Attempts to medicalise distress, and the backlash against alternatives
We know that capitalism makes us sick, but there is a deeper more insidious form of this process that we need to get to grips with if we are to find alternatives to the damaging ‘treatments’ that are doled out by mainstream psychiatry.
Psychiatry is often confused with other ‘psy’ disciplines (like psychology, psychotherapy and psychoanalysis), but what marks it out from the others is that it is deliberately and explicitly medical; psychiatry is underpinned by a ‘medical model’ of distress so what we feel when we feel bad is treated by specialist doctors as if it is really a ‘sickness’ that has an physical organic cause that can then be ‘cured’ by physical, usually drug interventions.
What that assumption about sickness and cure does, and it is drummed into the psychiatrist in their medical training before they specialise in ‘mental disorders’, is to effectively ignore the alienation, exploitation, oppression and misery of living under capitalism. The psychiatrist instead is trained to search for the ‘real’ underlying causes, as if poverty, exclusion, austerity, racism and sexism were mere additional factors that might just intensify or ‘trigger’ what the doctor detects underneath the symptoms they are trained to attend to. The fiction that medical psychiatrists really now work according to a ‘bio-psycho-social’ model is a hopeless delusion. When it comes down to it, they reduce distress to biology, or they break with psychiatry.
A psychiatrist, like other medical professionals, is under pressure to make speedy diagnosis, choosing a category from the DSM (the Diagnostic and Statistical Manual of Mental Disorders) or the ICD (International Classification of Diseases), and to administer treatment, and so the reduction of distress to a physical cause is the understandable default procedure. This pressure is added to by the marketing of an increasing number of new ‘disorders’ by the drug companies, and by the promise that symptoms can be dealt with by targeting a chemical imbalance in the brain.
So-called ‘psychopharmacology’ is a massive drug market, legalised and state-sanctioned drug-pushing, and big pharma pours huge investment into identifying disorders that are dampened by drug treatments. That investment includes paying medics to endorse or even add their names as authors to already-written research reports, and it includes smearing those who have second thoughts, whistleblowers and psychiatrists who realise that the medical model just does not work.
In some ways, the approach does work, of course. Symptoms are certainly dampened down by the drugs, and patients are got off the books. And many patients are relieved to be given a diagnosis, to find an answer of some kind to their distress, and to accept what they are handed as a life sentence, that is, to accept that the sickness is deep within them and could return at any time. The illusion that root causes have been found is often a comfort to the patient and, of course, the doctor, but it is disabling.
Yet, from the beginning of psychiatry, which took root as a more humane approach to the mad inside the old asylums at the end of the eighteenth century, there were fierce debates; many early psychiatrists favoured physical treatments – restraint and then, at worst, electroshock and surgery – while some, like the Quakers at the York Retreat, looked to ‘moral treatment’ that included encouragement to get back to work, to work alongside others in the community. The ‘chemical revolution’, discovery of major antidepressents in the 1950s, shifted the field of debate.
The more humane psychiatrists objected to the chemical cosh, just as their predecessors had objected to patients being manacled and put on show. It was then that quite a few psychiatrists broke with psychiatry altogether, and looked for alternatives in a disparate movement that became dubbed ‘anti-psychiatry’. That was a misleading label, covering a wide range of alternative approaches to distress, some inspirations, some dead ends and some real dangers for the poor patients who sometimes had good reason to cling to the labels they had been given.
Some of the most prominent ‘anti-psychiatrists’ hated the label, objected to it, sometimes because they weren’t actually against psychiatry as such at all. One of the most prominent, Thomas Szasz, who appears as the main representative of the tradition in psychiatry and social work textbooks, was a right-wing libertarian, who was against the whole notion of ‘mental illness’ because it let people off the hook; as well as leading to coercive practices, medical psychiatry gave people excuses, he said, for their bad behaviour.
Szasz’s spin on ‘moral treatment’ meant getting people to stand on their own two feet and take responsibility, individual responsibility for what had gone wrong in their lives. He was willing to ally with the scientologists to get his message across. This is neoliberalism in the field of mental health, not a progressive alternative, and recently some other critics of psychiatry have also dabbled with anti-vax and conspiracy theories.
Some on the left fell into the trap of putting a plus where the psychiatrists put a minus, and there was a temptation among some ‘anti-psychiatrists’ to romanticise distress, to make it seem as if madness was a kind of journey to enlightenment. Some of these were ostensibly, for a time, on the left but, like R D Laing, they travelled down a drunken road into quasi-spiritual nonsense, and celebration of the family as a refuge rather than, as they once had it, as a prison.
One of the most radical experiments, in Italy, and one that Laing disparaged as being ‘communist’, was the closure in Trieste of the mental hospital in the early 1980s. This was following a massive campaign by the far left against psychiatric abuse that managed to draw in the communist party and a pre-emptive partial reform of the Italian psychiatric system after a successful referendum. This was a time when mental health really became a political issue, politics involving thousands of people debating and building alternatives in the form of community mental health centres.
That experiment inspired a psychiatrist in Sheffield, Alec Jenner, using money left over from a conference about Trieste, to set up Asylum, which fashioned itself as a magazine for democratic psychiatry. ‘Democratic psychiatry’ had been the name of the reform movement in Italy, also led by a psychiatrist, Franco Basaglia who broke ranks with his medically-trained colleagues.
