STRUCTURES AND FUNCTIONS OF SUBORDINATION: A COMPARISON OF THE TREATMENT OF MADNESS IN THE AGE OF CONFINEMENT — AND TODAY
2 Madness From the Renaissance Through the Classical Era
3 Civil Commitment in Modern America
4 From Beggars, to the Homeless: Institutionalization of Social Undesirables
5 General Problems With Psychiatric Diagnosis
6 Psychiatric Assessment of the Poor and Homeless: The Continued Correlation Between Poverty and Madness
7 Responses of the Homeless Population to Psychiatric Treatment
8 Social Tolerance
9 From the Militia, to the Police
10 On the Good Intentions of Psychiatrists and Law Enforcement Officers
11 A Difficulty Psychiatrists Have in Acknowledging Madness as a Transcendent
12 Manipulation of the Labor Force
13 Economic Productivity Through Mental Health Services
14 Forced Labor vs. Forced Treatment
15 Methods of Control: From Chains, to Anti-Psychotic Drugs
16 Medicine and Morality in Service of Economy and Social Control
17 The Moral Influence on Psychiatric Categories of Mental Illness
In Madness and Civilization, Michel Foucault pursues a genealogy of madness in order to illuminate the way madness has been produced and defined by different civilizations. In particular, Foucault examines the Heideggerian “being” or essence of madness in three successive epochs: the Renaissance, the age of confinement (or classical era), and the modern era of moral reform. While Foucault highlights important changes in the way madness has been conceived and managed in these epochs, he concludes that the harsh treatment measures that were prevalent in the classical era are historically connected to the treatment developed by Pinel and Tuke in the era of moral reform.
It is true that Pinel and Tuke ensured that the use of chains and other abrasive treatment measures were no longer used to control madmen. Nevertheless, Pinel and Tuke morally and mentally limited madness almost as repressively as had hospital directors in the classical era with the assistance of metal weights. Madmen suffering from delirium were made to submit to reason; their condition was no longer believed to possess transcendent power or to be an expression of an innate human truth. Instead, madness became an error, or difference that mandated conformity to ethical norms of action and belief in order to be cured. The patient had to assert the foolishness of his madness and he would be accepted and considered healthy; however; if he insisted upon the meaning behind his delirium, then he would be chastised and punished. Lastly, Foucault believes that moral measures imposed on madmen by Pinel and Tuke are related to the structures and processes under which psychiatry operates today, though the psychiatrist is no longer conscious of the historical processes that envelop him.
While Foucault’s analysis is an interesting one that is worthwhile in its own right, it occurred to me that there might be an even closer relationship than Foucault has suggested between the treatment of madness in the age of confinement and in psychiatry today. The particular ambition of my thesis is thus to closely examine the relationship between the treatment of madness in the classical era, and in America from 1929–2001.
For example, there seems to be interesting correspondences between the way beggars were managed in the age of confinement and the treatment of the homeless in modern America as revealed through numerous statistical examinations. The research which I have reviewed raises an interesting question: to what extent are the original societal conditions that provoked the confinement of massive numbers of poor people throughout Europe similar to those which are operative in America over the last seventy years? And to what extent do these conditions produce similar responses by hospital administrations, particularly in terms of treatment for the homeless population?
In making this comparison, we will review the history of madness Foucault delineates from the Renaissance through the classical era. We will then consider the policy on involuntary admissions in mental hospitals, as well as the percentage of the general population that is held in mental hospitals in modern America. From this point, we will turn to statistical surveys detecting the incidence of mental illness, the length and frequency of hospitalization, and the rate of imprisonment of poor and homeless persons. It will be argued that consistent findings of a correlation between poverty and mental illness rather than resulting from genetic, adaptive, or occupational defects in the “mentally ill” themselves, may result from a rarely considered variable: a psychiatric bias in assessing poor populations.
Apparently, despite increased interest on the part of psychiatry in separating poverty from madness, as well as the development of sophisticated assessment techniques to help mental health professionals in this matter, psychiatrists may systematically misread poverty as ‘mental illness.’ Similarly, other factors, including social tolerance, the operation of law enforcement officers, social control through medicalization, and the infusion of an ethical sensibility could contribute to a systematic confounding of poverty and mental illness. We will further consider the manner in which the aforementioned social factors share structural similarities with and may often be disfigured forms of the original conditions that led to the practice of confinement. It will then be demonstrated that these factors assist our capitalist economy in manipulating the labor force to meet the changing market demand.
We will turn to the way the manipulation of the labor force shares functional similarities with the formation of labor workshops in the age of confinement. Lastly, we will consider two important motivating factors for the form of mental health services we have today, factors which were also integral in determining the type of treatment administered in the classical era: an interest in economic gain and the facilitation of social control. The important theme which this analysis focuses upon is that psychiatric hospital administrations appear to have advanced less than one might imagine, and in various displaced forms continue to serve analogous functions to the houses of confinement in seventeenth-century Europe.
Madness from the Renaissance, Through the Classical Era
In Madness and Civilization, Foucault describes the way madmen in the Renaissance occupied a position of exclusion held before them by the lepers in the Middle Ages. Madmen were either driven out of towns or handed over to sailors, who set them out to sea on ships of fools. In both instances, madness was conceived by the public consciousness as a passage or journey; it pointed to a horizon, or limit, the crossing of which was to help madmen rediscover their reason. The ship of fools was the origin where madness was not only conceived as folly due to pride, lack of good works, and failure to adhere to Christian values, but also resulted from “a sort of great unreason for which nothing in fact, is exactly responsible, but which involves everybody in a secret complicity.” [i]
In a similar fashion to the way the priests had rigorously excluded lepers yet promised them a spiritual reintegration in the next life for their suffering in this one, madmen had become representative of a truth which expresses the depths of man, despite being segregated from the general population. In farces and sorties we therefore find the mad fool or simpleton becoming a central figure who “reminds each man of his truth.” [ii]In Shakespeare, madness became aligned with the extremity of death and murder and, importantly, spoke of a beyond. Meanwhile, the gryollos represented the unnatural and animalistic portions of man, which fascinated the human mind with a frightening power. In a reversal of traditional biblical ordering, madness during the Renaissance seemed to have become the animal that will stalk man and remind him of his bestial side. Foucault thus states madness in this period reveals man’s “nights of privation in his own nature,” “hell’s pitiless truth,” and confronts “the dark necessity of the world.” [iii]
Between the Renaissance and the classical age, there was a tremendous growth in scientific understanding, a renewed faith in reason and with these developments a new demand for systematization, organization, and hierarchy. The attempt Descartes made to turn away from ontological questions in favor of concentration on his scientific practice is endemic of an age that championed positivistic science. Descartes further exemplifies the way men during the Enlightenment considered themselves to be rational beings in limited danger of erring so long as they distrusted information received through the senses, and acted according to systematic logic. This is also the period of endless classifications: massive encyclopedias, for example, were first produced by Diderot. The important point is that radical changes in the treatment of the mad and the rise in bureaucratic hospitals throughout Europe were part of a new ideological emphasis on hierarchy, rational ordering, and control.
Foucault argues the 1658 Decree that founded the Hospital General in Paris is a watershed date that precipitated the formation of great hospitals across Europe. In accordance with government legislation, one Sunday afternoon in May, a militia hunted down between five and six thousand beggars in the streets of Paris, many of them women and children, and confined them in the different buildings of the Hospital General. The directors of the Hospital General exercised an absolute though undiscriminating power over the newly confined populations, which consisted of beggars, criminals and madmen. “For these purposes” they had at their disposal, “stakes, irons, prisons and dungeons.” [iv]
Foucault has attributed the confinement of large populations in great hospitals across Europe, many of them replacing former leprosariums (which housed the lepers, the subgroup previously excluded from the major pathways of society) to specific socio-economic conditions. For example, confinement was a means of reducing the number of beggars who pestered the population in the streets of the city. In Paris, there was a historical pattern of governmental manipulations of the lower class. This is evidenced by an incident in 1532, when the Parliament of Paris ordered the arrest of beggars and mandated that they repair sewers in the city.
Confinement was additionally a way to confront the severe economic crisis that affected the entire western world in the seventeenth century: through it, unemployment was reduced, and the lowering of wages and scarcity of coins could more adequately be managed. Since the confined were often forced to work, the government had almost absolute jurisdiction over production, having at their disposal a cheap labor force in an age of high salaries. “Each time a crisis occurred and the number of the poor sharply increased, the houses of confinement regained, at least for a time, their initial economic significance. In the middle of the eighteenth century there was another great crisis: 12,000 begging workers at Rouen and as many at Tours; at Lyons the manufactories closed.” The Count d’Argenson, “who commands the department of Paris and the marshalseas,” gave orders “to arrest all the beggars of the kingdom; the marshalseas will perform this task in the countryside, while the same thing is done in Paris, whither they are sure not to return, being entrapped on all sides.” [v] In addition to warding off economic crisis, these governmental manipulations of the labor force protected society against uprisings and violence.
In order to encourage those aggregated in the great hospitals to work, a moral imperative was propagated condemning idleness. We see this, for example, in Colbert, Director of the Hospital General, who, in a hospital regulation, described idleness as “the mother of all evils.”[vi] Not long after Colbert, not only would economic unproductivity essentially be linked to amorality in the European consciousness, but failure to work would become a rebellious act or absurd pride in the face of poverty. And this was only part of what would become a more widespread attempt by despotic governments and their agents, hospital administrators, to correct imperfections considered inherent in the confined populations. A 1684 Hospital General decree therefore stated that boys and girls younger than twenty-five were to spend the majority of their day working in accompaniment with “the reading of pious books.” [vii] Meanwhile, faults “will be punished by reduction of gruel, by increase of work, by imprisonment and other punishments customary in the said hospitals, as the directors shall see fit,” as was regulated in Hospital articles XII and XIII. Similarly, the need for moral instruction in the great hospitals was reinforced by religious principles. Saint Vincent de Paul, in a sermon on the great hospitals cited in Pierre Collet, Vie de saint Vincent de Paul,stated: “the principal end for which such persons have been removed here, out of the storms of the great world, and introduced into this solitude as pensioners, is entirely to keep them from the slavery of sin, from being eternally damned…” [viii]
Slightly later in medicine, ethical fortitude became virtually equated with mental health. This can be seen particularly through the case of hysteria, which was thought to be caused by the irritation of the nervous fibers provoked by a sedentary lifestyle. For Louis Sébastian Mericier, an eighteenth century physician, nervous disease was the natural and entirely justified punishment for inactivity, and the embracement of indulgent sensuality. “Terrible State!…This is the torment of all effeminate souls whom inaction has plunged into dangerous sensuality, and who, to ride themselves of the labors imposed by nature, have embraces all the phantoms of opinion…Thus the rich are punished for the deplorable use of their fortune.” [ix] In Médecine Pratique, Thomas Sydenham, another eighteenth century physician, linked hysteria to both physiological weakness, and immersion in a delicate and innocuous social milieu: “This is why the disease attacks women more than men, because they have a more delicate, less firm constitution, because they lead a softer life, and because they are accustomed to the luxuries and commodities of life and not of suffering.” [x]
To summarize, the original causes for the confinement of the mad throughout Europe were predominantly moral and economic, as is suggested by the fact that an estimated ninety-percent of this population consisted of criminals and the poor. Houses of confinement sprouted up throughout Europe largely because they protected society against moral corruption and the threat of peasant revolt, reduced the number of unruly beggars in the street, and produced a cheap labor force that acquired needed income for despotic governments during a period of economic crisis. Madness, which possessed an imaginary freedom during the Renaissance, was no longer viewed as an eschatological figure in the classical period. Instead, it was made to answer to reason and to a moral order, which suppressed difference, exorcised what was threatening, and precipitated a neglect of transgressive voices that would last until Freud.
Civil Commitment in Modern America
Most of us today consider it axiomatic that the treatment of the mad in American hospitals and outpatient centers no longer results from economic or moral demands. Psychiatric assessment, as an extension of medicine, is believed to be objective, while conditions in hospitals and outpatient centers are thought to bear little resemblance to those found in the great houses of confinement in Europe. To understand this, one has only to read almost any textbook or history that discusses the changes in the treatment of madness, where it is almost always put forth that we have advanced in nearly every respect since the comparatively colder, crueler, and more tyrannical epoch of the great hospitals. The institution most often mentioned is Bedlam, which serves as a supreme example of man’s cruelty toward his fellow disturbed human being.
