A Decolonial Approach to Mental Healthcare

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]

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A Marxist approach to psychiatry is anti-capitalist and decolonial, and a reconceptualization of psychiatric disease using this approach asserts the following: 

1. A lack of communal care, welfare programs, healthcare access, etc. often precipitates and/or perpetuates psychiatric disease.

2. 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.

3. 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.

References

1.      Diagnostic and statistical manual of mental disorders: DSM-5 (2017). CBS Publishers & Distributors, Pvt. Ltd.

2.      Owen G (2023). What is formulation in psychiatry? Psychol Med. 2023 Apr;53(5):1700-1707. doi: 10.1017/S0033291723000016.

3.      Jiang S, Postovit L, Cattaneo A, Binder EB, Aitchison KJ (2019). Epigenetic modifications in stress response genes associated with childhood trauma. Front Psychiatry. 2019 Nov 8;10:808. doi: 10.3389/fpsyt.2019.00808.

4.      First Nations Health Authority (n.d). Our history, our health.

https://www.fnha.ca/wellness/wellness-for-first-nations/our-history-our-health.

5.      Thomas Sankara and the stomachs that made themselves heard (n.d.). Wellcome Collection. https://wellcomecollection.org/articles/Y1FlZxEAAEolDkdA.

6.      Squires N, Colville SE, Chalkidou K, Ebrahim S (2020). Medical training for universal health coverage: a review of Cuba-South Africa collaboration. Hum Resour Health. 2020 Feb 17;18(1):12. doi: 10.1186/s12960-020-0450-9.

7.      Moncrieff J (2022). The political economy of the mental health system: A Marxist analysis. Frontiers in Sociology, 6. https://doi.org/10.3389/fsoc.2021.771875.

8.      Cohen BM (2016). Psychiatric hegemony – A Marxist theory of mental illness. Springer. https://doi.org/10.1057/978-1-137-46051-6.

9.      Freire P (1972). Pedagogy of the oppressed. Penguin.

10.  Du Bois WEB (1947). The world and Africa: an inquiry into the part which Africa has played in world history. Viking Press.

11.  Rodney W (1982). How Europe underdeveloped Africa. Howard University Press.

12.  Nahem J (1982). A Marxist approach to psychology and psychiatry. International Journal of

Health Services, 12(1), 151-162.

13.  Fanon F (1967). The wretched of the earth. Penguin.

14.  Chieze M, Hurst S, Kaiser S, & Sentissi O (2019). Effects of seclusion and restraint in adult psychiatry: A systematic review. Frontiers in Psychiatry, 10.

https://doi.org/10.3389/fpsyt.2019.0049.

15.  Initiative, P. P. (n.d.). Mental health. Prison Policy Initiative.

https://www.prisonpolicy.org/research/mental_health/.

16.  Gao YN. Relationship between psychiatric inpatient beds and jail populations in the United States. J Psychiatr Pract. 2021 Jan 21;27(1):33-42. doi: 10.1097/PRA.0000000000000524.

A Mad World: Capitalism and the Rise of Mental Illness

By Rod Tweedy

Originally published at Red Pepper.

Mental illness is now recognised as one of the biggest causes of individual distress and misery in our societies and cities, comparable to poverty and unemployment. One in four adults in the UK today has been diagnosed with a mental illness, and four million people take antidepressants every year. ‘What greater indictment of a system could there be,’ George Monbiot has asked, ‘than an epidemic of mental illness?’

The shocking extent of this ‘epidemic’ is made all the more disturbing by the knowledge that so much of it is preventable. This is due to the significant correlation between social and environmental conditions and the prevalence of mental disorders. Richard Bentall, professor of clinical psychology at the University of Liverpool, and Peter Kinderman, president of the British Psychological Society, have written compellingly about this connection in recent years, drawing powerful attention to ‘the social determinants of our psychological wellbeing’. ‘The evidence is overwhelming,’ notes Kinderman, ‘it’s not just that there exist social determinants, they are overwhelmingly important.’

A sick society

Experiences of social isolation, inequality, feelings of alienation and dissociation, and even the basic assumptions and ideology of materialism and neoliberalism itself are seen today to be significant drivers – reflected in the titles of a number of recent articles and talks on this subject, such as those of consultant psychotherapist David Morgan’s groundbreaking Frontier Psychoanalyst podcasts, which have included discussions on whether ‘Neoliberalism is dangerous for your mental health’, and ‘Is neoliberalism making us sick?’

