By Aprotim C Bhowmik, Titilayo F Odedele, and Temitope T Odedele
Would the field of psychiatry hold firm against time and place? If the holy book, the DSM-5 [1], were written in a different century, in a different society, would the diagnosis and treatment of common psychiatric disorders be different? The answer, according to many, would be unequivocally in the affirmative, as psychiatry—and in particular, the DSM-5—is inextricably bound to politico-economic contexts and cultural norms/practices. So, perhaps a more specific and important question is—does the DSM-5, being a largely Western written text, contribute negatively to our understanding, diagnosis, and treatment of psychiatric disorders?
Psychiatric diagnosis
For those who have not cracked open a copy of the DSM-5, it consists primarily of diagnostic criteria for common psychiatric disorders—ranging from affective disorders (e.g., depression and bipolar disorder) to psychotic disorders (e.g., schizophrenia) to personality disorders, and the intersection thereof. Consider, for instance, the diagnosis of attention-deficit / hyperactivity disorder (ADHD), which can be classified into two types: inattentive and hyperactive. Diagnostic criteria for the former include difficulty following instructions, distractibility, and disorganization; for the latter include excessive talkativeness, inability to sit still, and inability to remain quiet. These symptoms of inattention and/or hyperactivity can be viewed as interruptions of productivity, either of the person with ADHD or of the people around them.
Consider, again, the diagnoses of depression, bipolar disorder, and schizophrenia. The diagnosis and treatment of these conditions is often indicated when activities of daily living (ADLs) are interrupted. And while that threshold makes logical sense, it would also be reasonable to ask why that threshold exists. The answer is that ADLs are often considered individual tasks, not communal or shared ones. As such, the aforementioned disorders are often brought to the attention of clinicians when occupational function is reduced—causing a decrease in productivity of both the person and the associated workforce.
Supplementary to these diagnostic criteria is the biopsychosocial formulation, a construction often used by psychiatric clinicians to understand the intersection of biological, psychological, and social phenomena that result in a patient’s diagnosis. [2] Common biological components include genetic contributions to disease, such as the heritability of illnesses like bipolar disorder and borderline personality disorder. And while the biological basis of these illnesses is evidence-based, there is also evidence for an environmental/social influence of these biological factors via epigenetics (i.e., the molecular silencing of DNA due to environmental factors). One example is the heritability of anxiety via epigenetic alteration, a phenomenon that has been connected to the presence of increased anxiety in the descendants of enslaved Black people in the US (dubbed “Post-Traumatic Slave Syndrome”). [3]
Other social factors within the biopsychosocial formulation that contribute to the pathophysiology of psychiatric disease include neglect (which could look different in societies where responsibility for children is shared beyond the biological parents); inaccessibility to health care (which could look different if profit was not a primary motive in service provision); drug use (which often perseveres due to lack of medical care); housing instability (which could also look different if a profit motive was not attached to a basic human need); and incarceration (rates of which are distinctly high in the US due to profit motives).
In short, in both the diagnostic criteria of and the biopsychosocial formulation for common psychiatric disorders, we see two common features: (1) interruptions to productivity as an indication for diagnosis/treatment, and (2) individual, rather than communal, systems of care that contribute to illness (e.g., privatization of services that address basic human needs, and/or lack of shared responsibility for different kinds of care).
Reconceptualization of psychiatric disease
How can our understanding of these two common features of psychiatric diagnostic criteria inform our approach to mental healthcare? We might ask why these common features exist, and when—if ever—they were different. The answer: We know that productivity and the relationship between the individual and the community were different at multiple times and places throughout the past and in the present:
Before the land known as the United States was colonized, many indigenous communities lived on it, and it is well-documented that these nations and communities cared for children together, with an emphasis on the extended family. Tasks like childcare, food production, and healthcare were shared responsibilities, and everyone would receive the healthcare that was available. In the case of wrongdoing, survivors were centered, and perpetrators were moved into alternative spaces where they were provided with food, shelter, education, and other necessary elements of rehabilitation— before eventually being reintegrated into society. [4]
In Burkina Faso, between 1983 and 1987, President Thomas Sankara emphasized communal systems of care. His tenure resulted in communal food distribution, an increase in the building of hospitals and access to healthcare, and the widespread construction of wells for clean water. And within these 4 years (before being ousted and murdered by a coup likely backed by France and other Western powers), he increased the literacy rate from 11 to 73%. [5]
Similar increases in communal food distribution and healthcare access were seen in times and places like Castro’s Cuba, and currently in Kerala state in India and in Vietnam, where increased healthcare access has been connected with low COVID rates, and increased safety net programs connected with improved food distribution. Cuba in particular is still famous for its medical programs, producing physicians who are trained in the quality provision of universal healthcare (in spite of US sanctions). [6]
Because the medical conceptualization and pharmacology of psychiatric disease is relatively recent and contextually informed, objective data on the diagnosis and treatment of psychiatric disease before the present day is scarce—but we can confidently say that people across different times and places, such as those above, would not fit our current conceptualization. Their conceptions of productivity and individual vs. communal systems of care would result in a different need for and conceptualization of psychiatry, one that is informed by different thresholds for productivity, neglect, housing, healthcare, incarceration, etc.
Perhaps more important than highlighting the difference in conceptualization is the question of whether our current conceptualization is even appropriate? Are we over-diagnosing people due to inhumanly high expectations of productivity? Are we as a society increasing the incidence of psychiatric pathology by increasing the number of people who experience neglect, housing instability, lack of healthcare access, and incarceration? This reconceptualization of psychiatric disease is not a novel one: the field of Marxist psychiatry is one that identifies capitalism (via its emphasis on the primacy of productivity and individual, rather than communal, systems of care) as a key contributor in the incidence and perseverance of psychiatric disease. This approach has been pioneered by psychiatrists, sociologists, and anthropologists—including some who are widely published on the molecular basis of psychiatric disease. [7], [8]
A Marxist approach to psychiatry is anti-capitalist and decolonial, and a reconceptualization of psychiatric disease using this approach asserts the following:
A lack of communal care, welfare programs, healthcare access, etc. often precipitates and/or perpetuates psychiatric disease.
