The Leftist Defense of Psychiatry

This article raises some typical points in service of a leftist defense of psychiatry. (NB: the post I am citing summarises rather than advocates for these positions). This defense hinges on the claim that if mental illness is held to be ‘socially constructed’, this conception may lead to a denial of the existence of certain forms of suffering. This denial is something that can then be exploited by contemporary governments increasingly eager to implement spending cuts and austerity measures. One person cited in the article was Tad Tietze, for whom ‘the logic of Szasz would empty hospitals and put the same people in prison’.

Much could be said on this theme, but I shall try to keep my remarks brief.

First, all ‘illness’, including that of organic origin, is ‘socially constructed’. No diagnosis derives from stone tablets on Mount Sinai. The organisation and nomination of symptoms is pre-eminently a discursive work, whatever the ‘scientific’ apparel involved in the exercise. This is just about the surest fact of all of medicine. In each case, it is therefore pointless to ask whether this or that illness is ‘socially constructed’, and one should instead enquire as to who is doing the constructing, and for what ends. As I have pointed out elsewhere, ‘ADHD’ may well be a diagnosis that corresponds to some ‘real’ referent (namely, a subject with neuro-cognitive symptoms of one sort or another), but the diagnosis functions essentially as a means by which parents, schools and health professionals can better discipline children with inconvenient behaviour. The diagnosis of autism can be used to designate a ‘disorder’, which then supposedly necessitates a regime of normalisation for the subject who bears it, but it can also be used designate a ‘differently-ordered’ rather than deficient subject.

Second, it’s conceivable – though exceedingly rare in practice – that some self-declared libertarian or anarcho-capitalist could seize upon the works of Foucault, Szasz or Laing as part of an argument against public mental health spending. I think, however, that we misunderstand the neoliberal hegemony altogether if we suppose that this sort of argumentation is the driver behind spending cuts. Neoliberalism is not liberalism, hence the ‘neo’ prefix. It is incongruent as a doctrine, but not as a practice. It combines an ideology of ‘self-reliance’, ‘self-management’, pathologisation of dependence alongside of increased coercive and surveillance powers of the state. Rather like fascism, one misses the essence of it if one’s analysis remains at the level of its incoherent ideological rhetoric, because the ideology operates more as a political fig leaf than as a driver of policy. Or, to put it differently, if Szasz and Foucault did not exist, it would be unnecessary for a neoliberal politician to invent them. Perhaps I am missing something, but I am unaware of any circumstance in which neoliberal implementation – under Thatcher, Reagan, or others – was conducted in the spirit of anti-psychiatry, or a critique of biopower.

Hence, the DSM system is greatly expanding the list of ‘disorders’ at the same time as publically-funded treatments are under threat in many countries. Even the most earnest affirmation of psychiatric diagnosis is no guarantee of a treatment, since treatment providers can simply use diagnosis itself as a means of refusing care (i.e. by diagnosing a ‘personality disorder’, for instance, or by characterising a suicidally depressed subject’s depression as ‘mild’ and a non-immediate risk).

Third, the accusation of discipline and coercion applies to clinical psychology as much as to psychiatry. We should not imagination that ideology functions as it did in the USSR, in which a centralised committee could direct policy outwards, as it were, and expect compliance. The psychologists and psychiatrists could construct a critical diagnostics that did not merely bow to prevailing ideology, but for a range of reasons, they fail to do so, and frequently, if unwittingly regurgitate the neoliberal ideology they purport to resist. Thus, clinicians and academics who oppose austerity measures, or who profess a fondness for Laing or Foucault, are all too often to be found uncritically peddling CBT, or SSRIs, or ‘positive’ psychology. (In Lacanian terms, these people are stuck within a discourse of the hysteric, vehemently addressing complaints to a master with whom they share an intimate complicity).

Finally, on the question of whether we are witnessing an emptying of the hospitals and a filling of the prisons, we should scratch a little beneath the surface. When we examine, for instance, a sad case of negligent hospital treatment such as this, it should be clear that the position of a suffering subject within such a health system is not altogether very different to that of a prisoner. In each case, the system treats the subject with contempt, and offers the minimum service it is mandated to provide. This is only partially a matter of depleted resources, since it is far from guaranteed that additional funding (i.e. for beds) would change the underlying attitude of condescension for personal suffering. Thus, in Australia, at least, the hospitals are run increasingly like prisons, and the prisons like hospitals. (The criminal justice system in Oz is one in which magistrates increasingly play the role of armchair psychiatrist, condemning the guilty to visit a small army of rehabilitative workers as part of a sentence).

I cannot recall any critique of the psy-disciplines that outright denied the existence of suffering. The key question, for me, at least, regards the sorts of responses the psy-disciplines provide to this suffering. To call for more resourcing of the disciplinary, coercive responses – whether these be at the extreme end, such as forced hospitalisation and ECT, or the relatively milder end, such as CBT, and ‘positive’ psychology – is less a stand against austerity than a left-liberal accommodation to it. There may be a day when Abbott, Harper, Cameron, et al. declare themselves committed Deleuzians, but until then, we should seek for the causes of austerity elsewhere than in critiques of psychiatry, and critique not only austerity and the psy-disciplines, but also the fraternal bonds between them.

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