Clinical psychologist and psychotherapist Jay Watts observes in the Guardian that ‘psychological and social factors are at least as significant and, for many, the main cause of suffering. Poverty, relative inequality, being subject to racism, sexism, displacement and a competitive culture all increase the likelihood of mental suffering. Governments and pharmaceutical companies are not as interested in these results, throwing funding at studies looking at genetics and physical biomarkers as opposed to the environmental causes of distress. Similarly, there is little political will to combine increasing mental distress with structural inequalities, though the association is robust and many professionals think this would be the best way to tackle the current mental health epidemic’.

There are clearly very powerful and entrenched interests and agendas here, which consciously or unconsciously act to conceal or try to deny this relationship, and which also makes the recent willingness amongst so many psychoanalysts and therapists to embrace this wider context so exciting and moving.

Commentators often talk about society, social context, group thinking, and environmental determinants in connection with mental distress and disorders, but we can I think actually be a bit more precise about what aspect of society is mainly driving it, is mainly responsible for it. And in this context it’s probably time we talk about the c word – capitalism.

Many of the contemporary forms of illness and individual distress that we treat and engage with certainly seem to be correlated with and amplified by the processes and byproducts of capitalism. In fact, you might say that capitalism is in many respects a mental illness generating system – and if we are serious about tackling not only the effects of mental distress and illness, but also their causes and origins, we need to look more closely, more precisely, and more analytically at the nature of the political and economic womb out of which they emerge, and how psychology is fundamentally interwoven with every aspect of it.

Ubiquitous neurosis

Perhaps one of the most obvious examples of this intimate connection between capitalism and mental distress is the prevalence of neurosis. As Joel Kovel, a former psychiatrist and professor of political science, notes: ‘A most striking feature of neurosis within capitalism is its ubiquity.’ In his classic essay ‘Therapy in late capitalism’ (reprinted in The Political Self), Kovel refers to the ‘colossal burden of neurotic misery in the population, a weight that continually and palpably betrays the capitalist ideology, which maintains that commodity civilization promotes human happiness’:

‘If, given all this rationalization, comfort, fun and choice, people are still wretched, unable to love, believe or feel some integrity to their lives, they might also begin to draw the conclusion that something was seriously wrong with their social order.’

There’s also been some fascinating work done on this more recently by Eli Zaretsky (Political Freud), and Bruce Cohen (author of Psychiatric Hegemony), who have both written on the relations between the family, sexuality, and capitalism in the generation of neuroses.

It is significant, for example, that one of the most prominent features of the psychological landscape that Freud encountered in late nineteenth-century Vienna were the neuroses – which, as Kovel notes, Freud saw as being entirely continuous with ‘normal’ development in modern societies – with much of these, he adds, being rooted in our modern experience of alienation. ‘Neurosis,’ Kovel says, ‘is the self-alienation of a subject who has been readied for freedom but runs afoul of personal history.’

It was of course Marx who was the great analyst of alienation, showing how capitalist economics generates alienation as part of its very fabric or structure – showing how, for instance, alienation gets ‘lost’ or ‘trapped’, embodied, in products, commodities – from the obvious examples (such as Nikes made in sweatshops, and sweatshops embodied in Nikes) – to a wider and much more pervasive sense that the whole system of production and creation is somehow alienating.

As Pavon Cuellar remarks, ‘Marx was the first to realise that this alienation actually gets contained and incarnated in things – in “commodities”‘ (Marxism and Psychoanalysis). These ‘fetishised’ commodities, he adds, seem to retain and promise to return, when consumed, the subjective-social part lost by those alienated while producing them: ‘the alienated have lost what they imagine [or hope] to find in what is fetishised.’

This understanding of alienation is really the core issue for Marx. People probably know him today for his theories of capital – how issues of exploitation, profit, and control continually characterise and resurface in capitalism – but for me the key concern of Marx, and one that is constantly neglected, or misunderstood, is his view on the centrality and importance of human creativity and productivity – man’s ‘colossal productive power’ as he calls it – exactly as it was in fact for William Blake, slightly earlier in the century.

Marx refers to this extraordinary world-transformative energy and agency as our ‘active species-life’, our ‘species-being’ – our ‘physical and spiritual energies’. But these immense creative energies and transformative capacities are, he notes, under the present system, immediately taken from us and converted into something alien, objective, enslaving, fetishised.

