM-III so very ominous.[6] The inclusion of these spheres of the human experience in the DSM was almost unprecedented, and the extent of these references certainly was unprecedented. This is what Cohen characterizes as the medicalization and thus problematization of everyday life in a manner which individualizes what are really structurally-rooted problems and experiences of distress. See, therapists are cops. They exist to regulate and modify behaviors, to produce docile bodies in the face of ruling class values and expectations. They exist to create a certain kind of person. Are you efficient in your work? Are you in control (do not ask whose control) ? If you are a woman, do you do house-work, care-work, and wage-labor with a smile on your face the whole time? These are really social and political questions posed in the form of a medicalizing discourse that treats them as individual psychological concerns to be addressed at an individual level.
Bio-Psychiatric discourse is individualizing in the exact same capacity that neoliberal discourse is, it assumes an individualistic model of human well-being whereby what ails us is thoroughly internal to our organic and psychological constitutions – not to be found in or through our connection to the outside world or other human beings. By framing the individual rational agent and their body as the primary sites of psychiatric knowledge and self-improvement, these bio-deterministic tendencies in the psy-professions render collective or political solutions effectively nonsensical, and generate care-pathways that effectively begin and end at pharmaceutical interventions, ECT, self-management of thoughts and emotions, therapy, and other individualized modalities for treatment. Humanists, psychoanalysts, and the proponents of CBT and DBT are not much better in this regard. These moral and practical teachers ask us to take power over our own lives, to grab ahold of our individual circumstances, of our individual will, and to lift ourselves towards… Well, you name it. You’ll be able to find a master for those purposes, provided you and/or your insurance are willing to pay.
Bio-psychiatry then, despite being a dominant form of psychiatric hegemony, is not the only form.With this in mind, whenever we deconstruct this particular form of psychiatric hegemony, we are already dealing with and deconstructing all the others, mutatis mutandis. The basic structure of the ideology remains the same from variation to variation, with a master-figure, a problematized patient-object and whatever they are doing/whatever condition they have that needs correction by means of external intervention. In the same way, therapists and other psy-professionals are the primary agents of the system of oppression that is sanism, they are the keepers of service users voluntary and involuntary alike and our experiences are universally brought beneath the obfuscating cloak of their discourse. But they aren’t the only agents of sanism or of psychiatric hegemony. If you want a clear picture as to who the rest of these agents are, I suggest you either look around you if there are people around or pick up a mirror. It is everybody and nobody in particular, that is what makes a hegemonic ideology hegemonic, it forms the very air we breathe, constitutes the very language we speak and hear, so that we do not even notice that our thoughts and actions vis a vis service users, survivors, psychiatrically-labeled persons, and mad people in general are prefigured for us at the level of the ideological superstructure before we even make a move.
Sanism, Power, and Epistemic Marginalization
Sanism is simultaneously the beginning and the end point of our investigation into Psychiatric hegemony. As a system of oppression it represents the multigenerational perpetuation of the same through the selective isolation and extermination of mental difference. As a rationalizing force, sanism today seeks to redeem the freaks and psychos of the world by rendering these persons “normal”, “functional”, “healthy”, “improving”, or out of sight and out of mind- all within the context of the dominant norms and values of the neoliberal capitalism under which we live today. In the sections above I have done my best to discuss the structural and historical factors which have led psychiatric hegemony to take on its contemporary ubiquitous forms of influence through the psy-professions, pharmaceutical industry, lay-discourse reproducing psychiatric hegemony in our day to day speech forms, etc. Going forward though, I would like to get back to what I see as the theoretical center of my argument as a whole: that by understanding the particular social and epistemic position occupied by the Psy-professions vis a vis their Patient-Objects we can come to contextualize the regular abuse and neglect experienced by service users and survivors not in terms of being exceptional incidents driven by bad personalities, but in terms of the Objective (Systemic and Symbolic) forms that actually perpetuate this systematized abuse and neglect.
Up to this point, I have generally followed in the steps of that old Slovenian giant, Slavoj Zizek, in attempting to look beyond the horrific and fleeting appearances of individually-experienced Subjective violence, and towards the Objective forms which make that Subjective violence possible by creating on a day to day basis it’s necessary preconditions. There are benefits to this interpretive method for the systematic philosopher, who by abstracting away from the immediate world of experience, comes to see the greater whole formed by these passing moments in their systematic unity.
