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A Marxist analysis of mental illness :
So despite mental illness being a pseudo-scientific concept and a social construct I wondered why humans still believe in it and take it seriously when it is obviously bullshit. The simple reasons is it is a useful tool of the ruling neo-liberal capitalist class to try to depoliticize the oppression of people under Capittalism. The only solution to this example , and other examples, of human oppression is a communist revolutiion comrades ! :
A Marxist Analysis of Mental Illness by professor Bruce Cohen :
While Marxist theory often draws on the critical work of labelling, social constructionist, antipsychiatry and Foucauldian scholars, it is clearly distinct from these positions in prioritising the structural dynamics of capitalism – particularly the material (economic) conditions – above all other variables in understanding mental illness and the mental health system. Capitalism is a system of societal relations based on the private ownership of the means of production and the systematic exploitation of the working-class population so as to maximise profit for the ruling classes. This dominant societal structure that we currently live with in the West is therefore marked by a fundamental disparity in the distribution of economic resources between the
majority of the population and the ruling elite. The first half of this chapter outlines the main directions of argumentation in the area of mental health which have been offered by Marxist- influenced writers – namely, an understanding of the mental health system as a source of direct and indirect profit generation, and as an institution of social and ideological control. In the second half of the chapter I update the latter arguments so as to theorise the contemporary expansion of mental illness discourse under neoliberal ideology as a form of ‘psychiatric hegemony’. In the first section that follows, however, I briefly outline a third line of Marxist argumentation which focuses less on the mental health system as an instrument of capitalism,
and more on the wider alienating conditions of that society which can determine poor mental health within the population.
Alienation
Although Marx never wrote explicitly on the subject of health or mental illness, Roberts (2015: 9) notes that he did see the increasing rates of lunacy in the nineteenth century ‘as a direct consequence of capitalism’. Indeed, the number of those diagnosed with a mental illness continued to grow throughout the twentieth century and is currently estimated to effect one in four people in countries such as the United States and the United Kingdom (Davies 2013: 1). Such afflictions are heavily mediated by social class position, with Rogers and Pilgrim (2003: 18) noting that the available research ‘suggests that a strong inverse relationship with social class exists for those with diagnoses of “schizophrenia”, “depression” (in women), “antisocial personality disorder”, “alcoholism”, “substance abuse”, and “non-specific distress”’ 46 Marxist theory (for a recent summation of the evidence, see Cockerham 2017: 149–66). Thus, some Marxist scholars have theorised the growing rates of mental illness as an inevitable consequence of the oppressive conditions and alienating tendencies of capitalism which especially impact the working classes. Rosenthal and Campbell (2016: 34), for instance, state that ‘[c]apitalism is a sick social arrangement which damages physical and mental health’. Similarly, Robinson (1997: 75) argues that capitalism is a ‘breeding ground’ for mental illnesses because it creates the social conditions in which people require such a label as a coping strategy (1997: 24). The acceptance of a mental illness label under these circumstances, he forwards, is totally under-standable (Robinson 1997: 2). For such writers, mental illness is fundamentally a product of capitalism and one which can only be eradicated with the overthrow of this class-based society.
