Tietze 2013—Neither psychiatry nor anti-psychiatry, but mental health as radical politics

8/14/2019 Tietze 2013Neither psychiatry nor anti-psychiatry, but mental health as radical politics

1/27


2/27

NEITHER

PSYCHIATRY NORANTI-PSYCHIATRY,

BUT MENTAL

HEALTH ASRADICAL POLITICSTad Tietze

Historical Materialism, London

10 November 2013


3/27

ABSTRACT

When working as a clinical psychologist in the NHS, Peter Sedgwickpursued a sustained critical engagement with the ideas of thinkersassociated with the anti-psychiatric movements of the 1960s and1970s Erving Goffman, Thomas Szasz, R.D. Laing, and MichelFoucault. He welcomed their critique of scientific positivism whilerejecting a tendency to annex psychiatric problems from health and

illness in general. He also laid the basis for a political economiccritique of the health industry by dissecting the distorting impact ofmedical individualism. Sedgwick's work only hinted at the increasingcentrality of diagnosis to the legitimacy of mainstream psychiatry.However, his theoretical innovations provide a powerful frameworkfor understanding controversies surrounding the newly releasedpsychiatric diagnostic bible, the DSM-5and for strategically

orienting radical political projects in relation to such struggles overthe boundaries of normality.


4/27

OUTLINE OF PAPER

Sedgwick & anti-psychiatry last time

Goffman / Laing / Szasz / Foucault

Sedgwick on health & illness

Critique of positivism

Health & illness as socially constructed

DSM-5 & new critical perspectives

Example of bereavement exclusion in Major Depressive Disorder

De-medicalising misery versus politicising medical goals


5/27

SEDGWICK'S LEGACY

Psychologist working in the NHS

Marxist intervention in the debates over psychiatry via a sustained

engagement with the ideas key thinkers associated with anti-

psychiatry

Early argument (1972) for more and better mental hospitals, moreand better doctors and nurses at the expense of armaments

and the profits of the rich

Controversial because he refused to simply condemn psychiatry,

and even praised the beneficial effects of medications and ECT

at a time the NLR was publishing Laing's writings uncritically


6/27

CHALLENGE OF ANTI-PSYCHIATRY

In the 1960s & 1970s anti-psychiatric critiques & movements

seemed to have mainstream psychiatry on the ropes

Heterogeneous but 3 basic themes:

1. Low quality of science of psychiatry when compared with

medicine2. Repressive nature of practice, robbing patients of individual

rights through mechanisms such as detention & forcible

treatment

3. Value-laden nature of psychiatric diagnosis that turned deviancy

from mainstream norms into an undefinable entity called mentalillness


7/27


8/27

SEDGWICK ON GOFFMAN

Represents only a small break from dominant functionalism

Stigma/oppression and rebellion happen, but only as they fit within a broader

functioning social order

Focus on oppressive aspects of micro-systems of social

interaction masks general defence of the social status quo

Political radicals seen in same terms as mad people

Goffman has no room for sense of the historical contingencies of

social institutions.This deficiency makes it absolutely impossible

for him to use his insights, either into particular local settingsor

into the general quality of everyday life, in any way which iscritical: which issues, i.e., a demand for change in a definite

direction. [S 1974]


9/27

R.D. LAING

Scottish psychiatrist &psychotherapist

The Divided Self (1960), TheSelf and Others(1961), Sanity,Madness and the Family(with

A. Esterson, 1964), ThePolitics of Experience and theBird of Paradise (1967)

Argued schizophrenia resultedfrom impossible binds peoplewere put in by their families

and society it was reallysociety (at the family level) &not the patient that waspathological


10/27

SEDGWICK ON LAING

Starts from conflict between twopersonalrealities psychotic

and normal in a crazy world; he cannot provide a way to have

a standpoint on the irrationality of the totality that is not merely

from within these two views

Because he favours the psychotic, and by privileging the mad experiences of

the psychotic patient as somehow positive, he falls into mysticism

Studies of families limited by lack of normal controls unclear if

he is describing relationships specific to schizophrenogenesis

Even in most anti-systemic phase moves without mediation

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


11/27

THOMAS SZASZ

Hungarian-American psychiatrist

The Myth of Mental Illness:Foundations of a Theory ofPersonal Conduct (1961), TheTherapeutic State: Psychiatry inthe Mirror of Current Events

