Social critique of psychiatry

Joanna Moncrieff, who I’ve mentioned before several times (see eg. previous post), analyses the mental health system from a Marxist perspective in a recent article. Marxist theory has been used in critical mental health writings (see eg. my review of book edited by Bruce Cohen). Psychiatry has been seen as a mechanism of social control of behaviour regarded as threatening the stability of the capitalist system. Framing social problems as individual pathology can divert attention away from the political and socioeconomic origins of mental health problems. Interestingly, Jo takes a kind of 'labelling theory' view of mental illness as  “simply the collection of challenging situations that remain when [for example] those that are amenable to the criminal justice system … are taken out of the picture” (see my review of Thomas Scheff’s classic book).

Jo wants to question the notion that mental illness is located in the individual. However, as I pointed out in a previous post, Aubrey Lewis noted that maladaptive behaviour is only pathological if it is accompanied by a disturbance of psychological functioning. Social criteria play no part in the diagnosis of mental illness as such. In a way, that fits with Jo's perspective as she doesn’t really accept the term ‘mental illness’, although she persists with it as “there are no widely accepted alternative ways to describe the problems in question”. 

The social function of psychiatry cannot really be denied as psychiatry manages madness on behalf of society. As Jo notes, “One of the functions of mental health services is to provide support and care for people when they are unable to look after themselves”. I would say this is a reasonable function of the state to support those with mental incapacity and includes intervening to prevent harm to others as well as the person themselves. Modern psychiatry did not really come into existence in the way we understand it now until the local authority asylums were built. The early alienists identified insane individuals who were deserving of poor relief on the basis of their mental state. As I said in the section on Foucault in a previous post, the birth of the asylum needs to be seen as a later phase of what Foucault called the ‘great confinement’, when the mad were extracted from places of confinement and placed into asylums specifically designed for their treatment. Similarly in modern welfare, the mentally ill receive sickness and disability benefits distinguished from unemployment benefits.

Jo says a Marxist analysis “suggests that the [psychiatric] institutions were closed because of the desire to reduce public spending”. I’m sure there was this element in the intention to replace the asylums by community care, although properly implemented community care may well in fact cost proportionately more. But the prime motivation was what David Clark called the 'dismay and disgust with the asylum system'. Attempts were made to make hospitals more therapeutic by opening the locked doors (see eg. my webpage). Essentially, the asylum became irrelevant to the bulk of mental health problems. I do agree with Jo that it is a national scandal the way mentally ill and learning disabled people who are difficult to manage or place have been shipped out of the NHS, but it isn’t just the privatisation of services that’s the problem but also their level of security and risk aversive nature (see eg. my eletter).

I also agree with Jo about the problems of increasing social inequality and poor social mobility over recent years, even if I don’t frame this within a Marxist critique of neo-liberal capitalism as she does. There have also been problems with a target culture created by the Risk Society, which has contributed to a reinstitutionalisation of mental health services over recent years (see eg. previous post). I'm certainly not against the mental health system becoming more transparent and democratic as Jo wants. It should be about encouraging the independence of people as much as they want and are able to be.