The Mental Health Industrial Complex: A Study in Three Cases

Abstract

Among the many sites on the battleground of the United States in which racism and classism rage is the all-too-overlooked mental health industrial complex. Over the past four decades, the mental health industrial complex has used the biomedical explanation for mental suffering. This focus on diagnoses that result from problems of the brain and not from social factors has contributed to an exponential increase of consumed medications and total revenue earned from the mental health and addiction services provided in the United States. Moreover, this specific ontology of subjectivity—that humans are solely defined by their material brains—helps serve the interests of the dominant hegemony. It is the assertion of this article that today as persons are conditioned to understand mental illness as a result of a purely individual problem, they become unaware of the ways in which the structural problems of race and class contribute to their mental illness. As a therapist who works with marginalized populations, I have seen firsthand how the biomedical model can be used to reinforce the illnesses that it aims to treat. The following article will illustrate the complex dynamics of the mental health industrial complex by way of analyzing three case studies of Black, male patients who I treated while working at a mental health facility in the Northeastern United States.

Keywords

biomedical model mental illness structural inequality profit psychologization classism racism

Among the many sites on the battleground in which racism and classism rage in the United States such as educational institutions (U.S. Department of Education Office for Civil Rights, 2014), the work force (Bertrand, 2003; Spalter-Roth & Rosenthal, 2005; Woods, Buchanan, & Settles, 2009), the medical field (Washington, 2006), the prison industrial complex (Alexander, 2012), real estate (A. Brown & Smith, 2015; Denton, 1967, Marable, 1983), is the all-too-overlooked mental health industrial complex (Rubin, 2006; Szasz, 1984). The oppression of disenfranchised populations in the history of the United States can be traced through the modern day mental health treatment facilities and the ways in which they coordinate services with the police, the prison system, and the education system, ultimately making their services a function of the state and big business (Cartwright, 1851; Coontz, 2010; Foucault, 1965; Grier & Cobbs, 1968; Hart, 2013; Metzl, 2009; Olfman & Robbins, 2012; Strous, 2007; Szasz, 1984; Whitaker, 2010). The following article will begin with some remarks about the biomedical model, its contributive factors to overall medication consumption in the United States, and contextual statistics about mental health in general and the location of the clinic in specific. The article will proceed with three case studies to illustrate the systemic violence of a mental health clinic on the oppressed. The article will end with some concluding remarks about possible approaches for change.

Profit, the Biomedical Model, and Psychologization

Over the past four decades, the mental health industrial complex has continued to oppress disenfranchised populations while generating billions in revenue by means of its biomedical model or explanations of mental suffering (Dumit, 2012; Luhrmann, 2001). For many proponents of this shift, a focus on biological bases of disease would alleviate the stigma, shame, and the residues of sin and moral failure that so often pervade mental illness, thus alleviating symptoms. In this model, mental illness is a chemical or mechanical failure of the brain that should be regarded no differently than failures of other parts of the body, such as the kidney or the foot. This is all to say that the shift of focus to diagnoses resulting from problems of the brain and not from social factors has contributed to an exponential increase of medication consumed by Americans and of revenue for total mental health and addiction services provided in the United States. For example, in 1986, total services for mental health services and substance abuse treatment generated 46 billion dollars in revenue. By 2003, that number jumped to 121 million; and by 2014, that number increased to 239 billion, which translates to about 739 dollars a year per adult on mental health services (Substance Abuse and Mental Health Services Administration, 2014). Furthermore, this psychopharmacological treatment helps condition patients to understand their mental health problems as arising from dysfunctions of the brain rather than the social contexts in which they live and seek care (Greene, 2017b; Hart, 2013; Jarecki, 2012; Kirsch, 2010; Parker, 2007; Robbins, 2013). One result of this kind of understanding is that problems that are sociopolitical become converted into problems that are psychological. This process has been called “psychologization” by Parker (2007). In short, “The current ruling ontology denies any possibility of a social causation of mental illness” (Fisher, 2009, p. 37). This specific ontology of subjectivity, which defines the entire human experience as an isolated unit of consumerism, and a product of brain chemistry, is a singular, restrictive and reductive understanding of all the ways in which humans and their subjectivity can be understood. The result of which, according to Layton (2002) is that this “bourgeois ideology splits the individual from the social, and in so doing fosters narcissistic character, an impoverishment of individuality in which dependence is repudiated and difference not tolerated” (p. 1). This atomization serves a specific political function, too. It keeps those who are oppressed inward looking and forecloses knowledge of the dominant class as they exert enough force to contribute to extensive suffering and mental illness in the oppressed. Fanon (1963, p. 180) writes, “Imperialism leaves behind the germs of rot which we must clinically detect and remove from our land but from our minds as well.” Which is to say, the psychogenesis of the psychological damage of individuals can be found in our political economic system. Likewise, for mental health workers, as Fromm (1956) writes,

