Oh, look, Lucas tries to write a book review! Thank God it doesn’t have to be academic here. My worst uni grade was a book review. So, consider this more of a book yap than an actual review.
I’ve deleted my main social media for a week or so. Plenty of time to do things I’ve been meaning to do, to actually use my brain outside of the minimum required for university. For a while now, I’ve been meaning to read Cohen’s ‘Psychiatric Hegemony: A Marxist Theory of Mental Illness” in full. I can hear you screaming at me through the screen – how haven’t you read it yet? That’s right up your alley! Listen, I know, I read the intro chapter and chapter three a few months back. I loved it, and then I got busy. I don’t have much else to do in my spare time at the moment other than read and write, so, I figured I would write to you, computer, and teach you something as I read. Maybe it’ll stick it all into my head better this way, too, since I’m forced to reword and understand if I’m writing. Isn’t that fun? Come do a little brain exercise with me! Let’s look at the first couple of chapters of Cohen’s Psychiatric Hegemony together, twin. Let’s understand how capitalism and psychiatry feed off of each other and couldn’t exist without the other, twin!
Psychiatric Hegemony takes Marx’s theory of historical materialism and applies it to a field of study that tends to lack in any substantive theoretical analysis; antipsychiatry (for the purposes of my book yap – call it abolition, critical analysis, whatever). Cohen tells of how, despite the long-standing tradition of psych-criticism within and outside of the field, antipsychiatry is deeply incomplete. In spite of foundational and crucial writings such as Szasz’s ‘The Myth of Mental Illness,’ Rosenhan’s ‘Being Sane in Insane Places,’ Foucault’s ‘Madness and Civilisation,’ among a myriad of others, deeper questions remain. Even left-wing analyses of psychiatry describing how, under socialism, psychiatry would supposedly become un-bastardised, fail to answer such questions surrounding how deeply embedded capitalism and psychiatry are into each other to the point of separation, or one existing without the other, being impossible.
Cohen first quells the doubts of the uninitiated, a step in this book which I find particularly effective and well-placed. Cohen doesn’t leave any room for interpretation; he lays out clearly the biomedical myth of mental illness. I find it particularly striking how he uses the pro-psychiatry logic of ‘believing the science’ against potentially pro-psychiatry readers, in laying out how even the most decorated ‘psy-professionals’ do not subscribe to the idea of mental illness as an observable, definable reality. This introductory chapter also squashes any claims that Cohen could be touting anti-science rhetoric, or simply doesn’t know what he’s talking about. In his discussion of the myth of mental illness, Cohen clearly demonstrates the difference between reliability and validity in statistics; just because there may be high inter-rater reliability in diagnoses of mental illnesses, as demonstrated in Rosenhan’s 1973 study among others, does not implicitly mean these socially and historically constructed categorisations are valid. Rather, Cohen asserts that these categorisations – while oftentimes naming real, tragic pain which is not to be dismissed as a falsehood – rather serve to uphold neoliberal capitalism on both macro and micro levels. This is not to say that the personal (micro) and economic-political (macro) are separate; Cohen, again, follows the idea of historical materialism, quoting Marx on the idea that “the mode of production of material life conditions the general process of social, political and intellectual life.” If, as asserted in historical materialist ways of thinking, history and political society and their changes come about via peoples’ lived experiences of their material conditions, where does psychiatry sit in this equation?
Cohen’s second chapter, after a succinct introduction to Marxism and historical materialism, gives an immediate answer to this question. Cohen argues that “the priorities and practices of the western health care system facilitate capitalist goals in two distinct ways: first, through direct and indirect profit accumulation, and second, through the social control of deviant populations and the ideological reproduction of dominant norms and values of the ruling classes.”
