Notes on mental health and neoliberalism

I recently read a couple of Foucault’s later lectures, namely Security, Territory, Population (1977-1978) and The Birth of Biopolitics (1978-1979). In this latter set of lectures, Foucault made a rare foray into contemporary economics, analysing various currents of neoliberalism (especially German and US varieties) and their relation to new forms of governmentality. I thought it beneficial, if only for me, to jot down a few notes on Foucault’s reconstruction of neoliberal thought, because I think it particularly pertinent in understanding contemporary knowledge and practice in mental health. I have a paper forthcoming in an academic journal on this topic, and perhaps after this post, I can move onto other things in 2016.

Foucault the Neoliberal?

From the outset, I think it’s worth refuting the claim, from Zamora and others, that Foucault was a sympathiser of neoliberalism, or some kind of proto-neoliberal. It is true that the manner in which he reconstructs neoliberal doctrine can appear as if he identifies with it, but this is Foucault’s manner of presenting all of his lecture topics, whether it is the Church Fathers, the Stoics, or whatever. Certainly, there is no reasonable reading of the lectures which would allow one to conclude that Foucault is in favour of neoliberalism. More to the point, however, there is criticism of Marxism (or at least certain elements of Marxism) and some disparagement of state socialism, the Soviet bloc, etc. This is neither new, nor clear evidence of crypto-Hayekianism. We should recall the famous debate between Chomsky and Foucault – that is, an intra-leftist debate – as a reference point here. Chomsky proposes revolution of the anarcho-syndicalist variety as a way forward. As ever, Foucault is sceptical, thinking that even an apparently democratic revolution of this sort would not preclude the possibility of violence being perpetrated through ‘neutral’ institutions, such as the prison, the school, the hospital, and so on. So, in these lectures, it is not as if Foucault is arguing that the shift from a Keynesian governmentality (broadly speaking) to neoliberalism implies a better governmentality, so much as a different one, and the differences, in my opinion, account for a great deal in contemporary mental health. As I indicated in recent comments, and at the risk of over-simplifying things, there has been a broad shift away from relational, mother-centric approaches under Keynesianism toward radically individualist doctrines of self-mastery (CBT and its cognates, positive psychology) under neoliberalism.

Obviously, there are few signs in the Anglophone world of either a rise in anarcho-syndicalism or the dismantling of psychiatric power. Nevertheless, elements of this debate continue to be recapitulated in intra-left debates on the role of mental health. I think we can posit the debate as one between those who are anti- or critical psy (the Foucauldians, the followers of Laing, etc) and the Sedgwickian socialists, who argue that some elements of psy knowledge and practice are necessary for the preservation of the welfare state. This is an important debate in my view, and I shall return to it shortly.

Neoliberalism in Two Continents

To assemble some notes from Foucault’s Biopolitics lectures, liberalism involves a self-limitation on the art of governments’, and sometimes involves the promotion of certain freedoms, but this is always paradoxical. As Foucault says (p. 64): ‘Liberalism…entails at its heart a productive/destructive relationship with freedom…Liberalism must produce freedom, but this very act entails the establishment of limitations, controls, forms of coercion, and obligations relying on threats, etcetera.’ Consequently, the liberal period, emerging in Europe and parts of the US in the 18^th Century, appears at one level as ‘progressive’ relative to it forebears, but in fact tends to involve ever more subtle, insidious and individualised practices of discipline and surveillance. Indeed, Bentham’s Panopticon is ‘the very form of liberal government’.

Neoliberalism is self-consciously aware of this insight, this paradox. Consequently – and Foucault stresses this point repeatedly – neoliberalism in its various iterations is not to be identified with laissez-faire. A neoliberal government is an activist government, one that conducts itself with ‘permanent vigilance, activity and intervention’ (p. 132) . What are its aims? According to Foucault, who was writing prior to the full onslaught on 1980s neoliberalism, there can be distinguished at least 2 broad movements, one emanating from Austro-German theorists, producing the economic ballast of the neoliberal doctrine, and the other from the US, with a greater emphasis on the application of economic processes on apparently non-economic phenomena.