[m]any psychiatrists and psychologists refuse to entertain the idea that society as a whole may be lacking in sanity. They hold that the problem of mental health in a society is only that of the number of “unadjusted” individuals, and not of a possible un-adjustment of the culture itself. (p. 6)

This specific kind of colonization of consciousness (i.e., ideology or false consciousness), by the political economic apparatus known as the mental health industrial complex contributes to what the professor of humanities, Dr. Robert Zaslavsky, has coined as the current “culture of incapacity” (2015, personal correspondence) and elicits mantras of self-blame while exploiting humans as patients for the bottom-line dollar. In short, the definition, diagnosing, and treatment of mental illness is political.

Classism and Racism in a West Philadelphia Clinic

As a therapist who works with disenfranchised populations, I have observed the ways by which the biomedical model shapes persons into patient-consumers and reinforces the illnesses and stigma that it aims to treat. In a clinic where I worked in West Philadelphia, Pennsylvania, 99% of the patients were African American and from lower economic status (i.e., a family of four earning less than $60,000) and impoverished (i.e., a family of four earning less than $24,000) communities (U.S. Department of Health and Human Services, 2015). In contrast, 75% of the clinicians at the clinic were White, middle-class professionals. Community violence was also an issue. Philadelphia had, on average, approximately 17,000 violent crimes committed each year between 2008 and 2013; more than 1,500 of those were in West Philadelphia. Of the more than 300 homicide victims, more than 80% were persons of color (Pew Charitable Trusts, 2013).

Within the clinic, the racial dynamic (i.e., White clinicians of middle-class status and Black patients of lower to impoverished status) combined with the lack of oversight functioned much like a “zone of social abandonment” (Biehl, 2005, p. 35) or a “buffer zone” (Kivel, 2000, p. 4), a zone which acts through employment and other means to “buffer” the working class from the elite to help contain any uprising or class clashes that would otherwise occur. In addition, Biehl (2005) writes, “In the face of increasing economic and biomedical inequality and the breakdown of the family, human bodies are routinely separated from their normal political status and abandoned to the most extreme misfortune . . .” (p. 38). In other words, persons are marginalized to the fringe of society wherein they are further exploited, oppressed, or abandoned with little to no recourse. The specific zone of social abandonment positioned on the fringe of Philadelphia society shaped staff and clinicians to behave as if they could transgress moral standards without any ramifications. For example, in the organization in which I worked, clinicians’ expressions of overtly racist attitudes about their patients were not uncommon. On one unforgettable day, a senior psychiatrist said, in reference to poor Black patients, “We should just drop a bomb on this whole community and end their suffering. They are evil and broken. They can’t help themselves. All they do is act like wild animals, and there is no way to help them.” I was so stunned by the comment. The only phrase I could utter was “How can you say something like that?” To which, he replied, “Because it’s true. They can’t be helped.” Furthermore, the inherent power dynamic of therapist–patient, Black–White, male–female, wealthy–poor, was exploited by the staff who regularly slept with their patients. On one specific occasion, I confronted a staff member about his sexual conduct with a patient. I said, “You’re not allowed to sleep with the patients. That’s the cardinal rule of therapy. Not to mention it’s extremely inappropriate and potentially very damaging for the patient. You’ve got to stop or I’ll be forced to report you.” His response, “Hey man, that’s just how it is around here. You can do whatever you want. I date many of the patients here. It’s all good. And go ahead and report me, you have no proof.” I contacted the local board to report sexual abuse and was told that if I did not see anything or witness anything then, according to them, there was nothing they could do about it. Additionally, during my time there, not a single patient filed a complaint about the conduct of a treating professional. The conclusions one could draw are that the patients felt as if they had no voice, were invisible and perhaps maybe, deserved to be treated that way. This dynamic could be understood to be a reiteration of the sociopolitical dynamics of the greater community.