But, there is also a tremendous cost to this method, in abstracting away from the lived experiences of real people we can render the particularity of those individual experiences invisible by only placing them in light of the role they play within the system as opposed to how they form a part of the person’s life, memory, and perspective. This allows for gross over-generalizations that may be inaccurate or at least insufficiently accurate at the intersection of different identities and/or systems of oppression. There is also something too emotionally distant about this interpretive procedure in my opinion, The lived experiences and felt emotions of persons are not merely the epiphenomenal residue of the real underlying social systems they inhabit. Rather, these experiences and emotions constitute our available data for any critical analysis and can act as real social/historical forces when channeled either into a deeper understanding of the phenomena in question, or directed in the form of organized political struggle on the basis of shared experiences and feelings of injustice. Zizek’s proposed method in Violence (2008) then, is insufficiently intimate with lived human experience for understanding what Feminist scholars so often refer to as the link between the personal and political, or what Hegel treats as the connection between Subject and Substance. This method for the analysis of Objective violence does not think this connection from the side of the personal/subjectivity itself, and so becomes one-sided in the pursuit of systematic thought.
Where before in my analysis I have followed Zizek (and to a lesser extent Cohen) in refraining from dwelling on Subjective violence in favor of systematic analysis, now it has become necessary to take the exact opposite turn, towards Subjective violence as it is constituted in the lived experience of individuals. In the context of a critical analysis of Psychiatric hegemony and sanism this also means a turn towards the experiential knowledge of service users/survivors, Mad activists and scholars, and those labeled with or self-labeling with a “mental illness”. This is a foundational theoretical turn within the Mad Studies movement as far as I am aware, the centering of experiential knowledge, specifically the experiential knowledge of those deemed and/or self-identifying as mad, as opposed to the medicalizing and objectifying forms of professional knowledge advanced by the Psy-professions.[7] This turn towards experiential knowledge in Mad Studies echoes similar turns made in other forms of critical theory and identity politics (Feminist theory, queer theory, intersectional social theory, etc.) and has deep historical roots in the disability rights and Mad Pride movements. In advocating such a turn as theoretically progressive I do not mean to eschew systematic analysis, on the contrary I mean to enhance it! To Validate and expand it by centering our systematic analysis going forward on the people catching hell and developing their ideas in light of their experience and struggle against sanism as a system of oppression.
One example of a Mad activist and scholar who has developed their ideas in light of their lived experiences and active participation in struggles against sanist oppression is Vesper Moore. Moore is a queer, Indigenous, Mad activist who has done work in the U.S. and internationally as a response to their own psychiatric incarceration. They spent four and a half years in and out of psychiatric facilities, at first willingly, but increasingly (especially after being labeled with the diagnosis of schizophrenia) unwillingly. While inside, they began to realize that what they were dealing with was really an institution of social control when they discovered that the experiences of pervasive apathy and body tremors that they had been experiencing for months while in “treatment” were actually common side-effects of Thorazine, still being used as a sort of “chemical lobotomy” for the sedation of Moore and their peers in psychiatric internment (Vesper Moore: Mad Activism and Psychiatric Abolition). When they were finally let out of involuntary inpatient care, Moore was determined to fight against what they viewed as a frankly outrageous system of coercive “treatment” pathways and institutionalizing responses to madness and distress. Since then, they have worked as an advisor both to the U.S. government and the United Nations on issues of trauma, intersectionality, and disability rights, acting as a peer/survivor advocate in their capacity as advisor to these bodies.
Moore argues for an Abolitionist perspective that includes psychiatric survivors and their unique experiences in our understanding of carceral responses to distress, disorder, and madness in society. They argue that people:
“Often… operate under the guise of mental health stigma; but people don’t think about historical discrimination on the basis of identity and being perceived as both “dangerous” and “incapable,” which Mad people face in our society. I think that that’s very critical. When we talk about the intersection, for Mad people in terms of disability rights, it’s different because we’re perceived as dangerous. And that danger has an impact on how people understand us in terms of defining sanism” (Mannoe, 2023).