At the heart of the Austro-German ‘ordoliberal’ project is the aim of making accuracy and efficiency of pricing mechanisms the fundamental principle of economic governmentality. Pricing is best achieved by establishing competition as a universal feature of the neoliberal economy. Economic competition is by no means natural, but rather, is something with an activist government must permanently establish. This is a key difference between neoliberalism and laissez-faire, since the latter system may very well lead to monopolies, centralisation of capital, and other phenomena the neoliberals regard as abhorrent. Second – and Foucault touches on this merely in passing, but I think it important – accuracy of price mechanisms require that the value of money be stable. Therefore, the role of central banks in neoliberalism is neither (principally) to stimulate growth nor full employment, but to ensure that inflation is restricted within tolerable limits.

The subject of economics under neoliberalism is not, as it was in Marx, that of commodity production or of exchange, but of enterprise. Each individual is his or her own entrepreneur, subject to the dynamic of competition in economic life. In this paradigm, what is an unemployed person? ‘He is not someone suffering from an economic disability; he is not a social victim. He is a worker in transit. He is a worker in transit between an unprofitable activity and a more profitable activity.’ (p. 139).

The ordoliberals tend to conflate any centralised welfare with totalitarianism, the threat of gulags and concentration camps, etc. (p. 188-189). (Hayek, who was a fan of dictator Pinochet, thought that Keynesian Britain was on the path to ‘serfdom’. The contemporary neoliberals also make similar revisionist claims, arguing that Hitler, for example, perpetrated atrocities on the basis of socialism, or that fascism is a subset of socialism). Thus, any welfare or social insurance measures are preferably individualised rather than collective under this system. (See the advocacy of vouchers rather than public education in the US, for instance).

Neoliberalism is not really ‘small government’ per se, since a society of entrepreneurs will be one in which there will be more conflicts between individuals, and hence more judicial and legislative regulation. ‘An enterprise society and a judicial society…are two faces of a single phenomenon.’ (p. 150). Managing disputes, individualising subjects, and promoting competition are therefore the goals of neoliberal governmentality. For a neoliberal government, the focus is ideally on removing anti-competitive effects rather than ameliorating the ill-effects of competition. (At least, insofar as this is politically permissible). If competition causes economic pain to somebody, the idea is not to relieve this pain directly, since this would mitigate the effects of competition and subsequently distort pricing mechanisms. Rather, the aim is to get the losers of the neoliberal game to ever more productivity and efficiency, that they may be better positioned with respect to competition. To give succour to the losers of neoliberal economics would, in this paradigm, be to encourage, or at least tolerate unduly, the less productive sectors of the enterprise economy. In this vein, budget cuts and austerity measures are the means by which neoliberalism is implemented, but by no means the aim, which is to establish competition at an individualised level.

It is with the US contribution to neoliberalism that we step closer, in my view, to contemporary mental health practice, since US neoliberalism, according to Foucault, consists less in establishing the economic framework furnished by the Germans and Austrians, and more in applying to apparently non-economics spheres of life. (It is from here that the term ‘human capital’ arises). If one conceptualises each subject as her own entrepreneur, then this is the paradigm in which such a subject will be compelled to be the principle of her own subjection. Entire industries – CBT, positive psychology, the notion of ‘self-care’ in physical and mental health – arise from this paradigm. Now, I don’t imagine that the hucksters of happiness, be they Beck or Seligman, consult the texts of neoliberals in order to formulate their views. (There’s little evidence that they read anything much, and even a little study would cause their paradigms to implode). Rather, neoliberalism is a necessary prerequisite to the sorts of ideas peddled by these doctrines and practices.

In the US model, almost every element of life can be brought into the realm of ‘contractualisation’, including love, parenting, friendship, education, etc. Foucault shows (p. 244) that the mother-child relation can be made reducible to a series of ‘investments’ – economic, rather than libidinal – in which both parties seek to profit. Economic rationality can be brought to bear on many areas of life, with the effect of greater productivity and efficiency.