During my time there, I observed the clinic functioning as a manufacturer of the quick-fix by means of administering medication. For example, once a month, the psychiatrists met with patients for medication management. Only on those days, the waiting room filled with patients. On most other days, many patients did not bother to show for treatment sessions. On several occasions, violent fights broke out over who would be seen first for medication refills. The verbalized goal from the director of the clinic was to “get as many patients in and out as possible.” Additionally, because therapists and the clinic were only paid for sessions in which patients received treatment, therapists were encouraged to see as many patients per day, often times as many as 16. The combined stress led to a high turnover rate among the staff in which length of employment was approximately 1 year, on average. The fleeting quality of these therapist–patient relationships likely contributed to an increased risk of mental illness. That is, patients who desperately needed long-term relationships were abandoned and neglected by the very treatment staff that aimed to help them.

Furthermore, the apperception of young Black boys as older and more criminal was reinforced in the clinic by means of biased diagnoses which misreads their symptomology as more aggressive, more criminalistics, and a result of some personal or biochemical failing (Grier & Cobbs, 1968; Hart, 2013; Metzl, 2009). The clinic and the therapies provided therein act as a tool of systemic oppression. Unless clinicians actively work against dominant racial inequalities and institutional forms of oppression, our tools work to perpetuate and exacerbate them.

To demonstrate in greater detail the “psychologization” (Parker, 2007) (i.e., converting sociopolitical problems into problems of personal failure) and the systemic failure and institutional oppression of these dynamics, I present case studies of three male patients of color of varying age and all of lower socioeconomic status.

The following cases provide illustrations of patients within their social context, the ways in which the mental health industrial complex reinforced their oppression by continuing to psychologize their problems, and the perpetuation of self-blame. The names and identifying details described in each case study have been coded to protect the identity of the patients.

The Cases of John, Tommy, and Edwin

John

Within the first week of seeing John, I wrote the following in my clinical notes:

John was an eight-year-old person of color, from a lower socio economic background. He grew up in West Philadelphia. He had steady eye contact, spoke well, and had normal thoughts. He was dressed appropriately, had normal gait and had above average IQ.

His school referred him for treatment citing aggression, an inability to focus, declining grades and impulsivity. This was the second school he attended in the past two years; he was expelled from the first.

John was first sent to the psychiatrist at the clinic where he was prescribed dextroamphetamine for diagnosed attention deficit hyperactivity disorder (ADHD) and aripiprazole for oppositional defiant disorder (ODD). The treating psychiatrist told John’s mother and grandmother that John suffered from a chemical imbalance, and the medication would correct it; it would help calm him down, make him less aggressive, and improve his grades. Aripiprazole is an atypical antipsychotic used, originally, to treat schizophrenia. Among the side-effects are headaches, anxiety, insomnia, and weight gain—all of which John developed over the course of his treatment. Because he had trouble sleeping, which was not one of his original problems, he was treated with a low dose of trazadone.

The Centers for Disease Control and Prevention (2013) has shown that the diagnosis for ADHD has been made in 15% of the United States’ high school–age children, and that the number of children on ADHD medications had increased from 600,000 in 1990 to 3.5 million in 2013 (Schwarz, 2013). Since 2002, sales for prescription stimulants have more than quintupled from less than 2 billion, to more than 8 billion per year (Schwarz, 2013).

John was sent to me to begin individual therapy to which he came regularly two times per week for 8 months. I learned that John’s family life was very difficult. Approximately 1 year earlier, his father had been sentenced to prison for 10 years for selling drugs and his mother worked several jobs to support him and his sister. John’s maternal grandmother also provided support. He was an animated and angry young boy who was in a lot of pain, desperate for more attention and to have a regular adult figure in his life. He appeared to be skeptical of getting too close, for fear that I would not be there in his life for the long run—not an inappropriate fear.

