“Empire of Normality: neurodiversity and capitalism” a review: The Empire Has No Clothes

A review of “Empire of Normality: neurodiversity and capitalism” Robert Chapman, Pluto Press 2023.

 

Introduction

Concepts of diagnosis and illness are fundamental to psychiatry. Challenge diagnosis, show that it lacks reliability and validity, show that its notion of mental illness lacks consistent biological correlates, and you threaten the whole of psychiatry. Reject diagnosis, refuse its categories, conceptualise distress in non-medical ways, and you reject psychiatry entirely. This is the view of many critics, including contributors to Mad in the World.

For a long time, there has been a broad consensus that the converse is also true. Accept diagnosis, grant it legitimacy, use it or the medicalised notion of mental illness upon which it rests, and you reinforce psychiatry. If you endorse diagnosis, or accept its concept of mental illness, your critique of psychiatry will be at best superficial.

“Empire of Normality” challenges this consensus. Its author, Robert Chapman, a UK lecturer in philosophy, is ‘proudly neurodivergent and disabled’ and identifies as non-binary (pronouns they/them). In this book, Chapman both builds upon and extends previous writing to present an account of mental distress that uses concepts from the neurodiversity movement. Simultaneously, Chapman uses Marxist theory in order to locate the origins of mental distress within the social and economic relations we call capitalism.

This might seem to broadly align “Empire of Normality” with many other critiques published here. Yet “Empire of Normality” overwhelmingly rejects contemporary critical psychiatry and related perspectives (from psychology, counselling, social work etc.). In fact, “Empire of Normality” describes them all as anti-psychiatry (p.18); consistently characterises anti-psychiatry as ‘Szaszian’; and dismisses it as “reactionary and outdated” (p.10).

Significantly, for “Empire of Normality” ‘Szaszian’ doesn’t only mean ‘influenced by anti-psychiatrist Thomas Szasz’. It also means promoting Szasz’s extreme right-wing politics (p.79) and dismissing as fakery the suffering of people given psychiatric diagnoses (p.80). Effectively, “Empire of Normality” implies that anyone who rejects the idea of mental distress as medical illness is pursuing an extreme right-wing agenda that ignores the anguish of mental health service users.

This verdict would apply to almost every contributor published by Mad in the World. It would apply to critics like James Davies, Lucy Johnstone, Joanna Moncrieff and Sami Timimi. And it would apply to experts by experience like Jacqui Dillon, Eleanor Longden, Olga Runciman and Laura Delano. All these writers and campaigners conceptualise mental distress in non-medical ways. For “Empire of Normality” this seems to mean that they all endorse right-wing positions, and dismiss very real and painful experiences as “merely illusory ‘labels’” (p.3).

Of course, what these critics reject is the psychiatric concept of mental illness and its associated diagnoses. None argue that the debilitating anguish of many people given psychiatric diagnoses is illusory. They simply do not conceptualise that anguish as symptomatic of quasi-medical illnesses.

This is such a well-established perspective that reviewers might have been expected to dismiss “Empire of Normality” as ill-informed. Instead, some influential commentators have reviewed “Empire of Normality” positively, and endorsed its account of mental distress as ‘ground breaking….a tour de force’ and ‘an instant seminal text’ What is more, similar arguments are being promoted elsewhere in the neurodiversity movement. This makes it important to carefully assess “Empire of Normality’s arguments and evidence. But first, some background is required.

 

Neurodiversity

Neurodiversity originated in the late 1990s as a unifying concept for political campaigning and online discussion. People described by psychiatry as having high-functioning autism, or Asperger’s Syndrome, began instead to describe themselves as neurodivergent. Rather than seeing their difficulties as symptoms of disorders, they reframed them as the consequence of living in a world organised to meet the needs of the neurotypical majority.

In many respects this was a straightforward application of the social model of disability^[1]. But even as the concept of neurodiversity became better known, neurodivergence remained ill-defined and its boundaries were not identified (and nor have they been since). This facilitated a rapid expansion, which has had two notable consequences.