This contractualisation of life is so pervasive as to be practically invisible now. Sexual perversion, for instance, has always been a dubious category, but whatever meaning it has now is in relation to matters of consent or contract. A sex crime is one in which there is a breach of contract, or a sexual activity without the proper establishment of contract (with the implicit notion of the body as a possession, a piece of capital). In mental health, too, we find contractualisation at the heart of practice, with every element of treatment now supposed to be consented to in advance, and then subject to customer feedback at the end of each session. Thus, in the UK, there was a proposal that psychoanalysts could not help patients self-interpret dreams without the patient’s consent, and that no interpretation could be given to a patient at the end of a session, lest there might be some aspect of it which the patient misunderstood. One can see that this sort of bureaucratic intervention would, if enforced, make psychoanalysis – or practically any spontaneous interaction impossible. It is no coincidence that we live in the era of scripted, standardised treatment protocols.

Neoliberal economics is economics in its imperialist phase in the sense that there is little that can escape its analysis. According to Becker, for instance, any conduct is amenable to economic analysis if it ‘accepts reality’ (p. 269). Foucault (p. 270) draws out the points of convergence between neoliberalism and Skinner’s Behaviourism (most of these apply to CBT as well). The meaning of some conduct or phenomenon is irrelevant, or, at the very least, subordinate to its position within economic stimulus and reinforcement. The kind of subject presupposed by both the cognitive-behaviourists and the neoliberals is essentially the same.

There is at least one point in Foucault’s reconstruction of neoliberal economics that calls for dispute, and this is when he asserts that neoliberalism should not be viewed as ‘no more than a cover, a justification and a  screen behind which something else is going on’ (p. 148). Perhaps this is true, at least, from the perspective of its intellectual adherents. But the question of cui bono remains as critical here as anywhere. The neoliberals would argue, on utilitarian lines, that their system has widespread benefits, but I think that we can identify some entities that benefit more than others. Firstly, a system that prioritises stability and limiting of inflation will naturally benefit the financial sector. It is true that inflation, especially in particular circumstances, can wreak widespread economic damage, but to prioritise stable inflation above growth, jobs, etc, benefits lenders in that it helps to preserve the value of a debt in real terms.  Second, the other obvious beneficiaries are the ever-increasing ‘public-private partnerships’ which emerge as a result of competition and privatisation being introduced into previously state-operated areas. In the US in particular, but elsewhere as well, this leads to highly profitable, destructive enterprises, such as Halliburton, or the prison-industrial complex. Of course, doctrinal neoliberals would say that these entities are monstrosities, deviations from pure, ‘classical’ liberalism, but this notion is as convincing as the idea that Lenin’s ideas had nothing to do with Marx.

Neoliberalism and Contemporary Mental Hygiene

It should be clear that the subject presupposed as on object of neoliberal activism – homo oeconomicus – is identical to that presumed by contemporary mainstream mental health. In both cases, it is a bare, atomisted subject without any internal division or unconscious. Or, if an unconscious exists, it neither contains nor leads to contradictions. Both economic and psychical pain derive from the same sources, such as lack of efficiency and productivity, an inability to ‘accept reality’, and must be treated with the correct reasoning (delivered by an expert). To expect anything at all of an Other, including the expectation of support from the state, is, in the words of a famous CBT peddler, ‘musterbation’. Such expectations – or demands – signify an error of reason, a self-indulgence, and ultimately, an unproductive and unhappy character flaw. An entire repertoire of refined techniques, from CBT, to positive psychology, to mass prescription of SSRIs, is designed to correct such expectations. Such mental health practice is the corollary of neoliberalism. When CBT practitioners in the UK protested against austerity in 2015, the irony, apparently lost on them, was that, as CBT practitioners, that were already doing austerity, whether via the crude imbecility of the standardised protocols, or the subtle ‘adaptation’ of schema therapy and the like. You can be ‘progressive’ or you can practice mainstream mental health, but you cannot do both.