It became evident very quickly that John loved and desperately missed his father since the incarceration, a traumatic event for John. Many of his symptoms resembled posttraumatic stress disorder (PTSD) and depression, more so than ADHD or ODD. As the months passed and the medication took effect, John became more quiet and subdued, and he gained weight. He was acting out less in school and at home. His grades remained relatively unchanged, but he was able to sit still.

During treatment, John’s mother revealed to me that she had beaten him physically. She reported feeling stressed-out and having a very short fuse when it came to John’s difficulties at school and talking back. She felt very guilty about it and said that she did not know what came over her sometimes; life seemed too difficult, and she often felt hopeless. On one occasion, she hung him up by his hands in a closet and beat him with a belt, yelling racial slurs at him, such as “you stupid nigger.” Her relating this incident reminded me of Mullan-Gonzalez’s (2012) work on the intergenerational transfer of trauma, and the inner-city neighborhood in which they lived. The trauma experienced by generations of slavery had become internalized into the psychological world of the victims and for many was transferred generation to generation without healing (Mullan-Gonzalez, 2012).

During case consultation, the psychiatrist and I would discuss John’s case. He would describe John’s situation as hopeless, and assert that the only help that John could get was, in his words, the “miracle of medicine,” Additionally, the psychiatrist dismissed the family situation as “normal” for “black people.” On multiple occasions he told me that “they have no sense of family integrity.” This type of racist statement completely disregarded the greater political dynamic by which Black people have been dominated for centuries, and from which currently Black people continue to suffer, thus making the cohesion of a family structure problematic and difficult (Alexander, 2012; Coates, 2015; Marable, 1983).

Within our case consultations, protesting such racist statements was not effective. On several occasions I attempted to discuss alternative dimensions to the patient’s suffering including economic hardship and historical context. These concerns were met with a nodding agreement and then a change of subject, or, the phrase uttered in response was, “yeah, but there’s nothing we can do about that,” or stated disagreement. On one occasion, I approached a psychiatrist privately to ask if he thought his opinion was obscured by racial and class bias, and he scoffed in reply, stating that his “objectivity” was “intact” and that (i.e., race and class) “did not matter.” It appeared that both racism and classism were entrenched in the functioning of the clinic and in the minds of its employees. These ideas and attitudes were not susceptible to critique. Accordingly, this structural violence perpetrated on the poor and the marginalized clients had less to do with inner-personal problems—which were also present—and much more to do with a system that seemed to have both given up on them and related to them by means of an antagonistic dynamic. This subaltern population had no voice and was therefore, invisible.

As unsettling as it was to hear the racist comments coming from fellow mental health workers in the clinic, it should also be noted that there is very little information afforded in the space of mainstream clinical psychology training to give clinicians tools to better understand and frame the way racism and classism affect our society, mental health, and the insidious ways they have structured our profession. For example, in general, persons of color are viewed with greater pathology (e.g., more aggressive, more psychotic, more criminal) and misdiagnosed with greater frequency than White people given this apperception (Adebimpe, 2004; Grier & Cobbs, 1968; Hart, 2013; Metzl, 2009; Yates & Marcello, 2014). Furthermore, persons of color are five times more likely than White people to be given a diagnosis of schizophrenia (Barnes, 2013; Metzl, 2009). They are also more likely to receive incorrect drug therapy (Barnes, 2013).

