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8/14/2019 Tietze 2013Neither psychiatry nor anti-psychiatry, but mental health as radical politics
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8/14/2019 Tietze 2013Neither psychiatry nor anti-psychiatry, but mental health as radical politics
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NEITHER
PSYCHIATRY NORANTI-PSYCHIATRY,
BUT MENTAL
HEALTH ASRADICAL POLITICSTad Tietze
Historical Materialism, London
10 November 2013
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ABSTRACT
When working as a clinical psychologist in the NHS, Peter Sedgwickpursued a sustained critical engagement with the ideas of thinkersassociated with the anti-psychiatric movements of the 1960s and1970s Erving Goffman, Thomas Szasz, R.D. Laing, and MichelFoucault. He welcomed their critique of scientific positivism whilerejecting a tendency to annex psychiatric problems from health and
illness in general. He also laid the basis for a political economiccritique of the health industry by dissecting the distorting impact ofmedical individualism. Sedgwick's work only hinted at the increasingcentrality of diagnosis to the legitimacy of mainstream psychiatry.However, his theoretical innovations provide a powerful frameworkfor understanding controversies surrounding the newly releasedpsychiatric diagnostic bible, the DSM-5and for strategically
orienting radical political projects in relation to such struggles overthe boundaries of normality.
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OUTLINE OF PAPER
Sedgwick & anti-psychiatry last time
Goffman / Laing / Szasz / Foucault
Sedgwick on health & illness
Critique of positivism
Health & illness as socially constructed
DSM-5 & new critical perspectives
Example of bereavement exclusion in Major Depressive Disorder
De-medicalising misery versus politicising medical goals
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SEDGWICK'S LEGACY
Psychologist working in the NHS
Marxist intervention in the debates over psychiatry via a sustained
engagement with the ideas key thinkers associated with anti-
psychiatry
Early argument (1972) for more and better mental hospitals, moreand better doctors and nurses at the expense of armaments
and the profits of the rich
Controversial because he refused to simply condemn psychiatry,
and even praised the beneficial effects of medications and ECT
at a time the NLR was publishing Laing's writings uncritically
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CHALLENGE OF ANTI-PSYCHIATRY
In the 1960s & 1970s anti-psychiatric critiques & movements
seemed to have mainstream psychiatry on the ropes
Heterogeneous but 3 basic themes:
1. Low quality of science of psychiatry when compared with
medicine2. Repressive nature of practice, robbing patients of individual
rights through mechanisms such as detention & forcible
treatment
3. Value-laden nature of psychiatric diagnosis that turned deviancy
from mainstream norms into an undefinable entity called mentalillness
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SEDGWICK ON GOFFMAN
Represents only a small break from dominant functionalism
Stigma/oppression and rebellion happen, but only as they fit within a broader
functioning social order
Focus on oppressive aspects of micro-systems of social
interaction masks general defence of the social status quo
Political radicals seen in same terms as mad people
Goffman has no room for sense of the historical contingencies of
social institutions.This deficiency makes it absolutely impossible
for him to use his insights, either into particular local settingsor
into the general quality of everyday life, in any way which iscritical: which issues, i.e., a demand for change in a definite
direction. [S 1974]
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R.D. LAING
Scottish psychiatrist &psychotherapist
The Divided Self (1960), TheSelf and Others(1961), Sanity,Madness and the Family(with
A. Esterson, 1964), ThePolitics of Experience and theBird of Paradise (1967)
Argued schizophrenia resultedfrom impossible binds peoplewere put in by their families
and society it was reallysociety (at the family level) ¬ the patient that waspathological
8/14/2019 Tietze 2013Neither psychiatry nor anti-psychiatry, but mental health as radical politics
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SEDGWICK ON LAING
Starts from conflict between twopersonalrealities psychotic
and normal in a crazy world; he cannot provide a way to have
a standpoint on the irrationality of the totality that is not merely
from within these two views
Because he favours the psychotic, and by privileging the mad experiences of
the psychotic patient as somehow positive, he falls into mysticism
Studies of families limited by lack of normal controls unclear if
he is describing relationships specific to schizophrenogenesis
Even in most anti-systemic phase moves without mediation
between small-scale pathologies & social pathologies (e.g.imperialism)
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THOMAS SZASZ
Hungarian-American psychiatrist
The Myth of Mental Illness:Foundations of a Theory ofPersonal Conduct (1961), TheTherapeutic State: Psychiatry inthe Mirror of Current Events
(1975), Psychiatric Slavery (1977) Mental illness a myth because
