Capitalism, Socialism, and Mental Illness (delivered as talk to Socialism 2014)

Capitalism, Socialism, and Mental Health

Dana L. Cloud

Socialism 2014

In the days after Eliot Rodger murdered six students of the University of California, Santa Barbara, commentators rushed to attribute the violence to “angry, resentful, mentally ill individuals” (Time) or “deep and puzzling psychological problems” (NYT). The problem could not lie in the ominpresence of misogynistic messages and attitudes that teach young men that they are entitled to the bodies of women, by force if necessary.

Another example: The New York Times ran a series called “Mothers’ Mind,” about the common experience of post-partum depression and even psychosis among new mothers. The series calls for greater attention to the mental health effects of changing hormones—but not for greater attention to women’s oppression in the family as a potential contributor to anxiety and desperation. One of the mothers interviewed in the series, however, makes the point clear. She wanted to have an abortion. But delays prevented her seeking that option. She comments, “When Benjamin was born, six weeks premature, Ms. Guillermo recalled thinking, “You’re not supposed to be mine. You were not supposed to be made.” After experiencing thoughts of harming her child, she was offered a solution: new medication.

There are many other examples that I could give where our society frames the results of social problems as individual illness. In this talk, I argue that capitalism creates and uses psychiatric problems in other ways as well. In addition to denying social causes to suffering and violence, capitalism’s pressures create the conditions—exploitation, oppression, and alienation—that lead to symptoms of mental illness. Then capitalism attempts to sell individualized cures to social problems in the form of dangerous pharmaceuticals, limited therapy, and rationed urgent care. In the broader political society, the ideas of psychotherapy—that suffering is a matter of individual biology or experience, of private life rather than produced socially—suffuse discourse from self-help books to advertising to political speeches.

I should say at the outset that I am neither a psychologist nor a psychiatrist, and so will not attempt to address diagnosis and treatments specific to particular disorders. I am talking about serious mental illness generall, including disorders from Axes 1(major mood disorders, psychosis) and 2 (personality disorders) from the Diagnostic and Statistical Manual (DSM) V. However, Axis 4, Environmental and Social Probems (including natural environment, social obstacles, and occupation), is misleadingly separated from the mood disorders and psychoses of Axis 1. The upshot of Axis 4 is, “It’s capitalism, stupid!”

Marxist psychologists tie the experience of illness and popular discourses about it to historical and social contexts. From such a perpsective, as Peter Sedgwick argues, mental should be understood as a kind of social failure, by which he means failure to adjust to society as it exists or failure to function ideally on its terms. Mental illness only has meaning in contrast to the dominant forms of social life. Perversly, capitalism drives workers so hard that they break down and become maladjusted. It is by meeting the imperatives of the existing society that continuing to conform is impossible. Thus R.D. Laing famously observed that what we label as mental illnesses are often adaptive or necessary responses to paradoxical social situations. The most obvious example here would be the suffering of PTSD by military veterans. Behavior that was adaptive in one setting is disordered in another.

Psychiatry and other treatments are sometimes instances of discipline or social control, but those of us living under the diagnosis of one or more mood disorders, personality disorders, psychosis, or other mental illnesses have to survive here and now, and no one should fault others for seeking out and using whatever resources there are available to make it through this day and the day after. Mental illness is real even if it has systemic origins and conservative uses. We have to live to fight for a better world in which caretaking is a social process and shared responsibility, where rest and solitude are not pathologized, where anyone can afford to be taken care of in an unalienated way.

As I continue, I will first sketch a historical overview of cultural approaches to madness. Then, I will describe contemporary depictions of and treatments for mental illness. The experience of patients varies profoundly by class, race, and gender, and the ruling class cultivates racial and gendered “sick” identities for patients. On the whole, the picture is bleak in neoliberal capitalism for people with mental illnesses today due to deinstitutionalization and lack of access to insurance and medications. I will turn at the end of my talk to a discussion of the kind of world socialists seek to implement and the standards for humane, useful, and collective remedies.

