The Political economy of the mental health system… a response to the response…

I was humbled to receive a response from Dr Joanna Moncrieff to my comment on her article on the political economy of the mental health system, so thank you Dr Moncrieff (the reader can find all the other links of the exchange at the link below).

First of all, I share the excitement of engaging in a discussion on HOW the system should or shouldn’t change, as opposed to a discussion with those who I call the traditionalists… those who, in short, don’t want to change anything, on whether things should change or not.

Your response is very helpful in narrowing down what our agreements and disagreements are. The picture is definitely a bit more more clear to me now. I’ll focus on the areas you highlight to hopefully narrow them down even further, which can become food for thought for anyone who’s interested.

Politics and science

Thank you for clarifying an important point in this respect, you say…

I was not trying to say that we should replace a political system with a scientific one- almost quite the opposite. I am saying we should replace the current pseudo-scientific mental health system, which is a system that claims to be based on science but is not, with a transparently political system, one that acknowledges that it is political and can therefore be subjected to democratic control and scrutiny.

I am totally with you in this respect, as quoted above. However, and this is a problem that I highlighted in my original response to your article, the way you further develop your argument shows that we likely mean different (perhaps even opposing) things with this, and that we make the same point based on opposing assumptions. You write…

But although all social systems may be political, the activity of doing science aims, at least, to be apolitical or objective. 

We definitely disagree on this. My thoughts on science have been significantly permeated by Paul K Feyerabend, and with him I believe that

The separation between the history of a science, its philosophy and the science itself dissolves into thin air and so does the separation between science and non-science.

— Paul K. Feyerabend From: Against Method: Outline of an Anarchistic Theory of Knowledge (1975).

I do not think that there is a fixed way in which science develops, and all sorts of subjective processes help science move forward. Our focus should be to expand the methods we have, not to limit ourselves to supposedly objective ones. Based on your take, it sounds like you see the subjectivity that permeates systems (including science), which implicitly must imply the political direction of a system, as a liability. This is hardly a Marxist analysis, unless you identify a clear boundary between science and non-science. I’m curious to know what this boundary is in that case!

I see subjectivity as an asset, as well as an inevitability, and when I claim that all systems are political I mean that they should invest on being as political as it gets, not that they should limit subjectivity (which in my view is a fuzzy and overall rather meaningless endeavour, and can only result in less democracy). Science is political and the mental health system should gradually move from a focus on social control to one based on solidarity.

You then say…

If we acknowledge that mental disorder is not a question of what is going on in someone’s brain, but a question of what behaviour society deems to be normal and acceptable, then it is quite clear that how we define and respond to this needs wide public debate. 

Speaking about subjectivity, this is another such example. Every experience of pain is arguably both a matter of what is going on in someone’s brain and at the same time of societal values. Of course it needs wide public debate. I do not see any grounds to expect everyone to define experience in any univocal way in this respect though…

You also say that claiming something to be scientific closes off the debate. Absolutely, that’s why we should NOT try to be more objective, but to open the debate as much as possible! As I often point out, science is always at the service of power. The more democratic power is, the more democratic science is.

In conclusion of this part, it is interesting how you point out that critics of Psychiatry are accused of being “subjective” or “unscientific”. It is true, this is also my impression, and it seems to me that both mainstream sides of the debate perceive and use “subjectivity” as a criticism of the other side.

The irony is that in my case this (the first, not the second of the two words) would be a perfectly legitimate criticism, I am indeed claiming that my approach values and invests in subjectivity much more than both traditional psychiatry and “drop the disorder”. Yet, amongst the fierce criticisms I have received, this is very rarely a line of attack on my views…

In short… My take in this respect is that we agree that all systems will always necessarily be politically driven, but we seem to disagree on whether the system should try to be political or objective (whatever it means).

Medicalisation

I agree with most things you say here. It is very helpful for you to clarify what I believe to be the central issue…

I agree that a non-medical narrative and system would not necessarily be more responsive to people’s needs or more humane. It could well be more punitive

You rather point at democratisation as a way forward, and I agree.

You also highlight how there are advantages but also significant downsides of a medical narrative. I agree on this as well and have made this point many times myself (I believe this of any narrative). I also agree that…

at a social level, regarding people’s experiential suffering as a disease rooted in their brains lets society off the hook.

