First published on Mad in America
BOOK REVIEW: Bruce M. Z. Cohen. (2016). Psychiatric Hegemony: A Marxist Theory of Mental Illness. UK: Palgrave Macmillan. Hardcover: $99.99, E-book: $68.20 (USD)
Many books expose psychiatry’s crimes against humanity. However, few analyze psychiatry in relation to capitalism, and even fewer attempt this with a marxist analysis.
In Psychiatric Hegemony: A Marxist Theory of Mental Illness, Bruce Cohen breaks new ground. He explains the expanding power and influence of psychiatry in terms of its usefulness to the capitalist system – the more useful it is, the more power it is given, and the greater its power, the more useful it becomes. More specifically, he analyzes DSM-1 through DSM-5 to show how psychiatry has supported capitalism’s neoliberal transition, gaining power and prestige in the process.
A professor of sociology at the University of Auckland, New Zealand, Cohen informs us that,
the current discussion is a critique of professional power not of personal experience and behaviour which may have been labelled (or self-labelled) as a ‘mental illness.’ (p.3)
His target is the ‘mental health industry’ which includes “the entirety of the professionals, businesses, and discourse surrounding the area of mental health and illness.” He labels all who work in this industry as ‘psy-professionals’ whose function is to “normalise the fundamental inequalities in capitalist society as natural and common sense.”
Cohen challenges the theory that the pharmaceutical industry’s lust for profit is the primary driver for psychiatry’s increasing authority or ‘hegemony’ over society. He also disputes the claim that growing inequality and loss of social support are causing more people to become ‘mentally ill.’ Instead, he applies the marxist method to reveal how psychiatry serves the capitalist system. To summarize his argument:
The capitalist class seeks to avoid responsibility for the many problems it causes, so it frames pain and suffering as somehow natural and inevitable. Psychiatry supports capitalism by ‘diagnosing’ socially-created problems as individual cognitive or biological defects, providing pseudoscientific ‘evidence’ for blaming the victims of the system. To use Erving Goffman’s metaphor,(1) if capitalism is a con game, then the role of psychiatry is to ‘cool the losers’ of the system so they don’t squawk, expose the con, and take their revenge.
While suffering may well be increasing, we are mistaken to label it ‘mental illness.’ Warnings about the ‘growing epidemic of mental illness’ followed by calls for more access to ‘treatment’ testify to psychiatry’s success in framing an expanding number of social problems as medical in origin. Psychiatric hegemony results when the medicalization of suffering has penetrated every aspect of society, to the point that sufferers ‘diagnose’ themselves and each other.
Through psychiatric hegemony, then, we are all implicated as ‘at risk’ of mental illness and must constantly self-monitor for potential signs of disorder. (p.90)
The pharmaceutical industry plays an important but secondary role. Pharma enhances the credibility of psychiatry as a medical (prescribing) profession, which increases its usefulness to capitalism.
The predominance of drug interventions does benefit capitalism directly by reducing the need for more expensive institutional ‘care.’ Also, chemical forms of social control are more subtle and raise fewer objections than physical constraint as a means to manage social deviance. However, psychiatric drugs would have no currency without the power of psychiatry to prescribe them as ‘treatment.’
Cohen’s textual analysis of the DSM, from 1952 through 2013, reveals the increasing extent to which psychiatry has positioned itself as an authority on ‘acceptable behavior’ at work, at school, at home, and in personal life – acceptable behavior being defined by what benefits capitalism.