And indeed, on a fundamental level, it is undoubtedly true that advancements have been made. Most particularly, overt measures of physical punishment have been eliminated as means of treating troublesome individuals. For example, there is nothing today resembling the cages that were devised for difficult inmates, cages which had gratings for floors raised fifteen centimeters above ground. Similarly, no person, however outlandish his behavior, would be chained in mental hospitals today with an iron ring around his or her neck. [xi] However, even with the elimination of overt measures of physical punishment, the mental hospital may still possess some important structural and functional similarities to the great houses of confinement that sprouted up throughout Europe in the latter half of the seventeenth century.
Near the end of the 1950’s, one out of every three hundred American citizens was held involuntarily in a mental institution. These numbers are similar to those found in the classical era in Paris, where one out of every hundred citizens was confined in the Hospital General. [xii] Of course, the reasons for civil commitment at the end of the 1950’s were more complex and psychiatric assessment techniques more developed than in the age of confinement. Similarly, the authoritative agencies in America during the 1950’s were much more interested in discriminating between populations than in Europe during the classical era. Yet this does not make it any less problematic that, as in seventeenth century Europe, numerous individuals were being held in institutions against their will. Indeed, it is remarkable that in the middle of the twentieth century more persons were confined in American hospitals than in any other country, the total placed in asylums through civil commitment procedures outnumbering imprisoned criminals. [xiii]
Over the last fifty years, there have been considerable changes in psychiatry, most particularly, a reduction in the number of institutionalized persons. This has occurred steadily since the practice of deinstitutionalization was established in 1963, a practice which broke up many large state hospitals and led numerous mentally ill persons to locate other forms of treatment, such as day care treatment or outpatient centers. However, even with the reductions produced by deinstitutionalization, recent estimates show that at least 130,000 persons in the U.S. are still housed in state hospitals. [xiv]
Moreover, though new legislative reforms over the last twenty years limit civil commitment procedures, particularly the 1983 Mental Health Act that guarantees patient rights, substantial populations are still involuntarily committed to asylums. For example, there has been an increase in involuntary hospital admissions over the last twenty years in California, and in the province of Ontario. [xv] The rate of involuntary admission may have increased in certain locations over the past twenty years because patient rights can be circumvented by issuing a community treatment order. Irwin Silverman, practicing clinical psychologist for over two decades, critic of psychiatric institutions, and associate of Thomas Szasz (the leader of a movement viewing mental illness as socially constructed), has further pointed out that those who voluntarily admit themselves to a treatment facility can easily be switched to involuntary admission. This suggests that patient rights, which are supposed to be ensured today, are upheld tenuously at best by the mental hospital.
The sizeable numbers of individuals still involuntarily admitted into American hospitals make it likely that, as tends to be the case wherever force is involved, certain patients will be treated in a manner that goes against their better interests. Indeed, it seems strange that in our progressive and liberal era, the mental hospital is a lasting remnant or archive from the past, the sole medical entity where treatment of almost any duration and considerable variety can be made mandatory. Britain
From Beggars, to the Homeless: Institutionalization of Social Undesirables
As in the classical era, a significant portion of the involuntarily admitted hospital population could consist of social undesirables from the lower classes. Does the role held by the beggars in the age of confinement, in particular, share similarities with the position in which some American homeless find themselves today? By considering sociological data, we can more clearly explore the relationship between homelessness, psychiatric diagnosis of mental illness, and the course of treatment today. 
In his review of several studies comparing the homeless to the housed poor, William Breakey, in Homelessness and Mental Illness, described the homeless population as “the poorest of the poor,” with “the housed poor this week becoming the homeless poor next week, moving along a continuum of residential stability.” (Appelby and Desai, 1987; Breakey and Fisher, 1995). [xvi] If, following Breakey, the subgroups “homeless” and “poor” are closely related, fluid categories, we might begin examining a potential correlation between homelessness and mental illness by reviewing the rate of mental illness detected in the poor population. But before making this attempt, it is worthwhile to note that even were higher rates of mental illness to be found in poor populations and among the homeless than in the general population, this does not mean that these findings (and a subsequently higher rate of hospitalization) result from problems in psychiatric diagnosis or other social factors. Indeed, there are several explanations psychologists and psychiatrists have expounded to account for a potential correlation between poverty and mental illness.
Higher rates of mental illness in poor populations could result from mental incompetence that reduces the quality of work performance, which leads greater numbers of the poor to aggregate on the lower end of the social field, as has been hypothesized by the downward drift hypothesis. There are additional explanations based on higher levels of stress in poor populations, both physical and mental, that lead to greater levels of mental illness.
The important element at this stage is that the correlations that might be established between mental illness and socioeconomic status are rarely considered to result from psychiatric bias or more structural, societal conditions. The examination of these rarely considered factors will constitute a considerable portion of the work of this paper. For now, it will suffice to turn to an examination of the rates of mental illness found in poor and homeless populations, which will be viewed in conjunction with the rates of hospitalization and incarceration in these groups. My attempt is to show that those at the bottom of the social field are more likely to be institutionalized, as was the case in the age of confinement.
Numerous epidemiological surveys have shown that rates of mental illness are much greater in those of low socioeconomic status than in the general population. Likewise, an inverse relationship has been established between rates of schizophrenia and socioeconomic status (e.g., Robbins et al., 1984). [xvii] Robbins’s finding of an inverse relationship is particularly relevant to the homeless population because were psychiatrists to obfuscate poverty and mental illness (a possibility that will be developed more thoroughly later), one would expect the highest rates of schizophrenia in the lowest class. In other words, Robbins’s findings could be attributed to the fact that the more impoverished one appears, the greater the likelihood of a misdiagnosis of mental illness. However, it must be noted that the downward drift hypothesis could account for Robbins’s data, since it may be that psychological disturbance may lead to more greatly restricted occupational capacity in the poor population.
In turning now to the rates of mental illness detected in the homeless population in particular, as revealed through epidemiological examinations, one quickly realizes that the findings tend to corroborate the relationship detected between poverty and mental illness. For example, one sample of homeless individuals showed symptoms of panic disorder at eight times the rate of regular residents from the same region (Koegel, Burnam and Farr, 1988). Likewise, more than one psychiatric study diagnosed 10 to 13 percent of the homeless with schizophrenia, 21 to 29 percent with mood disorders, and 14 to 20 percent with antisocial personality disorder (Fischer and Breakey; Koegel, Burnam and Farr, 1998). When we compare this rate of incidence to that of the general population, there is a significant gulf: an estimated 1 percent for schizophrenia (Karno et al., 1987), 12 percent for affective disorders, and 3.5 percent for antisocial personality disorder (Kessler, et al., 1994). [xviii] This means that there are at least one more homeless person with mood disorder, five more with antisocial personality disorder, and eleven more with schizophrenia per hundred than in the general population.
Other researchers estimate that one-half to three-fourths of the homeless population in the U.S. suffers from drug or alcohol abuse, or mental problems, and that many suffer from combinations of these problems (Fischer and Breakey, 1991). [xix]Finally, certain studies reveal that the correlation between these variables should be even closer. An examination conducted by Weller et al. on a group of single homeless persons attending a Christmas party showed 41 percent to have a history of psychosis and 72 percent to be psychotic during the interview. [xx]
In addition to evidence suggesting that homeless and poor populations are diagnosed with higher rates of mental disorder than the general population, there seems to be statistical support for the idea that the poor are hospitalized more frequently and for greater duration’s of time. For example, one study conducted by sociologists Fredrick Redlick and August Hollingsworth during the 1950’s found that lower class persons were admitted to mental hospitals more often and spent more time in these institutions than those of higher socioeconomic status. Jerome Myers and L. Bean replicated these findings.[xxi] Although a number of factors might account for these results, one explanation, which will be further considered in later sections, is that homeless individuals are institutionalized to a much larger degree because of poverty than because of psychopathology, a phenomena which may particularly result from a psychiatric bias in diagnosing poor populations.
Not only do the poor and homeless seem to have higher rates and longer periods of hospitalization, these populations are apparently imprisoned more often than the general population. Are homeless and lower class populations institutionalized for reasons similar to those that provoked the institutionalization of beggars in the classical era? Even if this were the case, social control would be taken up today by the joint operation of two institutions, the mental hospital and the prison, instead of simply being within the jurisdiction of the houses of confinement.
Though societal efforts to control wayward populations through institutionalization might account for findings of a correlation between poverty and incarceration, it must be pointed out that these findings could be due to more frequent criminal activity in those who have trouble securing food and housing. Finally, it could be that those who are mentally incompetent lack self-restraint, and are thus more likely to commit crimes. Yet, when the high rates of incarceration are considered in conjunction with the high rates of hospitalization and the use of police to detect mental illness, it seems likely that efforts at obtaining social control contribute to these statistical findings, a possibility I will consider more thoroughly later in this paper. But for now, let us consider the data.
A number of studies have illustrated that crime, violence and antisocial personality disorder are all highly correlated with poverty. (e.g., Robbins, et. al, Hill Soriano, Chen and LaFromboise, 1994) [xxii] Similarly, The Single Homeless Person Survey, conducted on a large sample population, found that 60 percent of reception center residents admitted to a prison record, and 9.4 percent confessed to having been released from prison in the two preceding months (National Assistance Board, 1966). In Los Angeles, an analysis of five-hundred and twenty-nine homeless adults by Gelberg et al. concluded “those with a history of hospital treatment, had higher rates of imprisonment and longer periods of homelessness than the non-hospitalized homeless.” [xxiii] As part of the work done by Tidmarsh (1977) on his Camberwell Reception Center Residents, Tidmarsh examined the criminal history of residents at Camberwell Reception Center according to psychiatric diagnosis and found significant correlations: those with no diagnosis had the lowest rate of prior convictions (38%), followed by the mentally ill (55%), and those with a personality disorder (66%). [xxiv]
Other epidemiological studies have demonstrated a close relationship between law enforcement and psychiatry. Upon surveying the admission of homeless persons to a Birmingham psychiatric hospital between 1961 and 1965, Berry and Owin (1966) found “69 percent of the schizophrenics had been admitted to the hospital via the police or the prison.” In addition, Berry and Owen’s findings reinforce the studies mentioned above, which have detected high rates of criminality in hospital populations, with a sizeable thirty-seven percent of the Birmingham Hospital population admitting to criminal records. [xxv]
The above findings appear to share commonalties with more recent conditions. When Herzberg (1987) compared male and female homeless admissions to an East London psychiatric hospital over a ten-year period, he found “social disadvantage, previous psychiatric admissions and previous episodes of imprisonment amongst his samples.” [xxvi]
Compared with the classical era, in modern America, there are more sophisticated methods of discriminating between poor, mad, and criminal populations as well as a higher level of interest in separating these populations and providing them appropriate treatment measures. Yet, even with these advances, the poor today still constitute a significant institutional presence in American prisons and hospitals. Sociological surveys suggest that the problems which beggars in France presented to administrators, government officials, and the general population in Paris in 1658 may be related to the disturbances which homeless persons create for governmental agencies and American society today. The correlation between socioeconomic status and the diagnosis of mental illness, the greater duration and frequency of hospitalization in the lower class, the much higher incidence of imprisonment in homeless and poor populations, and, finally, the operation of law enforcement in certain instances in conjunction with psychiatry, all suggest that the mental hospital and the prison may now fulfill the role once held by the great hospitals.
General Problems with Psychiatric Diagnosis
Irwin Silverman reviewed diagnostic reports from various mental hospitals in the United States and found ten percent of the samples showed precise characteristics of disorder. He asked other clinicians to perform the same task and claimed that most found comparable results. Interestingly, this is the same percentage of the population records from the Hospital General show to be insane or demented.[xxvii]
In Pure Types Are Rare: Myths and Meanings of Madness, Silverman argues, in conjunction with this finding, that mental illness is as mythical as were witch hunts in Salem, Massachusetts. One reason for this suggestion, which is similar to the one Thomas Szasz makes in his essay The Myth of Mental Illness, is that mental illness is not something one can see, but an entity discovered based on solipsistic, or self-referential constructs. Accordingly, in his introduction to Silverman’s book, Szasz elaborated the way most psychological theorems depend upon an abstract organizing principle to explain ‘ mental illness’; in Freud this is “redistributed libido,” in Reich these are “accumulated orgones,” and in Mesmer the “magnetic fluid.” [xxviii]
Silverman additionally reviews several studies questioning the accuracy of psychiatric diagnosis and treatment measures. To cite one example, David Rosenham in 1973 selected eight well-adjusted, ‘normal’ individuals without history of mental illness and asked them to admit themselves to different hospitals across the United States. The subjects were to claim they were hearing voices of late, but were otherwise instructed to act normally. Upon admittance into a hospital, they were directed to tell doctors and nurses that the voices they once heard had ceased.