Moore continues by saying that they like to conceive of sanism as a sort of ableism which assigns value to people’s minds based on socially constructed definitions of “normality, productivity, desirability, intelligence, excellence, and fitness” and that these ideas are deeply rooted in things like eugenics, anti-Blackness, misogyny, colonialism, imperialism, and capitalism, making sanism a kind of lynch-pin that works to reinforce these other systems of oppression through institutionalized responses to those defined outside of the boundaries of normality. This institutional violence weaponized against Mad people disproportionately impacts Black, brown, and Indigenous people and Moore makes the case that this is because forces like systemic racism, white supremacy, and colonialism define normality, functionality, and danger in ways that help to protect and perpetuate what is white, cis, and acceptable in society. This extends to the criminalization of Mad and homeless people, who are seen as unsightly and unacceptable and are therefore subject to police harassment and violence. Moore conceptualizes these institutionalized and institutionalizing responses as a form of “layered policing”, policing in a multiple sense and with multiple bodies of enforcers:
“It’s important to emphasize here that when we’re talking about clinicians, we’re talking about social workers, we’re talking about militarized law enforcement, and the court system. These are institutions that have been designed to keep the colonizers and their institutions intact. From the very beginning, by design, these systems do not incorporate Indigenous people who have ancestral ties to these lands, or the folks who may consider these lands home to them, having immigrated to these lands or brought to these lands because their ancestors were enslaved. When we’re talking about clinicians – whether white, brown, or Black – we’re talking about systems of oppression that are designed by colonizers in these lands, including the power struggle of determining “effective” practice. This is rooted in what is acceptable and “evidence-based,” but I have heard critique of that term – evidence-based as a euphemism for being properly vetted by white supremacist institutions. That includes clinical practice and social work” (Ibid.).
Moore’s perspective, then, is a serious theoretical and political response to the conditions of unfreedom that prevail in settler-colonial, white supremacist, capitalist societies – conditions of unfreedom and discrimination that they have personally been made subject to, and which they are seeking to displace or eliminate through participation in both liberatory social movements and institutionalized attempts at reform. For these reasons, Moore is supportive of the development of peer run, communally based, alternatives to existing crisis services with the eventual goal of abolishing the mental health Industrial complex and psychiatry as a whole. Central to this project is the building of aforementioned peer run networks simultaneously with our attempts at abolishing existing hierarchies within the “mental health systems” by putting those most affected by the application of power in positions of power – all with the eventual goal of “eliminating power” to use Moore’s formulation (Vesper Moore: Mad Activism and Psychiatric Abolition).
What does this “elimination of power” effectively look like in the context of psychiatric abolition? What fundamental hierarchical inequalities must be abolished, what relations inherent between psy-professional and service-user? We have already come quite far in answering this question with Moore alone, but for a more comprehensive understanding of what must be abolished it might be best to appeal to other Mad scholars and activists for their views on the matter. The scholar I have in mind in particular is Jessica Lowell Mason, a psychiatric survivor and feminist scholar working and organizing in the city of Buffalo, New York alongside the grassroots, peer-run organization “Madwomen in the Attic”. Her 2018 essay The Therapist and the Two Realities of Power is perhaps simultaneously the simplest and most illuminating piece I have come across in terms of revealing the fundamental inequality that prevails between those epistemically marginalized by Psychiatric hegemony and sanism, and the Psy-professionals who are tasked with the management and “care” of these epistemically marginalized service-users and survivors.
In the essay, Mason begins by discussing a fundamental difference “between a ‘fabricative realist’ (one who invents a reality for the purpose of manipulating or holding control over another) and a ‘deluded realist’ (one who believes in the reality that a person with more power convinces them to believe)”. With these two roles corresponding to the relationship that inheres between therapist and the client; The therapist, the fabricative realist:
“manipulates and controls the deluded realist client’s understanding of the “reality” of their relationship by creating the fabricated reality of trust, leading their client to believe that the reactions and feelings of the therapist are real in a therapeutic setting – when in fact they are fabricated for therapeutic purposes: which are to diagnose (based on an invented diagnostic manual), to treat (based on a diagnosis based on an invented diagnostic manual), and to receive a form of payment for doing so” (Mason)
This fabrication of a mystifying conception of reality on the part of the patient, whereby a certain degree of trust, reciprocity, and recognition are all assumed, is a purposeful fabrication rooted in the professional goals of the Psy-professions. In reality, as Mason points out, the therapist occupies an elevated position vis a vis the patient in terms of their presumed knowledge, access to information, ability to determine course of treatment, and ability to deceive and direct the disempowered patient towards particular treatment and talk-therapy modalities through this selective release and retention of information. Expressed in her words:
“Often, in therapeutic settings, in order to earn a client’s trust, a therapist must be deceptive. They must privately break the client’s trust, by writing private notes about their subject – notes that their subject must never see but this is never knowable to the client in order for the therapy to be carried out “properly.”