In my clinical and academic training, the social correlations between poverty and mental health were not stressed as a major factor to attend to with clients. Yet public health data in this regard is both indisputable and alarming. In 2010, more than 15% of the U.S. population lived in poverty: 27.4% of persons of color and 26.6% of Hispanics were poor, compared with nearly 10% of non-Hispanic Caucasians and 12.1% of Asians (DeNavas-Walk, Proctor, & Smith, 2010). The World Health Organization (1995) has described extreme poverty as “the world’s biggest killer and the greatest cause of ill-health and suffering across the globe” (p. 1). It follows then, that poverty is directly correlated with an increased risk in mental illness (Hudson, 2005; Santiago, Kaltman, & Miranda, 2012; Yoshikawa, Abert, & Beardslee, 2012). Furthermore, “Poverty is strongly associated with deficits in children’s cognitive skills and educational achievement” and “disruptive behaviors are most marked in children of families facing persistent economic stress” (Murali & Oyebode, 2004, p. 220). Poverty can affect neurobiology. Although previous models had separated social factors from biological processes in human behavior, we now know of their interconnections. For example, the economic stresses related to poverty lead to an increase of cortisol secretions in the brain, increasing the risk of mental illness (Lupie, King, Meaney, & McEwan, 2001). Furthermore, poverty has been shown to be associated with an increased risk for schizophrenia, depression, and anxiety (Murali & Oyebode, 2004; Santiago et al., 2012; Yoshikawa et al., 2012). Psychiatric conditions occur at higher rates in the poorest areas (Murali & Oyebode, 2004). Children in the poorest households are three times more likely to have a mental illness than children in the wealthiest households (Department of Health, 1999). Racial minority individuals are more likely to be economically disenfranchised putting them at higher risk for mental illness. Rather than seeing this as an effect of the constraints on social and economic opportunity, the medicalization and psychologization of a person’s suffering by the mental health industrial complex further oppresses and stigmatizes those who are marginalized, which leads to an increased risk for mental illness (Fisher, 2009; Greene, 2017b; Whitaker, 2010).

Specifically, John’s prolonged economic stress exacerbated his psychological symptoms, and contributed to some of his difficulties in school. As the clinic encouraged John to focus his attention on his personal failing—problematic brain chemistry—John’s consciousness was shaped to ignore societal oppression and the ways in which it increased his risks for mental illnesses. In addition, the loss of his father directly affected his school performance. Curiously, he was diagnosed with ADHD and ODD instead of PTSD. This specific kind of diagnosis shifts the attention to brain chemistry in that, PTSD, while affecting brain chemistry, serves to point to an external event which traumatizes the patient and could have been a way to help John understand his situation without self-blame. My superiors (a team of psychiatrists, psychologists, and case managers) did not address the loss of his father, his overworked mother, and the crime-ridden neighborhood in which he lived as primary factors for his difficulties. Last, the effects of intergenerational transfer of trauma to John from his mother were never mentioned. Instead his mother was labeled as “psychotic” by the treating psychiatrist.

The next two case studies further illustrate how the space of the psychological clinic is greatly affected by its wider social dynamic and expose similar invisibility of systemic failure at different life stages.

Tommy

This next case study is of a teenager who I saw for a year, one session per week. Tommy’s background was similar to John’s: He was raised by his mother, and his father was imprisoned for most of his life for selling drugs. Tommy was 17 years old when he entered treatment with me. He was a sweet, soft spoken, and curious teenager. Like John, he desperately needed more attention. His thoughts were coherent and understandable, he had a very closed body posture, he rarely made eye contact and his affect was flat. He liked comic books. His mother worked many jobs and was not regularly at home. He had no other family.

He was encouraged to seek treatment by his mother and his school. His grades were declining, and he was acting out in class. This was the third school Tommy had attended in the past 5 years. Furthermore, he was caught robbing his neighbor’s house with a couple of friends. In my notes, I wrote, “When asked why he did it, he responded, ‘I don’t know why, bored I guess, hangin’ out with the wrong crowd maybe, maybe I’m just damaged or broken.” Tommy accepted responsibility for his actions by completing the mandated treatment and attending a juvenile detention center (he was sent to juvenile detention for a year).

Tommy’s response to my question indicated that he thought his behavior was a result of a biochemical malfunction, “maybe I’m just damaged or broken,” or a personal failing, “hangin’ out with the wrong crowd,” all of which are variations of a mantra of self-blame. But it is his first statement “I don’t know why [I did it]” that spoke to an additional complexity; a reaction to a dimension of oppression that colonized his mind daily and which remained unknown to him. For example, research demonstrates that among elementary school children, White teachers and teachers of color tend to interpret the same behavior as more aggressive, abnormal, and pathologic in the students of color than among White students (Yates & Marcello, 2014), thereby increasing the potential for mental health treatment interventions among Black students. This kind of structural racism in schools is further reinforced by the disproportionate number of persons of color being suspended or expelled and becomes a direct pipeline into the criminal justice system (Nelson & Lind, 2015; U.S. Department of Education Office for Civil Rights, 2014). In addition, the United States jails more of its citizens than any other country in the world, and there are more persons of color (by number not percentage) under correctional control today than there were enslaved a decade before the Civil War (Alexander, 2012). The social milieu from, and in which, the mental health industrial complex functions is structurally racist.