Restructuring desire

The image he evokes is of mothers giving birth – another form of labour perhaps – with the baby immediately being taken away and converted into something alien, something doll-like — a commodity. He considers what effect that must have on the mother’s spirit. This, for Marx, is the source of the alienation and unease, the sort of profound dislocation of the human spirit that characterises industrial capitalism. And as Pavon Cuellar shows, we can’t buy our way out of this alienation – by producing more toys, more dolls – because that’s where the alienation occurs, and is embodied and generated.

Indeed, consumerism and materialism are themselves widely recognised today as key drivers of a whole raft of mental health problems, from addiction to depression. As George Monbiot notes, ‘Buying more stuff is associated with depression, anxiety and broken relationships. It is socially destructive and self-destructive’. Psychoanalytic psychotherapist Sue Gerhardt has written very compellingly on this association, suggesting that in modern societies we often ‘confuse material well-being with psychological well-being’. In her book The Selfish Society she shows how successfully and relentlessly consumer capitalism reshapes our brains and reworks our nervous systems in its own image. For ‘we would miss much of what capitalism is about,’ she notes, ‘if we overlook its role in restructuring and marketing desire and impulse themselves.’

Another key aspect of capitalism and its impact on mental illness we could talk about of course is inequality. Capitalism is as much an inequality-generating system as it is a mental illness producing system. As a Royal College of Psychiatrists report noted: ‘Inequality is a major determinant of mental illness: the greater the level of inequality, the worse the health outcomes. Children from the poorest households have a three-fold greater risk of mental ill health than children from the richest households. Mental illness is consistently associated with deprivation, low income, unemployment, poor education, poorer physical health and increased health-risk behaviour.’

Some commentators have even suggested that capitalism itself, as a way of being or way of thinking about the world, might be seen as a rather ‘psychopathic’ or pathological system. There are certainly some striking correspondences between modern financial and corporate systems and individuals diagnosed with clinical psychopathy, as a number of analysts have noticed.

Robert Hare for instance, one of the world’s leading authorities into psychopathy and the originator of the widely accepted ‘Hare Checklist’ used to test for psychopathy, remarked to Jon Ronson: ‘I shouldn’t have done my research just in prisons. I should have spent some time inside the Stock Exchange as well.’ ‘But surely stock-market psychopaths can’t be as bad as serial-killer psychopaths?’ the interviewer asks. ‘”Serial killers ruin families,” shrugged Bob. “Corporate and political … psychopaths ruin economies. They ruin societies.”‘

Pathological institutions

These traits, as Joel Bakan brilliantly suggested in his book The Corporation, are encrypted into the very fabric of modern corporations – part of its basic DNA and modus operandi. ‘The corporation’s legally defined mandate,’ he notes, ‘is to pursue, relentlessly and without exception, its own self-interest, regardless of the often harmful consequences it might cause to others.’ By its own legal definition, therefore, the corporation is ‘a pathological institution’, and Bakan helpfully lists the diagnostic features of its default pathology (lack of empathy, pursuit of self-interest, grandiosity, shallow affect, aggression, social indifference) to show what a reliably disturbed patient the corporation is.

Why should all of these contemporary social and economic practices and processes generate so much illness, so many disorders? To answer this I think we need to look back at the wider Enlightenment project, and the psychological models of human nature out of which they emerged. Modern capitalism grew out of seventeenth century concepts of man as some sort of disconnected, discontinuous, disengaged self – one driven by competition and a narrow, ‘rational’ self-interest – the concept of homo economicus that drove and underwrote much of the whole Enlightenment project, including its economic models. As Iain McGilchrist notes, ‘Capitalism and consumerism, ways of conceiving human relationships based on little more than utility, greed, and competition, came to supplant those based on felt connection and cultural continuity.’

We now know how mistaken, and destructive, this model of the self is. Recent neuroscientific research into the ‘social brain’, together with exciting developments in modern attachment theory, developmental psychology, and interpersonal neurobiology, are significantly revising, and upgrading, this rather quaint, old-fashioned view of the isolated, ‘rational’ individual – and also revealing a far richer and more sophisticated understanding of human development and identity, through increased knowledge of ‘right hemisphere’ intersubjectivity, unconscious processes, group behaviour, the role of empathy and mentalisation in brain development, and the significance of context and socialisation in emotional and cognitive development.