This is knowledge-witholding and it is an act of deception that many mental health practitioners carry out when they keep notes that reflect a different reality than the one that they share with their clients. If a therapist nods and listens to a client, or offers kind words and suggestions, while writing down diagnostic information that they do not also verbally share with their client (justified as being part of the practice of good medicine), they are being deceptive” (Ibid.)
The fact of the matter is that this capacity on the part of psy-professionals for deception is institutionalized by means of the unequal epistemic and institutional footing of the therapist and client. Mason rightly points out that “The very foundation of therapeutic practice is based on the accepted belief that therapists know something that clients do not know – as well as based on the accepted belief that therapists are able to know more than clients are able to know” (Ibid.). This is all predicated on the selective and hierarchized distribution of knowledge and authority, so that without this basic inequality in access to information, the “therapist-client” dualism would be effectively impossible. There would be no bifurcation of perceived reality along two lines, privileged master-figure and patient-object, there would only be healers and people seeking healing. By proposing the abolition of the“therapist-client” relationship, Mason effectively calls for the abolition (sublation) of Psychiatry as such through the elimination of the basic inequalities that make Psychiatry possible.
In these ways, Mason poses a radically egalitarian alternative to the prevailing hierarchized and marketized forms of psychiatric intervention that dominate today, an alternative based on a recognition of the humanity and agency of people seeking healing. This alternative vision for care-work, in my opinion, contains within it the same basic insight regarding psychiatric Abolition that Vesper Moore’s proposed “elimination of power” contains: these Mad scholars have correctly identified how it is Psychiatry as such, the very social and epistemic position occupied by the Psy-professions – along with the presuppositions prevailing in the basic categories and practices of the the Psy-professions – that are responsible for experiences of institutionalization, abuse, neglect, and marginalization on the part of service users/survivors. The ending of psychiatric abuse, then, is predicated on the Abolition of Psychiatry and of the Psy-professions either in toto or at the very least as they presently exist – as masters over and above patients, with authority and access to information beyond what service-users or peer advocates could even dream of within the context of present institutional arrangements.
The presuppositions that sustain this unequal relationship between the therapist and the client are precisely the presuppositions of sanism. These include assumptions that the mad are dangerous, unstable, incapable of showing any deep understanding of their own condition or experiences, and/or are lacking in a capacity for agency. All of these are used by Psy-professionals, authorities, and lay-people alike to justify what amounts to a total lack of mechanisms of democratic accountability and oversight in the mental health industrial complex. In reality, as the philosopher and Bioethicist Kathleen Lowenstein points out in her very informative 2021 talk Engaging the Margins: Exploring the Intersection of Critical Mental Health and Bioethics, it is exactly these presuppositions of deficit-agency imposed upon service users and survivors through psychiatric categories and discourse that functions to relativize the experiences and perspectives of these service users/survivors – thus leading to greater and greater amounts of objectification, abuse, and epistemic marginalization.
What Moore, Mason, and Lowenstein all share is this radical critique of the very position from which the Psy-professions theorize and practice, as well as a corresponding turn to service user/survivor experiences, concerns, and autonomy as methods of decentering Psy-professional authority and advocating for more deeply egalitarian, accountable, and community based modalities of care-work – modalities that actively involve the people receiving healing as equals in decisions regarding the nature and course of their care, and which do away with any and all forms of coercion or deception that are presently used by the psy-professions to force compliance with “care”.