Several examples of psychiatry reinforcing capitalism, and vice versa, are used throughout this chapter. First is the idea of the ‘Mad Doctors’ and ‘moral therapy,’ epitomised by Pinel’s unchaining of the mad in France in 1793, and the Quaker’s York Retreat. Reminiscent of tepidly-pro-and-also-anti-psychiatrists today, these older forms of psychiatry emphasised in their rhetoric care, compassion, and help over punishment. However, in practice, “successful treatment depended on the employment of psychological terror and fear to gain the compliance of the insane” for Pinet, while for the Quakers, inpatients (I use this term through gritted teeth) were to work, be productive, and recover. Cohen describes asylum techniques used to turn patients “gentle and submissive” – from tranquilizer chairs, to bloodletting, to high-dose insulin to induce hypoglycaemic comas and seizures in the hopes of sedation. These methods being touted as successful refers only to how submissive and orderly the victims became, how well their behaviour was controlled and normalised according to what a capitalist society needs to be hygienic and productive. In psychiatry, there is someone lesser to be commanded, stripped of their worth, and scared straight. Patients are to be shoved into compliance, and then made to work and recover so that they can give back as penance for their drain on the economy and society at large. You must be made rational; failure to do so results in punishment in the form of horrific physical abuse amounting to torture. Alongside it, weakened social status, reduced privileges, and so on. This clearly mirrors not only discussions around psychiatric reform today, but capitalist modes of production. These methods employed by the ‘Mad Doctors’ were so successful for psychiatry that it becomes evident that the success of the industry depends on its usefulness to capitalist production and the political economy.
Cohen paints an especially horrifying picture of 1900’s psychiatric abuse that, to psychiatrised people, comes not so much as a surprise. What stuck out to me most was the story of the invention of ECT – electroconvulsive therapy – a treatment still employed to this day, even if “more controlled” (a ridiculous statement I have seen many times; you can’t seriously believe giving people brain damage to control them with no confirmed biological illness is a good and un-horrifying idea?). ECT was born from Italian psychiatrist Ugo Cerletti’s trip to a slaughterhouse, where pigs were shocked to make them more manageable for butchers to kill. Sounds about right. Cerletti’s human guinea pig was a homeless man from Rome, who, when tied down and shocked, had a seizure, was dazed by this, and begged the psychiatrist not to kill him. This made Cerletti declare the practice successful. To be clear, this is the precise way in which ECT functions to this day – it induces a seizure which “calms” the victim and results in brain dysfunction and an increased risk of death. Do you think it’s a form of torture for social control and obedience to capitalist modes of production that you’ve just accepted as science yet?
“Why is it that 10 volts of electricity applied to a political prisoner’s private parts is seen as torture while 10 or 15 times that amount applied to the brain is called ‘treatment’?” Because, I would argue, the threat of ECT is effective in policing those who fail to perform their family, school, work, or consumer roles in western society.” – Leonard Roy Frank (cited in Mills, 2014: 93), a survivor of ECT.
“... drilled holes into her skull, used a syringe to squirt absolute alcohol onto the exposed white fibers, which killed tissue through dehydration, and then sewed her back up.” The woman was subsequently returned to the asylum, where the psychiatrists reported that she remained in a calm state. Following this “successful” operation, further prefrontal operations on the incarcerated population were performed.” – Description of the first lobotomy, performed on a former sex worker.
“The psychiatric concept of prevention attributed nervous and mental disease to failure of adjustment between individual and society, and assumed successful adjustment would prevent disease. Adjustment underlies every application of psychiatry to social control; young people must be adjusted to the orderly world, soldiers must be adjusted to trench warfare, workers must be adjusted to factories.” (Abbott, 1988; 298).
“Everywhere society is meeting a mass of problems, in the street, at work, in the family, etc. – and we psychiatrists are the functionaries of social order. It is up to us to make good these disorders. We have a function in public hygiene. That is the true vocation of psychiatry. And that is its true context, its destiny.” (Foucault, 1988; 180).