unlike physical illness noanatomical & genetic contexts to
judge someone ill, only social ðical ones
Psychiatrists deprived people ofliberties by bestowing spuriousdiagnoses
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SEDGWICK ON SZASZ
Uses positivist standard (pathological lesions) to separate
medicine from psychiatry, but in fact this is untenable
Uses extreme examples of repression by psychiatry to make
general case c.f. rest of medicine but then has nothing to say
about illiberal aspects of medicine in general Extreme right-wing libertarianism poses itself as being anti-
authority but is in fact mostly against collectivism
Ultimately glories in contractual aspects of medical individualism
disconnects medicine from its place in capitalist social relations
8/14/2019 Tietze 2013Neither psychiatry nor anti-psychiatry, but mental health as radical politics
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MICHEL FOUCAULT
Histoire de la folie l'geclassique - Folie et draison(1961; translated & abridged asMadness & Civilisation, 1965),Naissance de la clinique - unearchologie du regard mdical(1963; translated as The Birth ofthe Clinic)
Concepts of mental health &illness were purely social-historicalconstructs
Shifted & changed over time butalways played the same role in
upholding power relations The asylum & the analysts couch
were equally parts of systems ofrepression & control of the victoryof reason over unreason
8/14/2019 Tietze 2013Neither psychiatry nor anti-psychiatry, but mental health as radical politics
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SEDGWICK ON FOUCAULT
Vital corrective to liberal teleological picture of ever-improving,
ever more benevolent scientific advances in psychiatry
But puts too much store in the irrational rationalismof modern
medical approaches to insanity as unique to the current era. He
therefore cannot relate psychiatry to social change adequately Reason/unreason is effectively the driver of history
Cannot account for shifts back & forth to & from holistic & mechanistic
approaches
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PSYCHIATRIC POSITIVISM
The critique of psychiatric positivism unites the anti-psychiatric
thinkers & is their strongest card
What we do have is a consistent and convergent tendency of
oppositiondirected againstpositivist method in the study of
abnormal human behaviour. Positivism, for the presentdiscussion, may be taken to refer to an approach towards the
investigation of human pathology which, modelling itself upon
antecedents which it believes to be characteristic of the natural
sciences, (a) postulates a radical separation between factsand
values(declaring only the former to be the subject-matter of the
professional investigator) and (b) suppresses the interactive
relationship between the investigator and the factson which he
works. [S 1972]
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LIMITS OF THE CRITIQUE
Sedgwick: Critique of positivism must be extended to all of
medicine
It appears to me that none of [the critics] have begun by asking
the question: What is i l lness? Only in the light of an answer to
thisquestion could we determine our answer to the question: Ismental illness really illness in the medicalsense? [S 1972]
The difference so forcefully argued by anti-psychiatric theorists,
between the biological normsto which physical medicine
appeals and the social normswhich back up psychiatry,
dissipates into nonsense as soon as we are brought to see thatthe medical enterprise is from its inception value-loaded; it is not
simply an applied biology, but a biology applied in accordance
with the dictates of social interest.[S 1974]
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SOCIAL CONSTRUCTION OF
HEALTH
It may prove possible to reduce the distance between psychiatry
and other streams of medicine not by annexing
psychopathology to the technical instrumentation of the natural
sciences but by revealing the character of all illness and disease,
health and treatment, as social constructions
Outside the significances that we voluntarily attach to certain
conditions, there are no illnesses or diseases in nature[S 1982]
8/14/2019 Tietze 2013Neither psychiatry nor anti-psychiatry, but mental health as radical politics
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ILLNESS AS SOCIAL DEVIANCY
All sickness is essentially deviancyfrom social norms, which
themselves must be understood in terms of conflicts over ideas &
practices within a given society
BUT: Not all deviancy is illness!
Not a relativism: Definitions of health & sickness always productof specific, historical social processes meaning can only be
judged if one has a critique of social structure and change
However illness is specified from culture to culture, the attribution
of illness appears to include a quest for explanation. [S 1972]
Illness arises historically alongside practice of treatment & tied up with it
8/14/2019 Tietze 2013Neither psychiatry nor anti-psychiatry, but mental health as radical politics
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DSM-5 & BEREAVEMENT
DSM-5 (2013) has deepened the crisis of psychiatric authority
Debate over diagnostic categories has focused on issues such as
inappropriate medicalisation, disease mongering, etc.