See, therapists are cops, agents of social control, even if the therapists don’t see it that way or direct their actions on that basis- they exist variously to regulate, channel, and eliminate forms of mental difference deemed too unruly, too unstable, too dysfunctional, or too dangerous to the prevailing social order. They exist to integrate people into this order – either as active participants, as prisoners, or as proverbial parolees (patients). Just like literal cops then, we must develop the necessary communally-based institutions and degree of organized political power to abolish (sublate) the psy-professions as a whole. Naturally, this does not mean the end of institutionalized care-work or of the empirical study of human well-being in their entirety, but it does mean the end of the hierarchical, institutionalizing, pathologizing, and dehumanizing tendencies of psy-professionals old and new, and therefore the end of the psy-professions as such, whose epistemology and practice are inherently based on a hierarchical conception of the therapist/client relationship.
Bibliography
Barry, E. (2022, May 2). He spurred a revolution in psychiatry. then he “disappeared.” The New York Times. https://www.nytimes.com/2022/05/02/health/john-fryer-psychiatry.html
Burstow, B. (2015). Psychiatry and the business of madness: An ethical and epistemological accounting. Palgrave Macmillan.
Foucault, M. (2009). Madness and civilization: A history of insanity in the age of reason. Routledge.
Harcourt, B. E. (2011). An institutionalization effect: The impact of mental hospitalization and imprisonment on homicide in the United States, 1934-2001. SSRN Electronic Journal.https://doi.org/10.2139/ssrn.970341
LeFrançois, Reaume, & Menzies (Eds.). (2013). Mad matters: A critical reader in canadian mad studies. Brown Bear Press.
Mannoe, M. (2023). Confronting ableism & sanism in policing: An interview with Vesper Moore. Pivot Legal Society.https://www.pivotlegal.org/confronting_ableism_sanism_in_policing
Mason, Jessica Lowell (2018, September 18). The therapist and the two realities of power. Madwomen in the Attic. https://madintheattic.org/2018/09/17/the-therapist-and-the-two-realities-of-power/
Moore, V. (2018, January 15). Our sexualized culture and the prejudiced roots of psychiatry. Mad In America. https://www.madinamerica.com/2018/01/prejudiced-roots-psychiatry/
Peer advocates mobilizing in opposition to SB 326 and the governor’s proposal to “modernize” the Mental Health System. Peer Advocates Mobilizing in Opposition to SB 326 and the Governor’s Proposal to “Modernize” the Mental Health System | Disability Rights California. (2023, August 21).https://www.disabilityrightsca.org/press-release/peer-advocates-mobilizing-in-opposition-to-sb-326-and-the-governors-proposal-to
Racca, M. N. (2019, November 6). The gay activists who fought the American Psychiatric Establishment. Literary Hub. https://lithub.com/the-gay-activists-who-fought-the-american-psychiatric-establishment/
Racism and involuntary psychiatric commitments in the United States. Office of Academic Affairs, The Ohio State University. (2023, April 8). https://oaa.osu.edu/racism-and-involuntary-psychiatric-commitments-united-states
Ramaswamy, V. (2023, August 24). Don’t remove guns from law-abiding citizens. remove violent, psychiatrically deranged people from their communities and be willing to involuntarily commit them. Revive Mental Health Institutions: Less reliance on pharmaceuticals, more reliance on faith-based approaches that… pic.twitter.com/9f2noz9y9x. Twitter.
Rose, N. S. (1999). Governing the soul the shaping of the private self. Free Association Books.
Russo, J., & Sweeney, A. (2016). Searching for a rose garden challenging psychiatry, Fostering Mad Studies. PCCS Books.
United States of America – World Prison Brief. United States of America | World Prison Brief. (1970, January 1). https://www.prisonstudies.org/country/united-states-america
Whitaker, R. (2001). Mad in America. Perseus Publishing.
YouTube. (2021, September 22). Vesper Moore: Mad activism & psychiatric abolition. YouTube. \https://www.youtube.com/watch?v=dmV9o1KIKgM&t=793s
YouTube. (2022, January 7). Engaging the margins: Exploring the intersections of Critical Mental Health and Bioethics. YouTube.
Cohen, B.. (2016). Psychiatric hegemony a Marxist theory of mental illness. Palgrave Macmillan. UK :Imprint: Palgrave Macmillan.
Žižek, S. (2008). Violence: Six sideways reflections. Profile.