The results seriously challenge psychiatry, particularly the accuracy of diagnostic assessment techniques. All of the patients Rosenberg had asked to mimic mental illness were readily accepted into the various hospitals to which they submitted themselves for treatment; all but one was diagnosed with schizophrenia. The average hospitalization period was nineteen days and the maximum fifty-two. One pseudo-patient heard himself described as having “oral-acquisitive” tendencies, while another who was pacing in the corridor, a typical response to hospital life, was reproached by a nurse for his nervousness.
It is rightly claimed, in opposition to this finding, that Rosenberg does not prove that psychiatrists cannot detect mental illness, but solely that they are unable to identify a quack who pretends to be mentally ill. A young man could similarly be treated in a medical hospital for profuse bleeding from the leg for applying synthetic blood to his appendage. Were some youngster to get away with this prank, most of us would not believe this makes medical assessment inaccurate.
Yet even with this reservation in mind, Rosenberg’s study hint at the ease with which patients may be construed as mentally ill simply for making unusual statements. His study, moreover, shows that upon admittance into a hospital, patients are classified and managed by hospital administrators according to psychological, textbook theories, and that they are often viewed as objects or mechanical instruments rather than as human beings. This is particularly evidenced by the fact that normal responses to hospital life in psuedo-patients were viewed as typical manifestations of mental disorder.
As part of his attempt to prove mental illness is a social construction, Irwin Silverman additionally doubts the accuracy of clinical psychological tests. He argues most of these, such as the Thematic Apperception Test or the Rosarch Ink Blot Test, are only slightly more reliable than the witch teats tests once practiced in Salem Massachusetts, tests which searched for skin blemishes. In addition to problems with objectivity in both tests, standardization is apparently emphasized before accuracy. Moreover, in both instances, virtually no one is ever found healthy.
Silverman’s comparison of the operation of modern psychiatry to the witch-hunts in 1692, though seemingly a partial notion at first glance, might appear more valid when considered in light of Adorno and Horkheimer’s well-known essay The Dialectic Of Enlightenment. In this brilliant, mid-twentieth century work, the two theorists suggest that when reason is reduced to mere instrument of application, it destroys its own efficacy. In searching for mental illness, as in locating witches, elaborate typologies may be developed to assist one in finding evidence for any number of presumptions, but this does not guarantee that these suppositions are valid outside of a self-referential system. It is only when we question the techniques we apply, checking the rationale behind those techniques, that we can hope to overcome the tremendous threat of adopting beliefs and standards that are partial.
Nevertheless, it is improbable that psychiatry today is as biased in its perceptions as were the leaders of the witch-hunts in Salem, Massachusetts. Yet even if it is unlikely that mental illness is entirely a social construction (since some individuals are really mentally disturbed and handicapped), the evidence suggests that social factors have a tremendous influence upon the conditions under which mental illnesses are conceived and diagnosed, as well as the rate of institutionalization in certain populations. This was also the case during the age of confinement.
Psychiatric Assessment of the Poor and Homeless: The Continued Correlation between Poverty and Madness
Though the results of Rosenham’s study have been supported by other research challenging the accuracy of psychiatric assessment measures,it is difficult to determine the degree to which psychiatric bias is a factor in determining the constitution of a hospital population. This is particularly the case when considering a possible confounding of poverty and mental illness. The major reason for this is that there are other potentially valid explanations for the high rates of mental illness in homeless and poor populations.
There are two dominant models most psychiatrists, psychologists, and sociologists rely upon to explain the relationship between poverty and mental illness. Stress-based models propose that more anxiety provoking events occur at the lower end of the social field. For example, studies suggest disrupted family lives, foster care placement, and domestic violence predict homelessness in mentally ill persons (Shinn, Knickman, & Weitzman, 1991; Susser, Lin Conover, & Struening, 1991). Similarly, Watt and Saiz are two researchers who work from a diathesis-stress approach to mental illness: they attribute the development of schizophrenia to a combination of environmental and genetic factors. Watt and Saiz (1991) assert that low socioeconomic status influences the development of schizophrenia by acting as a stressor “with both psychological and physical dimensions — in as much as it often results in poor prenatal care, birth complications, viral exposure, and family disruption.” [xxix] Conversely, the downward drift hypothesis adduces that since mentally ill persons are less effective workers, they will drift downward in the social field eventually aggregating at the bottom of the social ladder. In conjunction with this hypothesis, one team of sociologists proposed that schizophrenia restricts educational achievement to the degree where occupational and financial status suffer. (e.g., Dohrenwend et al., 1992). [xxx]
While the idea of increased stress produced from economic hardship and the downward drift hypothesis are plausible explanations for higher rates of mental illness in poor populations, these models rarely consider social factors that appear to influence rates of mental illness. Some of the social factors for which these models seem unable to account are the levels of social tolerance, the influence of the police, and the ethical sensibility of the populace. Evidence illustrating that diagnostic assessment of the lower class is unreliable is rarely considered in psychiatry, possibly because of the vested interest the mental health industry has in the accuracy of its assessment measures. Above all, it is certain that both the downward drift hypothesis and the stress-based models attribute high rates of mental illness in poor populations to biological, developmental, and adaptive defects in individuals psychiatrists determineto be mentally ill.
In turning now to the diagnosis of poor and homeless populations, sociological research suggests that assessment of these groups may be even less reliable than in the general population. For example, in an essay warning clinicians of potential biases in assessment techniques, Kenneth S. Pope and Paula B. Johnson claim that: “extensive and detailed longitudinal studies, which have been in process for over a quarter of a century (Hollingshead and Redlich 1958; Redlich and Kellert 1978), have documented the degree to which people from the lower social classes — when matched with all other relevant characteristics with those from the higher social classes — are generally perceived to be more mentally ill.(e.g. Efron 1970; Lee 1968).”[xxxi] Evidence reinforcing Pope and Johnson’s assertion comes from an examination of 427 psychiatrists, psychologists, social workers and graduate students by Umbenhauer and Dewitte (1978). Participants were given nearly identical case material, with the only variants being race and social class. While there were no significant race effects, strong social class effects were observed, with the more serious diagnoses attributed to those from the lower class. In an analogous study where mental health professionals interpreted identical Rosarch records, Hasse found lower class records were more frequently given diagnosis of psychotic or character disorder, while middle class records were interpreted as neurotic or normal. The diagnostic bias these studies establish is reinforced by Boyle’s work (1982) demonstrating that clinicians judge a lower class person to be more dangerous than an upper class person with whom he is identical in every other respect.[xxxii]
It has also been demonstrated that affective responses of individuals to long-term unemployment resemble the emotional life of the mentally ill. Apathy, irritability, negativity, emotional overdependence, social withdrawal, isolation and loneliness, loss of respect and identity, and lack awareness of time have all been found to be common among those facing extended unemployment. [xxxiii] The idea that unemployed persons might express affects more aberrant than those found in mentally ill persons was further illustrated through a study of a large sample of Scottish and Lancashire unemployed persons conducted during the Great Depression that found “the level of negativity and pessimism about the future…to be greater than that of psychotically depressed and schizophrenic patients.” [xxxiv]
The anguish and malcontent rife among the unemployed might often be misdiagnosed as mental illness. In his review of Snow’s work (1998) on the homeless, Bachrach claims: “certain behaviors and characteristics prevalent among homeless people, such as inappropriate affect and appearance, depressed mood, agitation and unresponsiveness, may in fact be adaptive responses to the arduous nature of life on the streets or patterned manifestations of a subculture or way of life different from the larger normative order.” [xxxv] Similarly, Baxter and Hopper (1982) point out that many homeless persons experiencing physical hardship, sleep deprivation, poor diet, and lack of social contact might, under improved conditions, have many symptoms subside.
In sum, despite the sentiment among the majority of psychologists, psychiatrists, and sociologists that a relationship between socioeconomic status and mental illness are indicative of genetic, developmental or social defects or incapacity’s in poor populations themselves, a considerable amount of less favored evidence suggests diagnostic assessment is unreliable, particularly when considering poor populations. “Under the best of circumstances, there is a distinct absence of consensus regarding who is chronically mentally ill (Bachrach, 1986); under conditions of homelessness this problem is vastly exaggerated (Snow et al, 1998; Barrow et al, 1998).” [xxxvi]
Unfortunately, psychiatrists may encourage a continued obfuscation of poverty and mental illness. In Psychiatric Diagnosis Fifth Edition,a handbook in which Donald Goodwin and Samuel Guze enumerate the criteria and classifications for the major mental disorders listed in the fifth and most recent Diagnostic Statistical Manual, there is a section reviewing shortcuts to help mental health professionals diagnose patients. Goodwin and Guze state: “schizophrenics, for example, are often poorly groomed and sometimes dirty.” [xxxvii] The point is not to be overly exacting about phraseology, so much as to suggest that clinicians may often be encouraged to judge illness based on generic, visible signs of poverty.
The majority of evidence suggests that the poor on the lower rung of the social ladder remain a target population who, in certain instances, may be institutionalized against their will. Psychiatry today may systematically misdiagnosis poor populations, because of problems in assessment techniques, as well as cultural misunderstandings of the lower class. Consequently, psychiatry may intermingle and confuse poor and mad populations in mental hospitals, as was evident in seventeenth century Europe when hospital directors failed to discriminate between these populations. The idea of psychiatric assessment bias seems the most plausible explanation for the higher rates of mental illness and the more frequent, lengthier periods of hospitalization in poor and homeless populations.
Responses of the Homeless Population to Psychiatric Treatment
Were psychiatrists in mental hospitals to be systematically misreading poverty as mental illness, one would expect responses of discontent from the involuntarily hospitalized populations in the lower class, particularly the homeless. In fact, there is some evidence that the homeless are dissatisfied with mental health services.
It has been shown that homeless women, despite numerous mental and physical health problems, express a strong preference for a normal independent living situation rather than hospitalized care. (Goering, 1990). [xxxviii] The fact that homeless women who are ‘mentally ill’ strongly prefer living in volatile street conditions to an environment where food, shelter, and therapy are amply provided is explainable through two major hypotheses. It could be that these women are so disturbed that they are unable to accurately comprehend the most appropriate form of treatment for themselves; hence, they desire a lifestyle that is actually against their best interest. Conversely, it is possible that homeless mentally ill women understand the difference between life on the street and life in a hospital, believe they do not need treatment, and consequently resent being hospitalized against their will.
The latter possibility seems at least marginally reinforced by a study Ball and Havassy (1989) performed on male and female homeless persons. When Ball and Havassy asked the mentally ill homeless to describe the importance of different needs, they found “mental health treatment was far down the list.” (Herman et al., 1993) The lack of interest in mental health treatment could be conceived as proof that homeless mentally ill people cannot accurately evaluate what is best for them. However, since street survival requires a degree of competence, self-management skills, and self-awareness, the idea that the homeless mentally ill have little understanding of their needs appears suspect. Indeed, the above response suggests that there might be a variance between the treatment measures psychiatrists and psychologists believe the homeless require, and those homeless population themselves consider to be necessary.
Accordingly, when Ball and Havassy asked interviewers of homeless persons to assess the percentage in need of mental health services and compared these figures to the level of treatment the homeless believed they needed, they found a discrepancy. While interviewers believed mental health services were required by 41 percent of those surveyed, only 17 percent of homeless persons thought they needed psychiatric
There may be certain instances where it is not only the amount, but also the type of psychiatric care that diverges from the best interests of homeless populations. Cohen and Thompson (1992) have pointed to in a tendency in psychiatrists and psychologists to ‘medicalize’ the homeless, which often leads professionals to ignore their wide range of needs “focusing on their ‘psychiatric needs’ and often engendering feelings of humiliation.” [xl] Such feelings of humiliation could, in certain instances, result from psychiatrists’ mistaking nutritional, shelter, and relationship needs for signs of mental illness, as was suggested through our earlier review of Baxter and Hopper’s work. Thus a man who hasn’t eaten in a week may not be exceedingly calm, collected, or sure of his future, but this is not necessarily a sign of illness, so much as a sign of desperation.