Whereas the DSM-I and the DSM-II make hardly any reference to such arenas of life, the DSM-III dramatically increases such phrasing – a trend which continues as neoliberalism progresses. (p.79)
Work: Enforcing Compliance
Cohen explains how psychiatry frames ‘under-performance’ at work as an individual ‘mental illness’ requiring ‘treatment.’
psychiatry and allied psychological sciences have expanded their areas of jurisdiction into the workplace of the white-collar worker at the behest of capitalist enterprise, where self-surveillance and a continual working on the self have become a part of the increased need for an efficient, flexible, and mobile labour force. (p.98)
He documents how work-related terminology increases in each edition of the DSM, from 10 mentions in DSM-1 to almost 40 times that number in DSM-5, with a significant jump between DSM-2 and DSM-3. By focusing on individual performance, psychiatry depoliticizes workplace conflict.
instead of recognising power disparities in the work environment, new and/or changing diagnostic categories of mental illness encourage workers to problematise the self rather than the organisation or wider society. (p.104)
An expanding service sector requires workers who are sociable go-getters who can sell products and services. Those who are quiet, withdrawn, or shy are disadvantaged. Quoting Ron Roberts, “It is no longer enough just to shift product, one must now do it with a smile, with ‘sincerity,’ with a friendly touch,”(2) Cohen concludes,
the pathologisation of shyness reflects neoliberal capital’s desire for ‘emotional labour’ within the work force. (p.109)
To better “align their ‘expertise’ and ‘science’ with the needs of capitalism,” psychiatry adds Social Phobia and then Social Anxiety Disorder to the DSM.
since the original construction of social phobia in 1980, workers have become more inclined to self-label and entertain the possibility of therapy and drug treatment for their failure to be more sociable and assertive at their place of work. This situation has further legitimated the extension of the psy-professions in the areas of unemployment, job training, and work, reinforcing the neoliberal focus on the self as the site of change, while simultaneously depoliticising the increasingly alienating work environment and constant pressures on employees to upskill and be ‘more employable’ in the jobs market. (p.108)
The ‘mental- health industry’ has penetrated the workplace to the extent that, in 2014, the Bureau of Labor Statistics ranked industrial psychologist as the fastest-growing occupation in the United States.
Youth: Medicalizing Deviance
In this chapter, Cohen reveals how
the increasing infiltration of the psychiatric discourse into the education system serves a significant function for capitalism in enforcing dominant moral codes and economic prerogatives while pathologising any deviation or resistance to these patterns of authority. (p.113)
He points out, “just a hundred years ago cases of mental disorder in children were considered most rare, with there being no specific pathology that psychiatry believed affected young people in particular.” Today, millions of American children are prescribed psychiatric drugs for a growing number of ‘mental disorders.’
Cohen explains this shift by noting that neoliberalism demands greater social control, and psychological testing in the school system is a way to identify and pathologize non-conformists.
As a result of the pressures on teachers and pupils in this neoliberal environment, there has been a need for a closer surveillance of behaviour in school and, more readily, a desire to discipline the defiant child through the application of various mental illness labels. (p.127)
The expansion of psychological testing in schools contributes to the growth of the ‘mental health industry,’ making it more useful to the system.
The psychological sciences have become increasingly useful for teachers and the schools system in supporting the exclusion of troublesome pupils and labelling non-conformist students as mentally disturbed. (p.126)
From its very first edition, the DSM has linked unwanted behavior and conduct in the classroom to childhood ‘mental illness.’ Cohen recounts the shameful history of pathologizing school-age children who do not conform, from the label of “moral imbecile” at the start of the 20th century, through EL (encephalitis lethargica) or “sleepy sickness” in the 1920s, to ‘hyperkinesis’ in the 1950s to ‘minimal brain dysfunction’ in the 1970s, to ADHD today.
Clear within the phraseology and the “symptoms” of ADHD is the concern to medicalise the behaviour of unruly children in the classroom…and, therefore, the APA developing the label of ADHD as a device of social control. (p.129)
Cohen’s analysis reveals that the number of youth-related diagnostic categories rose from 8 in DSM-1 to 47 in DSM-5. More remarkable is the dramatic rise in the number of youth-related words or phrases from 45 in DSM-1 to 1,983 in DSM-5 with a particularly steep rise between DSM-2 (112) and DSM-3 (1024). Cohen explains,
the DSM-III and the growing focus on youth mental illness can be understood as a consequence of the deinstitutionalisation of deviant youth from special education facilities. (p.124)
As tighter school budgets eliminate engaging programs and activities, it becomes more difficult to hold students’ attention. Correspondingly,
With the construction and expansion of the ADHD category to greater numbers of young people, the emphasis is changing from overt disruption to student inattention. (p.133)
Women: Reproducing Oppression
In this chapter, Cohen shows how psychiatry polices the behavior of women in ways that adapt to the changing needs of capitalism.