(1975), Psychiatric Slavery (1977) Mental illness a myth because

unlike physical illness noanatomical & genetic contexts to

judge someone ill, only social &ethical ones

Psychiatrists deprived people ofliberties by bestowing spuriousdiagnoses


12/27

SEDGWICK ON SZASZ

Uses positivist standard (pathological lesions) to separate

medicine from psychiatry, but in fact this is untenable

Uses extreme examples of repression by psychiatry to make

general case c.f. rest of medicine but then has nothing to say

about illiberal aspects of medicine in general Extreme right-wing libertarianism poses itself as being anti-

authority but is in fact mostly against collectivism

Ultimately glories in contractual aspects of medical individualism

disconnects medicine from its place in capitalist social relations


13/27

MICHEL FOUCAULT

Histoire de la folie l'geclassique - Folie et draison(1961; translated & abridged asMadness & Civilisation, 1965),Naissance de la clinique - unearchologie du regard mdical(1963; translated as The Birth ofthe Clinic)

Concepts of mental health &illness were purely social-historicalconstructs

Shifted & changed over time butalways played the same role in

upholding power relations The asylum & the analysts couch

were equally parts of systems ofrepression & control of the victoryof reason over unreason


14/27

SEDGWICK ON FOUCAULT

Vital corrective to liberal teleological picture of ever-improving,

ever more benevolent scientific advances in psychiatry

But puts too much store in the irrational rationalismof modern

medical approaches to insanity as unique to the current era. He

therefore cannot relate psychiatry to social change adequately Reason/unreason is effectively the driver of history

Cannot account for shifts back & forth to & from holistic & mechanistic

approaches


15/27

PSYCHIATRIC POSITIVISM

The critique of psychiatric positivism unites the anti-psychiatric

thinkers & is their strongest card

What we do have is a consistent and convergent tendency of

oppositiondirected againstpositivist method in the study of

abnormal human behaviour. Positivism, for the presentdiscussion, may be taken to refer to an approach towards the

investigation of human pathology which, modelling itself upon

antecedents which it believes to be characteristic of the natural

sciences, (a) postulates a radical separation between factsand

values(declaring only the former to be the subject-matter of the

professional investigator) and (b) suppresses the interactive

relationship between the investigator and the factson which he

works. [S 1972]


16/27

LIMITS OF THE CRITIQUE

Sedgwick: Critique of positivism must be extended to all of

medicine

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

the question: What is i l lness? Only in the light of an answer to

thisquestion could we determine our answer to the question: Ismental illness really illness in the medicalsense? [S 1972]

The difference so forcefully argued by anti-psychiatric theorists,

between the biological normsto which physical medicine

appeals and the social normswhich back up psychiatry,

dissipates into nonsense as soon as we are brought to see thatthe medical enterprise is from its inception value-loaded; it is not

simply an applied biology, but a biology applied in accordance

with the dictates of social interest.[S 1974]


17/27

SOCIAL CONSTRUCTION OF

HEALTH

It may prove possible to reduce the distance between psychiatry

and other streams of medicine not by annexing

psychopathology to the technical instrumentation of the natural

sciences but by revealing the character of all illness and disease,

health and treatment, as social constructions

Outside the significances that we voluntarily attach to certain

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


18/27

ILLNESS AS SOCIAL DEVIANCY

All sickness is essentially deviancyfrom social norms, which

themselves must be understood in terms of conflicts over ideas &

practices within a given society

BUT: Not all deviancy is illness!

Not a relativism: Definitions of health & sickness always productof specific, historical social processes meaning can only be

judged if one has a critique of social structure and change

However illness is specified from culture to culture, the attribution

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

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


19/27

DSM-5 & BEREAVEMENT

DSM-5 (2013) has deepened the crisis of psychiatric authority

Debate over diagnostic categories has focused on issues such as

inappropriate medicalisation, disease mongering, etc.