As neuroscientist David Eagleman observes, the human brain itself relies on other brains for its very existence and growth—the concept of ‘me’, he notes, is dependent on the reality of ‘we’:

We are a single vast superorganism, a neural network embedded in a far larger web of neural networks. Our brains are so fundamentally wired to interact that it’s not even clear where each of us begins and ends. Who you are has everything to do with who we are. There’s no avoiding the truth that’s etched into our neural circuitry: we need each other.

Dependency is therefore built into the fabric of who we are as social and biological beings, hardwired into our mainframe: it is ‘how love becomes flesh’, in Louis Cozolino’s striking phrase. ‘There are no single brains,’ Cozolino observes, echoing Winnicott, ‘brains only exist within networks of other brains.’ Some people have termed this new neurological and scientific understanding of the deep patterns of interdependency, mutual cooperation, and the social brain ‘neuro-Marxism’ because of the implications involved.

Capitalism is, it seems, rooted in a fundamentally flawed, naive, and old-fashioned seventeenth-century model of who we are – it tries to make us think that we’re isolated, autonomous, disengaged, competitive, decontextualised – an ultimately rather ruthless and dissociated entity. The harm that this view of the self has done to us, and our children, is incalculable.

Many people believe, and are encouraged to believe, that these problems and disorders – psychosis, schizophrenia, anxiety, depression, self-harm – these symptoms of a ‘sick world’ (to use James Hillman’s terrific description) are theirs, rather than the world’s. ‘But what if your emotional problems weren’t merely your own?’, asks Tom Syverson. ‘What if they were our problems? What if the real problem is that we’re living in wrong society? Perhaps Adorno was correct when he said, “wrong life cannot be lived rightly”.’

The root of this ‘living wrongly’ seems to be because we live in a social and economic system at odds with both our psychology and our neurology, with who we are as social beings. As I suggest in my book, we need to realise that our inner and outer worlds constantly and profoundly interact and shape each other, and that therefore rather than separating our understanding of economic and social practices from our understanding of psychology and human development, we need to bring them together, to align them. And for this to happen, we need a new dialogue between the political and personal worlds, a new integrated model for mental health, and a new politics.

Rod Tweedy is an author and editor of Karnac Books, a leading independent publisher of books on mental health and therapy. His edited collection, The Political Self: Understanding the Social Context for Mental Illness, is published by Karnac.

Marxism, Psychiatry, and Capitalism: An Interview with Dr. Bruce M. Z. Cohen

By Brenan Daniels

This is the transcript of a recent email interview I did with Dr. Bruce M. Z. Cohen, senior lecturer at the University of Auckland and author of "Psychiatric Hegemony: A Marxist Theory of Mental Illness" (Palgrave Macmillan, 2016), where we discuss capitalism and psychiatry, and view psychiatry under a Marxist lens.

What made you want to apply a specifically Marxist view to psychiatry and psychology?​ Are you personally a Marxist and how did you come to be one?

That's a good question. I didn't expect to ever be writing such a book, but thanks to my students I realised that someone had to take responsibility for filling a current gap in the literature. I run a postgraduate course on the Sociology of Mental Health, in which my students complete project essays on topics of their own choosing. As it is a sociology course, they are obviously required to apply different theoretical approaches to their chosen issue. I always encourage the students to consider the wide range of theoretical approaches available to them including structural functionalism, labeling, social constructionism, Foucauldian, critical feminist and race theory, as well as Marxist scholarship. Regarding the later, my students complained that they couldn't find anything much out there. As a lecturer, I am always a little skeptical of such claims, but -hats off to my students!- they were correct on this occasion. With all the literature on mental health and illness currently in circulation, I found it astounding that there was no standard Marxist account available. Hence, the main reason for writing Psychiatric Hegemony: A Marxist Theory of Mental Illness.

To answer the second part of your question, yes I am a Marxist! Though I grew up in a very conservative -large as well as small 'c'- part of England in the 1980s, my parents were members of the CPGB (Communist Party of Great Britain). (In fact, my mother became the first communist parish councilor in the area, kicking out a Tory in the process). So I was politically conscious and politically active from a young age thanks to my family, imbued with a strong sense of social justice, and particularly incensed by Thatcher's attacks on the trade unions and the working classes at the time (which most people in my area thought was just fantastic!). But I think being a sociologist has really made me a fully committed Marxist; whichever area you are studying or working in, be it religion, education, health, crime, the family, or whatever, it doesn't take long to uncover evidence that the needs of capital determine the priorities of these institutions- they reproduce inequalities, oppress the majority of the population, and produce surplus value for a privileged minority. Is this a kind of society that, in good conscience, I or any sociologist can accept or support? Of course not! That's why I'm a Marxist. Human beings can do better.