The wrenching transition from a rural peasant economy to an urban industrial one was particularly difficult for working women. Initially incorporated into industry, they were later excluded by ‘protective’ legislation. Restricting women’s role to reproductive work in the home effectively assigned them to the status of second-class citizens.
Psychiatrists become increasingly important throughout the industrial period as initially incarcerators of deviant working-class women and then as moral enforcers of gender roles, “respectable femininity,” and the sanctity of the family. In this way, the institution of psychiatry takes over the moral role previously performed by religion in feudal society. (p.142)
Psychiatry provided ‘medical’ justifications for women’s oppression. Pseudoscientific theories about women’s ‘weaker’ minds were used to justify keeping women at home and discriminating against them at work.
Women who protested the prescribed female role of submissive wife and daughter, doting mother, and eager housekeeper became targets for compulsory hospitalization, mutilating surgery, and other punitive measures in the guise of ‘treatment.’
In Victorian society, drinking, dancing, or even having a political opinion were all potential grounds for psychiatric incarceration. The confinement of these mainly working-class women in asylum becomes the backbone of institutional and scientific development of the psychiatric discipline, and the over-representation in asylums then provides justification for its focus on mental disease as a distinctive “female malady.” (p.142-3)
Cohen’s analysis of the DSM reveals how the number of ‘feminised’ diagnostic categories rose from 4 in DSM-1 to 24 in DSM-5 with, yet again, a significant jump between DSM-2 and DSM-3.
Today, more women are in waged work than ever before, in effect, challenging the ‘female role.’ To contain that challenge, the number of gender-related words/phrases found in the DSM rises from 105 in DSM-1 to an astonishing 3,096 in DSM-5.
The total count increase witnessed with DSM-III, DSM-IV, and DSM-5 is evidence of the increasing usefulness of psychiatric discourse as a means of ideological control of female behaviour, both policing the boundaries of acceptable gender roles as well as reinforcing heteronormativity. (p.154)
psychiatric hegemony serves to depoliticise the reality of women’s experiences through recasting patriarchal and capitalist oppression as personal distress and individual pathology. (p.149)
Resistance: Pathologizing Dissent
The use of psychiatry to pathologize protest is well-documented.
As a supporting institution of capital the role of the mental health system is to delegitimise such political action as signs of irrationality, dangerousness, and mental pathology rather than a rational and logical consequence of widening social and economic disparities within western society. (p.193)
Cohen recounts some of the stomach-turning atrocities of psychiatry, including,
the normalisation of conditions of slavery, the psychiatric incarceration of political activists, the labelling and drugging of young people with school related “disorders,” the lobotomising of problematic wives, the torture of war combatants, the castration of working class men and women, the pathologisation of the unemployed, and the mass murder of psychiatric inmates. (p.206)
Cohen shows how the number of protest-related words/phrases rose from 11 in DSM-1 to 201 in DSM-5, with two significant jumps: one between DSM-2 (11) and DSM-3 (80); and an even larger jump between DSM-4TR (63) and DSM-5 (201). Of particular note is the increased use of the terms ‘delusions of persecution’ or ‘paranoia,’ from 3 in DSM-4TR to 14 in DSM-5, and a corresponding increase in references to ‘violence’ from 43 to 148. As Cohen points out,
The irony of psy-professions’ focus on political violence as symptoms of pathology is the denial of their own involvement in inflicting systematic institutional violence on others…. a contemporary case in point is the American Psychological Association’s involvement in the torture of detainees at US military prisons at Abu Ghraib and Guantanamo Bay. (p.196)
This service is amply rewarded by the capitalist State.
the psy-professions have increased their professional capital and power through promoting a psychiatric discourse which serves to incarcerate, torture, and murder political opposition and deviant groups under the rhetoric of “medical progress” and “acting in the best interests of the patient.” (p.200)
In his concluding chapter, Cohen states, “the mental health system is a fundamentally political project” whose priority is not the mental health of the population but social control.