Taking the notion of being ‘driven crazy by a crazy world’ (Parker 2007: 214) one step further, Rosenthal and Campbell (2016: 58) conclude that, in fact, ‘[i]t is impossible to be mentally healthy under capitalism’. In such circumstances, we are all implicated as alienated from a state of mental well-being by current economic conditions. As Laing (1967: 11) questioned of the human psyche in this environment, What is to be done? We who are still half alive, living in the often fibrillating heartland of a senescent capitalism – can we do more than reflect the decay around and within us? Can we do more than sing our sad and bitter songs of disillusion and defeat? This focus on the alienated individual in capitalist society, perhaps inevitably, has influenced some forms of therapy within the mental health system itself. Fromm (1991) famously argued that it was not people who were mad but society. However, he believed that a form of ‘moral change’ within individuals was still required to bring about a better society (Nahem 1981: 32), suggesting therapeutic interventions were inevitable. Similarly, Laing and his antipsychiatry col-leagues worked with their patients as transcendental guides to understand and give meaning totheir states of madness (Sedgwick 1982: 102–24). As a result, critical and left-leaning therapeutic interventions have aimed to ‘emancipate’ people from capitalist alienation. Following Fromm and Laing, for example, the US-based Radical Psychiatry Center in the 1970s declared of their self-proclaimed method for working with people that, The radical psychiatrist sees anyone who presents himself with a psychiatric problem as being alienated; that is, as being oppressed and deceived about his oppression, for otherwise he would not seek psychiat-ric succor. All other theoretical considerations are secondary to this one.Steiner 1975: 14, emphasis originalThere is, however, a significant problem with this narrow focus on the alienating factors of capitalism as the explanatory variable for mental illness, in that it largely ignores any critical theorising of the mental health system itself. The practices, priorities and knowledge claims of mental health professionals are exempt from blame and, whether intentional or not, such an approach actually supports the expansion of mental health services aimed at the working classes and other oppressed populations. If Marxist scholars only focus their critical gaze outwards – on the victims of capitalism that have been labelled as ‘mentally ill’ – they risk ignoring the more salient dynamics of the mental health system which follow the prerogatives of capitalism to maximise profits and control the working classes. This will be demonstrated in the two sec-tions that follow, beginning with scholarship which has theorised the economic dimensions of the mental health system. 47Bruce M. Z. Cohen
Profit accumulationThe most often cited example of capitalism profiteering from the business of mental health in contemporary society is the dominance of drug treatments. Despite the ineffectiveness of such interventions (see, e.g. Breggin and Cohen 1999; Burstow 2015; Davies 2013; Kirsch 2009; Moncrieff 2009; Whitaker 2010), the sales of psychopharmaceutical agents have recently exceeded US$40 billion (Whitaker 2010: 320). As critical scholars have noted, the introduction of a plethora of new mental illness categories over the past few decades (such as attention deficit/hyperactivity disorder (ADHD), borderline personality disorder (BPD), generalised anxiety disorder (GAD), post-traumatic stress disorder (PTSD), premenstrual dysphoric disorder (PMDD) and social anxiety disorder (SAD)) alongside a psychiatric discourse that has falsely claimed mental disease as a biological reality, has served to expo-nentially increase the profits of pharmaceutical corporations as well as the credibility of mental health experts (see Whitaker and Cosgrove 2015). However, this is only the most recent example of capitalism extracting profit from a mental health system that has, since its beginnings, facilitated what the critical historian of madness Andrew Scull (1989, 1993,2015) describes as an ongoing ‘trade in lunacy’. Scull’s (1993: 29) analysis of the formation and growth of the public asylum system across Europe and America in the nineteenth century demonstrates that,the main driving force behind the rise of a segregative response to madness (and to other forms of deviance) can... be asserted to lie in the effects of a mature capitalist market economy and the associated ever more thoroughgoing commercialization of existence. Psychiatric institutions, he argues, became an economically efficient means of both separat-ing the able from the non-able bodied (e.g. the sick, disabled, poor, alcoholic, vagrant and elderly) and keeping them under close surveillance by new professional authorities (Scull1993: 33). The asylum offered an institutional base for the emerging psychiatric profession who, over time, could sell an increasing range of services to the marketplace (Scull et al. 1996: 5). While asylums sought to institute work regimes which could – at least in theory –return patients to the workforce (Cohen 2016: 99–101), private practice offered therapeutic