Please discuss the connection between psychiatry, psychology, education, and capitalism and how the former institutions have been influenced by the latter, historically speaking.

Following my point above, the mental health system (I use this as an umbrella term here to bring together psychiatry, psychology, and the various support professions and agencies working in the area of mental health including therapists, counselors, psychiatric nurses, and social workers) and the education system in their contemporary forms are both products of industrial capitalism. Briefly, compulsory schooling developed across western societies in the nineteenth century due to the needs of capital for higher skilled workers as well as to socially control working class youth (through, for example, socializing them into the norms and values of capitalism as the only "correct" way to think and understand the world). As I discuss in my book, the mental health system develops during the same period as another institution of social control: the asylums separate the able from the non-able bodied, it pathologises and confines problematic populations (primarily working class groups).

In neoliberal society, I argue that the connections between the mental health system and the education system (as well as many other areas of public and private life) have become much stronger and more explicit. For example, my socio-historical case study of attention-deficit/hyperactivity disorder (ADHD) in the book demonstrates that the origins of the diagnosis began with psychologists' concern for deviant working class youth who failed to "adapt" to the demands of compulsory schooling. A hundred years later, we can still see in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) that the symptoms of ADHD have nothing to do with having a mental illness but rather denote the requirements for more productive and efficient students and workers (for instance, forgetting or losing homework, failing to complete assigned tasks, poor time-management, and so on). As the demands on young people to stay on at school and go further in education have increased, so we have seen an increase in mental health experts in this area, and thus the increasing medicalization of "at risk" (I would argue, non-conforming) children. The expansion in the use of diagnoses such as autism and "oppositional defiant disorder" by psychiatry can also be theorized as serving a similar purpose here.

In what way does capitalism utilize psychiatry and psychology to demonize and ridicule those who have politics that don't fit with the status quo? (This has been talked about somewhat before and I would be interested in hearing you expand upon it.)

I devote a chapter to this issue in my book, but to be honest I think a whole monograph is required on the subject. It's a fascinating (and, as you do the research, shocking) issue. I can follow many other scholars by reiterating that the mental health system is highly effective in neutralizing threats through pathologising political and social dissent. I think it's more effective than say the criminal justice system because the courts are usually questioning the legality of the person's actions alone, rather than the rationality or sanity on those actions. Imprisonment of a protester, for instance, does not fundamentally undermine his or her actions or beliefs in the same way as being labeled as mentally sick does.

There are many examples of this process in operation. In the late nineteenth century, the suffragette movement was a frequent target for the "hysteria" label. During the civil rights movement in the US, there was a significant increase in the labeling of young Black men with "schizophrenia" (psychiatrists sometimes referred to this as "the protest psychosis"). Similarly, young African-Caribbean protesters in the deprived inner cities of 1980s Britain were theorized by psychiatrists as prone to "cannabis psychosis." As I mention in the book, I think an increasingly popular diagnosis which the mental health system is utilizing to pathologize those involved in civil disobedience or political violence today is antisocial personality disorder (APD): post-9/11, you can see that psychiatry is taking a much greater interest in medicalising any behavior which breaks the legal or moral status quo within capitalist society, particularly acts which involve perceived or actual violence.

How is psychiatry not an actual science in some ways? May people assume it is just by virtue of its utilization of 'experts' and 'quantitative studies'?

This is really at the heart of the matter. To be considered as a valid branch of medicine, psychiatry has to reach the medical "gold standard," which is to observe and identify real pathology on the body. And, though they're tried repeatedly to do this, so far psychiatry has failed in this fundamental goal. Most recently, for example, the American Psychiatric Association's (APA) DSM committee (which was responsible for producing the DSM-5) came to the following conclusion: the causation of mental disease remains unknown (for example, there is no useful biological marker or genetic test that has been identified) and psychiatrists still cannot distinguish between mentally healthy and mentally sick people. And of course without accurate identification of disease, a medical discipline cannot claim proof of causation or evidence of successful treatment, and they certainly cannot predict future cases of that disease.

So, to answer your question, no psychiatry is not a valid medical science. However, I argue in the book that progressing knowledge on madness (if such a thing is even possible) was not the reason for the establishment of the psychiatric profession or the continuation and expansion of the mental health system today. Rather, it's a discipline that has supported capitalism, both in the pursuit of surplus value as well as being an institution of ideological control, responsible for reinforcing the norms and values of this society and punishing deviations from them.