Like John, Tommy was first assessed by the treating psychiatrist. He was diagnosed with bipolar disorder and prescribed medication because of his age and criminal behavior. The psychiatrist concluded that his “characterological anti-social behavior” was a result of “a chemical imbalance,” and that this imbalance helped explain why Tommy acted impulsively, erratically, and criminally. He was prescribed quetiapine fumarate, an atypical antipsychotic used to treat schizophrenia as well as bipolar disorder and depression. This flattened his affect even more.

In 2007, the United States spent more than 25 billion dollars on antidepressant and antipsychotic medication alone (Whitaker, 2010), more than any other nation on the planet. From 1996 to 2004, the diagnosis of bipolar disorder rose 56% (Whitaker, 2010). Furthermore, the former chair of the DSM-IV task force, Allen Frances (2013a) argued that inflation of the kinds of mental illnesses in the DSM-V to include every day human emotions runs the serious risk of pathologizing normalcy, and that the definitions are based largely on subjective judgments as opposed to objective tests. The expansion of the kinds of mental illnesses also increases the profits of pharmaceutical firms who, in violation of the principle of avoiding conflict of interest in medicine, are directly tied to the psychiatrists who author the DSM-V (Dumit, 2012; Frances, 2013b).

In the beginning of my work with Tommy, progress in treatment was slow. He did not trust me and was very depressed. When he started to open up, his stories were devastating, filled with violence and trauma. He reported that in the previous year he was sitting on his porch when a man ran into his neighbor’s house. There was a struggle in the house. The two men stumbled out of the door onto the porch. A shot was fired. It blew a hole through the homeowner’s head, splattering blood all over the wall, and pieces of skull stuck to Tommy’s face. He told me he was never the same after that. Tommy smoked marijuana, he said, to keep calm. As an effective anxiolytic (Jiang et al., 2005), marijuana could have been serving the purpose of easing the extreme anxiety he experienced on a daily basis.

As therapy continued, Tommy came regularly, and never missed appointments. He was a responsible patient in that he wanted to work on himself to improve his quality of life. He developed a positive attachment to me. He hoped one day to become a teacher and to go to college. He worked hard to try to get better; he did not, however, like the diagnostic label “bipolar disorder.” He said it made him feel “broken” and “uncomfortable.” Because diagnostic labels may serve an oppressive social and political function by marginalizing and discriminating against those who suffer from mental illness, the stigmatization of those diagnostic labels has been shown to increase the risk of mental illness (Angermeyer, Holzinger, Carta, & Schomerus, 2011). The stigmatization includes the social perception that persons who suffer from mental illness are more criminal, dangerous, and aggressive (Hart, 2013). This inaccurate perception shames persons who suffer from mental illness and creates distance from the greater community (Byrne, 2000).

Despite the efforts in treatment, Tommy’s situation was evidently grim. He feared that he could not get into college. His grades in school were mediocre. He was terrified to step outside his community, because he had no idea what the world was like beyond it. His world had been saturated with drugs and violence. His world was filled by violence and a false consciousness—he believed that his problems and those of the community were their own fault. He did not think he could support himself with a legal job, so he occasionally turned to selling marijuana as a means to support himself. Intensely paranoid about the police, he was worried that at any day he would be killed by them. In 2015, Black men and boys between the ages of 15 and 34 were five times more likely than White men and boys to be killed by the police even though Black individuals make up only 12% of the U.S. population, accounting for 15% of all deaths (Guardian, 2016). Tommy said that he was regularly stopped and frisked at gunpoint, even when he was just sitting on his porch. He told me that he “never felt safe in [his] own neighborhood.”

The treatment with Tommy continued to the end of my time at the clinic, and he was very upset that I had to leave. I was concerned that the severing of our relationship would further discourage him from trying to reach out to others in the future. When I left, he was approaching graduation from high school. He had no support for applying to college—neither from the school nor from his mother. He was trying to find manual labor positions from community resources, but struggled to gain employment.