I have drawn on extensive evidence to argue that the psy-professions were created and progressed to regulate and manage western populations through personalising social and economic issues, pathologising political dissent, policing and punishing problematic and deviant groups, and reproducing the dominant norms and values of the ruling elite through psychiatric discourse. (p.205)
However, when it comes to solutions, the book flounders.
Cohen links “ the ‘crisis’ of psychiatry in the mid-1970s, the construction of the DSM-III in 1980, and the wider development of neoliberal policies.” (p.70)
psychiatric discourse becomes increasingly important in reinforcing the dominant goals of neoliberalism, focusing on the self – rather than the group, community, organisation, or society – as the appropriate site for change and ‘growth.’ (p.76)
the psychiatric discourse witnessed in the DSM-III (as well as subsequent DSMs) reflects the emergence of neoliberal obsessions with efficiency, productivity, and consumption. (p.79)
By the time of the DSM-5, psychiatric diagnoses are blatantly mirroring neoliberal ideology in relating mental illness to under-performance.” (p.80) Psychiatric labels increasingly “focus on deficits and failings in character which threaten the productivity and consumption activities of the individual in many social and economic arenas of life. (p.87)
Cohen stresses that “the recent demands of neoliberal capital have necessitated the expansion of the psychiatric discourse to the point where it has become hegemonic and totalising” (p.70), However, he does not explain why neoliberalism needs to exert so much control.
The capitalist class embraced neoliberalism to counter a social and economic threat. The mass rebellions of the 1960s and 70s had helped to defeat the U.S. in Vietnam, demolished the presidency of Richard Nixon, and were demanding higher living standards and greater corporate accountability. Psychiatry also came under siege as activists forced the removal of homosexuality from the DSM and campaigned against the inclusion of gendered ‘diagnoses’ like Self-Defeating (Masochistic) Personality Disorder and Pre-Menstrual Dysphoric Disorder.(3) Add to all this an economic recession and a falling rate of profit.
Neoliberal policies aim to boost the rate of profit through deregulation, cutting social programs, transferring public assets and services to the private sector, lowering corporate taxes, and gutting unions. To support these policies, neoliberalism exalts individualism – the claim that social programs promote laziness and reduce productivity, that no one is entitled to anything, that one should work for what one has, and that too many people are ‘freeloaders.’
People naturally resist deteriorating living conditions, so coercion becomes more important. The penal system manages the law-breakers, and psychiatry manages the rule-breakers. Both institutions have expanded tremendously since the mid-1970s.
Why does Cohen not acknowledge that psychiatric hegemony developed in order to counter popular revolt? Strange as it may seem, some marxists believe that the victory of the working class over capitalism is ‘inevitable’ or ‘destined.’ In Cohen’s words,
Given the oppressive economic conditions that workers endure under capitalism, Marx prophesied the proletariat revolution as inevitable. (p.71)
Ultimately, [capitalism] is a system defined by the permanent struggle between the proletariat and the bourgeoisie over the means of production – a conflict which the workers are destined to win… (p.30)
Religious concepts like ‘inevitable’ and ‘destined’ have nothing to do with genuine marxism. Marx never ‘prophesied,’ because the outcome of struggle cannot be guaranteed. He stated that the working class has the power to defeat capitalism; however the outcome could also be “ the common ruin of the contending classes.”(4) This could happen through war or environmental destruction. Marx emphasized that what happens in the future depends on the choices we make today.