Sharp debate over the bereavement exclusion(BE) in Major

Depressive Disorder (MDD) DSM-5 workgroup claimed BE wasinvalid

Argument is that BE doesnt differentiate between two different types

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

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

MDD e.g. sadness, difficulty sleeping, decreased appetite, fatigue,diminished interest or pleasure in usual activities, and difficulty

concentrating on usual tasks PLUS clinically significant distress or

role impairment


20/27

Zisook (2012): Depression can and does occur in the wake ofbereavement, it can be severe and debilitating, and calling it byany other name is doing a disservice to people who may requiremore careful attention

Wakefield & First (2012) found the evidence wanting:

Kendler & Zisook (2007 x 2): Looked at MDD v BE patients, but confusingmethodology

Treatment response no different But should this make a difference?

Suicide risk driving need to diagnose? BE accounts for this, so irrelevant

No more likely to have recurrent MDD than people who have never beendepressed

The Lancet (2012): Grief is not an illness; it is more usefullythought of as part of being human and a normal response todeath of a loved one.


21/27

CAUGHT IN A TRAP?

Development of medicalpracticewithin capitalist social relations

increasingly technical-physical definition of illness

Psychiatry under pressure to prove its illnesses are (reductively)

physical or to accept they lie outside the bounds of medicine

Some progressives line up with latter want to de-medicalisemisery

Resisting the psychiatrization and psychologization of almost every aspect of

human experience, and finding a way to place what are, frequently, essentially

moral and politicalnot medicalmatters back at the centre of our

understanding of human suffering is a massive and multifaceted task.

[Moncrieff Chap 1]

Psychiatry provides analgesia at the expense of understanding[Jureidini

2012]

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

constructed


22/27

SEDGWICK ON BEREAVEMENT

The example [of a bereavement causing symptoms] is revealing

in several ways. A doctor may prescribe some form of minor

tranquilliser to relieve some of the effects of a bereavement, even

though depression of activity and feeling following the death of a

close relative would scarcely be regarded as constituting a

mental illness. Bereavement has, however, also been reportedas a significant precipitating event in the onset of actual

psychiatric illnesses The line of division between a

bereavementand a psychiatric illness following bereavement

would seem to depend on our culturally-derived expectations

about how to mourn properly. [S1974]


23/27

POLITICISING GOALS (1)

Greatest advances in combatting illness have come through

social and political measures

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

medicalise) , nor to technologise it further

The alternative is topoliticisemedical goals Mental illness, like mental health, is a fundamentally critical

concept: or can be made into one provided that those who use it

are prepared to place demands and pressures on the existing

organisation of society. [S 1972]


24/27

LIBERTY VS. COLLECTIVE

PROVISION

Capitalism creates antagonism between medicine/psychiatry as

legally-inspired, contractual & individualistic on one hand, and

collectivist on the other

Complicated by double meaning to collective: (1) due to

collective political struggles from below and (2) provided by state

& its social agencies from above

Warned RCPsych [in S 1983] that Rights libertarian critique of

psychiatric authority was a way of breaking down collective

provision without challenging state/ruling class authority


25/27

POLITICISING GOALS (2)

Just as the revolutionary exposes and pressurises Parliamentary

democracyby demanding consistent democracy; just as he

exposes and fights the courts of bourgeois justiceby demanding

consistent justice: so he must and combat the evils of our anti-

therapeutic institutions of 'psychiatry' by demanding consistent

psychiatry. [S1972]

That is, more and better psychiatrybut not more of the same.


26/27

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

possible treated, fully and effectively, in this society; for no matter how

many maladjustments may become adjusted through expert techniques,

the workings of capitalism will ever create newer and larger discontents,

infinitely more dangerous to the system than any number of individual

neuroses or manias.[S1972]


27/27

BIBLIOGRAPHY

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

Salmagundi

S 1972PS, Mental illness isillness, Salmagundi

S 1974PS, Goffman's Anti-Psychiatry, Salmagundi

S 1982PS, Psychopolitics, Pluto Press

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

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

DSM and the Medicalization of Everyday Life in Rapley, Moncrieff

& Dillon (eds), De-Medicalizing Misery: Psychiatry, Psychology

and the Human Condition, Palgrave Macmillan

Documents

Tietze 2013—Neither psychiatry nor anti-psychiatry, but mental health as radical politics