Madness in the Enlightenment

First, historical evidence shows that mental illness—its existence, definitions, explanations, and treatments—are historically and culturally specific in ways that are dialectically related to the economic system. Illnesses that are rampant today did not even exist as such before the 20th century, and many appeared during the Industrial Revolution. Madness emerged as an explanation in Enlightenment society for uncontrollable actions and desires in contrast to prior explanations focusing on demonic possession. As social historian and theorist Michel Foucault argues, the conception of madness as unreason originates in the period of the Renaissance and comes into fullness during the Enlightenment.

The Enlightenment was itself the product of a revolutionary shift in how the necessities of life were produced and distributed, the transition from feudalism to mercantile capitalism. Peter Sedgwick notes that the category of “neurosis” was not invented until this time period, in the middle of the 18th century. Enlightenment ideals constituted the ideology of the rising bourgeoisie. The dominant philosophy of the period was a distinct improvement on what came before, with its emphasis on human reason, progress, and freedom. Yet Descartes’ famous proclamation of the superiority of reason born of the mind over and above anything having to do with the body (labor, and, not incidentally, women) served to deny those deemed to be unreasonable the benefits of full citizenship.

The transition to industrial capitalism required and produced a philosophy of self-determination and the free exchange of goods and ideas; of course, this free exchange depended on the hidden labor of slaves, indentured servants, and women who, when rebellious, were defined as “mad” and disciplined accordingly. Rather than eliminating social control, as its founders claimed, the Enlightenment and the Bourgeois revolutions in France and elsewhere that produced it instituted new forms of control, one in which exclusion from society is justified by madness, newly defined as “unreason.”

The Enlightenment did bring with it some desire to humanize the treatment of the mad. It was Philippe Pinel who, along with the lesser-known Jean-Baptiste Pussin, abolished the brual repression of the deranged at the French hospitals Biecetre and Salpetriere in order to replace the system with a humanitarian medical approach. However, new modes of treatment operated as a different form of control. At this historical moment, places of confinement were created in which the mad were locked up with the poor and the unemployed, prostitutes, and other deviants on the basis that they had all chosen unreason. However, madness was also becoming the subject of scientific study and medical intervention in the lives of persons whose “selves” were incoherent.

Conservatism of Mental Illness Approaches Under Capitalism

Industrial capitalism made explicit what its forbears did not: The definition of an “incoherent” self is one who cannot labor. In the United States in the 1920s, organizational consultants led by psychologist Elton Mayo, aiming for maxium productivity among the industrial workforce, interviewed workers at the Western Electric’s Hawthorne plant. The idea was to provide workers a sense of compunity and participation and to meet workers’ needs in a time of rapid social change. Most workers complained of fatigue, boredom, and “feeling low.”

The solution proposed by the consultants? Better lighting. Interviewers seemed deliberately blind to the source of workers’ suffering in the fast-paced, Taylorized labor they were made to perform. One wrote of a worker who had compalined that his pay was too low and htat his supervisor treated him badly. The interviewer concludes that the worker was having “hard luck at home,” and “feeling dumpy many a day.” The interviewer offered encouraging words and working overtime as a solution—quite the opposite of what the worker really needed. For these psychologists, he problem could not be industry itself; nor did the company bear any responsibility for the alienation and injury of the workforce.

During this same time period, depression emerged as an experience, but more importantly, as a clearly defined illness. According to Michael Denning and Emily Martin, mood-tracking charts began appearing in the 1920s, whereby doctors and patients could peform the empirical and tedious labor of marking down every symptom, defining oneself as “ill” every step of the way. Depression itself was defined as an illness in 1921. Its major diagnostic criterion was the inability to get up and go to work. It is also not surprising that major therapeutic interventions occur in reaction to major labor strikes. As I have argued in previous work, therapeutic discourse as always positioned itself as an alternative to class-consciousness, prescribing medication and self-help over and above a critique of exploitation, oppression, and awareness of common cause.

Although the ideas surrounding of mental illness are socially constructed, it is the case that capitalism makes us literally sick with diseases caused by environmental toxins, the stress of overwork, difficulties in supporting a family, hunger and malnutrition, substance abuse, and so on. Capitalism also makes us sick of it, leading to protest and rebellion. A hallmark of militant social movements is to turn around the definitions of mental illness and describe the system itself as irrational and harmful.