services to the middle-classes, including the management of ‘disobedient’ daughters and wives (Cohen 2016: 149). Similarly, the introduction of psychiatric ‘treatments’ such as electroconvulsive therapy (ECT), psychosurgery and drugs can be understood as profitable services which have been useful in modifying the behaviour of the patient, in turn aiding capitalist prerogatives for increased productivity in the family, school and the workplace (Cohen 2016: 41–52). As a number of medicalisation scholars have detailed (see, e.g. Conrad 2007), subsequent to the de-institutionalisation of patient populations across Europe and America in the 1960s and 1970s, we have witnessed an increasing de-regulation of the market, leading to the rapid expansion of private mental health services and products. Not only are enormous profits being made for the multitude of therapeutic services, drug treatments, research agen-cies, third sector organisations and insurance companies which surround the mental health industry, but also, notes Scull (2015: 376), from ‘the growth of nursing homes and board and care homes in which large numbers [of former patients have come]... to be confined’. This
is the new trade in lunacy, he argues (2015: 376), in which ‘[a]n entrepreneurial industry [has] emerged, one which profits from this form of human misery, and is almost wholly unregulated by state authorities’.48Marxist theory
Social control
Alongside profit accumulation, Marxist scholars most often theorise the mental health system as a key institution of social control. That is, they argue it is an authority responsible for reinforcing the dominant moral codes of capitalist society and punishing deviations from these (through, for example, the application of a mental illness label). As a branch of medicine mental health experts can claim a scientific neutrality and objectivity to their work, yet, in reality, their role is to sanc-tion the behaviour and emotions of people which run contrary to the prevailing social order.As Scull (1993: 392–3) reminds us, psychiatry’s claims to ‘scientific practice’ means it has ‘great potential value in legitimizing and depoliticizing efforts to regulate social life and to keep the recalcitrant and socially disruptive in line’. With the continuing lack of evidence for their area of expertise (for a recent summation, see Cohen 2016: 9–17), it is generally agreed by critical scholars that psy-professionals (including psychiatrists, psychologists, therapists and counsellors)
can only ever make historically and culturally bound judgements on the ‘correct’ and ‘appropri-ate’ behaviour of society’s members. Ingleby (1980: 55), for example, makes the point that, what one thinks psychiatrists are up to depends crucially on what one thinks their patients are up to; and the latter question cannot be answered without taking an essentially political stand on what constitutes a ‘reasonable’ response to a social situation.In the same manner, the British psychiatrist Joanna Moncrieff (2010: 371) agrees that a ‘psychiat-ric diagnosis can be understood as functioning as a political device, in the sense that it legitimates a particular social response to aberrant behaviour of various sorts, but protects that response from any democratic challenge’. Even the highly respected and staunch supporter of psychiatric medicine, Edward Shorter (1997: viii), admits that the profession is responsible for policing social deviance when he remarks that ‘[p]sychiatry is, to be sure, the ultimate rulemaker of acceptable behaviour through its ability to specify what counts as “crazy”’. The social control function within psy-professional work practices and knowledge claims is reasonably easy to identify and has been a major focus of labelling, social construction-ist and medicalisation scholarship since the 1960s (see, e.g. Conrad 1975; Goffman 1961; Rosenhan 1973; Scheff 1966). For example, considering the mental health system as a moral and political enterprise helps to explain the nineteenth-century labelling of runaway slaves in the Deep South of the US with ‘drapetomania’ (Breggin and Breggin 1998: 144–5) and early
feminists and suffragettes with ‘hysteria’ (Showalter 1980). Likewise, it can help us understand the psychiatric labelling of young civil rights activists in the US as ‘schizophrenic’ in the 1960s (Metzl 2009), the inclusion of homosexuality as a mental illness in the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) until 1973 (Kutchins and Kirk 1997: 55–99) and the more recent labelling of unruly young people with ‘ADHD’ (Conrad 2006). While there is general agreement among critical scholars that the mental health system is a source of moral policing, there is less agreement as to what specific ends it serves. As a liber-tarian, Szasz (2010: xxii), argues that psychiatrists are fundamentally self-serving in seeking to ‘enlarge the scope and power of the therapeutic state’; their aiding of government authorities in managing groups of deviants is useful only insofar as it aids their own professional expan-sion. In contrast, the neo-Foucauldian Nikolas Rose (1999) suggests that the psy-profession-
als in fact carry out a positive role as moral arbiters of our behaviour and emotions under advanced liberal conditions; the mental health system aids the self-surveillance of the subject and informs the limits of our conduct in contemporary society. Marxist scholars, however, 49 Bruce M. Z. Cohen