The possibility of psychiatrists’ believing the homeless population requires more treatment than they actually need is further reinforced by clinical work. William Breakey, who has examined significant quantities of clinical work on the American homeless, had this to say: “Homeless people frequently distrust authority and are suspicious of psychiatrists and other mental health professionals. They may have had unpleasant experiences with hospitals or doctors, which lead them to be wary of further involvement. Some former patients who had experienced unpleasant medication side effects choose to stay away from psychiatrists to avoid being pressured into another course of treatment.” [xli]
It is a valid point that, again, for reasons of questionable mental competence, one cannot entirely rely either on self-assessment or accounts of self-assessment in determining the quality and fairness of treatment of homeless populations. Still, responses of suspicion towards psychiatrists and other mental health professionals, a preference for street life, and a fear of being pressured into taking medication all corroborate the idea that the homeless may often be involuntarily hospitalized unnecessarily.
A factor contributing to the hoarding of beggars in the great hospitals was low social tolerance for an unruly street presence. Today, social tolerance may continue to influence the makeup of a hospital population. In particular, attitudes of family members towards disturbed individuals are more integral than they were in the classical era. The fifth and most recent addition of the Diagnostic Statistical Manual accordingly claims:
Psychiatry, probably more than any other specialty, benefits from informants, friends, and
family who will tell what the patient will not (and cannot). Although caution should be exercised
in judging the merits of such information it can be very helpful in making diagnosis. [xlii]
Instead of negative social sentiment leading to the formation of a militia that rounds up beggars, grievances of family members seem to influence diagnosis of mental illness and hospitalization rates. Harvard sociologist Harvey Brenner has suggested that in times of stress caused by economic downturn (the exact conditions in the age of confinement), family members of a “sick” person will more often admit relatives to treatment facilities. In making this analysis he reviews a statement made by Clausen:
Tolerance (or any other response to forms of deviant behavior) may in the last analysis determine not only who is brought to treatment, but whether or not the person needs to be hospitalized. In our own research on the families of mental patients, we have encountered instances in which an accepting and nurturing wife has been able to sustain a schizophrenic spouse for five to ten years before symptomatic manifestations in the work situation caused him to be brought to treatment. In other instances, we have seen the utter rejection of a husband within a few days or even hours of his manifesting far less deviant symptomatology. The latter instances are often followed by a period of acting out which brings the patient to the hospital.” [xliii]
It may be that in times of economic crisis, family members will be more likely to commit troubled individuals for hospital treatment, since they are unable to cope with symptoms they would find manageable in more stable periods. To the extent this is case, there is a repetition of conditions from the classical era where psychiatric symptoms were less important than social tolerance of those symptoms in determining whether a ‘mentally ill’ person was hospitalized.
The high rates of mental illness and hospitalization found in poor and homeless populations are likely to be caused by diminished tolerance by family or friends. The tolerance of family members may be a particularly strong determinant when these individuals have occupational problems or are unemployed. This resembles the classical era where the unemployed, in particular, were more likely to be confined. It is probable, moreover, that social sentiment as a whole still influences homeless and poor populations (we will consider this perspective later), particularly because this population tends to be so out of place in urban settings. The important element here, however, is that though the dominant agent over the past seventy years in America has become the family, the total effect is very similar to that of the classical era. Apparently, levels of social tolerance influence hospitalization rates, as was the case in the age of confinement.
From the Militia, to the Police
Though there is no longer a militia rounding up beggars in the street, there are modern incidents where the police gather social undesirables and demand that they accept hospital treatment. For example, New York City enacted Project HELP (New York City Homeless Emergency Liaison Project) to remove the homeless from the streets and to provide them with medical and psychiatric care. Some activists engaged in Project HELP undoubtedly meant to aid individuals either incapable of seeking therapeutic treatment or unaware of a need for it. Yet, the irony of Project HELP is that in addition to being spurred on by the intention of helping the homeless, its enactors and the City of New York undoubtedly procured benefits from the project.
Foucault believed that the pestering of local populations and the threat of peasant revolt were two significant reasons that the poor population was confined in the seventeenth century. While beggars in the street no longer present a threat of aggregating together in a peasant revolt, street disturbances caused by the homeless might still be a factor that partially accounts for the large numbers who are treated in American hospitals. Indeed, it is because the homeless continue to create street disturbances and remain difficult to manage that one questions whether Project Help was ultimately established to assist the homeless population or the City of New York.
Yet even if social undesirables generate difficulties and solutions by governmental agencies analogous to those in the age of confinement, the percentage of the homeless population treated in mental hospitals as a result of the police is probably considerably smaller than the percentage of beggars institutionalized in seventeenth century Europe due to the militia. To return to our example, estimates show that approximately two percent of homeless persons gathered by law enforcement officers through Project HELP were involuntarily committed to hospitals.
A smaller percentage of homeless persons who were civilly committed does not eliminate the possibility that the overall numbers of committed individuals was still quite large. A much larger sample of individuals could originally have been brought to the mental hospital than were brought during the classical era, from which the two percent were then selected. Moreover, it is certainly problematic that the demands for involuntary admission to a hospital were made more lenient during Project HELP. To be involuntarily admitted into hospitals, homeless persons had to be interpreted as being in danger of causing harm to themselves or others “within the foreseeable future,” rather than the standard test of presenting “imminent danger.”[xliv] This suggests that, as has already been illustrated with the Mental Health Act, laws protecting patients’ rights are often circumvented to facilitate the hospitalization of social undesirables.
It must further be pointed out that a psychiatric standard based upon a threat of future violent activity may have been particularly biased against the homeless, more than would normally be the case (as discussed when we considered a potential psychiatric bias in assessing poor populations). Boyle’s study demonstrated that clinicians judge a lower class person to be more dangerous than a middle class person with whom he is otherwise identical. Another reason psychiatric bias was likely to have occurred in Project Help is that clinicians were requested to judge whether a patient was capable of causing harm within the foreseeable future; an indefinite, flexible category both temporally and conceptually offering the analyst considerable leniency in formulating a diagnosis.
Could the fairly open-ended standards used in Project Help have been instituted so that the mental hospital could assist the City of New York in facilitating social control? The operation of the police force, in conjunction with the functioning of the mental hospital during Project Help, seems to resemble the militia’s rounding up beggars in the streets of Paris and bringing them to hospital administrators. Granted, a police force is more discriminating and less oppressive than a militia. Still, it is only our current era’s attempts to control the homeless through hospitalization that might be viewed as forms of service to the homeless themselves.
Another example of law enforcement’s influencing the diagnosis of mental illness comes from Los Angeles, where twenty percent of emergency calls to the Los Angeles Police Force are related to psychiatric problems (Walker, 1991). Because of the large number of psychiatric cases that the Los Angeles Police receive, they have developed a mental evaluation unit which accepts 1000 referrals a month. [xlv] Research suggests that there are similar police structures in many other American cities, the effect being that modern law enforcement has a major influence on which populations are hospitalized by psychiatrists.
Institutionalization in mental hospitals may continue to facilitate control of social undesirables, with law enforcement replacing the militia as the primary agency. For reasons to be described in the next section, this may take place against the better interests of law enforcement officers and psychiatrists.
On the Good Intentions of Psychiatrists and Law Enforcement Officers
The operation of psychiatry and law enforcement today does not reproduce exactly the same repressive system in place during the age of confinement, particularly since today’s police officers and psychiatrists have the interests of the treated populations in mind. But even when a psychiatrist or a law enforcement officer has good intentions, it is certainly possible that he or she is not producing the best results. This is the problem Deleuze and Guattari review in Anti-Oedipus: Capitalism and Schizophrenia, when they consider Reich’s psychological analysis of the motivations behind German fascism.
Reich, the social-minded psychologist, once wondered not how the Germans were duped or misled into fascism (since it is unlikely a whole people were actually fooled by Hitler), but rather how they desiredfascism? One only has to view one of Leni Riefenstahl’s cinematic portrayals of fascist rallies such as Triumph of The Willto realize that this is the only question that adequately accounts for the fanatic effusion of support for Hitler. What Deleuze realizes in the process of reading Reich is that people can desire their own repression, or desire to be led, whether by impressive iconography and spectacular scenerization, a powerful figure, a despotic government, a state agency, a boss, a parent, or a lover.
The important consideration is that under capitalism, socialism, or despotism, a state agency still directs the population, limiting the number of objectives a people can have, as well as the channels through which those objectives are to be achieved. Today, the primary limitation is capital, which leads the population to offer their labor and services to various corporations, and, in certain instances, to work for industries that participate in activities that violates their ethics.
Under capitalism, a law enforcement officer or a psychiatrist may be fulfilling his or her duties and still be contributing to social repression. To understand this, one has only to look at the Vietnam War and the way obedient soldiers fulfilling the commands of their superior officers often acted against their better consciousness. Stanley Kubrick’s film, Full Metal Jacketaptly illustrates the problem of obedience in the military in Vietnam through his portrayal of basic training for marines in South Carolina.
Sergeant Hartman teaches new recruits that being an effective Marine means obeying superior officers without reservation. The message we receive through Sergeant Hartman’s treatment of Private Pyle (the overweight soldier who cannot endure either physically or mentally in Hartman’s ‘beloved’ marine core) is that efficacy depends upon the contributions one makes to a war machine. Each individual’s primary function is to kill. There is little possibility of escape from basic training, which has the express function of turning men into organ-stops: one has to be as thoughtless and efficient as everyone else or drop out of the corp. The only option aside from quitting, in fact, the only method any Marines found to avoid the grip that Sergeant Hartman had over their bodies and minds was chosen by Private Pyle. At the end of the first major sequence of the film, Private Pyle precipitated a subversive reversal of the law of the military by becoming delirious, shooting Sergeant Hartman, and then taking his own life. By this eerie act, madness generates the only and yet most unwanted means of escape. Private Pyle practiced the efficiency, the order, and the lack of reservation that Sergeant Hartman had taught him to utilize in operating his rifle in combat, but now these skills were used against his own Marine Corp. Kubrick apparently was suggesting that Private Pyle targeted and killed the real enemy, which was not the Vietnamese, but a military apparatus that teaches soldiers to kill without adequately considering the consequences of their actions.
Of course, psychiatrists and law enforcement officers are not in a situation comparable to the Vietnam War, yet these positions, stationed within a hierarchical chain of command, encourage individuals to accept the decrees of their particular practice, good or bad, right or wrong, useful or noxious. Deleuze has shown that becoming a member of the State, being obedient and hard working, can, in many instances, mean accepting the State’s desire. Under the figure of Oedipus, which is the essence of all repression, everything has a fixed place “here is mommy, there daddy, and there you are — stay in your place.”[xlvi]
There is also the related point in speaking of the psychiatrists and police officers as Oedipalized, that these individuals, given their position, are limited in their ability to acknowledge what Deleuze and Guattari have deemed universal delirium. Universal delirium is a madness of the majority. It occurs when numerous individuals obey authority (a government, a profession, a military officer etc.) in opposition to the general good.
Thomas Szasz discusses a similar issue when he considers the operation of a psychiatrist in a court of law. He says the psychiatrist, as an agent for institutional authority, “is expressly barred from stating, for example, that it is not the criminal who is “insane” but the men who wrote the laws on the basis of which the very actions that are being judged are regarded as “criminal.” [xlvii] The psychiatrist can hardly analyze a patient in a court of law from an independent standpoint. In general practice, he usually is taught to diagnose the individual rather than the social setting. Whenever there is any sort of collective problem, as demonstrated in the extreme in Nazi Germany and in Vietnam, a clinician is essentially barred from acknowledging it.
A Difficulty Psychiatrists Have in Acknowledging Madness as a Transcendent
It should further be pointed out that as agents of the state, psychiatrists and psychologists often have particular difficulty viewing madness as other than an illness. This seems aptly demonstrated in Anton Chekov’s short story An Attack of Nerves,where we find Vasilyev in a more complacent setting than Private Pyle in Full Metal Jacket, though a similar thematic is expressed. Vasilyev, an accomplished student, is frustrated with the double-sided, hypocritical nature of his friends, an artist and a doctor, who take him to whorehouses yet show no visible signs of disgust with the appearance and operation of these establishments. Utterly in despair over the wretched state of the women in these whorehouses, Vasilyev feels terrible agony and is unable to function for a few days, so is taken by his friends to a psychiatrist. While being observed by the psychiatrist and his companions Vasilyev had this to say: “because I have written a thesis which in three years will be thrown aside and forgotten, I am praised up to the skies; but because I cannot speak of fallen women as unconcernedly as of these chairs, I am being examined by a doctor, I am called mad, I am pitied!” Vasilyev points out that expressing emotions over real conditions that exist on the street is considered a sign of pitifulness or madness, while were he to isolate himself in the world of his academic training, he would strangely be considered sane. Therefore, there seems to be a way in which persons’ who wish to transcend the normal boundaries of the ‘appropriate’ are considered mad.