In what ways does this massive increase in the labeling of people having psychological disorders affect us on a personal, familial, and community level? How does this increase the alienation from ourselves and our larger communities that has been going on for some time now?

The biggest issue is that it individualizes what are fundamentally social and political issues in this society. This obviously suits capitalism, it follows a neoliberal ideology that you need to work on yourself and look nowhere else for solutions to your problems. As I argue in the book, this is why the psychiatric discourse has been allowed to become all-encompassing (effectively "hegemonic") over the last few decades; it has become highly useful in de-politicizing the oppressive reality of our lives. The involvement of the mental health system here is only one factor in the bigger issue though, which is of course the way the neoliberal project has attempted to destroy the social and the collective.

What are the negative aspects of self-diagnosing and how does that reinforce the status quo?

As with Marx's famous comments on religion as the opium of the people, I think we can understand self-labeling and people desiring to have such a label as a way of coping with the alienating tendencies of capitalism. It's no solution to the fundamental issues they have, but it can be a means of survival and maybe a limited form of "emancipation" at times. For example, the parents of a child who is underperforming in school may desire a mental illness diagnosis so that they can claim extra funding for study assistance, or someone who doesn't enjoy socializing in large groups may seek a psychiatric diagnosis so that they can legitimately take antidepressants which dull their inhibitions.

There are a number of significant problems with self-labeling: most obviously, you cannot solve the social and political problems of capitalism with a mental illness label or by being subjected to talk therapy, drugs, or electroconvulsive therapy (ECT). It can obviously be dangerous to your health (for example, long-term users of antidepressants tend to die at a considerably younger age than non-users), and it can be stigmatizing. Further, it falsely legitimates the mental health system as a valid medical enterprise.

How do you see the working class overcoming this system?

Ultimately it's a case of abolishing the mental health system and all its supporting apparatus. As with the criminal justice system, this is not an institution that has ever functioned in the interests of the working classes. At the end of my book I suggest a few practical things that can be done immediately to challenge and weaken the power of the mental health experts, these include: campaigning to remove psychiatry's compulsory powers to confine and drug people against their will, withdrawing their prescription rights, and outlawing ECT. I also think it is crucial to form closer alliances between academics, left wing activists, community groups, and progressive psychiatric survivor organizations to build a strong abolitionist alliance against the psychiatric system.

Tell us about your upcoming book and where you and others argue that "the best form of treatment for mental disorder is no treatment at all, and the causation of mental illness itself has yet to be established." It would be great to hear about those last two parts in-depth.

Well, I've hopefully addressed those two specific issues previously in this interview - what passes for "treatment" at the hands of the mental health system is, ironically, very bad for your physical and emotional health. Perhaps that is unsurprising given that mental disorders are fabrications produced by psychiatry without real evidence for their existence.

The Routledge International Handbook of Critical Mental Health (due out later this year) is an edited collection of original contributions from colleagues in the US, Europe, Australia, New Zealand, and Canada, which systematically problematizes the practices, priorities, and knowledge base of the western system of mental health. Basically, I have constructed a comprehensive resource manual which offers a variety of ways in which to theorize the business of mental health as a social, economic, political, and cultural project. So, for instance, the book provides updates on critical theories of mental health such as labeling, social constructionism, antipsychiatry, Foucauldian, Marxist, critical feminist, race and queer theory, critical realism, critical cultural theory, and mad studies. But it also demonstrates the application of such theoretical ideas and scholarship to key topics such as medicalization and pharmaceuticalisation, the DSM, global psychiatry, critical histories of mental health, and talk therapy. I'm very pleased at how it has turned out.

Is there a way to bring back a form of alternative psychiatry or psychology at all?

Some scholars are positive about the development of a post-revolutionary "Marxist psychology" or similar. I don't think that's possible, and I worry about giving these professions any sort of way out. My analysis points to these professions as agents of social control; they have always been responsible for policing the population not for emancipating them. So my answer to that question is an emphatic "no!"

Bruce M.Z. Cohen is a Senior Lecturer in Sociology at the University of Auckland, New Zealand. His other books include Mental Health User Narratives: New Perspectives on Illness and Recovery (Palgrave Macmillan, 2008) and Being Cultural(Pearson, 2012).