Cohen’s look into capitalism and psychiatry thankfully doesn’t end at the economy and reproduction of oppressive economic structures within psychiatry. Cohen refers to some examples of the family, capitalism, and psychiatry being in bed with each other. Firstly, to follow on from the torture of ECT and lobotomies; Cohen describes how lobotomies were what “gets them home” – them being wives who experienced distress and difficulty in performing household tasks. Then, onto psychiatry’s lovely concept of ‘masturbatory insanity’ – a net under which anyone regardless of sex-gender or age can be caught and therefore classified as deviant. Deviance, of course, is to be punished under capitalism and psychiatry, in this case with restraint mechanisms, castration, and more. Sexuality in a capitalist economy must serve a purpose. Your sexuality must not be idle, or pleasure-centric; it must focus only on reproduction. For men, this social control manifests in the obligation to create a workforce, to uphold the sterile, productive, uniform image of the nation. For women, a more insidious form of social control under capitalism/psychiatry arises when she deviates from her role as a homemaker, wife, and mother. It was believed that female madness stemmed from masturbation – in the eyes of psychiatry, disobedient women must be surgically mutilated for stepping in any way outside of her role under capitalism as a heterosexual homemaker. This was all, of course, highly profitable for medical psychiatry, but also, beneficial to a heterosexual, patriarchal capitalism in its stellar, accepted, and posited-as-scientific execution of social control. It’s a symbiotic relationship of the worst kind.
In a neoliberal (therefore imperatively capitalist) political society, we are termed rational, free actors, and individualism is central to our existence. Psychiatry, in its entwinement with pharmaceutical companies, reinforces this way of the world. In addition, and on a more blatant and obvious level, psychiatry’s entwinement with ‘big pharma’ and its profiteering illustrates again how psychiatry reinforces and feeds capitalism at every turn. Psychiatry’s consistent need to find the miracle pill for mental illness (which can never exist unless a definitive biological illness is found) reinforces neoliberal capitalism on both the personal and economic levels. On the personal level, responses to societal or interpersonal abuse are routinely medicalised in order to place blame for suffering onto the individual, free, rational actor in a neoliberal society. This, I’d hope is clear and is argued by Cohen, absolves capitalism and its associated social structures of criticism, questioning, or meeting its inevitable overthrow sooner. In this individualisation of suffering, psychiatry is able to reinforce capitalist modes of economic production by profiting massively off of the medicalisation of the aforementioned personal responses to abuse. It’s your fault, not capitalism’s fault, take the drugs, cash or card? Most importantly here, Cohen returns to his core argument that psychiatry doesn’t just reinforce capitalism, but that capitalism also reinforces psychiatry. He writes of how it surely cannot be a coincidence that the birth of neoliberalism under Reagan and Thatcher in the 1970s aligns so well with psychiatry’s relative deinstitutionalisation. Instead, cheaper, more subtle, and therefore more widely used forms of social-control-termed-treatment, such as the use of psychotropics, boomed. I’m going to assume you know how neoliberal economics works at least a little bit, so as to not be insulting. Don’t you think psychiatry putting the profits of companies and the cutting of the welfare state first in its social control in the 1970s is an interesting coincidence?
“The psychiatric institution was no longer economically viable as a holding place for problematic populations, so the hype created around new “neuroleptic” drugs such as chlorpromazine and the possibility of returning patients to “the community” were used in a way which “allowed governments to save money while simultaneously giving their policy a humanitarian gloss.” (Scull, 1984; 139).
“The success of the psychiatric professionals is predicated on their knowledge claims aligning with the goals of the ruling classes for subservient and compliant workers.”
“[Capitalism] must settle everywhere, nestle everywhere, establish connections everywhere.” (Marx and Engels, 1965; 37).
All in all, I’m glad to read a so-far pretty holistic account of psychiatry and capitalism’s little love affair. Cohen’s argument revolving around a symbiosis between the two structures and their inseparability in both directions makes it a difficult argument to poke holes in. His ability to succinctly but effectively lay out Marxist, scientific, psychiatric, and other concepts from several fields makes this genuinely enjoyable to read. It isn’t patronising, it isn’t too much, it’s just right; and it’s right. I hope this trend continues in the next chapters – maybe I’ll report back for another exercise in forcing myself to actually pay attention and use my brain while reading.
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