[1] According to Poole (2014) Sanism is a system of oppression which affects people who experience “mental health stuff” and who identify as Mad (we might add here that it also affects those simply labeled or perceived as having some kind of “mental illness” or neurodivergence). As per Poole, this term is inclusive of negative attitudes, assumptions, the use of derogatory terms (or) “hate language”, discrimination, and institutionalized forms of violence used against those perceived as mad or mentally/emotionally unstable.
[2]“Psy-professions : my argument in this book implicates not only the psychiatric profession, but also allied groups such as psychologists, counsellors,psychiatric social workers, psychoanalysts, and the many other “talk therapy” professionals. Collectively, I follow Rose ( 1999 : viii) in understanding these groups as the “psy-professions”: “experts” who have over time acquired an authority on the supposed “real nature of humans as psychological subjects.” As medically trained practitioners, psychiatrists have the ultimate authority to define and police abnormal behaviour—which is why the book focuses primarily on this profession—yet they are ably assisted by other groups which have subsequently emerged and have vested interests in continuing to align themselves with the same knowledge base. The discussion in this book will
demonstrate, for example, that psychologists, therapists, and counsellors can all be implicated in systematically serving the interests of the powerful” (Cohen 2016 : 8)
[3] Psychiatric Hegemony is a term that describes how Psychology and Psychiatry have come to constitute “an all-encompassing form of knowledge which works to naturalise and reinforce the norms and values of capital [and of other forms of systematic exploitation and domination such as Patriarchy, Sanism, and Ableism] through professional claims-making” (Cohen 2016, highlighted additions mine).
[4] “For the drug companies, psychiatry can medically legitimate their products as well as facilitate the expansion of the potential population for their products. In turn, the drug companies legitimate the institution of psychiatry as a “real” (meaning biomedically-based) part of medicine and facilitate the expansion of its areas of research and expertise through various funding and
revenue streams. The outcome of this relationship has been fairly predictable— both parties have benefited enormously over time” (Cohen 2016 : 61).
[5] As best as I can tell, when Burstow makes reference to the “neo-Kraepelinians” she is referring to a faction within the Psy-professions who followed in the tradition of the German Psychiatrist Emil Kraepelin (1856-1926). Kraepelin believed that the etiology of “mental illness” could be identified by some underlying biological and/or genetic dysfunction which in turn gave rise to particular “mental illnesses”. He also believed that a key task of modern scientific Psychiatry was the development of classificatory schemes for different kinds of “mental illness” that could be used for the purposes of diagnosis. For our purposes, then, it would be easiest to think of this faction as representatives of a rising Bio-psychiatry in the 1970’s, helping to declassify homosexuality as a mental illness as a way of saving face for the discipline as a whole and to outflank their competitors in the APA: the Psychoanalysts.
[6] According to Cohen (2016): the DSM-II (1968) included only one reference to work and two references to home/house work and school respectively. On the other hand, the DSM-III (1980) included 72 references to work, 59 references to home/house work, and 91 references to school. For some perspective on just how much this trend has accelerated since the 1980’s, the DSM-5 (2013) contains nearly 300 references to work (288), 109 references to home/house work, and over 250 references to school, often as symptoms (or) indicators for specific diagnoses.
[7] For more on this one can reference collections of work by Mad activists and scholars themselves, such as Mad Matters (2013) edited by LeFrançois, Menzies, and Reaume (or) Searching For a Rose Garden: Challenging Psychiatry, Fostering Mad Studies (2016) edited by Russo and Sweeney. An essay in the latter collection that is useful for conceptualizing Mad Studies as a form of identity politics based around the centering of service user/survivor knowledge and interests is Peter Bereseford’s The role of survivor knowledge in creating alternatives to psychiatry (pages 25-34).