theorise the moral entrepreneurship of the mental health system as ultimately tied to the requirements of the market, whether they be through the pathologisation of potential threats to capital, the profiteering from individual treatments, the expansion of professional services or the reinforcement of ‘normal’ and ‘acceptable’ behaviour in the name of ‘successful’ treatment outcomes. Through a Marxist analysis we can then understand the pathologisation of runaway slaves as an example of psychiatry supporting the (agrarian) economic system of the Deep South, the labelling of civil rights activists as the de-politicisation of threats to a US system of apartheid which exploited low-paid working-class black labour and the stigmatisation of suf-fragettes as ‘hysterical’ as the mental health system’s attempt to reinforce gender roles and the division of labour which so effectively serves capitalism (Cohen 2016: 169–204). Historically, as well as in the contemporary environment, the working classes are the primary target for the mental health system, with lower socio-economic groups being labelled, incarcerated and ‘treated’ for ‘mental illnesses’ at much higher rates than other groups, in turn de-politicising and neutralising threats to ruling-class authority. Neoliberalism, risk and psychiatric hegemony In my recent book Psychiatric Hegemony: A Marxist Theory of Mental Illness (2016), I argue that the social control function described above has taken on increased significance as neoliberalism has progressed. Primarily, the mental health system can now be considered as an ideological tool of capitalism which normalises the ongoing oppression of the majority of the population through a psychiatric discourse which has become totalising – or ‘hegemonic’. This section briefly outlines
my rationale for this argument. Despite the dubious knowledge base upon which psy-professionals rest their continuing claims to expertise on the mind, there is no doubt as to the contemporary proliferation of the psychiatric discourse into areas of public and private life previously untouched by the mental health industry. In day-to-day conversation, for example, when we make assessments of char-acter or behaviour, we often articulate these using the language of the DSM – ‘your kid’s a bit hyperactive’, ‘those guys in the IT department are all on the [autistic] spectrum’, ‘she’s obviously experiencing mental health issues today’, ‘I’ve just got a compulsive personality’, ‘he’s totally addicted to gaming’, ‘you sound clinically depressed’ and so on. This is a seismic transformation in the way people talk about and make sense of themselves and others in contemporary society compared to some 40 years ago when the mental health system was viewed with a large amount of suspicion, their profession was experiencing an epistemological crisis and few people wished to align their personal behaviour with stigmatising psychiatric labels (Cohen 2016: 11–13). This change signifies the increasing ideological power of the psy-professionals to the point where their discourse has become ‘hegemonic’ – that is, an all-encompassing form of knowledge which works to naturalise and reinforce the norms and values of capital through professional claims-making. Our behaviour, our personalities, our lifestyles, our relationships and even our shopping trips are now closely observed and judged under the ‘science’ of the psy-professions, and we have, in turn, come to monitor and understand ourselves through a dominant psy-discourse. The reasons why we are in this current moment of psychiatric hegemony can be better understood with reference to Gramsci’s ideas on civil society and changes which occurred across Western societies, beginning in the 1970s.
In analysing the survival of capitalism in the twentieth century, the Italian Marxist Antonio Gramsci (1971) argued that the coercive powers of the state (e.g. the army, police and the judicial system) were comparatively ineffective in ultimately halting the revolution; instead, the ruling classes had secured a greater chance of survival through hegemonic power – the rule of the (50 Marxist theory) bourgeoisie by consent. This consent for ruling-class authority is achieved through an intellectual and moral leadership which resides in civil society – public and legal institutions such as the school, the church, the media and the criminal justice system, as well as the health system (see, e.g. Navarro 1986; Waitzkin 2000). Civic institutions are much more effective than direct, repres-sive organs of the state in manipulating the masses due to their perceived detachment from elite control. Hegemonic power is conducted under the guise of objective and neutral institutional practice, though it is in reality nothing of the sort. Instead, intellectuals and professionals are responsible for legitimatising ruling-class ideas within the public sphere, articulating such values as seemingly natural and taken-for-granted knowledge about the world. What we understand as ‘normal’ and common sense is, in fact, dominant, capitalist ideas imparted through professional discourse. Thus, the mental health system can be understood as an institution of civil society with the potential to impart a hegemonic, ruling-class ideology through its practices, priorities and discourse. This, I argue, has come to fore with the development of neoliberalism.