Nowhere is this clearer than in the case of racism. The Protest Psychosis by Jonathan Metzl. details the incarceration of angry Black men at an asylum outside of Detroit under the diagnosis of schizophrenia. It was no coincidence that these efforts way corrolated to the eruption of anti-racist urban rebellions and prison prostests among Black inmates.

The establishment was none too slow in response to label Black men, especially angry Black men, as schizophrenics. In the 1960s and 1970s, schizophrenia basically became a Black disease. The FBI diagnosed Malcolm X with pre-psychotic paranoid schizophrenia by virtue of his membership in radical organizations. They diagnosed Robert Williams, head of a North Carolina chapter of the NAACP as schizophrenic because he fled from false kidnapping charges. In his influential book Negroes with Guns, Williams turned the diagnosis around and defined racism itself as a “mass psychosis.” However, labeling angry Black men as schizophrenic justified the confinement and drugging of those who refused to adjust. The DSM-II identified masculinized hostitliy, violence, and agression as key components of the illness, along with the tendency to blame others for one’s illness. Advertisements for anti-psychotic drugs like Haldol and Thorazine featured images of raging Black men out of control.

However, theorists like Frantz Fanon and WEB Dubois had long been identifying the psyche as a battleground for equality, noting the deep psychological scarring of colonization, slavery, poverty, prejudice, and segregation. Martin Luther King, Malcolm X, Stokely Carmichael, and other militants turned the rhetortic around to label the oppressive, racist system itself as sick. Jonathan Metzl writes, “In this context, the language of paranois, psychosis, and schizoprhenia became a means of pathologizing white society while justifying aggressive self-defense.”

The same mode of psychological discipline has long been applied to women, defined in terms of their bodies as “hysterical” from the get-go. I do not have time to review the entire history of the psychiatric persecution of women. I am not an expert on Freud, although I know that he attributed the discontent of women to their infatuation with their fathers and envy of the penis. However, I would recall what I said earlier about the Enlightenment imposing a new set of dualisms on society; prime among them is the mind-body split. Reason and the mind were the province of men; women became only bodies and by definition, unreasonable. And so it was that white women in the Victorian era whose complaint was their confinement in the domestic sphere, were prescribed futher confinement as a treatment (hence my reference to Perkins-Gilman, above). Today poor women are disproportionately represented in mental hospitals, and are the majority of people diagnosed with borderline personality disorder, whose main symptom is difficulty in appropriately regulating one’s emotions.

Mezl documents contemporary efforts to discipline women with diagnoses of depression. Arguing for continuity in the misogynistic assumptions of psychoanalysis and pharmacological psychiatry, he calls attention to how criteria for wellness are shaped by culture and used by the powerful to designate a particular group as a “problem” for society. He writes, “Psychotropic medications are imbued with expectation, desire, gender, race, sexuality, power, time, reputation, contertransference, metaphor, and a host of important factors”—that the idea of psychiatry as a medical science obscures.

Mezl examines American print culture over the latter half of the 20th Century to show how the implementation of psychiatric medication reinscribes sexist and heterosexist Freudian beliefs. New tranquilizers were advertised as “mother’s little helpers” and advertisements depicted mad feminists being “tamed” by Valium. He links efforts at gender discipline to material and ideological challenges to the idea of the nuclear family and a fragile paternal order. This edition of the manual defined menstruation and pregnancy, features simply of being female, as disorders. In the 1980s and 1990s century, Prozac came to be associated with liberation for women—defined as unmitigated happiness. Among the fascinating observations Mezl makes about the transition to pharmapsychology is that it minimizes human contact and community responsibility for wellness. This element is characteristic of more than psychiatry. It is the modus operandi for neoliberalism.