It is not that psychoanalysis, by way of contrast, is necessarily progressive. Nonetheless, its practices tend to undermine the logic of neoliberalism, as well as other bio-political systems. Under a dictatorship state-administered behaviourism, cognitivism, or neuroleptics are perfectly coherent, as they have been through modern history. Psychoanalysis, on the other hand, tends to be banned by Hitler and Stalin alike, and rigorously excluded (where it cannot be co-opted) under neoliberalism. Contemporary mental health situates the pathology within the individual who has failed to accept or adapt to reality. Things stand differently in psychoanalysis where, as in Freud’s thesis in Civilisation and its Discontents, there is ineluctable conflict between the subject and his or her world and, to the extent that this latter is internalised, an inner conflict as well. There is no utopia to be found in Freud.

Sedgwick, and the Leftist Defense of Psychiatric Power and Concepts

It is with this background of neoliberal doctrine and contemporary psy-practice that I turn to the re-opening of the debate initiated by socialist psychiatrist, Peter Sedgwick. Sedgwick proposed a leftist defense of psychiatry, and, if I grasp it accurately, his argument is as follows. (See here for other reflections on this topic). Foucault, Laing and others mount various critiques of psychiatric power and epistemology, and the abuses that derive therefrom. This is ‘nihilism’, however, since the critics posit no viable alternatives. Moreover, in abandoning psychiatric language and practices, the leftist critics of mental health relinquish a vocabulary for making ‘demands’ of the state. The state may very well appropriate the critiques of Foucault et al, and use it to justify cuts to the welfare state. The end result of anti-psychiatry will be that of the working classes having to manage their psychical suffering alone, without state assistance.

In some ways, this resembles the old intra-left debates about the nature of the bourgeois state. Sedgwick, unlike his contemporary followers, was writing prior to the full flush of neoliberalism under Thatcher and Reagan. History has not supported Sedgwick’s thesis. The budget-cutters have gone about their business without any need for referencing Foucault or Laing. They haven’t only cut, however, but just as one would expect from neoliberal doctrine, have promoted treatments that in turn further individualism, productivity, competition and the like. Sedgwick’s idea – that the working classes should retain the shonky concepts and practices of mental health in order to better formulate a demand to the state – omits the psychoanalytic notion that every demand is addressed to an Other. The Other (as bourgeois Keynesian state) in Sedgwick’s time may well have entertained, occasionally, the notion of supporting some long-term, non-coercive treatment for its own political benefit, perhaps. The neoliberal state is different, however, and Sedgwickian demands will not only fail to avert the working classes self-managing their mental suffering, but will provoke further treatments designed expressly for this purpose. More mental health, in a neoliberal context, means more SSRIs, more CBT, more positive psychology, etc, which is to say, more measures designed to shift the burden of mental suffering onto the sufferers themselves, that they may obtain a better ‘acceptance and commitment’ regarding their reality.

Consequently, even as political strategy, the Sedgwickian approach is rather quixotic, and resembles something like a leftist apologia for mercantilism or national chauvinism. Moreover, if Sedgwick can disparage his opponents as ‘nihilists’, it is only because he is advocating something utopian. He and his followers will only admit of solutions to mental suffering that are ‘social’. Well, at one level, every intervention whatsoever is ‘social’. On the other hand, if by ‘social’ we refer to some collective, revolutionary situation, even if at a micro-scale, then virtually all ‘social’ mental health treatment is rendered impossible. Sedgwick’s utopia is literal, in that it posits no topos at all.

The claim that there is no alternative to a bad mental health system, racing to the lowest common denominator omits the fact that there is a non-coercive alternative, namely, psychoanalysis, which, when practiced in the vein of Freud or Lacan, cannot be used to perpetuate neoliberal capitalism. (Unfortunately for Sedgwick, it could not be used to promote other forms of political doctrine either). Psychoanalysis concerns itself with demands, and, after a time, some of these demands, intensely linked to personal suffering, can find refraction in an analysis of desire. This, and not adaptationism, is one possible point of advocacy for the Sedgwickian socialists. It goes without saying that it could not and ought not to be a servant to the state.