The caveat, and it looks like at least on some level we agree on this, is that I think that society defining experiential suffering in ANY univocal way lets society itself off the hook. There is a conflict of interests there! If problems are, for example, identified as being due to a mystified notion of capitalism, then all people with an abusive role in the mental health system can call themselves out and say:”I know you criticise what I’m doing, but it’s not up to me. This is my job, it’s what happens within the constraints of capitalism”. This would be a convenient half truth, and when problems are never individualised, then the structure cannot be changed. Indeed, traditional Psychiatry often uses this line of defence of questionable practices and takes the opportunity to call for more funding for abusive institutions as a solution.

The effect of changing the dominant epistemological narrative of experience, leaving power structures in charge of the new narrative and power imbalances equally unchanged (the professional knows the objective truth and the patient does not), is that the new narrative will be used in the same way as the old one. I am not saying that this is what you suggest, but similar points are made very often in the critical UK landscape, and possibly by many readers. I also fully appreciate that the critical landscape comprises different and diverse positions, one of them certainly being mine…

In short… We agree that all narratives can be used to hurt people, and that there is no justification for a medical narrative to be in charge of the system. I’m not sure to what extent we agree that there shouldn’t be a univocal narrative in charge, and rather a negotiated landscape where first person narratives are both valued and challenged within therapeutic relationships.

Coercion

Coercion, from my perspective, is a topic that permeates the entire system. It has not just to do with physically assaulting patients as a form of “care”, but has also to do with forcibly labelling people or excluding/including them from help based on strict parameters defined from the top down. Not to mention that help in the UK mental health system is often a form of symptom control rather than a response to needs, and is often based on more or less implicit forms of coercion or threat (if you’re too complex, too suicidal, too resistant, then the therapeutic alliance ends here and you will be abused or totally neglected).

I don’t believe that there can be a situation of “no coercion” or “no control” or “no institution”, just like probably virtually no-one fighting for democracy believes there can be total or perfect democracy, with no injustice whatsoever. Crucially, it is very different to fight for more democracy and to value first person perspectives (as I do) or to fight to “drop the language of disorder”, as some in the UK critical landscape argue for, stating that we’re saying the same thing (not making claims about you here).

In any case, it is clear that the more one moves away from coercion, the more what coercion actually is becomes a philosophical question. It is also clear that anyone who tries to promote change within an autocratic system must accept to live in a contradictory position, where the new institutional mechanisms that are built, are at the same time critiqued and destroyed.

You say…

there are circumstances in which coercion of some sorts is justified.

Sure… that is very different from saying:”there are dangerous people that must be coerced”. Circumstances are the result of a range of personal/interpersonal conditions that we can work at preventing. If those circumstances are no longer in place, then we have different options. My take is that the current system is not even trying to build on its potential for freedom, and that the “drop the disorder” movement is not putting forward a coherent proposal to change things meaningfully.

The way we balance the needs of individuals and those of others in the community is by responding to the needs of people within an inclusive community, not by means of more sophisticated forms of, or rules on, exclusion. It’s a win-win process…

The rules may change, and that is good, but if the system is not providing more hope as it changes, then we’re just going to end up re-arranging institutional violence in new forms. You very effectively explained how this happened in the UK process of de-institutionalisation in your original article.

I would say that the legal pretext for coercion (whether it’s illness or an understandable reaction to capitalism) is the least of our problems; it’s the impossibility of finding a negotiated way forward that we need to act on, and this requires services and society to undermine power imbalances and democratise in a pretty sharp way. I have lived and studied in Trieste, so a system with no locked doors nor physical restraint (as in assaulting people), is not pie in the sky to me… despite the limits that approach still has, even in terms of coercion.

The whole debate on subjectivity, imposing narratives and all the rest is key to this process. It’s key to respond to people’s needs, being able to find compromises and ways forward in difficult situations, with people with different takes on life than ourselves… and a powerful symptom of the entire system’s culture is the extent of the perceived need to incarcerate people.

Szasz challenged Psychiatric coercion, and that’s good, but had no problem with legal coercion taking its place in the name of its supposed fairness… and to me the denomination of the violent institution, or whether it’s medical or not, is scarcely relevant. The last thing I want is the punitive, hypocritical vision explained in the latter part of this clip (from minute 5.01) by Szasz to take the place of the current one…

In short… We disagree to some extent, but perhaps these differences will become more clear and get clarified as the system, hopefully, starts changing.

Thank you,

Vincenzo

Published by vincenzo120887

I qualified as a Psychologist in Italy. I have experience of supporting people in different settings in Italy and the UK. Currently I'm hosting a podcast (A place of safety?) and I'm active on twitter as @apospodcast . Sometimes it's helpful to put down thoughts in writing and this blog exists for that purpose! Hope you enjoy it, feel free to ask questions...

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