Abstract
There is a good deal of unease about the role of medical psychiatry today, and it is tempting for psychologists to turn that unease into a weapon in disciplinary turf-wars through which one way of managing distress and adapting people to society may triumph over another. Perhaps, indeed, psychiatry has had its day, and the psychologists are kicking at an enemy that is already on the way to being ostracised. Psychiatry can be viewed as the master discourse of late feudal society, relying on a form of expertise in which a trained specialist is able to identify the signs of degeneration in their poor patient before confining them or subjecting them to physical treatment. Bit by bit the psychiatric institutions have been replaced by softer, ostensibly more humane “psychological” treatments, in the final fulfilment of the process of unchaining the mad that seemed to inaugurate psychiatry itself. What these two books have in common, to their credit, is their refusal of that temptation to simply crow at the demise of psychiatry and to celebrate the role of psychology instead.
There are some common conceptual reference points that enable Bruce Cohen and Stijn Vanheule, in very different ways, to embed the problem of psychiatry—of psychiatric hegemony and psychiatric diagnosis—in the broader network of power relations that include psychology and psychotherapy. Foucault is summoned by both to explain how it is that the psy complex came to operate as a form of governmentality and moral treatment (Cohen emphasises these aspects) and of objectification and reification (Vanheule’s concern). Foucault is thus able to buttress the main argument of Cohen in Psychiatric Hegemony, that this particular medical component of the psy complex must be understood as an oppressive overarching paradigm that is held in place by dominant institutions and coercive mechanisms that suppress the voices of those who attempt to resist it. And Foucault is on hand for Vanheule in Psychiatric Diagnosis Revisited to reinforce the argument that the patients’ voices are turned against them, turned from being the expression of distress into being a collection of symptoms to be decoded, “diagnosed.”
It is possible to detect, in these two books, two compatible but slightly different Foucaults: the Foucault writing in the tradition of French Marxism, sometime member of the Communist Party, and then theorist and activist pitting himself against regimes of truth; and the Foucault writing alongside the anti-psychiatric French psychoanalysts Félix Guattari and, of course, Jacques Lacan, Vanheule’s main point of reference in his careful dismantling of the logic of the DSM. But those two Foucaults speak in these books within different narratives of the human subject and, more obviously, conceptions of the social. Vanheule, when it comes down to it, is more concerned with the subject—putting Lacan to work alongside phenomenological psychiatry to unravel the DSM from within—and Cohen is more preoccupied with the social realm, though he does, of course, attend to the relationship between the political and the personal, with the way that political oppression manifests itself in personal distress.
The two books tread different paths that occasionally cross but, most of the time, they run alongside each other, even operating at times as if they were working in parallel universes. In Cohen’s Marxist account of the problem of “hegemony” in psychiatry—a conceptualisation from the work of Antonio Gramsci which explains how it is that ideological assumptions come to saturate a society so that psychiatry, in this case, assumes absolute dominance as an explanatory grid and system of moral guidance—psychoanalysis is at one with the enemy; Freud is to be avoided and Lacan is not mentioned. In Vanheule’s Lacanian account of the problem of “diagnosis” in psychiatry—a conceptualisation of the peculiarities of German medical systems of classification and then bureaucratic symptom checklists—politics is hinted at as a correlative problem, but Marx’s name does not appear and Marxist critique is completely absent.
There are some significant consequences of this separation of discourses—two equally important complementary discourses against psychiatry—which manifest themselves not so much in the mobilisation of Marxist or Lacanian theory as in the attention to other crucial aspects of the problem each of the books is aiming to tackle. Cohen’s Marxism, perhaps due to the concern with the Gramscian tradition of critique which broadens out the focus from social class to other cognate forms of oppression, is clued-up about the role of sexuality in psychiatry, and he makes explicit reference to the work of feminist researchers such as Jane Ussher and the radical feminist standpoint institutional ethnographer Bonnie Burstow. There is a detailed discussion of the way that the diagnostic categories in the DSM have been insidiously “feminised,” reproducing stereotypical views of masculinity and femininity, with femininity usually treated as something pathological. Vanheule’s Lacanian standpoint, on the other hand, fails to mention feminism at all, and here he misses a trick, failing to engage with a tradition of work that actually made Lacan attractive to a generation of critical researchers from the 1970s. As in Cohen’s book, Vanheule inveighs against the treatment of “homosexuals,” but tends to write within a tradition of Lacanian writing that revolves around taken-for-granted notions of “femininity” rather than engaging with feminist critique. Neither of the books, rather curiously, mentions the work of Kate Millett, the second-wave radical feminist who also wrote about her experiences in and against the mental health system.
There is a strong and necessary connection between feminism and critique of psychiatry, whether that critique is configured primarily through Marxism or Lacan. For example, in 1998, the Foucault Tribunal on the crimes of psychiatry met in Berlin (you can guess what the verdict was) with a jury that included Kate Millett and Thomas Szasz. These were strange bedfellows, and Szasz appears as a rather strange bedfellow of Marxists in the Cohen book and of Lacanians in the Vanheule book. For Cohen, in a book that is rather too much situated in a “sociological” reading of psychiatry (and that is also, perhaps, where Gramsci comes into the picture), Szasz is portrayed as if he is an unalloyed good ally for the kind of argument that Cohen is making. There is no mention in the book of R. D. Laing, and no contrast is made between Laing’s left-libertarian critique of psychiatry—something that could be articulated in some way with Marxist critique—and Szasz’s right-wing libertarianism. Vanheule mentions Szasz’s libertarian views in a footnote, but there is only a brief fleeting reference to Laing, and no contrast is made between these two figures (both of whom were psychiatrists and then trained as psychoanalysts), or with Lacan. Other critical figures, such as Franco Basaglia or Marius Romme are also missing from both books. These are two great books, but something more is still needed, and more than simply trying to patch the two kinds of critiques together.