Psychiatry and Neoliberalism

Neoliberalism is the intensification of privatization and austerity around the world in a system governed to a significant extent by corporations and their unelected organizations like the World Trade Organization. Naomi Klein has called the neoliberal approach to crisis the “shock doctrine,” that is, to replace all that is slow, broken, inefficient, and less than optimally profitable with corporate control. In the United States, neoliberalism has meant the disappearance of full-time skilled jobs as fewer workers are made to do the tasks that many had done and the erosion of what meager social safety nets we have. Neoliberalism is what has left the insurance companies and the pharmaceutical industry in charge of health care.

If capitalism makes us sick, we would expect neoliberal capitalism to intensify that suffering and capitalize on it more effectively. And indeed, this is what we find. Neoliberalism breaks people down. According to the World Health Organization, there are at least 450 million people with diagnosed mental health issues. In the United States, the numbers of those disabled by mental disorders as indicated in Supplemental Security Income (SSI) or Social Security Disability Insurance (sSDI) increased two and a half times between 1987 and 2007, from one in 184 in Americans to one in 76. The United States’ rate of mental illness is higher than that of any other country, at nearly 30 percent. (Just after the US is Ukraine.) Historical statistics are difficult to come by, since most studies count only hospital admissions, excluding many millions who do not become hospitalized. Another statistical complication is that neoliberal capitalism works puts increasingly brutal pressure on the working class and the poor and has radically decreased the numbers of hospitalized mental ill patients.

James Petras notes that neoliberalism in crisis is even more prone to adversely affect the personality and the person, amplifying “the socio-psychological damage inflicted on salaried and waged workers, . . . including unemployment, job insecurity, and degrading work; high rates of chronic depression, family breakup, suicide, family violence child abuse, anti-social behavior particularly where the unemployed are isolated an unable to exteriorize their hostility and anger via collective social action.” Neoliberalism has reduced living standards and income, forcing wokers to seek lower paying jobs or fall below the poverty line. The unemployed face, along with the inability to pay bills, “deep and perpetual anxiety and a loss of self-respect.”

James Petras notes that neoliberalism in crisis is even more prone to adversely affect the personality and the person, amplifying “the socio-psychological damage inflicted on salaried and waged workers, . . . including unemployment, job insecurity, and degrading work; high rates of chronic depression, family breakup, suicide, family violence child abuse, anti-social behavior particularly where the unemployed are isolated an unable to exteriorize their hostility and anger via collective social action.” Neoliberalism has reduced living standards and income, forcing wokers to seek lower paying jobs or fall below the poverty line. The unemployed face, along with the inability to pay bills, “deep and perpetual anxiety and a loss of self-respect.”

Deinstitutionalization is the most significant neoliberal experiment in the treatment of the mentally ill. Although efforts to move patients out of hospitals and into homes and communities becan in 1955 (as soon as medications were available to make patients “manageable”, it became clear that it was anything but humane. PBS reported that the magnitude of deinstitutionalization of the severely mentally ill qualifies it as one of the largest social experiments in American history. In 1955, there were 558,239 severely mentally ill patients in the nation’s public psychiatric hospitals. In 1994, this number had been reduced by 486,620 patients, to 71,619. In effect, approximately 92 percent of the people who would have been living in public psychiatric hospitals in 1955 were not living there in 1994. Most of those who were deinstitutionalized from the nation’s public psychiatric hospitals were severely mentally ill.

Thus deinstitutionalization helped to create the mental illness crisis by discharging people from public psychiatric hospitals without ensuring that they received the medication and rehabilitation services necessary for them to live successfully in the community. Deinstitutionalization further exacerbated the situation because, once the public psychiatric beds had been closed, they were not available for people who later became mentally ill, and this situation continues up to the present. In 1997, approximately 2.2 million severely mentally ill people did not receive any psychiatric treatment. That number is much greater today. Approximately 200,000 individuals with schizophrenia or bipolar disorder are homeless, constituting one-third of the estimated 600,000 homeless population. Nearly 300,000 individuals with schizophrenia or bipolar disorder, or 16 percent of the total inmate population, are in jails and prisons (“More Mentally Ill Persons Are in Jails and Prisons Than Hospitals: A Survey of the States,” Treatment Advocacy Center and National Sheriffs’ Assn., May 2010). The World Health Organization estimates that in the US, only 41 percent of people with mental health dorders receive treatment.