It might additionally be that part of what is threatening about madness is its transcendence of societal norms, routines, or expectations. According to Deleuze and Guattari, schizophrenia may be a transgressive state, a non-restrictive process of moving through flows, eruptions, and overflights. Such mobility, particularly of desire, makes the schizophrenic threatening even revolutionary to the prevailing order, since such an individual does not complacently accept social repression. The delirium of the schizophrenic, likewise, is not disconnected from the world, but reflects upon the racial, continental, and world-historical matter of humanity.
R.D. Laing, a leader in the anti-psychiatry movement has suggested a similar idea, claiming madness is more than simply a state of illness but has productive, generative potential. “Madness need not be all breakdown. It may also be breakthrough…The person going through ego-loss or transcendental experiences may or may not become in different ways confused. Then he might legitimately be regarded as mad. But to be mad is not necessarily to be ill, notwithstanding that in our culture the two categories have become confused.” [xlviii] Antonin Artaud, in turn, claims psychiatry intentionally eradicates singularity, particularly where it excels. In Van Gogh The Man Suicided By Society, Artaud argues that psychiatry’s function is to protect the majority against: “certain superior intellects whose faculties of divination would be troublesome.” [xlix]
The extent to which schizophrenia, no doubt a serious condition that is often debilitating, may nevertheless be considered a mental illness because it generates a creative potential for breakthrough, artistically, psychically and ethically is certainly interesting and challenging. For again, it suggests that mentally disturbed persons are often confined for their difference, their refutation of state authority, and their denial of societal regulation. The important element is that madness exists in a contextual web of relations and that a part of psychiatry’s function, as we will discuss more thoroughly later, may be to facilitate social control.
Manipulation of the Labor Force
In addition to problems in psychiatric assessment that operate on the individual level, and social tolerance and law enforcement which function predominantly at the societal or molar level, the economy seems to be another factor that influences the constitution of modern hospital populations. Harvard sociologist Harvey Brenner has found that the greatest predictor of hospitalization rates in New York State over the past 127 years is the level of the economy.(An analogous examination was conducted by other researchers covering the U.S. as a whole between the years 1922–1968, which obtained similar results.)[l]
In Mental Illness and The Economy, Brenner establishes an inverse relationship between economic productivity and the hospitalization rate in New York through numerous epidemiological examinations. Surprisingly, this relationship holds for private hospitals which cost per night as much as an expensive hotel, which suggests the tremendous importance of the economy in determining hospitalization rates. For the question this finding leads one to pose is: why would most people spend larger sums of money on hospital treatment when they have considerably less funds, as was the case during the Great Depression?
Still, Brenner admits to difficulties ascertaining the causal relation between the variables he studies. It is unclear whether fluctuations in the rate of hospitalization are produced by stress responses to economic changes altering levels of psychopathology, or rather whether changes in the demand for labor influence the amount of mental illness ‘detected’ in the population. The former possibility is the proposition Watt and Saiz made when they attempted to prove environmental stressors influenced the production of mental illness. While this consideration is perhaps a factor, for reasons described above, it may not be as effective as proposing psychiatric bias on the individual level, along with social tolerance and the influence of the police on a molar level, help to ensure that the demand for labor is met, with the labor demand itself being the major determinant of hospitalization rates.
In opposition to an overt manipulation of labor in the classical era, the above contributing factors and the major mechanism, a psychiatric bias, operate more subtly today, taking place with the assistance of bourgeoisie-run corporations instead of government decrees under a despotic authority. It is also true that any manipulation of the labor force today would have to be circumlocutory, as opposed to the age of confinement where it was direct and purposeful. Still, Brenner’s results suggest a comparison to the classical era is worthwhile, since economic factors in both epochs appear to heavily influence the rates of hospitalization.
In light of this possibility, consider the changes in the rate of hospitalization and effectiveness of rehabilitation in America during the Great Depression. Not only was there a 73 percent increase in the number of hospital beds, but there was a drop in the recovery rate from schizophrenia from an average of 20 percent to 12 percent. [li] It may be that an increase in hospital beds between 1929 and 1938 (i.e. hospitalization rates increase as well) was a method of reducing competition in the labor force and of controlling falling wages. Furthermore, rehabilitative efficacy dropped eight percent during the Great Depression despite the fact that hospital overcrowding was no more of a problem than in the late 1920’s or mid 1950’s, and government funding had been increased. Since the other potential causal factors were controlled, rehabilitation was probably less effective because treatment efforts were socially discouraged (due to less of a labor demand), resulting in a lowered rate of recovery.
A similar explanation may account for the way the level of the American economy is the best predictor of hospitalization rates. When there is a period of economic downturn with high unemployment and falling wages, more individuals are hospitalized for mental disturbances. Conversely, during economic growth periods where low unemployment and rising wages are the norm, hospitalization rates decline.
For Karl Marx, the maintenance of an industrial reserve army largely built upon members of the lower class essentially belonged to capitalism and fulfilled its ends. Capitalism is the great manipulator of labor and production because it disguises its coercive potential. “In times of great prosperity,” Marx wrote in Capital, Volume One,the industrial reserve army can be “speedily and in large numbers enrolled in the active army of labourers.” [lii]
The poor on the streets no longer have to be rounded up, chained, and forcefully put to work during periods of economic downturn, as was the case when the Count d’Argenson ordered the marshalseas to arrest beggars and put them to work in France. Fluctuations in the hospitalization rate under the influence of market demand produces a similar manipulation of labor. When workers are needed in a period of growth, capitalist merchants swallow the excess labor supply. However, when there are too many laborers in periods of recession, larger numbers of social outcasts from the lower classes are admitted to mental hospitals. The fluctuations of capitalism are likely to be assisted by social factors discussed above, the influence of the police, social tolerance, rehabilitative efficacy, and especially the rate of examiner bias, all of which help to meet the varying demand for labor through manipulations of the rate of hospitalization in the lower class.
However, it must be pointed out that whereas in the mental hospital workers were paid very little, if at all, for their services, workers today not only obtain a salary but also have a degree of freedom in choosing an industry. Nevertheless, since studies show that a considerable portion of hospitalized populations are made up of poor and homeless populations, it seems probable that the constitution of the manipulated labor force resembles that which was present in the age of confinement. Moreover, many homeless and poor that would otherwise be hospitalized are likely to find themselves in a subservient and readily exploitable position similar to the one held by beggars in the classical era. This occurs because most of the poor population is forced to offer their labor and services to various corporations who pay them much less than they are worth. As Marx has shown, underpaying the proletariat and maintaining them in a position of dependence is one of the major methods that bourgeoisie enterprise is effective. In short, there is today a subtler exploitation of the labor supply for profit than in the classical era.
Furthermore, even though there are certainly no modern structures comparable to the workshops in the great hospitals, it seems clear that the mental hospital profits from institutionalized populations in periods of economic downturn. Some of the more subversive measures through which this profiteering might occur will be considered in the next section of this paper. The important point for now is that Marx’s understanding of bourgeois materialist exploitation of the lower classes extending conditions serfs were in when manipulated by the aristocracy is exemplified by Brenner’s statistical data. However, the fluctuations in market demand probably require the assistance of other the social factors detailed above to have their full effect. Additionally, the particular nature of the manipulation of the labor supply Brenner’s work suggests transcends Marx’s conception, since it is an institutionalizedpopulationthat is forced to work. Hence, this is not merely a question of a hidden industrial reserve army of unemployed persons but one built entirely on previously unavailable workers.
There are no workshops in our mental hospitals today that allow a despotic agency to directly manipulate labor for profit. Yet modern hospitalization, like confinement serves economic interests through a manipulation of the labor force. This, and not treatment, may be its primary achievement.
Accordingly, in making conclusions based on his research, Brenner claims: “Psychiatry is an arm of the social system which has been called upon largely to assist in patching up ruptures resulting from poor economic and social integration.” [liii] Apparently, the idea regarded in the public consciousness that psychiatry facilitates social repair is largely based in propaganda, rather than statistical findings. It is for this reason that Brenner goes on to suggest “strategies of psychiatric care have, theoretically, been largely irrelevant to large scale social disequilibria.” [liv]
It is not being claimed that individual psychiatrists and psychologists have anything other than the best of intentions when treating patients. Moreover, it is not being denied that in certain instances rehabilitative efforts are helpful to patients. Rather, the suggestion is being made that those housed within psychiatric walls are most often in this state because of their economic status rather than their mental disturbance, replicating conditions established in the classical age. 
Economic Productivity Through Mental Health Services
In the classical era, there was a bureaucratic hospital structure that manipulated the confined populations to produce economic gain. Yet the system of government in the great hospitals seems limited compared to modern psychiatry, both in terms of the range of functions and the complexity of the structural organization. Modern psychiatry is a colossal industrial machine, with hospital care, day treatment centers, outpatient centers, university and academic programs, community groups, personal practices, addiction and crisis centers, pharmaceutical companies, and more. All of these agencies, though they possess distinct functions, exist in an interrelated web, support and validate each other’s power, and ensure that psychiatry as a whole produces the wealth needed to operate.
A massive division of responsibility yet joint access to channels of profit-making differs from the direct production of capital through crude, explicitly manipulative measures in the great hospitals. This is particularly because the great hospitals were static industries, producing predominantly one product or commodity. Consider Foucault’s review of the workshops in the great hospitals in Germany during the age of confinement. Foucault states “each house of confinement in Germany had its specialty: spinning was paramount in Bremen, Brunswick, Munich, Breslau, Berlin; weaving in Hanover. The men shredded wood in Bremen and Hamburg. In Nuremberg they polished optical glass; at Mainz the principal labor was the milling of flour.” [lv]
The formation of single-product workshops throughout Europe suggests production was limited to the confines of the great hospitals, and was predominantly obtained through the commodities that the inmates produced. The way the administrators at Bedlam made their inmates into a spectacle for outsiders, who would pay an entrance fee to view them, further testifies to the restricted means of producing capital that the hospital directors had at their disposal. The important element is that the houses of confinement did not operate in conjunction with other societal agencies or have elaborate, diversified means of wealth production.
By comparison, modern mental health services have a more extensive array of functions, since they are relied upon for treatment of hospitalized populations as well as having a large influence over the general population. Psychiatrists are situated in schools; they treat problems of the home; they are utilized to testify in courts, and are asked to rehabilitate prison populations. The agents of power in the classical era, such as the hospital directors, never had real access to the community, nor did they affect the general population as psychiatrists appear to today. Along with the increased jurisdiction and influence psychiatry now possesses, the methods used to produce wealth have multiplied and infiltrated the major veins of the social sphere.
Finally, psychiatry is a more elastic industry than the great hospitals were, often altering the forms of treatment it provides the general population depending upon profitability needs. For example, psychiatry often extends the number of disorders that are to be treated within the mental hospital. Similarly, psychiatry manages populations outside the mental hospital by developing new products and services.
Yet even with these differences between the structures and operations of mental health services in modern times and the classical era, it is nevertheless apparent that in both periods the hospital is a functioning mercantile entity that must find methods to produce wealth. Modern psychiatry, instead of forming workshops, depends upon the construction and classification of numerous illnesses, the propagation of the need for drug treatment (through their link to pharmaceutical companies), and the fostering of demand for psychotherapy and hospital treatment.
An example of the increased range of services offered by the mental hospital implemented to bolster economic productivity is the recent psychiatric management of alcohol addiction. As will be demonstrated later, the disease model of alcoholism that is promoted by psychiatry seems to have minimal scientific basis. In spite of potential problems with the model of alcoholism, a social sentiment has been propagated over the last two decades that alcoholics require hospitalized care for their condition.
The formation of this social sentiment is a valid one to the extent that it serves the interests of patient health. Moreover, I would not want to discourage hospital treatment for alcoholism for those who feel it necessary. Yet at the same time, it seems useful to question a social sentiment that encourages hospital treatment because such rehabilitation measures are unprecedented historically, and in certain respects they are difficult to justify. Accordingly, estimates show rates of death from alcohol to be fifty times lower than 200 hundred years ago.  Why have there been large increases in hospital treatment for alcoholism when abusive use of alcohol seems to have drastically declined?