Tommy’s challenges were too great to solve in our weekly therapy sessions. The medication that was prescribed to Tommy to reduce his impulsivity also flattened his emotions. For Tommy, medication did not address the violence of racism or classism all around him, and reinforced the stigma and mantra of self-blame that he was mentally ill or “broken.” He was courageous, despite the psychiatric label given to him, despite the few employment opportunities available to him, and despite the mental health industrial complex’s failure to deliver treatment services. Tommy was falling through the institutional cracks. To those in positions of privilege and power, Tommy was invisible and so was the structural violence perpetrated on him.

Edwin

The last case study presented here is that of Edwin, a 46-year-old man who sought treatment to get help with his addiction to crack-cocaine and alcohol. Edwin spoke easily, had above average intelligence, and his thoughts were understandable and coherent. He was dressed appropriately, made steady eye contact, and had a nihilistic attitude. He was generally calm, though occasionally presented as nervous. Edwin and his older brother grew up together in an intact family. His brother joined the army, but Edwin struggled to get out of his situation. He earned his GED and worked as an electrician for a several years. His parents were married throughout his life.

Edwin’s complaint was that he felt incredibly alone and depressed, and was unable to find steady work for himself. By the time he entered treatment, he had been out of steady work for nearly a decade. Occasionally, he was able to acquire work cleaning up buildings or painting cars.

He agreed to come to therapy two times per week. When he was not actively using, he came to therapy regularly. However, when he was actively using, he missed sessions for weeks at a time. The treatment team diagnosed him with bipolar disorder, in addition to a dependency on crack and alcohol as well as marijuana abuse. He was prescribed quetiapine fumarate and aripiprazole. To my surprise, the treatment team interpreted his behavior as “hostile” and “aggressive.” I thought he was quite calm, with occasional psychomotor agitation, and impulsive behavior.

In the mid-1980s, when Edwin was in his 20s, he began using crack-cocaine and developed an addiction that he had struggled with ever since. He often referred to a few years in the 1980s as the “black period” because he could not remember much of what had happened. He reported that he was in and out of homeless shelters and described waking up on sidewalks without any recollection of what happened the night before.

In the early 1980s, overall drug use was on the decline, but by the mid-1980s, crack-cocaine was on the rise (Jarecki, 2012). It was advertised as a poor-man’s cocaine, and the media portrayed it specifically as a “black man’s” drug, despite the statistics demonstrating that more White individuals were in fact using the drug. Cocaine was seen as the “white man’s” drug. Strikingly, there is no significant chemical difference between crack-cocaine and cocaine (Hart, 2013). Thirteen percent of crack users were persons of color and yet 90% of those imprisoned for crack-related offenses were persons of color (Jarecki, 2012). Within many domains of psychology, users were described in highly racist ways. According to Hart (2013), significantly skewed research and biased psychological interpretations resulted in descriptions of users of crack-cocaine as more aggressive, psychotic, out of control, and acting more criminal than cocaine users. The research was shaped (unconsciously or consciously) to support the racist and classist violence of the time (Hart, 2013). In short, psychological authority provided a cloak for racism. The criminal justice system participated in this structural racism, too. For example, the sentence for possession of one gram of crack-cocaine was equivalent to the sentence of 100 grams of cocaine (Alexander, 2012). Then U.S. President Nixon’s “War on Drugs,” which was taken up aggressively later by then President Reagan, could be described more realistically as the war on the poor and on people of color. Terms like crack baby, crack whores, and Time magazine’s selection of crack as the number one concern of 1986 served to strengthen racism (Alexander, 2012). The police too had incentive to boost its arrest numbers—more arrests looked better on paper, offering better promotions and affording a department city privileges to boast of its so-called success (Jarecki, 2012). The mental health community was complicit too. The number of treatment facilities to treat those who suffered from addictions greatly increased (Hart, 2013). Many of these facilities (e.g., Alcoholics Anonymous) promoted the idea that the problem was in the patient, that the symptoms were a result of a disease, that it was beyond their control, and that in order for them to change, they had to admit their weaknesses. This kind of psychologization shaped many who suffered from addictions to ignore the systemic violence that dominated their daily lives. In other words, patients were trained to turn inward and focus on their subjective problems, to internally solve external problems thereby ignoring the overwhelmingly oppressive system of which they were a part.