The magazine hosted innovative work around ‘hearing voices’ developed by yet another psychiatrist Marius Romme. Many people hear voices, and for many different reasons, Romme realised; the task then was to explore what that meant rather than silence the voices, rather than put the experience under a chemical cosh. Meetings organised by Asylum magazine also included another group of rebel doctors in the Critical Psychiatry Network.
Prominent among that new generation of psychiatrists turning against the medical model, effectively becoming ‘anti-psychiatrist’, was Joanna Moncrieff who, in her ground-breaking book The Myth of the Chemical Cure, showed that the psychiatric drugs did not in any way ‘rebalance’ disordered brain processes. Instead, as with alcohol, nicotine or other recreational drugs, the psychiatric drugs changed the chemistry of the brain. That ‘drug-focused’ assumption had actually been guiding research before the so-called chemical revolution of the 1950s, but we need to remember it and follow the consequences if we are to break from the ‘illness-focussed’ assumption that the drug companies base their research and advertising campaigns on.
The battlefield now
All of this brief potted history is to make the point that ‘anti-psychiatry’ is a very mixed enterprise, and that we need many alternatives to the medical model, alternatives that take distress seriously. If we don’t do that, there is a big risk that we will take fright and fall for the lure of bedrock biological explanations. This is where we are now, with recent attempts to rehabilitate the medical model and to reduce the alternatives to caricature. And this is where some on the left who are desperate to find what they think of as being ‘materialist’ explanations for distress seem to be giving ground to the assumptions peddled by big pharma.
If we are materialists, the argument goes, then surely we should acknowledge that at least some of the causal mechanisms to distress are biological, so why not call the problem ‘medical’ in a very broad sense, and if there are such causal mechanisms in the brain what would be wrong in sifting out what causes what and valuing the drugs that do actually make a difference. And, here they twist the knife, it seems very difficult to show exactly how what bits of capitalism or other forms of oppression cause exactly what bits of distress.
This is a version of standard right-wing arguments against Marxism, that because you can’t directly and immediately observe and precisely measure the link between personal distress and oppression, it is not capitalism (or racism’s or sexism’s etc) fault. Work on the ‘spirit level’ that shows that inequality in society is correlated with unhappiness goes some way to addressing that, but we need a deeper more radical practical-theoretical understanding of capitalism to keep ourselves grounded in the possibility of alternatives, and not only in the field of mental health.
We’ve seen the medical line of argument, an attempt within the left to roll back critiques of psychiatry, a couple of years ago, in 2020, and there have been good responses to that psychiatric backlash by radicals.
The dice are loaded against us because, it is true, there is something inexplicable about distress that cannot be simply ‘diagnosed’ – whether that is depression or more profound alienation labelled, in the medical model, ‘schizophrenia’ – and we have been unable to construct societies in which we can give people space – genuine ‘asylum’ that the democratic psychiatry and critical psychiatry movements called for – and access to real care.
Instead, the randomised controlled trials, between effects of drugs and ‘placebos’, are all against the background of a rotten society; the ground-rules mean that a base-line ‘biological’ cause becomes as tempting an answer as the possession by demons was convincing to religious folk way back before the asylums were built. Friends and comrades involved in supporting people in distress are desperate to get out of this predicament, but over and again they lose hope that things could ever change dramatically enough to rule out drug treatment. In the meantime, they say, we need to patch people up, and hope for better psychiatric research; this is desperate, understandable, but a mistake that gives ground to psychiatry.
As with every other challenge to the power of institutions under capitalism, vested interests tell us that the fault is in ourselves instead of in society, we need to acknowledge that people need to find ways to cope, but the way they do that has to be collective, which means, short-term, supporting patients subjected to medical treatments to share information and weigh up what they want to accept and what they cannot. That collective agency was the basis of the ‘hearing voices’ movement – groups of people exploring what their voices meant to them – which ‘de-medicalised’ that experience, took it out of the hands of the doctors to define what was normal and what was abnormal.
It also means working with those who have broken and are still are breaking with psychiatry, to expose the research agendas of the pharmaceutical companies. Yes, we can imagine that under other conditions, resources could be put into exploring what drug treatments might help, but that means looking at what works in line with a ‘drug-focused’ model rather than buying into the idea that there is an underlying illness that needs to be cured. Meantime we need to focus on the question of power and on building radical clinical alternatives rather than digging about in the brain. And that means supporting those who are breaking from psychiatry inside the mental health care services.
It is the search for a cure for this wretched miserable society that needs to take priority now, and that collective process is one that can give hope, channel energy and enthusiasm, give meaning for people who are usually labelled as ‘crazy’ or ‘sick’ or ‘abnormal’. The apparently ‘balanced’ and ‘neutral’ arguments about what might be happening in the brain for people who are in distress are not really ‘balanced’, any more than is the fiction of chemical ‘rebalancing’ in pharmaceutical propaganda, and they are not ‘neutral’.
Good research is not neutral, but knows what choices are being made, and why, and in line with what agendas. The medical model locks people into their distress, into their biology, while we need to be finding a way out of it, together.
This is also part of the FIIMG project to put psychopolitics on the agenda for liberation movements