The addiction model and the idea that the alcoholic is consistently at risk of losing control benefits the psychiatric industry, since it encourages more individuals to seek hospital treatment for alcoholism, for which the industry charges top dollar. Indeed, hospital treatment for alcohol addiction is extremely profitable for psychiatry, costing patients an average of twenty-five thousand dollars. But the real problem is not that psychiatry profits from substance abusers, but that hospitalized care has been promoted for alcoholism despite statistical evidence indicating that it is unnecessary, perhaps even counterproductive compared to other, less intensive forms of treatment.
Several studies have shown that treatment settings have no effect on outcome in alcoholics or that less intensive settings actually produce more favorable outcomes. Despite this finding, hospital care for substance abuse has increased several fold during the 1980’s, with rises in levels of hospitalization continuing into the present.Considerable increases in hospital care for alcoholism may partially result from psychiatrists promoting the need for hospital treatment in opposition to scientific findings. The question must therefore be raised: does the American mental health industry promote the need for hospitalized care largely because it is economically productive for their industries? Moreover, could an interest in economic gain in other instances as well be prioritized over therapeutic intent?
The need for economic productivity conflicting with interests in rehabilitation, may be a problem today not only within the mental hospital, but also in forms of treatment administered through the pathways psychiatry has established to numerous social structures, including schools, addiction centers, courts, and prisons. Consider the rapidly expanding use of drugs for psychiatric conditions. Antibuse for alcoholism, methadone for heroine addiction, Depo-Provera for sexual obsession, psychoactive drugs for mental disorders, and stimulant medication for hyperactive disorders in children are all part of a significant rise in the demand for pharmaceuticals in America over the last fifty years. The administration of these substances in certain instances seems excessive.
Let us examine the use of Valium, a drug that reduces anxiety, nervousness and general malaise. The pharmaceutical industry spends over one billion dollars a year promoting prescription drugs such as Valium mostly to physicians, fully 25 percent of total sales dollars. In 1974, 59,500,000 Valium prescriptions were filled, making it the best selling drug in America. The number of prescriptions filled for Valium in one year seems particularly surprising when one considers that scientific analysis has demonstrated that moderate levels of anxiety help us obtain optimal levels of performance. Similar psychological research has shown that moderate levels of anxiety lead us to be more productive than when experiencing minor levels of anxiety. [lvi]
Obviously, a certain portion of the population benefits from the use of Valium, such as phobic persons or those who experience panic attacks. The same must be said of those in the general population experiencing extreme duress. However, even accounting for these individuals, it is unlikely that 59 million prescriptions for Valium needed to be filled in one year. Moreover, given that moderate anxiety is productive, why have there likely been numerous instances where Valium was prescribed for manageable anxiety?
Psychiatrists and pharmaceutical companies may often unfortunately prioritize profit making over the needs of patients. This differs from the direct exploitation of labor for profit in the seventeenth century. Still, in both epochs there are instances where economic motivations are closely related to the form of treatment administered. Remember in particular that to overcome madness, one had to contribute to the labor force in the workshops not because of any therapeutic benefit (though this was, of course, asserted by hospital administrators), but rather because working inmates guaranteed that hospitals would produce needed commodities. In an analogous fashion, it may be that psychiatrists frequently promote certain drugs such as Ritalin or Valium and administer them to increasing numbers of people because they are profitable for their industry: they particularly accrue wealth for pharmaceutical companies. A similar rationale seems to have propelled the promotion of hospitalized care for alcoholics.
Of course, it must be pointed out that the relations are not the same between the two ages. Whereas in years past it was the confined populations that were put to work, today those who are administered drugs are themselves the raw material that enables the complex psychiatric machine to run. In the next section, we will more closely consider the function of institutionalized populations as raw materials for psychiatry, particularly in hospitalized populations who are forced to take medications for mental disorders.
Forced Labor vs. Forced Treatment
The workshops in the great hospitals were transparent illustrations of administrative exploitation of the confined populations to produce badly needed capital. Today, we no longer have structures comparable to the textile and industrial factories that many of the great hospitals in Europe became, yet modern psychiatry continues to manipulate hospitalized populations to achieve a similar end. In particular, hospitalized populations have become the raw materials around which a therapeutic industry has been built. The hospitalized populations no longer need to produce commodities, as they themselves are inserted into a system that profits off them. Mental Health treatment is very expensive, and hospitals accrue wealth for most patients they accept from insurance companies, governmental agencies, or family members.
Furthermore, profits are guaranteed in the instances when patients are forced to take psychotropic medications. The anti-psychotic medications that schizophrenic and bipolar patients are in many instances forced to ingest are highly lucrative for pharmaceutical companies, so that with each involuntary patient admitted, psychiatry guarantees economic productivity. This is similar to the situation in the classical age where economic gains were ensured by the labor of hospitalized populations.
The forced labor camps the great hospitals became seem no more of an oppressive and restraining means of exploitation of hospitalized populations than the forced intake of drugs. This is so particularly because many anti-psychotic medications have serious side effects, the most common being tardive dyskinesia. Though this condition is not life threatening, it is irreversible even if medication use is suspended. Symptoms of TD include “involuntary facial movements such as grimacing, tongue thrusting, lip smacking, and motor activity in the hands and feet.” [lvii] Estimates show that fifteen to twenty percent of patients taking neuroleptic (anti-psychotic) drugs present manifestations of tardive dyskinesia, most often after six months to a year of treatment.  Another side effect of neuroleptic drugs is akathisia, which is marked by fidgeting and unstable muscular movements. There is also neuroleptic malignant syndrome, a serious condition where the patient develops fever, escalations in pulse, muscle rigidity, and must be treated immediately. Finally, toxicity, “resulting in unsteadiness, sedation, and impaired psychomotor behavior,” may occur when medications are mixed with alcohol or drugs, or when patients are administered dosages that are too high. [lviii] In addition to these and other potentially deleterious side effects, many anti-psychotic medications have been shown to be brain-damaging (Breggin 1983, 1990). One study showed that of the many schizophrenics who are told they must take psychotropic medication at least 40 percent would become brain-damaged. (Breggin, 1990; Breggin, 1991, pp. 68–91)
Given the destructive effects anti-psychotic medications have, it seems strange that most of us consider this treatment necessary and beneficial, while the forced labor in workshops is widely upheld as a form of human injustice. In both epochs the process is essentially the same: freedom is restricted in order to make a profit. Although treatment measures were harsh in the classical era, patient health was not systematically endangered to the degree it is today.
Finally, it seems likely that the poor population receives the greatest quantities of anti-psychotic drugs treatments since this population is diagnosed with higher rates of schizophrenia and psychosis and has more frequent and lengthier periods of hospitalization. Additionally, this population is probably most often administered drugs that are unnecessary because of the problems with psychiatric assessment of the poor detailed above. Thus the poor serve as one major source of raw material for the mental health industry. Given Harvey Brenner’s findings, it seems likely that in times of economic downturn the number of individuals who are institutionalized rise in order to reduce the competition for labor and escalate the rate of pay in the general population and to guarantee the hospital profits off involuntarily treated populations. Essentially, by manipulating poor populations, American Psychiatry accomplishes nearly the exact same economic ends (producing wealth within the hospital and reducing competition outside its walls) as those achieved in the classical era by confining beggars across Europe and forcing them to work in the factories of the great hospitals.
Methods of Control: From Chains, to Anti-Psychotic Drugs
Even without chains, cages, and other measures of physical restraint, modern treatment practices facilitate administrative management of hospitalized populations. Accordingly, it does not seem incidental that anti-psychotic drugs were not originally developed to treat schizophrenics, but were adopted from antihistamine derivatives whose stupor inducing properties were depended upon in preventing surgical shock. Anti-psychotic drugs are potent substances that blunt the minds of the individuals who ingest them. Regular use of these drugs could potentially make a relatively healthy person seem unstable, perhaps even mentally ill. As Irwin Silverman has put it, anti-psychotic drugs “provide a common denominator, so that no matter how benign or bizarre the patients behaved at the time of their entry into the hospital, all do eventually appear demented.” [lix]
Anti-psychotic drugs may therefore be administered to ensure patients are restrained and express a limited number of affects. The way psychiatrists prescribe anti-psychotic medication to restrict mental activity is similar to the classical era where physical labor was encouraged by hospital administrators to reduce use of the imagination. In many instances, facilitating social control is probably not on the minds of psychiatrists’ today that prescribe anti-psychotic medication for patients. At the same time, however, there are probably some incidents where doctors use drugs as a threat to encourage patients to behave or to sedate them when they do not.
The intake of patient medication is strongly encouraged by a hospital staff. It has been shown that patients today who have been found to not be taking their medication are reprimanded as if they had no idea what they were doing (Boczkowski, Zeicher & Desanto, 1985). [lx] This is similar to the way inmates who did not work during the classical era were scolded for their moral decrepitude and indolence. In both instances, the hospital administration ensures the treated populations remain in a subordinate position.
Foucault has demonstrated the particular circumstances through which repression was viewed as a form of therapeutics, even more than in the classical era, during the period of moral treatment of madmen propelled by Pinel and Tuke. While in the classical period showers and baths were used as medical remedies to madness it was only in the age of asylums that baths were used as a punishment that was to alert madmen to their transgressive behaviors. For an example of this, Philippe Pinel wrote in 1801 that: “We profit from the circumstance of the bath, remind him of the transgression, or of the omission of an important duty, and with the aid of a faucet suddenly release a shower of cold water upon his head, which often disconcerts the madman or drives out a predominant idea by a strong and unexpected impression; if the idea persists the shower is repeated, but care is taken to avoid the hard tone and the shocking terms that would cause rebellion; on the contrary the madman is made to understand that it is for his sake and reluctantly that we resort to such violent measures; sometimes we add a joke, taking care not to go too far with it.” [lxi]
In the age of moral reform, physical punishment was a means of making the madman felt guilty for his delirious beliefs and actions. Moreover, the madman was instructed to consider punishment to be for his own benefit. The submission of madmen to reason produced ideological humiliation and a divestment of the meaning of all delirious discourse in order to obtain a ‘cure.’ Finally, the keeper, the hospital administrator and the doctor were provided near absolute authority in surveying and judging madmen. The important element in reviewing this history is that in the era of the asylum, as in the preceding age of confinement, treatment ensures conformity rather than rehabilitation.
More recently, therapeutics may continue to be explicitly linked to repression. In 1938 when Ugo Cereletti first developed shock therapy, he administered low dosages to a patient who remained conscious and then burst into song upon recuperating from the shocks he received. Given the lack of real change in the patient, Cereletti wondered at the effectiveness of shock therapy. However, the next day, when Cereletti continued the shock treatment at higher voltages he noticed: “All at once the patient, who had evidently been following our conversation, said clearly and solemnly without his usual gibberish: Not another one! It’s deadly!” [lxii]
Cereletti aptly illustrates the way a ‘cure’ may often be mistaken for a fearful response. Cereletti did not consider whether shock therapy actually aided his patient’s mental constitution, reducing the number of hallucinations he had, for example, but only addressed the visible form of his madness. It was his outward commentary; his refraining from singing and the removal of a delirious conversational voice that was of concern. It is probable that Cereletti’s patient did not feel healthier when he spoke ‘normally,’ but instead emitted ‘normal’ speech due to the threat of physical punishment. Yet, Cereletti read the above incident as a sign of the effectiveness of shock therapy. Cereletti’s response seems indicative of a trend that has lasted until today, where mental health professionals focusing on measurable behavior from patients ignore unseen consequences of treatment.
It needs to be pointed out that shock therapy can be effective in helping individuals who otherwise might not be able to manage, such as those with serious depression who cannot experience pleasure or fall asleep. Moreover, the number of individuals who are administered shock therapy has drastically declined since Cereletti developed the procedure. Nevertheless, the above incident is another exemplification of the way psychiatry confuses rote conformity with convalescence in recent times.
Very often patients who are managed and surveyed by mental health professionals are treated almost as if they were children. Even in the less extensive facilities such as outpatient and rehabilitation centers, the idea is readily accepted that patients need a supportive environment that resembles a surrogate family with the analyst at the helm functioning as a symbolic Father figure. Clinicians order, classify and arrange a patient’s delirium providing it a symbolic and representational meaning which it is believed it would otherwise not possess, particularly since Freud.