The post-war period of social welfarism and popular state intervention in many spheres of social and economic activity (including state provision of health and welfare services, public housing, nationalised industries and a highly regulated labour market) effectively came to an end in the 1970s with high levels of inflation and unemployment (Schrecker and Bambra 2015: 13). In this climate there was a popular response from the economic elites – and then the electorates –to the ‘neoliberal’ ideas of economic philosophers such as Hayek (1976) and Friedman (1982), who argued that the well-being of the individual was predicated on the autonomy and freedom of the market in capitalist societies. As with the ‘freeing’ of capital from state intervention, neoliberal philosophy argued that the individual must also be ‘freed’ from the state. The with-drawal of the state from many areas of social and community activity and the refocusing on the individual as the site of responsibility and transformation begins to explain how the psy-disciplines came to expand their areas of jurisdiction. Rose (1996: 150–1) eloquently refers to the populace in this new set of political and social relations as ‘enterprising individuals’ – that is, subjects imbued with the core values of neoliberalism. This includes the very language we now use to speak of and understand ourselves – as autonomous individuals seemingly free to choose, yet personally respon-sible for our ‘failures’. As Harvey (2005: 65–6) has suggested of the neoliberal self,While personal and individual freedom in the marketplace is guaranteed, each individual is held responsible and accountable for his or her own actions and well-being... Individual success or failure are interpreted in terms of entrepreneurial virtues or personal failings (such as not investing significantly enough in one’s own human capital through education) rather than being attributed to any systemic property (such as the class exclusions usuallyattributed to capitalism). How we understand ourselves and the world is both shaped by and relies on the dominant language of this ‘enterprise culture’. In other words, the discourse traditionally associated with business and economics (e.g. ‘efficiency’, ‘productivity’ and so on) is now also used to refer to our own experiences, emotions and behaviour. In neoliberal ideology, the self has replaced the group, the community or wider society as the site for reform and change. This emphasis on the individual has seen the de-politicisation of social and economic inequalities to the point where, in the words of Ulrich Beck (1992: 100, emphasis original), they have been redefined ‘in terms of an individualization of social risks’. Most pertinent to understanding the role of the psy-professions in neoliberal society is that ‘social problems are increasingly perceived in terms of psychological dispositions: as personal inadequacies, guilt feelings, anxieties, conflicts, and neuroses’ (Beck 1992:100). In this ‘risk society’, ‘expert’ groups such as psychiatrists and psychologists have become 51Bruce M. Z. Cohen
increasingly important to capitalism in their attempts to scientifically speak to the ‘risky’ behav-iour of the individual. This rise of ‘expert knowledge and expert opinion’ in neoliberal society, remarks Turner (1995: 221), means that such discourse is ‘highly politicised’. Thus, as the social state has fallen away with the expansion of neoliberal ideology, the psy-disciplines have come to play a key role in promoting and perpetuating the focus on the risky subject. They have progressed their moral authority into new areas of jurisdiction, with every individual within a population redefined under a hegemonic psychiatric discourse as ‘in a permanent condition of vulnerability’ to mental illness (Furedi 2004: 130). For Rose (1999: vii), the psy-professions have played ‘a very significant role in contemporary forms of political power’, so much so that the disciplines ‘make it possible to govern human beings in ways that are compatible with the prin-ciples of liberalism and democracy’. This is due to their professional focus on character reform and self-realisation – values which have a high degree of symmetry with the neoliberal project. As the priorities of capitalism changed, so did psychiatric discourse. It was, for example, with the publication of the third edition of the DSM in 1980 (the DSM-III, see American Psychiatric Association 1980) that the APA significantly increased the range of mental disorders, as well as making them more user-friendly (Cohen 2016: 75–81). The DSM began to speak the language of neoliberalism, highlighting everyday issues in settings beyond the institution. Rather than only disability and illness, recovery and growth were now also promoted as possible. Previously dominated by the negative institutional classifications of schizophrenia and manic depression, the expanding range of personality, identity and anxiety disorders from the DSM-III onwards has initiated a more ‘positive’ discourse of day-to-day concerns, inadequacies and traumas. In the post-institutional climate, acute and severe mental disorders have been