Cohen believes that the defeat of capitalism is assured, so he does not concern himself with the class struggle but on what can be done ‘in the meantime.’
My Marxist argument necessarily entails the end of capitalism, yet there is also plenty that can be done to subdue and diminish psy-power before the current economic order finally collapses. (p.207)
Even if it were true that capitalism will eventually collapse of its own accord, why not do everything we can to bring that day closer, to prevent as much suffering as possible?
Cohen’s marxism is mechanical; it has been stripped of all revolutionary dynamic. The heart of marxism is the self-emancipation of the working class, which is now the majority of humanity and the single greatest threat to capitalism. Yet the working class appears in this book only as victim, never as liberator.
Capitalism needs psychiatry to impose social control because it fears working-class revolt. The greater the threat, the greater the need for repression. Cohen sees the repression, but not the potential power of the working class that makes such repression necessary. This leaves him with no workable solution to the problem of psychiatric hegemony.
Early in the book, Cohen acknowledges class divisions in medicine.
the exploitative work relations within capitalist societies are replicated within the rigid hierarchy of medicine, with high-waged, upper middle-class consultants holding a great amount of decision-making power at the top, the lower middle-class nursing managers administering consultants’ needs in the middle, and – holding no power whatsoever and subject to the whims of health managers – the low-earning working-class orderlies and auxiliary staff at the bottom of the pyramid. (p.32)
If the working class holds “no power whatsoever,” then why the need for repression?
While it appears that workers have no power, this is an illusion. When workers strike, ‘business as usual’ grinds to a halt.(5) When workers move into action as a class, they not only have the power to stop producing or serving capital, they can also redesign work, and therefore society, to meet human needs. This is the power that capitalism most fears, the power that can bury it. Cohen does not acknowledge this, and he dismisses the working class as a force for social change.
While (rightly) condemning the ‘mental health industry,’ Cohen (wrongly) condemns everyone who works in it, “not only the psychiatric profession, but also allied groups such as psychologists, counsellors, psychiatric social workers, psychoanalysts, and the many other ‘talk therapy’ professionals,” on the basis that
The psy-professions are not on our side, they have never stood up for us. In fact, quite the reverse. As we have seen in this book, the class interests of the psy-professions closely align with the ruling elites… (p.207)
This is simply untrue. Like all institutions, the ‘mental health industry’ is divided by class, between the few who set policy and the many who carry out orders.
While understandable, it is a mistake to counterpose psychiatric survivors and workers in the ‘mental health industry.’
Psy-workers are as vulnerable to psychiatric victimization as any other group of workers, if not more so.(6) And a great many psychiatric survivors (or their family members) become counselors and psychotherapists in order to provide better care than they or their loved ones received.(7)
Many people who work in the psy-industry write, organize, and campaign against psychiatry, including those who blog on websites like Mad in America.
Many psy-workers are sickened by jobs that promise to help, yet too often hurt. Others risk their livelihood to demand that human needs come before profit-making.(8)
In short, there is a large base of workers in the ‘mental health industry’ whose class interest conflicts with those who decide policy, and this is true of every institution under capitalism.
Capitalism is an all-encompassing system of relationships which means that we are all “implicated in systematically serving the interests of the powerful.” (p.8) All paying jobs serve the capitalism system, even if the people doing those jobs are trying very hard to do something else.
The fact that we all participate in reproducing capitalism every day does not stop people from rebelling. On the contrary, it promotes rebellion, because our best instincts as human beings are repeatedly violated by the work we are expected to do to serve a brutal and brutalizing system.
Cohen is correct that most psy-workers are bamboozled about the value of what they do – believing they are making the world a better place, when they are actually contributing to psychiatric hegemony. Nevertheless, most do not enter the industry to serve as agents of oppression, and when they realize they are, they can become magnificent fighters against it. Marxism calls this a ‘contradiction.’ Institutional Ethnography calls it a ‘disjuncture.’ Psychology calls it ‘cognitive dissonance.’ These conflicts provide openings for consciousness and behavior to change.