Sedgwick writes, “It is not the therapuetic spirit of Hippocrates, but the capital-accounting ethos denounced by Marx and hymned by Weber, which in different phases of capitalist development herds the multitudes inside asylum walls and expels them again when the operation becomes too costly for a fiscally overextended social order.”

Over the past two decades, governments in the industrialized West have pursued policy agendas that reflect several characteristic elements of neoliberalism including a normative privileging of the individual; a preference for private sector funding for, and provision of, services, and the integration of corporate management practices into the work of government. During the same period there has been increasing attention – within the business community, among researchers, in the media, and by governments and international organizations – to the problem of depression, particularly among adults in the paid labor force. In addition over this time, many of the social and economic policies adopted by governments in these jurisdictions have reflected neoliberal goals and orientations. This approach, as described by Canadian scholar Katherine Teghtsoonian, is one of “responsibilization,” or locating responsibility for distress with the distressed, all couched in a language of helping.

However, neoliberal capitalism has jettisoned the stated humanitarian goal of “helping.” Other scholars, for example Australian legal scholar Terry Carney, have documented the rapid shift toward pharmaceutical intervention and “community-based” care, which, although it sounds humane, means, “You are on your own.”

In Mad in America, Robert Whitaker sketches the history of treatments for mental illness from bedlam to progessivism, then through eugenics, torture, brain surgery, electroshock, and dangerous but profitable neuroleptic medications hailed as miraculous. Sedating the mentally ill became the standard treatment. The reliance on medications prescribed by physicians grew as the interests of physicians and pharmaceutical companies converged in the 1950s.

Whitaker’s second book takes on the behemoth pharmaceutical industry as the key beneficiary of the explosion of medication-based treatment. Whitaker states that US patients spent $25 billion on anti-depressants and antipsychotics in 2007. The explosion of diagnoses and disability due to mental illness since 1987 has brought millions of children into treatment for newly diagnosed disorders such as ADHD. Likewise, in The Emperor’s New Drugs, Irving Kirsch reviews dozens of clinical trials and discovered that anti-depressant medications were hardly more effective than placebos.

Whitaker questions the validity of attributing mental illness to imbalances of chemicals in the brain and raises a number of alarms about medications designed to address those imbalances. For example, in the 1980s, the National Institute for Mental Health concluded that there is no research affirming a causal relationship between low serotonin levels and depression. Likewise, the theory that schizoprenia was caused by high dopamine levels was also discredited. Many antipsychotic drugs carry the risk of permanent tardive dyskinesia and increased risk for dementia later in life. Moreover, since the introduction of psychoactive medications, there has been an increase in chronic disabling mental illness. Anti-anxiety medications like Xanax and Klonopin cultivate dependency to drugs that in the long term do not alleviate anxiety. Despite numerous studies indicating that neuroleptics create significant changes in the brain but do not affect the rate or incidence of recovery from major mental illness, the prescription of medications like Prozac, Lamictal, Risperdal, and Klonopin is still the front line of treatment.

I believe that Whitaker is wrong to attribute the increase in mental illness rates largely to the selling of and dependence on psychotropic medications. Many of us probably know someone whose life was improved or saved due to psychopharmacological intervention. In addition, Whitaker does not consider social and economic factors that could affect the number of people in mental and emotional distress in neoliberal capitalism. The “bipolar boom” he describes could as easily be attributable to neoliberalism’s appreciation for sped-up productivity and uncontrollable consumer spending—adaptive, as Emily Martin explains, until the patient becomes profoundly depressed. In addition, it could be, as I am suggesting, that the intensification of austerity and the decimation of working class strength around the world has created ever greater numbers of actual cases of mental illness. However, the studies Whitaker cites warrant careful attention if the majority of people benefiting from pharmapsychology are (pharmaceutical company-backed) physicians and pharmaceutical companies.