replaced with the now ‘common disorders’ of ADHD, autism, BPD, GAD, PTSD and SAD, for which the prescribed treatment is much more likely to be drugs or therapy rather than committal. The impressive results of this neoliberal shift in the psychiatric discourse towards the idea of ‘positive’ mental health can be seen in the countless ‘awareness campaigns’ invoking the risk of mental illness within the general population (‘it’s everyone’s problem’), as well as the mass screenings and ‘early intervention’ programmes in schools to ‘catch’ the early phases of mental illness in children and thereby ‘prevent’ a more serious disorder in adulthood. Further examples include the expanding number of epidemiological studies which claim to highlight yet more cases of mental pathology which have gone undetected and/or untreated in the community, the grassroots movements
campaigning for further aspects of behaviour or personality to also be classified as an official mental disorder and the general high levels of self-labelling within the population. What is also evident here is that the APA’s turn to the biomedical model of mental disease with the DSM-III (Whitaker and Cosgrove 2015: 9–25) has been crucial to promoting neolib-eral solutions focused on the individual. This has successfully de-politicised the non-conformity of the individual through suggesting that ‘chemical imbalances’ in the brain are the root of the problem. As Moncrieff (2008: 243) has recognised, the rise of biomedical psychiatry and neolib-eralism are intrinsically linked – ‘the chemical imbalance idea of psychiatric problems facilitates the neoliberal project’, she argues, and ‘features of neoliberalism in turn strengthen the chemical balance theory and biopsychiatry more generally’. The increasing social and economic disparities in neoliberal society are individualised through biomedical ideology. Moncrieff (2008: 248–9) states that this represents: a clear instance of the medicalization of political discontent. But this situation is not overtly coercive. This view has not been imposed on people by direct force. People themselves have come to see their problems as individual problems, emanating from their brain chemistry. 52Marxist theory Thus, biomedical ideology as a part of psychiatric hegemony has become the dominant ‘solution’ to what are social and economic conditions of late capitalism. Biomedicine promises a range of corrections in line with neoliberal conduct, such as improved productivity and marketability as well as ‘recovery’ and the ‘normalisation’ of mental disorders for those who are at risk of deviat-ing from their expected roles as workers, consumers, students, homemakers and reproducers of the future workforce. Yet psychiatric hegemony encompasses more than the dominant biomedi-cal rhetoric and can also be detected in social models of the psy-professions. Feminist therapists, for example, argue that a legitimate response to a climate of antifeminism is now to work on the self-esteem of their clients. ‘Hence,’ remarks Dubrofsky (2007: 266), ‘social, political, and economic problems are turned into personal problems that can be solved by an individual who is willing to work on him- or herself.’ It is but one example of an all-encompassing psychiatric discourse that denies the social and political realities of late capitalism and has successfully placed the focus back on the individual as the site of change.
Conclusion
This chapter has outlined a number of Marxist approaches with which to understand both the rise of mental disease in capitalist society as well as the growth in professional power and profiteering from the business of mental health. While theorising mental illness as a result of the alienating conditions of capitalism may appear to have merit, I have suggested that it is neces- sary for Marxists to focus their energies more on analysing the ways in which the mental health system supports the economic and political prerogatives of the ruling classes. This allows us to make sense of the ‘trade in lunacy’ – from the birth of the psychiatric profession with the asylum system to the current market for psychopharmaceuticals – as well as the medicalisation of groups of deviants with various mental illness labels. Ultimately, the business of mental health supports profit accumulation alongside the social control of problematic populations. As neoliberal ideol- ogy has developed over the past four decades, so psychiatric discourse has infected more and more areas of economic and social life; we are now living with what I refer as a ‘psychiatric hegemony’, a totalising form of professional claims-making, imbued with neoliberal values but appearing as an objective and neutral discourse on mental disease. As such, mental health ‘experts’ have probably never been as powerful as they are now. Under such circumstances, it is more urgent than ever that critical scholars of mental health are encouraged to engage with and utilise Marxist approaches so as to be able to more thoroughly analyse the structural determinants of the psychiatric expansion we are currently witnessing.
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