During the course of treatment, Edwin continually referred to himself as an “addict.” He had been in full-time treatment facilities throughout his life. He learned from therapists that his addiction was his responsibility, that it was more powerful than him, that it was caused by a disease of his brain, and that he needed to avoid the triggers of person, place, and things. These variations of a mantra of self-blame through the ideology of the biomedical model of mental disease continually denied significant factors, such as the fact that Edwin faced a nearly impossible living situation within a racist and classist environment, one that was punctuated by violence at the hands of the police. For example, he recalled several instances of severe police brutality. In one instance, he was driving his car to work when he was pulled over at gunpoint, dragged out of his car, and forced on the ground. He was not booked for any crime. Shaken, he said that he was unable to drive for 2 years after that. He used drugs and alcohol less because he was addicted to them, but rather because he wanted to avoid the pain of his world (Greene, 2014). Despite how desperately he clung to the mind-set of self-blame, Edwin’s suffering was not just an inner problem. Toward the end of our time together, Edwin disappeared. I do not know what happened to him.

Conclusion and Recommendations

Mental illness is political. The cases of John, Tommy, and Edwin illustrate the ways in which racism, classism, and the dangers of the medical model as a function of the political economy in coordination with the police and education systems, are a triple threat, which rot minds, exploit persons, and contribute to a person’s mental illness. The mental health industrial complex’s long-standing tradition of overmedicating and necessarily turning people into patients and consumers while shaping their attention inwardly to focus on biological origins of their suffering further oppresses patients by denying the effects of their social context (Fanon, 1963; Fisher, 2009; Fromm, 1956; Greene, 2017b; Parker, 2007). This ideology or colonization of consciousness contributes to a culture of incapacity through the mantra of self-blame for the purpose of control, exploitation, and the bottom-line dollar.

As a treating psychotherapist, my experience in this clinic was overwhelming. My training in school had not prepared me for the quick-fix treatment, and the racist and classist attitudes embedded in the mental health industrial complex. Likewise, my many graduate courses on multiculturalism did not prove effective in negotiating with the treatment staff in this clinic. That is to say, the discourse of multiculturalism was superficially acknowledged by the treatment team, which ultimately quieted the conversation about race and class. Furthermore, the dynamic of race and class was ultimately excluded when considering the treatment plans. From my many experiences with patients dealing with difficult social, economic, and political challenges, I know that my acquired skills in therapy can often soothe the wounds caused by social and political domination. Yet I have come to realize that, ultimately, only radical institutional change can more durably alleviate patients’ symptoms.

Attempting to address these concerns is complex. Byrne (2000) has argued that psychiatrists and psychologists who face patients with the “double discrimination” (p. 70) of mental illness and ethnicity must collaborate with other fields to create structural solutions. Fisher (1994) has argued that empowerment is essential to recovery. Lee, Smith, and Henry (2013) advocate for mental health professionals to become involved in social policy and action.

Fanon (1963), Fromm (1956), Layton (2002), Parker (2007), and Greene (2017a) link psychologization with the emergence of neoliberal ideology, and therefore, a critique of the mental health industrial complex is a critique of a form of the ideological functioning of capitalism. This particular form of consciousness, which defines the mind of the subject through inward attention, contributes to a culture of incapacity and a mantra of self-blame, and it ought to be confronted, changed, or dislocated as the organizing coordinates of subjectivity in order to make material change in the social world around. In addition, structural racism and classism require structural change. Focusing on multiculturalism, empathy, understanding the “other,” identifying everyday violence and micro-aggressions, and recognizing the potential for empowerment are all helpful to create greater awareness and consciousness of the problems one faces, but institutional changes that affect the psychology of disenfranchised persons are more likely to happen by means of a radical confrontation with a racist and classist system. The social world needs to be changed, too.

Mental illness is not merely a personal problem that can be located internally and isolated from the world. It is embedded within the ensemble of social relations and can benefit the dominant by means of control, oppression, exploitation, and the bottom dollar. In this way, mental illness is political.

Footnotes

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

Author Biography

Eric M. Greene, PhD, is a therapist in Los Angeles, CA, serving the severely mentally affected. He earned his master’s and doctorate in clinical psychology and focuses his research on structural forms oppression and mental illness. He lives with his wife Shelley and daughters Amelia and Eve.

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