Mad Studies Avec Marxism
On a first glance it may seem that the Mad Pride and Mad Studies movements have little to do with the theory and practice of Marxism (dialectical and historical materialism). In their development of the materialist conception of history with all its emphasis on the means and relations of production, on commodity fetishism, and Primitive accumulation, it seems at first that Marx, Engels, and their intellectual descendants would have little to say about the fundamental issues at the heart of Mad Studies (A Central emphasis on experiential knowledge, an epistemic decentering of professional authority, standpoint analysis, day to day manifestations of interpersonal and systemic sanism, identity-making in opposition to hegemonic power, etc.). And if we look merely to the text of Marx and Engels themselves, this would be a well-justified contention, they really do not talk much at all about mad, neurodivergent, and disabled people or the suppression thereof. But dialectical and historical materialism are not religious doctrines, and Marx and Engels are not church fathers with an exclusive claim to the interpretation of the holy texts. Marxism is a scientific method for the politico-economic, historical, and ideological analysis of class society from a partisan class-perspective. Most importantly, any truly systematic application of Marxism requires that the theoretical tenets of dialectical and historical materialism be applied, stretched, and shifted in accordance with the specific material conditions faced by those trying to apply it.
There is a long tradition now of Marxist and Leninist thinkers who have performed such a specific material analysis of the class societies in which they lived. Vladimir Lenin, a leading figure in the Russian Social Democratic Labor Party (Bolshevik) famously changed the classical Marxian saying of “working men of the world, unite!” to “working class and oppressed people of the world, unite!”. In the material conditions of the autocratic Russian Empire, a prison-house of oppressed minority nationalities made subject to both military and economic violence, where neither women nor men had the right to vote and where femininity was often seen as synonymous with domestic servitude, the Leninist reformulation of Marx was a more accurate and more effective refrain – declaring to ALL the people suffering under the boot of Tsarist absolutism that Marxist politics were not merely concerned with the conditions of the urban proletariat, who anyways made up a vast minority of the people with the exception of a few large cities, but that Marxist revolutionaries sought the total liberation of the people from every possibility of exploitation, domination, and oppression.
Lenin is just one example of an interpreter of Marxism who applied materialist dialectics to those systems of exploitation not fully grappled with by the work of Marx and Engels. Revolutionary theorists like Frantz Fanon, Kwame Nkrumah, Sam Marcy, Sylvia Federici, Angela Davis, Larry Holmes, Leslie Feinberg, and Gerald Horne have further illuminated how Imperialism, Colonialism, White Supremacy, and Cis-heteropatriarchal regimes of social reproduction form the essential infrastructure of Capitalist hyper-exploitation and oppression. Whereas before it might have been said that the Marxian theory of Primitive Accumulation had been left incomplete, except for perhaps in Marx’s more obscure writings and notebooks known mostly only by scholars, we now have a plethora of texts effectively tracking the bloody emergence and development of global capitalism in great detail. This historical literature has made two facts incredibly clear:
First, that Marx was correct when he said that “Primitive accumulation plays in Political Economy about the same part as original sin in theology” – that the wealth in those societies where the capitalist mode of production prevails was originally generated and continues to be reproduced through incredible violence, expropriation, dislocation, and exclusion. These interlocking systems of exploitation and domination are not peripheral to Capitalist accumulation, they form the very core of it (A Dying Colonialism, 1959; Neo-Colonialism: The Last Stage of Imperialism, 1965; High Tech Low Pay: A Marxist Analysis of the Changing Character of the Working Class, 1986; Transgender Liberation: A Movement Whose Time has Come, 1992; Are Prisons Obsolete, 2003; Caliban and the Witch, 2004; Marxism, Reparations, and the Black Freedom Struggle, 2005; Freedom is a Constant Struggle, 2015; The Apocalypse of Settler Colonialism, 2018; Patriarchy of the Wage, 2021).
Secondly, that the struggle against global capitalism today can only be fought through a relentless effort against every possibility of exploitation, domination, and oppression – Not in the very simple sense that “we are all in this together, there is only one struggle, the struggle against global capitalism”, which paints over the particularities of the struggles faced by oppressed peoples by absorbing them into the final battle against capitalist oppression – but in the sense that we must attend to the particularities of each struggle in our systematic analysis and link up in solidarity with oppressed peoples in order to have a chance in hell at finally overcoming, abolishing, sublating this wretched system which feeds off the blood and sweat and misery of the people.