Causality is difficult to assess, as three trends originated in the early 1970s: a neoliberal capitalism that met economic crisis with ruthless austerity; a dramatic rise in the incidence of reported mental illness; and the medicalization of mental illness such that a physician can treat the symptoms of workers in distress with a quick and efficient pill. The government at this time withdrew research support for long-term psychotherapy in favor of the biological model which dominates neoliberal health care. In corporate health care, time with doctors is rationed and expensive, and psychiatry relies heavily on “medication check” appointments; fewer and fewer offer any talk therapy or even conversation. Medications can be prohibitively costly and uncovered by insurance, especially before the brand-name patents expire.

Capitalism is distressing but incapable of remedying its subjects’ distress. This contradiction stands as an analogue to Marx’s observation that capitalism creates its own gravediggers and:

Modern bourgeois society, with its relations of production, of exchange and of property, a society that has conjured up such gigantic means of production and of exchange, is like the sorcerer who is no longer able to control the powers of the nether world whom he has called up by his spells.

Proponents of an oppressive psychiatry and of the capitalist system itself are terrified of the madness of crowds—of Black people and women and workers and the poor whose anger appears to bourgeois society to be “unreasonable.” And well they should be because there are millions of people around the world who are sickened by the neoliberal social order. But it is that order that is malignant and disordered.

Toward a Healthy Species-Being

What are we maladjusted socialists to do? We can look to the history of mental health reform for inspiration. There have been important movements, many growing out of the 1960s and 1970s, to improve the conditions and access to care of mentally ill Americans. One important example is the movement that forced the American Psychological Association to remove homosexuality from the list of mental disorders catalogued in the DSM in 1973. It is clear that the social movements of the late 1960s and 1970s, including the movement for LGBTQ liberation, were instrumental in achieving this victory.

A commemorative panel at the APA in 2013 brought together psychiatrists who played crucial roles in the fight to end the stigma attached to homosexuality both within and outside the mental health field. According to one account, Melvin Sabshin, M.D., a member of the APA Board of Trustees in the early 1970s and chair of the Scientific Program Committee at that time, credited the gay liberation movement as the impetus for change. He recalled the 1970 annual meeting in San Francisco where Gay Liberation Front activists along with political protesters in support of other social and political causes disrupted the meeting. “It was guerilla theater” at that meeting and the one held in Washington, D.C., the next year, he said.

In 1972, for the first time, the annual meeting featured exhibits and discussions spotlighting positive aspects of the lives of gay individuals.

In a key vote in December 1973, the Board of Trustees overwhelmingly endorsed psychiatrist Robert Spitzer’s recommendation to delete homosexuality from the DSM. A small group of gay psychiatrists was holding informal meetings to explore forming an organization that would heighten their visibility and that of gay patients. This organization eventually became the Association of Gay and Lesbian Psychiatrists (AGLP), now comprised of more than 600 members.

Building movements for social justice, including defending the lives and rights of the mentally ill, is the only way forward. Granted, can be very difficult while suffering as an individual from mental illness to participate fully in social movements and socialist organizing. Our political organization cannot take up the tasks of group therapy. However, political action can become a site of agency, a position from which to diagnose the system as irrational and to claim our own collective power.

We have to survive in order to fight, and that survival sometimes means availing ourselves of the meager and dangerous tools of coping that capitalism has afforded us. As Emily Martin explains, one can be both a patient with a diagnosis doing whatever it takes in the everyday setting—including staying on one’s meds—and an anthropologist, a critic of the hegemonic functions that psychiatry has played throughout modern times. There is no contradiction between filling your prescription for Lamictal at the pharmacy while seeking to bring big pharma down. There is nothing counter-revolutionary in surviving.

Capitalism grinds us down. In the past, it allowed for some meager remedies in the name of Enlightenment, but neoliberalism has shed even the veneer of civilization and reason. We cannot know what health looks like until we make a society built to meet our needs, one where caretaking is a social priority and where our jobs do not make us sick. We aim to create a society where misogyny is a thing of the past not a reason for violence, and where women and men are no longer disciplined to bear the burdens of society in the private family.

At the nexus of biology and culture, mental illness will persist beyond a socialist revolution. But can we not envision a world of abundance not austerity, one of social provisioning of basic needs not isolation and self-blame? There, health will be a matter of collective striving to foster a society built to achieve the well being of the human race.

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