Psychiatric healthcare in the West perseveres as a means of control rather than care for people who are already disadvantaged by the state and the capitalist class.
Patients of psychiatric disease are given the lowest-cost treatment to allow the continued productivity of the state.
Another Marxist approach to psychiatry involves the recognition that it is essential to a people’s mental well-being that that they be the “owners of their own labor.” Brazilian scholar and educator Paulo Freire emphasizes in his book, Pedagogy of the Oppressed, that labor “constitutes part of the human person,” and that “a human being can neither be sold nor can he sell himself.” [9] The capitalist mode of production compels all workers to “sell themselves” to survive. Many pre-capitalist polities and societies, such as those found on the African continent, had no knowledge or practice of capitalist phenomena (e.g., private property or excessive accumulation of wealth due to labor exploitation and privatization). [10], [11] Due to the ultimately unknowable violence perpetrated against Black and Brown peoples that began the global capitalist system [10], people have been transformed into workers who were, and are, sadistically coerced into believing that the construct of “earning wages” is normal, rather than understanding it as a method that facilitates their exploitation and destabilizes their personhood and well-being. Dr. Joseph Nahem spoke about the harm caused by the disconnection fundamental to all labor under capitalism:
Marx rooted alienation in the very process of capitalist production itself. Marx saw the worker as alienated from the product of his labor and from work itself. Since the product belongs to the capitalist, the worker's work is "forced labor . . . not his own, but someone else's." Further, workers are estranged from their true nature as human beings because their work and its product are alien to them. They cannot feel a oneness with nature and society. Alienation is, therefore, intrinsic to capitalism and the private ownership of the means of production. [12]
Human beings must be rooted to their source, to their land, to what they produce with their labor. If people are not or are not permitted to be connected to that which is theirs and that which they produce, psychiatrist Frantz Fanon wrote that there “will be serious psycho-affective injuries and the result will be individuals without an anchor, without a horizon, colorless, stateless, rootless.” [13] If mental healthcare professionals care about the psychological wellbeing of their patients, then they will 1) stand in solidarity with those who seek to own that which they produce and 2) pending the former, seek to reconceptualize psychiatric disease and diagnoses according to a humanizing decolonial Marxist approach that does not prioritize bourgeois cultural values like individualism, productivity, and carcerality.
Seclusion, restraint, and incarceration for psychiatric disease
Illustrated below is just one example of how the critical assertions of Marxist psychiatry rear their ugly head in the US today:
We know that people with psychiatric disease are often diagnosed and treated when ADLs and productivity are interrupted, but what happens when a patient does not respond to treatment? For many disorders, a number of medications and/or therapies is attempted, but there is a point at which patients are viewed as refractory to treatment. And for patients who are disruptive and/or violent, seclusion and restraint in padded rooms is common, despite evidence showing that these patients have PTSD between 27 and 45% of the time, along with an increase in negative symptoms like anhedonia and self-imposed alienation. [14] Seclusion and restraint are often seen as the lowest cost, lowest-effort treatment to allow the continuation of productivity of the psychiatric unit.
When seclusion and restraint prove ineffective, incarceration is considered. Notably, 43%/44% of people in state/local prisons have a mental illness, and 66%/74% of people in federal/state prisons do not receive any mental healthcare during their stay, suggesting that there is at the very least a significant role for psychiatric care for these people. This is not surprising given that the number of psychiatric beds has decreased from 339 to 22 per 100,000 people in the US from 1955 to 2000. [15], [16]
A profit-maximizing motive is certainly present, as a psychiatric bed is $864/day, while prison is $99/day. But is it actually true that psychiatric care could decrease incarceration, or do these statistics describe people who would be incarcerated by the state regardless? A recent study matched hospital referral regions (HRRs) by zip code with jails and prisons, and looked at abrupt increases/decreases in psychiatric hospital bed capacity (by about 80-90 beds). Decreases in psychiatric bed capacity were associated with an increase of 256 inmates; increases in psychiatric bed capacity were associated with a decrease of 199 inmates—suggesting that proper, non-profit-driven psychiatric care would likely be a good fit for many incarcerated people. [16]
Studies like this one make it difficult to believe that patient care is at the heart of the US medical industry—and make it even more compelling to consider a decolonial Marxist approach. And based on an understanding of the past and present of psychiatry, it would be incomplete to assert that current psychiatric diagnosis and treatment is informed by contextual and cultural norms/practices without noting the harm that these norms/practices cause. Current heuristics of psychiatric diagnosis and treatment—and the emphasis of productivity and individual systems of care—must be scrutinized and are incompatible with adequate patient care.
Aprotim C Bhowmik (he/him) is a third-year MD/MPH student at Hofstra/Northwell School of Medicine and Johns Hopkins Bloomberg School of Public Health. His research interests include social determinants of health and carceral health systems.
Titilayo F Odedele (she/they) is a PhD student at Northeastern University, where they also received their MS in Criminology and Criminal Justice and MA in Sociology. Her research interests include political economy of the world system, decolonial Marxism, and Pentecostalism in the Global South. She enjoys spending time with her family and dog.
Temitope T Odedele (she/her) is a psychology and biology student at the University of Massachusetts Boston who plans on a career in medicine. She enjoys reading history books and watching telenovelas.
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