First, neurodivergence now embraces a dizzying variety of conditions. As well as autism (since DSM5, Autistic Spectrum Disorder: ASD) and ADHD, which predominate, neurodivergence has been said to include the experiences associated with such psychiatric diagnoses as bipolar disorder, social anxiety disorder, schizophrenia and the personality disorders. At the same time, many neurological diagnoses have been proclaimed instances of neurodivergence, including Tourette’s Syndrome, Down’s Syndrome, Parkinson’s Disease, epilepsy, dementia and the effects of brain injury.

The second consequence is that neurodivergent people hold differing attitudes toward psychiatric diagnosis. Some reject it as reductive, medicalising, stigmatising and so on; others accept it as a description of difference, whilst questioning its implications of disorder or illness; others simply embrace it, feeling that it wholly explains their difficulties.

Some people clearly find neurodivergence a useful concept. The readership of Mad in the World probably includes people who endorse any one of these three possibilities, each holding their particular attitude in good faith. Personal understandings of mental distress are shaped by many influences, and no criticism is made or intended here of anyone’s interpretation of their own predicament.

 

Neurodivergent Marxism

In place of established critical perspectives in mental health, “Empire of Normality” proposes neurodiversity – specifically its own neurodivergent Marxism – as the truly critical way forward. The rapid expansion of neurodivergence has generated momentum which “Empire of Normality” aims to harness or guide. “Empire of Normality” looks forward to “more neurodivergent Marxist­-Leninist organisations in the coming years” (p.162), and strives to be in the vanguard of what it sees as an emergent mass movement:

“Our neurodivergent praxis must… be internationalist in its orientation, aiming to destroy the eugenic borders that structure and limit movement globally… the collective building of a mass anti­capitalist politics of neurodiversity will be necessary for not just neurodivergent liberation but also for our broader efforts towards collective liberation.” (p.164/165)

There is considerable ambition here. To an extent this is understandable since “Empire of Normality” does have some positive potentials. The neurodiversity movement would benefit from a structural account that diluted or neutralised its unhelpful tendencies toward identity politics: “Empire of Normality” could conceivably supply this. Additionally, “Empire of Normality’s use of Marxist theory gives it a language, concepts and analytic style in common with other groups: this could facilitate alliances.

More generally, “Empire of Normality’s work of honing and refining neurodiversity, to produce an account that centrally implicates capitalism in the production of clinically significant distress, has considerable appeal. In fact, in this regard “Empire of Normality’s analysis might even be said to somewhat resemble that of critics whose work “Empire of Normality” dismisses: the Power Threat Meaning Framework^[2], for example.

 

Assessing “Empire of Normality”

Overall, “Empire of Normality’s analysis engenders some positive potentials. Yet if these potentials are to have any possibility of being realised, “Empire of Normality” needs to be both accurate and coherent.

As this review will show, this is not consistently the case, and “Empire of Normality” is frequently flawed in one of three ways. First, a shortage of detail and historical context sometimes creates misleading impressions. Second, significant assertions sometimes lack adequate (occasionally, any) evidence. And third, “Empire of Normality’s historical interpretations are sometimes contradicted by other, well-regarded histories.

These flaws will now be illustrated by carefully analysing two significant topics in “Empire of Normality”: the pathology paradigm, and anti-psychiatry. As we have seen, for “Empire of Normality” anti-psychiatry includes both the 1960s movement and contemporary critics. For this reason, “Empire of Normality’s” critiques of anti-psychiatry will be addressed even where their contemporary relevance is unclear.

Before that comes an analysis of “Empire of Normality’s” history of the pathology paradigm. This analysis will consider the paradigm overall, but the connection that “Empire of Normality” identifies between Emil Kraepelin and the paradigm’s ‘founder’ Francis Galton will be a particular focus. This is because “A key part of [“Empire of Normality’s”] argument is that [the pathology] paradigm was … taken up and expanded, with great fervour, by influential psychiatrists such as Emil Kraepelin” (p.16).