This brings us, naturally, to the question of Mad liberation, Mad Pride, and Mad Studies. It goes without saying that there has been significant overlap, both in theory and in practice, between Mad activists/scholars and Marxists. In Therapists Are Cops, at least four of the authors that I cite are either Mad scholars who are significantly influenced by dialectical and historical materialism or Marxists engaging actively with Mad studies (Here I am referring to Beresford, Cohen, Mason, and Moore but I suspect there are others in the bibliography I may be unaware of). These activists and scholars have simultaneously recognized the need for the abolition of capitalism and for the centering of Mad people’s dignity, autonomy, and ultimately liberation in their work. At the level of social movements, these insights have been hard won victories, born of political practice in the Disability Justice and Mad Liberation movement. Principled workers parties and mass organizations must follow suit! Only a handful of Workers parties here in North America have internal disability caucuses or bring their cadre out in solidarity with movements for Disability Justice, even less are willing to go beyond empty phrases for Mad Liberation. Such a program of reforms does not just mean fighting against sanism within our own organizations, but centering the perspectives and knowledge of Mad people in our own political analyses and practice, showing active solidarity with progressive movements seeking Mad liberation by helping to organize and bring bodies to the struggle, agitating around demands to smash the carceral state in all of its forms – including asylums. It means that we self-proclaimed Revolutionaries have a lot of work to do that must begin sooner rather than later both internally through political education and externally through solidarity-building, mass work, and agitation.
Marxism needs Mad Studies and Mad Studies urgently needs the kind of razor sharp material and historical analysis that Marxism provides to move beyond the event-horizon of liberal and reformist approaches, which merely amend the practices of psychiatric institutions without eliminating the coercive, pathologizing, and profit-driven forms that constitute their everyday existence. It is only by identifying the roots of sanist oppression in the commodification of everything, even human bodies and minds, that we can identify how socialist forms of social organization are a necessary precondition to ending the institutionalization of the deviant and the supposedly “non-productive”. The emergence of Psychiatric Hegemony as a near all-encompassing form of ruling class Ideology is almost unintelligible as a historical process if we do not properly grapple with the objective economic and political interests of those psy-professionals, insurance agencies, and politicians who were the primary drivers of that process.
Marxism with Mad Studies, Mad Studies Avec Marxism, to attempt to link these fields theoretically in the terms of a structural and historical analysis, that is the basic thrust underlying Therapists Are Cops. By drawing heavily from these two traditions in my attempts to analyze the historical development of the Psy-Professions in the U.S. during the mid to late 20th Century, my intention has been to reveal the connections between systems and actors motivated simultaneously towards the perpetuation of both sanist oppression and capitalist domination, though I am almost certain they would not frame their own actions and ideas in such a manner. This is the positive function of ruling class Ideology, beyond mere “false consciousness” which obfuscates “true reality”, that this Ideology is already objectified on the side of material reality in the Systemic and Symbolic forms which function to perpetuate and justify the antagonistic class society that gave birth to them:
“The illusion is not on the side of knowledge, it is already on the side of reality itself, of what the people are doing. What they do not know is that their social reality itself, their activity, is guided by an illusion, by a fetishistic inversion. What they overlook, what they misrecognized, is not the reality but the illusion which is structuring their reality, their real social activity.” ~ Slavoj Zizek – The Sublime Object of Ideology, 1989
Abigail Reinbold is an aspiring political philosopher and Marxist-Leninist organizer in the City of Buffalo New York. Working primarily in the traditions of Continental philosophy, Marxian political economy, and intersectional social theory, her work attempts to derive insights from these fields to apply to qualitative historical analysis and participation in local social movements. She received her bachelor’s degree in Sociology from SUNY University at Buffalo in May 2023, where she was also an organizer with the University at Buffalo branch of the Young Democratic Socialists of America, helping to organize demonstrations, community events, meetings, and study sessions in her capacity as a member.
Shortly after her graduation from the University at Buffalo, Abigail became a founding member of the Marxist Youth League – Buffalo, a multi-gendered, multi-National Marxist-Leninist youth group operating out of the East Side of Buffalo as active participants in the anti-war and BDS movements in the city. She places herself in a tradition of queer Communist organizers who have been operating in the city of Buffalo for a long time, and is hoping to bring her analyses and experiences back to the University at Buffalo in her graduate education. As of now, Abigail is applying to the University’s Global Gender and Sexuality Studies and American Studies programs for the Fall 2024 semester.
Madwomen in the Attic 
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