Sharp debate over the bereavement exclusion(BE) in Major
Depressive Disorder (MDD) DSM-5 workgroup claimed BE wasinvalid
Argument is that BE doesnt differentiate between two different types
of problem (i.e. between illness & not-illness)
Normal grief often meets criteria (5 symptoms over >2 weeks) for
MDD e.g. sadness, difficulty sleeping, decreased appetite, fatigue,diminished interest or pleasure in usual activities, and difficulty
concentrating on usual tasks PLUS clinically significant distress or
role impairment
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Zisook (2012): Depression can and does occur in the wake ofbereavement, it can be severe and debilitating, and calling it byany other name is doing a disservice to people who may requiremore careful attention
Wakefield & First (2012) found the evidence wanting:
Kendler & Zisook (2007 x 2): Looked at MDD v BE patients, but confusingmethodology
Treatment response no different But should this make a difference?
Suicide risk driving need to diagnose? BE accounts for this, so irrelevant
No more likely to have recurrent MDD than people who have never beendepressed
The Lancet (2012): Grief is not an illness; it is more usefullythought of as part of being human and a normal response todeath of a loved one.
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CAUGHT IN A TRAP?
Development of medicalpracticewithin capitalist social relations
increasingly technical-physical definition of illness
Psychiatry under pressure to prove its illnesses are (reductively)
physical or to accept they lie outside the bounds of medicine
Some progressives line up with latter want to de-medicalisemisery
Resisting the psychiatrization and psychologization of almost every aspect of
human experience, and finding a way to place what are, frequently, essentially
moral and politicalnot medicalmatters back at the centre of our
understanding of human suffering is a massive and multifaceted task.
[Moncrieff Chap 1]
Psychiatry provides analgesia at the expense of understanding[Jureidini
2012]
A false counter-position if we see all illness as socially
constructed
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SEDGWICK ON BEREAVEMENT
The example [of a bereavement causing symptoms] is revealing
in several ways. A doctor may prescribe some form of minor
tranquilliser to relieve some of the effects of a bereavement, even
though depression of activity and feeling following the death of a
close relative would scarcely be regarded as constituting a
mental illness. Bereavement has, however, also been reportedas a significant precipitating event in the onset of actual
psychiatric illnesses The line of division between a
bereavementand a psychiatric illness following bereavement
would seem to depend on our culturally-derived expectations
about how to mourn properly. [S1974]
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POLITICISING GOALS (1)
Greatest advances in combatting illness have come through
social and political measures
The point is not to deny the illness-ness of illness (to de-
medicalise) , nor to technologise it further
The alternative is topoliticisemedical goals Mental illness, like mental health, is a fundamentally critical
concept: or can be made into one provided that those who use it
are prepared to place demands and pressures on the existing
organisation of society. [S 1972]
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LIBERTY VS. COLLECTIVE
PROVISION
Capitalism creates antagonism between medicine/psychiatry as
legally-inspired, contractual & individualistic on one hand, and
collectivist on the other
Complicated by double meaning to collective: (1) due to
collective political struggles from below and (2) provided by state
& its social agencies from above
Warned RCPsych [in S 1983] that Rights libertarian critique of
psychiatric authority was a way of breaking down collective
provision without challenging state/ruling class authority
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POLITICISING GOALS (2)
Just as the revolutionary exposes and pressurises Parliamentary
democracyby demanding consistent democracy; just as he
exposes and fights the courts of bourgeois justiceby demanding
consistent justice: so he must and combat the evils of our anti-
therapeutic institutions of 'psychiatry' by demanding consistent
psychiatry. [S1972]
That is, more and better psychiatrybut not more of the same.
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I myself am perfectly happy to see as many mentally-ill persons as
possible treated, fully and effectively, in this society; for no matter how
many maladjustments may become adjusted through expert techniques,
the workings of capitalism will ever create newer and larger discontents,
infinitely more dangerous to the system than any number of individual
neuroses or manias.[S1972]
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BIBLIOGRAPHY
S 1971PS, R. D. Laing: Self, Symptom and Society,
Salmagundi
S 1972PS, Mental illness isillness, Salmagundi
S 1974PS, Goffman's Anti-Psychiatry, Salmagundi
S 1982PS, Psychopolitics, Pluto Press
S 1983PS, The Fate of Psychiatry in the New Populism, BJP
M 2011Rapley, Moncrieff & Dillon, Carving Nature at its Joints?
DSM and the Medicalization of Everyday Life in Rapley, Moncrieff
& Dillon (eds), De-Medicalizing Misery: Psychiatry, Psychology
and the Human Condition, Palgrave Macmillan