As part of their function as guardians, hospital administrators and clinicians punish patients who are difficult to manage. A hospital staff accomplishes this by keeping close surveillance on its inhabitants and ensuring they behave in an orderly fashion. In an effort to ensure patient’s act appropriately hospital authorities often remove certain privileges or grant rewards (operant conditioning). Moreover, in certain instances, they rely on overt measures of punishment, such as the straitjacket or isolation room, which even when only used as a threat are powerful means of enforcing authority. While certain measures of restraint are needed in mental hospitals it must be pointed out that rather than making patients better or healthier measures are often instituted to make them less dangerous.
We may have eliminated chains, cages and forced labor in our mental hospitals, but the policy on psychotropic medications, Cereletti’s understanding of shock therapy and the periodic use of punishment measures as a threat suggests psychiatry continues to regard conformity as convalescence. Patients may further be restricted from protest to facilitate financial exploitation through the forced administration of drug and other psychiatric treatments. Wealth production through social control takes place more subtly today then when madmen were forced to produce commodities in the workshops, yet it is no less effective.
Medicine and Morality in Service of Economy and Social Control
Modern psychiatrists do not believe moral weakness produces mental illness as was upheld during the classical era by European physicians, particularly when they evaluated hysteria. Yet morality continues to influence psychiatric diagnosis, most prominently through the agency of medicine. Peter Conrad has outlined the way medical solutions are increasingly being sought after for behavioral problems.
As treatment rather than punishment becomes the preferred sanction for deviance, an increasing amount of behavior is conceptualized as illness in a medical framework. As noted above, this is not unexpected as medicine always functioned as an agent of social control, especially in attempting to ‘normalize’ individuals and return people to their functioning capacity in society. [lxiii]
Earlier we showed how expansion of medical treatments both within the hospital and across an increasing number of social institutions could be very profitable for psychiatry. The widened jurisdiction of medicine seems to have the additional function of facilitating social control outside the mental hospital. The drug Ritalin, which is administered for Attention Deficit Hyperactive Disorder, is a prime example of the new function of drug treatments.
In the short time since Maurice Liaufer first described ‘hyperkinetic impulse disorder’ (1957), drug treatment for the ADD has had a significant, rapid expansion. Today, five to ten percent of elementary school children are given medication for Hyperactive Attention Deficit Disorder and Attention Deficit Disorder. Why such rapid rises in drug treatment for ADHD and ADD when these were not even recognized mental disorders a mere fifty years ago?
It may be that these drugs are administered so frequently because they help teachers obtain social control in the classroom. Hence, schoolteachers often refer unruly children to psychiatrists in schools, or to principals or parents who bring them to the attention of other mental health professionals. Since Ritalin is frequently administered for hyperactivity, schoolteachers can limit the deviant behavior of children who are felt to be unmanageable through this process of referral. In other words, Ritalin has replaced the hickory stick as a means for ensuring compliant behavior in the classroom. Lastly, the widespread administration of Ritalin is a means of using school children as commodities to produce a profit.
If one looks back into American history it quickly becomes apparent that medical formation of ‘illnesses’ and the subsequent medical treatments for the behaviors that accompany these ‘illnesses’ had very often been a means of facilitating social control. In this respect, the history of mental health services in America is akin to the history of the great hospitals in Europe. In both locations social control supported ethical norms, facilitated economic exploitation of the treated populations, and wherever possible achieved both these ends.
Thomas Szasz has uncovered a condition in his archives that accomplished both these intents. Draepotomaniawas a mental disorder before the civil war that doctors diagnosed black slaves with when they tried to free themselves. The formation of such a medical condition suppressed the desire for freedom in slaves, as well as obviously supporting a continued exploitation of manpower. Another condition, masturbatory insanitywas gradually eliminated from psychiatric nomenclature over the past 100 years, as the practice became less of a violation against ethical norms.
As we turn to our present era, we find the condition nymphomania,which is supposed to be a medical disease referring to “pathologically excessive sexual desire in a female.”[lxiv] Not only is there no equivalent disorder in males, nymphomania most likely is a mental disorder because current social sentiment dictates women should not behave licentiously, while sexual libertinage is more permissible in men. There is also the ‘disease’ of homosexuality which in 1973 the American Psychiatric Association determined was no longer a mental illness.
But the manner in which morality continues to be a means of repressing social deviance is best illustrated through the recent medical treatment of alcohol and drug addiction. From 1870 to 1990 most physicians considered addiction to be “a morbid appetite, a habit, or vice,” while substances such as “acetanilide, bromide and caffeine attracted almost comparable concern to that drawn by opium.” [lxv] Essentially, in this period addiction was not a recognized notion and when individuals used the term ‘to addict’ they were referring to a bad habit. Along the same line of reasoning, Marshall has recently pointed out “beverage alcohol is not a problem unless it is defined as such.” Similarly, prominent ethnographers have discovered “drinking problems are virtually unknown in most of the world’s cultures.” [lxvi]
I am not suggesting alcohol has not been overused in many cultures, since it clearly has been used excessively cross-culturally and throughout history. Instead, I am emphasizing that alcohol, which has been ingested medicinally and in religious ceremonies in many cultures, has only recently been considered an addictive substance worthy of medical treatment. The conception of the problem-drinker or gamma alcoholic that cannot control himself therefore largely results from recent psychiatric promotion of the disease model of alcohol addiction. For example, Keller and associates, have defined alcoholism as “repetitive intake of alcoholic beverages to a degree that harms the drinker in health, or socially or economically, with indication of inability consistently to control the occasion or amount of drinking.” [lxvii]
It is also interesting that one of the criteria that must be met to receive a diagnosis of alcoholism in the Fifth and most recent edition of the Diagnostic Statistical Manual is: “recurrent substance-related legal problems.”[lxviii] If the law reprimands a person he is considered an alcoholic. However, another person who may be more destructive to the state but is not fined or incarcerated by authorities is not. Yet another mystifying criteria the DSM V lists for alcohol addiction is “proper” levels of economic and social functioning. This seems to be a relatively ambiguous criterion that provides therapists’ leniency when making diagnoses.
Yet the most relevant point about alcohol addiction is that those drinking moderately upon completion of a hospital program were more stable than those who abstained from drinking (Proknoy, A.D., B.A. Miller and S.E. Cleveland, 1968). The view that moderate alcohol use will inevitably force and alcoholic to relapse into a state of binge drinking may thus be a modern myth. Finally, the idea that all alcohol use even in normal populations is a deleterious activity may result from widespread acceptance of partial information. For example, a study conducted by Turner and associates challenges the notion that alcohol is a harmful substance, illustrating that the risk of coronary heart disease is lower in persons using alcohol moderately than in abstainers. [lxix]
Of all the scientific research that has been done on alcoholism very little validation for the concept has been amassed. For example, when studies were conducted on the genetic influence on alcoholism no convincing evidence was found in support of the condition. In discussing twin studies examining genetic influences on alcoholism in Psychiatric Diagnosis, Samuel Guze and Donald Goodwin thus remark: “In summary, two twin studies produced results consistent with a genetic influence, one did not, and a fourth was equivocal.” [lxx] Similarly, there is contradictory evidence on the influence of the family on alcoholism. Some studies have shown twenty five percent of fathers and brothers are themselves alcoholics. However, other adoption studies have not revealed significant differences in rates of alcoholism between children of alcoholics or nonalcoholics. Finally, if alcoholism were a valid psychiatric condition one might expect that intensive psychotherapy would improve those suffering from the condition; however, it has not been shown that intensive psychotherapy helps alcoholics. [lxxi] Given these inconsistent and at times contradictory findings why do mental health professionals continue wholeheartedly affirming the need for medical treatment for alcoholism?
The addiction model serves hospital interests since they receive extra funds from the increased numbers of users who submit themselves to hospital programs. Promoting the disease model of alcoholism is one method of assisting judicial administrators and law enforcement officers in their efforts to control deviant behavior brought on by excessive alcohol intake.
The use of alcohol can create difficulties and it is not my intention to discourage treatment efforts for those who desire them. Yet Alcoholics Anonymous and the psychiatric model of alcohol addiction seem problematic, particularly because these agencies refuse to consider that the ‘alcoholic’ might be responsible for his actions. Lastly, it seems objectionable for government agencies and psychiatric services to downplay statistical findings that seriously challenge the addiction concept in order to continue making a profit. Clearly, however, these developments make sense when compared to the forced labor that was morally promoted by Colbert in order to ensure continued economic profitability in the classical era. Overt moral instruction would not be effective today so the prevailing social sentiment is promoted medically.
Illegal drugs have also been used medicinally and for religious purposes cross-culturally. Psychiatry proposes a similar drug addiction model to that which is used for alcohol. In the DSM V, there are two forms of drug addiction listed, physical dependence and psychological addiction. Physical dependence refers to:
The physiological state produced by the repeated administration of the drug which necessitates the continued administration of the drug to prevent the appearance of the stereotyped syndrome, the withdrawal or abstinence syndrome, characteristic for the particular drug. [lxxii]
As was the case with alcoholism, sociological examinations challenge the validity of the drug addiction concept. The evidence in opposition to the drug addiction model is particularly strong in regard to the use of serious drugs, such as heroine and cocaine. For example, Robins, Helzert et al. studied the use of heroine in addicted GI’s returning from Vietnam. They found only twelve percent of GI’s who used heroine regularly overseas showed signs of addiction after their return from Vietnam. Moreover, low rates of readdiction were found although half the men who had been addicted in Vietnam used heroine after returning home. Why is a heroine promoted as one of the most addictive substances that exist when apparently, given the above findings, heroine is no more addictive than amphetamines or marijuana?
Statistical research on patterns of cocaine use similarly challenges the drug addiction model. In his review of the 1988 NIDA National Household Survey of Drug Abuse, Stanton Peele suggests few cocaine users become addicts.
The survey found that 21 million Americans had used cocaine in their lives, 8 million had used it in the last year, 3 million were current users, but that only 300,000 used cocaine daily or nearly every day. Government statistics thus show that 10% of all current users and about 1% of lifetime users use the drug close to daily. [lxxiii]
If only one percent of lifetime users was found to be using cocaine close to daily, why do so many psychiatrists consider cocaine to be a highly addictive substance? Psychiatric models of addiction may be developed to assist law enforcement in restraining drug use. By promoting the cocaine or heroine user as out of control psychiatry encourages the avoidance of these substances in the general populous and reinforces the “war on drugs.” The more extensive psychiatric treatment measures and the rise in the number and variety of rehabilitation facilities for drug addicts serves a similar function to the increased prison sentences given to those who are caught with illegal drugs. In both instances, new regulations are instituted largely because they limit social deviance.
In the age of confinement, social control of madness was predominantly limited to the great hospitals. Modern psychiatry has a much greater scope of influence being able to influence and subordinate diverse populations outside the mental hospital. The addiction concept exemplifies the way medical solutions are being relied upon to manage an increasing range of behavioral and social problems.
The Moral Influence on Psychiatric Categories of Mental Illness
The formation of mental diseases remains heavily influenced by the ethics of the general population. In support of this idea, Irwin Silverman has shown that the American Psychological Association ratified the DSM II based on a vote by its members which was highly responsive to political and social interests. An observer of the process described it in this way:
…a veteran’s group successfully lobbied for a syndrome they wanted to call “Post-Vietnam Combat Disorder.” Feminist women forced a change in a category called “Sexual Sadism,” which they argued would excuse rapists from responsibility for their acts. [lxxiv]
Apparently, social sentiment influences the disorders that are classified as mental diseases. In many instances, categories of mental illness are largely the effects of political and social trends. As Silverman has pointed out, the way conditions are ratified based on group vote with political groups rallying for new disorders bears a strong resemblance to the operation of the lobbyists in the capitol building.
Even in the instances when the formulation of diagnostic illnesses is based in psychological research the criteria upon which these disorders are constructed remain influenced by morality. After reviewing the fifth and most recent Diagnostic Statistical Manual, one finds occupational and social dysfunction to be criteria for psychiatric diagnosis of schizophrenia, obsessive-compulsive disorder, antisocial personality disorder, alcoholism and drug dependence. This suggests attempts to provoke the mad to work in the classical period by morally condemning idleness today are continued through the activity of the therapist who is instructed to consider social/occupational dysfunction to be a sign of mental illness. Idleness may not be “the mother of all evils” today as Colbert once suggested; instead it now becomes a symptom of illness.
