The profession of psychiatry, along with related fields (the “psy-professions”), is the subject of criticism from a variety of quarters. That is, of course, not a new state of affairs — from at least the early work of Thomas Szasz to the present, the practice of psychiatry has engendered considerable controversy. The most recent incarnation of skepticism about the psy-professions has been dubbed “critical psychiatry.” Its protagonists range from concerned and aggrieved psychiatric consumers/survivors/ex-patients to reformist and radical clinicians and academicians. The targets of their dissatisfaction include the disease model of psychiatric problems, the influence of the pharmaceutical industry on psychiatric practice, and the role of coercion in psychiatric care, among others. The author of the book herein under review, sociologist Bruce Cohen, seeks to redress what he sees as a deficiency in the literature on this topic to date: its failure to employ a sufficiently theoretical lens in its scrutiny of modern psychiatry and related disciplines. And in particular, he suggests Marxism as the theoretical framework best suited to grasp the problems he identifies.

 

          Although Cohen views most aspects of the psy-professions as problematic, his primary focus, reflected in the book’s title, is on what he considers to be the hegemonic status of psychiatric discourse in contemporary society. In the service of demonstrating how this purported hegemony was achieved, he traces the origins of the mental health system to the socioeconomic forces associated with the rise of industrial capitalism. Cohen identifies the task of the psy-professions as naturalizing “the fundamental inequalities in capitalist society as natural and common sense” (169), thereby depoliticizing and individualizing its effects on people and medicalizing deviance from norms imposed by those who benefit from the capitalist order. Only with the advent of neoliberalism over the past few decades, however, has psychiatric discourse — framing of human emotion, cognition, and behavior in the linguistic and conceptual idiom of the psy-professions — become, in the author’s view, hegemonic in society at large.

 

          After introducing the above-described foundations of his thesis over the course of three chapters, Cohen catalogues in three subsequent chapters how — both historically and currently — the psy-professions exert their influence at the behest of ruling-class imperatives and sensibilities on, respectively, the worlds of work, youth, and women. He argues that

 

[t]he need to be constantly working on the self in the workplace, at home, and at school is reinforced through the psychiatric hegemony which has individualized and pathologized many aspects of our lived experience in neoliberal society. Predicated on the moral judgement of who is “normal” and “rational” in this society, … and who is seen as abnormal and therefore in need of … intervention, these professional groups are therefore fundamentally political in nature (169).

 

Cohen goes on to identify the absence of “a sufficient scientific base for any mental disorder” as the basis upon which “the psychiatric discourse promoted at a given time is mutable to the dominant norms and values of that society” (169). Thus, he asserts that

 

[t]he inherent political nature of the psy-disciplines has been … successfully hidden behind their appropriation of the language and practices of scientific enquiry. This perceived objectivity and neutrality of expert knowledge on mental illness is, however, based on the liberal democratic status quo and a positioning of “normality” which is inevitably framed by the values of the free market; to disagree or rebel against such values is to risk being seen as “abnormal” and in need of “treatment” by the mental health system (170).

 

In his penultimate chapter, Cohen expands on the sense in which, through the medicalization of dissent, he believes psychiatry to be a fundamentally political — and specifically conservative and morally controlling — enterprise. He closes with a brief chapter on suggested measures aimed at mitigating the psychiatric hegemony, which he concedes are mere palliatives pending the ultimate solution: abolition of the profession in the context of the collapse of capitalism.

 

          Although overtly polemical, this book is not without sober messages. The recognition, for example, that the dominant psychiatric paradigm fixes the locus of problems that people experience as being within them, thereby shielding from critical scrutiny the adverse consequences of our social and economic system, is crucial. Emancipation under psychiatric hegemony is thereby reduced to forms of self-governance, including self-diagnosis and treatment-seeking, in lieu of political action. Similarly, Cohen debunks the widely accepted myth that mental disorders as currently defined by official psychiatry are well characterized neurobiologically (among other ways). He points out that psychiatry derives much of its authority from perpetuation of that triumphalist canard and that, rather than objectively identifiable dysfunctions, it is deviation from social norms — and the characteristic socioeconomic imperatives that drive those norms — that brings people within the purview of the psy-professions. As vital as that point is, however, Cohen uses it to jump to the apparent conclusion that psychiatry cannot, in principle, have anything to offer people in distress. Fueling that non-sequitur is an absence of analysis of the different routes people take to deviation from social norms. Specifically, he conflates inability with refusal to conform to such norms, thereby considering all such people as engaging in willful acts of rebellion or civil disobedience. Inability to conform to social norms certainly entails political meaning. And in neoliberal societies, where social safety nets have been decimated, that political meaning is particularly pernicious. But failing to attend specifically to the predicaments of those who, through no choice of their own, are unable to conform to social norms appears callous in its countenancing of unnecessary suffering.