Cohen rightly concludes that the institution of psychiatry must be abolished, yet he offers no workable way to do this. Instead of supporting workers to challenge capitalism and psychiatry, he writes them off.
Thus, despite having some psy-professional friends and colleagues whom I continue to work with on various research projects, I would at this stage be a fool to recommend anything other than the wholesale abolition of their profession. (p.208)
How ‘their profession’ would be abolished is never explained. Once the working class is dismissed as a force for social change, the only weapon left is moralism. And moralism has no power to accomplish the goals that Cohen identifies.
Firstly, we must remove psychiatry’s compulsory powers. This includes the power to incarcerate and to enforce shock treatment and drugs – including the use of compulsory treatment orders…Secondly, the prescribing rights of the profession should be withdrawn…thirdly, ECT needs to be outlawed. (p.208-9)
Who will remove psychiatry’s compulsory powers? Who will withdraw psychiatry’s prescribing rights? Who will outlaw ECT? Cohen replies,
This involves the disruption of the psychiatric discourse on many fronts through an alliance of political activists on the left, psychiatric survivors, critical and radical academics and students, and community leaders. (p.207)
These groups have important contributions to make. However, on their own, they do not have the power to defeat capitalism, and psychiatry cannot be abolished without abolishing the system that requires it. As Cohen has shown, the two are organically linked.
A revolutionary working-class would have the power to abolish capitalism and psychiatry. In the absence of such a force, one can mount only a moral challenge. Capitalism is more than capable of repelling moral challenges; it enlists psychiatry to label them paranoid.
This is an expensive book and a difficult read, and many of the arguments have been stated before. Nevertheless, Cohen provides new insights into the growing power of psychiatry in general and biological psychiatry in particular.
Psychiatric Hegemony is a welcome contribution. However, it takes us only part of the way. We need revolutionary marxism to take us the rest of the way. As one psychiatric survivor declared,
To be clear: ‘helping rooms’ [for psychiatric containment] are the problem, not necessarily their employees. I have sat at tables where hospital workers and psychiatric survivors alike acknowledge them as traumatizing, sometimes for both sides. Many psychiatric hospital workers find their work miserable and exhausting, in part because they must act in unnatural, professional (code for distant), and sometimes violent ways towards people. But insofar as staff hold all the power in these rooms, we need them to revolt.(9)
- Goffman, E. (1952). On cooling the mark out: Some aspects of adaptation to failure. Psychiatry: Journal of Interpersonal Relations, Vol.15, No.4, pp.451-463. http://infofranpro.wdfiles.com/local–files/19520101-on-cooling/19520101%20On%20cooling.pdf
- Roberts, R. (2015). Psychology and capitalism: The manipulation of mind. Alresford: Zero Books.
- Caplan, P.J. (1995). They say you’re crazy: How the world’s most powerful psychiatrists decide who’s normal. Addison-Wesley.
- Marx, K. & Engels, F. (1848). The manifesto of the communist party. Chapter 1. https://www.marxists.org/archive/marx/works/1848/communist-manifesto/ch01.htm
- Rosenthal, R. (2014) Rank and file rebellion: The 1981 Ontario hospital strike. Toronto: ReMarx Publications. http://www.remarxpub.com/rank-and-file-rebellion-the-1981-ontario-hospital-strike/
- See Chapters 3, 8, & 9 in Burstow, B. [Ed.] (2016). Psychiatry interrogated: An institutional ethnography anthology. Palgrave MacMillan.
- Lewis, S. (2015). The skeletons in my closet. TEDx. https://youtu.be/G17iMOw0ar8
- Winslow, C. (2015). When workers fight: NUHW wins battle with Kaiser. Beyond Chron, Nov. 24. http://www.beyondchron.org/when-workers-fight-nuhw-wins-battle-with-kaiser/
- Morgan, S. (2016). The helping room. Mad in America, October 27. https://www.madinamerica.com/2016/10/the-helping-room/