Strangely, the person who inherits money and fails to see the need to find work would be considered normal by most psychiatrists while the poor unemployed person would most likely be viewed as mentally ill. This is because the unemployed poor person would be considered occupationally impaired while the unemployed wealthy person with whom he is identical in all other respects would probably not. Hence, based on the occupational/social dysfunction alone those who are poor and unemployed are more likely to be granted medical treatment by psychiatrists than those who are unemployed but have money.
A final example of psychiatry’s promotion of the essential virtues of society are the diagnostic criteria for antisocial personality disorder or sociopathy. Some criteria for this disorder listed in the Fifth Diagnostic Statistic Manual are “failure to conform to social norms with respect to lawful behaviors,” “reckless disregard for safety of self or others,” “impulsivity,” and “failure to sustain consistent work behavior.” [lxxv] Formerly deemed moral insanity, antisocial personality disorder is today a mental illness that is detected by locating behaviors that break laws. Accordingly, Donald Goodwin and Samuel Guze write in Psychiatric Diagnosisthat: “some investigators,” “have required police trouble for the diagnosis of sociopathy.” [lxxvi]
The individual who is caught by authorities is given a diagnosis of Antisocial Personality Disorder more often than the individual who is not. Because police trouble is generally required for an individual to be diagnosed with antisocial personality disorder the condition is a prime exemplification of the tremendous influence law enforcement has on psychiatry. Finally, Goodwin and Guze state “few sociopaths volunteer for treatment. They are nearly always brought to the physician’s attention by pressure from schools, parents, or judges.” [lxxvii] The use of agents to bring sociopaths to mental health services is another illustration of psychiatry assisting the legal and punitive system by facilitating social control.
Even without overt moral instruction in mental hospitals, the recent criteria for mental illnesses and the context around the formation of illnesses in the last few editions of the Diagnostic Statistical Manual remain influenced by social sentiment. Apparently, mental health services are not much more objective than in the classical era since we have not eliminated psychiatric treatment measures that have the primary function of reinforcing ethical norms.
Statistical findings of higher rates of mental illness and more frequent and longer periods of hospitalization in poor and homeless populations are best explained by problems in psychiatric assessment. The likelihood of these complications is reinforced by the inaccuracy of clinical assessment tests (which Irwin Silverman highlights) and Rosenberg’s study in which every patient mimicking mental illness was diagnosed with schizophrenia and then hospitalized.
There are numerous signs that psychiatric assessment is particularly inaccurate in assessing poor and homeless populations. For example, long-term unemployment, nutritional and sleep deficits, and normal responses to life on the street may all be misread as signs of mental disorder. Most importantly, a host of psychological and sociological studies consistently showed psychiatrists diagnose a poor person with higher levels and more severe forms of mental illness and consider him or her to be more dangerous than a middle or upper class person. The overwhelmingly negative and suspicious responses of the homeless population to psychiatric treatment further bolsters the idea that the homeless and poor continue to be obfuscated with madmen and subject to treatment measures they do not desire. In sum, the homeless population appears to be subordinated today by psychiatry in a similar fashion to the way beggars during the age of confinement were by the houses of confinement.
The level of tolerance from family members and the general population, as well as the operation of law enforcement officers also probably contribute to the higher rate of hospitalization in poor populations. For example, law enforcement brings homeless people to psychiatrists in mental hospitals through urban treatment programs such as Project HELP. The influence family members and law enforcement have today on hospitalization rates is very similar to the influence public sentiment and the operation of a militia had during the classical era.
Harvey Brenner’s statistical analysis illustrated that a manipulation of labor to meet market demand continues to be the major determinant of hospitalization rates. An ‘industrial reserve army,’ made up largely of the poor and homeless appear to be added to the labor force during periods of economic growth and hospitalized during periods of economic downturn. Manipulation of the American labor force has essentially the same function as the rounding up of beggars in the streets and forcing them to work (either on street repairs or in workshops in the great hospitals) when there was an economic crisis. In both epochs, increasing the number of poor people who are hospitalized during economic crisis reduces competition in the labor force and allows wages in the general population to rise. Additionally, it guarantees increased profits for the mental hospital through economic exploitation of a larger number of involuntarily hospitalized persons.
Instead of hospital patients producing commodities in labor workshops, patients themselves seem to have become the raw materials that are treated by the mental hospital in order to produce profits for psychiatry.
Psychiatry continues to control deviant behavior. Instead of corporeal punishment and overt moral instruction it is the medical classifications of mental illnesses and the subsequent medical treatment measures that today facilitate patient management. For example, anti-psychotic drugs have replaced the chains used as measures of restraint in the classical era. As was the case historically in America, the variety of mental disorders and the criteria for those disorders depends upon the ethics of the majority, ethics which medicalization further upholds. Finally, as in the classical era, subordination of hospitalized populations at oncefacilitates social control andfinancial exploitation.
There are obviously important differences between the great hospitals and modern American psychiatry. Mental health services today influence a much larger range of institutions and have more diversified and complex means of wealth production. The mental hospital is no longer a place where human beings are caged, are chained, and are tortured. Nevertheless, psychiatry continues to control and profit off homeless and poor populations. It continues to rely on law enforcement officers and to be heavily swayed by the levels of tolerance and the ethical virtues of the general population. The question therefore must be asked: to what degree have we progressed in our treatment of madness?
It remains the job of mental health professionals to counteract the above effects. In particular, mental health professionals should take precautionary measures in assessing poor and homeless populations, providing a degree of leniency in making diagnoses in order to limit psychiatric bias. Furthermore, patient rights need to be upheld by the mental hospital rather than being circumvented by a community treatment order. Patients should not be required to take anti-psychotic drugs except in instances where there are no other options, since they have serious side-effects and have been shown to be brain-damaging. Lastly, mental health professionals should do their best to prevent diagnosing patients based on ethical feelings and to avoid Cereletti’s error of confabulating repression with rehabilitation. Nevertheless, since many of the problems psychiatry faces are structural, are functional, and are systematic, a significant improvement in mental health services would require drastic alterations in the therapeutic industry.
 There will be a few references to 20thCentury conditions in Great Britain.
Foucault has shown that mental illness the medical concept, is not the same as madness the critical concept. Yet, for the purposes of this examination they will be used interchangeably. This is first because sociological studies concern themselves with the psychiatric category mental illness. And second because the important element in this examination is the way those in positions of authority (psychiatrists, hospital directors, administrators etc) conceive of mental patients under their care.
In Pure Types Are Rare, (p.48) Irwin Silverman points out that in studies where pairs of psychiatrists independently assess the same individuals, rates of agreement have been shown to be as low as fifty-three percent.
Brenner points out this does not mean the woman who begins therapy because of abandonment by her husband is wrong for neglecting economic factors. The abandonment influenced her coming to therapy; however, it was secondary to molar changes in the economy that provoked her separation. Moreover, it seems probable that the patient who is cognizant of economic factors will downplay less immediate causal effects in therapy, particularly since they are often marginalized by psychiatrists in comparison to the importance of family life or personal difficulties.
Instead, of an estimated 100 deaths per 100,000 there are now a mere 2 per 100,000. These estimates are based in historical findings taken by American physician Benjamin Rush.
“Every study has reported either no statistically significant differences between treatment settings or differences favoring less intensive settings.”
These rates are even higher in elderly populations and individuals taking high-level dosages. Kendall and Hammen, Abnormal Psychology, Houghton Mifflin Company, Boston 1998 p. 287
[i]Foucault, Madness and Civilization, A History Of Insanity in the Age of Reason,Random House, 1965
[iv]Ibid., p. 40
[v]Ibid., p. 51
[vi]Ibid., p. 53
[vii]Ibid., p. 68
[viii]Ibid., p. 62
[ix]Ibid., p. 157
[x]Ibid., p. 149
[xi]Ibid., pp. 73–74
[xii]Ibid., p. 38
[xiii]Kenneth S. Pope and Paula B. Johnson Psychological and Psychiatric Diagnosis, p. 387
[xiv]Kendall and Hammen, Abnormal Psychology, Houghton Mifflin Company, Boston 1998, pp. 561–563
[xv]Irwin Silverman, Pure Types Are Rare, Praeger Publishers, New York, 1983 p. 112
[xvi]Homelessness and Mental Health, Edited by Dinesh Bhugra, Cambridge University Press, Cambridge, 1996 p. 111
[xvii]Kendall and Hammen, Abnormal Psychology, p. 269
[xviii]Ibid.,pp. 222, 242, 269, 439
[xix]Ibid., p. 563
[xx] Homelessness and Mental Health, Edited by Dinesh Bhugra, p. 30
[xxi]The Political Economy of Schizophrenia, Ch. 6 Labor, Poverty, and Schizophrenia.
[xxii]Kendall and Hammen, Abnormal Psychology, p. 440
[xxiii]Homelessness and Mental Health, Review of (Gelberg et al; 1998) by P. Joseph, p. 82
[xxiv]Ibid., p. 82
[xxv]Ibid., p. 83
[xxvi]Ibid., p. 83
[xxvii]Irwin Silverman, Pure Types Are Rare, p. 54
[xxviii]Ibid., Foreword ix, x.
[xxix]Kendall and Hammen, Abnormal Psychology, p. 284
[xxxi]Kenneth S. Pope and Paula B. Johnson Psychological and Psychiatric Diagnosis, p. 397
[xxxii]William Hasse, “The Role of Socioeconomic Class in Examiner Bias,” in Riessman, Cohen and Pearl, Mental Health of the Poor, Free Press, 1964, pp. 241–248.
[xxxiii]The Political Economy of Schizophrenia, Ch 6 Labor, Poverty, and Schizophrenia
[xxxv]Homelessness and Mental Health, Edited by Dinesh Bhugra, p. 233
[xxxvii]Donald W. Goodwin and Samuel B. Guze, Psychiatric Diagnosis Fifth Edition, Oxford University Press, Oxford, 1996, p. 320
[xliii]Brenner, M. H. Mental Illness and the EconomyCambridge: Harvard University Press, 1973, p. 184
[xliv]Homelessness and Mental Health, pp. 270, 271
[xlv]Ibid., p. 271
[xlvi]Deleuze and Guttari, AntiOedipus: Capitalism and Schizophreniap. 75
[xlvii]Thomas S. Szasz, The Myth of Mental Illness p. 7
[xlviii]R.D. Laing, The Politics of Experiencepp. 129,133
[xlix]Antonin Artaud, Selected Works, edited by Susan Sontag, University of California Press, Berkley, California, 1973, p. 483
[l]Brenner, M. H. Mental Illness and the EconomyCambridge: Harvard University Press, 1973, Intro, x, xiii.
[li]The Political Economy of Schizophrenia, Ch. 6 Labor, Poverty, and Schizophrenia.
[lii]The Marx-Engels Reader, edited by Robert Tucker, W.W. Norton & Company, New York, 1978,
[liii]Brenner, M. H. Mental Illness and the Economy, p. 227
[lv]Foucault, Madness and Civlization, pp. 51,52
[lvi]Kendall and Hammen, Abnormal Psychology, Houghton Mifflin Company, Boston 1998, p. 164
[lvii]Ibid., p. 90
[lviii]Ibid., p. 90
[lix]Irwin Silverman, Pure Types Are Rare, p. 61
[lx]Betram P. Karon, The Fear of Understanding Schizophrenia,Lawrence Erbaulm Associate Inc.Michigan State University, 1992
[lxi]Irwin Silverman, Pure Types Are Rare, p. 267
[lxiii]Peter Conrad, On The Medicalization of Social Deviance, p. 109
[lxiv]Irwin Silverman, Pure Types Are Rare, p. 30
[lxv] Stanton Peele, Psychology: Perspectives And Practice, Addiction As A Cultural ConceptAnals Of The New York Academy Of Sciences, Volume 602, New York 1990, pp. 205–207
[lxvi]Ibid., p. 210
[lxvii] Donald W. Goodwin and Samuel B. Guze, Psychiatric Diagnosis Fifth Edition, p.179. Italics mine.
[lxviii], Ibid.,p. 181
[lxxi]Ibid.,pp. 202, 203, 208
[lxxii]Ibid., p. 218
[lxxiv]Irwin Silverman, Pure Types Are Rare, p. 39
[lxxv]Donald W. Goodwin and Samuel B. Guze, Psychiatric Diagnosis Fifth Edition, p. 264