 

          In arguing his case, the author gives evidence of a superficial familiarity with some of his subject matter and/or an overzealous application of his ideological commitments. An example of the former (if not the latter) is his invocation of electroconvulsive therapy (ECT) as the quintessential exemplar of psychiatric malevolence. He fails to distinguish between the odious history of unmodified (i.e., without anesthesia) ECT performed on involuntary patients for punitive purposes and modified ECT performed on voluntary patients after informed consent (which might or might not be sufficient). Moreover, Cohen seems oblivious to the fact that provision of ECT (at least in the U.S.) is essentially confined in recent decades to voluntary patients outside of the public mental health system. While ECT plays a particularly prominent part in his catalogue of the sins of psychiatry past and present, the diagnosis of and incarceration for “sluggish schizophrenia” — the paradigmatic instantiation of the politicization of Soviet psychiatry — makes its first appearance on page 187 of Cohen’s 212-page text. And even then he parlays his discussion of those abuses into an indictment of Western psychiatry by adducing its complaints about psychiatric practices in the Communist world to demonstrate its own failure to acknowledge its fundamentally political role in suppressing dissent. One need not be a political conservative or an apologist for psychiatry to find such an implied equivalence grotesque.

 

          Notwithstanding its association with the horrors of the Soviet system (among others), and the recognition that Marxism can be used ideologically for malevolent purposes, the valuable insights offered by Marxist critique are many. But they are not limitless. In some places Cohen seems to acknowledge that the impulse to pathologize deviance from expected norms is a phenomenon that transcends capitalism. Thus, in quoting Ussher, he notes, “As the outspoken, difficult woman of the sixteenth century was castigated as a witch, and the same woman in the nineteenth century a hysteric, in the late twentieth and twenty-first centuries, she is described as ‘borderline.’ All are stigmatizing labels All are irrevocably tied to what it means to be a ‘woman’ at a particular point in history” (164). He recognizes all of these categories as reflective of misogyny, with the latter two seen as products of capitalism and the switch from hysteria to “borderline” as explainable with reference to the evolution from early industrialization to neoliberal capitalism. One might be excused for finding such an analysis somewhat tortured. Similarly, the author shows psychiatry to be an instrument of social control and conservatism across space and time, including the agrarian antebellum southern U.S. (via the ignominious diagnostic category of drapetomania), Victorian central Europe (hysteria), contemporary neoliberal capitalism (social phobia), and state socialism (sluggish schizophrenia). So where is the specificity for capitalism? It seems clear that a firm grasp of phenomena such as racism, sexism, and demand for sociopolitical conformity is needed in order to understand the specific shape that economic relations (and psychiatric thinking) take during a particular era. But is it simply asking too much of a Marxist economic theory, or any particular conceptual framework, to explain everything without residue?

 

          The arrogance of official psychiatry and of many members of the profession is all the more remarkable given the modest accomplishments of the discipline in executing its mission of understanding and ameliorating human distress. Rather than defensiveness, critiques of psychiatric practices should be welcomed and encouraged. Cohen’s analysis is particularly useful in its explicit attention to the hegemonic status of psychiatric discourse in contemporary society and to the underpinnings in neoliberal capitalism of this development, the consequences of which are largely baleful. His proposed remedies — short of the definitive solutions of abolition of the profession and the replacement of capitalism — include removal of the power to compel people into psychiatric treatment and removal of the necessity of prescriptions from physicians to obtain drugs. Both have been proposed by others and both have merits. One wonders how much of what ails psychiatry and related disciplines might be remediable through a focus on and concerted efforts toward honesty, transparency, humility, and genuine democratization. Cohen likely sees structural factors in contemporary society as rendering such a prescription naively utopian. And he might be right.

 

 

 

© 2017 G. Scott Waterman and Douglas Porter

 

 

 

G. Scott Waterman, M.D., University of Vermont, Burlington

 

Douglas Porter, M.D., Algiers Behavioral Health Center and Louisiana State University, New Orleans