 

The Pathology Paradigm

Background

The pathology paradigm is the set of resources which function to impose societal norms of ableness and disability. As these norms change, so does the paradigm. Its existence was first proposed in 2012 by neurodiversity theorist Nick Walker, who explains that it assumes:

“ … that there is one ‘right’ style of human neurocognitive functioning. Variations in neurocognitive functioning that diverge substantially from socially constructed standards of ‘normal’—including the variations that constitute autism—are framed within this paradigm as medical pathologies, as deficits, damage, or ‘disorders’.”^[3]

“Empire of Normality” uses Walker’s concept, but proposes instead that the pathology paradigm makes three assumptions:

“… that mental and cognitive functioning are [1] individual and [2] based on natural abilities, and [3] can be ranked in relation to a statistical norm across the species.” (p.63; numbers added)

The pathology paradigm resembles the ‘medical model’ of psychiatry in assuming that (hypothetical) deficits are the underlying causes of the disorders it identifies. But it is a broader concept that also includes “restricted standards of mental normality and … the default pathologisation and stigmatisation of divergence” (p.6). Rather than being confined to psychiatry the pathology paradigm underpins “psychiatric and psychological research and practice, as well as more general societal responses to neurodivergence” (p.6).

“Empire of Normality” claims that the pathology paradigm both reinforces, and is reinforced by, “capitalist logics” (p.17). For example, a business might try to enhance efficiency by identifying and replacing poorly performing workers. To do this it is likely to use the resources of the pathology paradigm. If profits subsequently increase, both the logic of ‘enhanced efficiency’ and the paradigm itself are reinforced.

In association with capitalist initiatives of this kind, the pathology paradigm is foundational to “Empire of Normality’s” neurodivergent Marxism. The opening chapters of “Empire of Normality” establish this foundation by describing its emergence in relation to major historical events of the last 400 years or so, including the Enlightenment, the 1789 French revolution and the Industrial Revolution.

In Chapter 3, “Empire of Normality” draws two related conclusions from this history. First, that the pathology paradigm could equally be called Galton’s (or the Galtonian) paradigm, after British polymath and ‘father of eugenics’ Francis Galton. Second, that Galton significantly influenced German psychiatrist Emil Kraepelin’s seminal contribution to modern psychiatric diagnosis.

 

The Galton Connection

“Empire of Normality” describes how Galton ‘fused’ Darwinian theory with a modified version of Quetelet’s statistical analyses. This created both a numerical procedure for defining normality and an argument for the evolutionary superiority of exceptional individuals. Galton believed that abilities were individual and largely natural (rather than learned). He assessed them by calculating averages and standard deviations of their measurement, and by constructing statistical distributions. Because of this and other accomplishments, “Empire of Normality” asserts that Galton was:

“…the founder of the pathology paradigm, in the sense that he provided both its metaphysical basis and developed many of the experimental methods that provided blueprints for later researchers. And it was this – Galton’s paradigm – that would then be taken up by Emil Kraepelin” (p.47)

Kraepelin is renowned for pioneering the use of scientific research to develop categories of mental distress, which he understood as representing discrete biological illnesses. Kraepelin’s work is widely recognised as the basis of modern psychiatric diagnosis (although his research was flawed^[4]).

People given psychiatric diagnoses are central to the pathology paradigm. Demonstrating a connection between Galton, whom “Empire of Normality” designates the paradigm’s ‘founder’, and Kraepelin would make “Empire of Normality’s” account coherent. Simultaneously, in revealing a previously-unnoticed connection between the two men, “Empire of Normality” would make an original contribution to the history of psychiatry.

The unequivocal assertion that Galton developed a paradigm, metaphysics and methods, which Kraepelin subsequently expanded, gives the clear impression that such a connection has been identified. But there is a problem. Other scholars have not discerned any substantial influence of Galton – either on psychiatric diagnosis in general, or Kraepelin in particular. As “Empire of Normality” admits:

“it is curious that, despite his influence being acknowledged elsewhere, Galton is barely mentioned in general histories of psychiatry, whether those written by mainstream psychiatrists or anti­psychiatry critics.” (p.47).

Notwithstanding, a few pages later “Empire of Normality” again asserts that “While he inspired a number of doctors, the most notable to expand Galton’s paradigm was … Emil Kraepelin” (p.53).

Below, this claim will be assessed. First, a more general concern will be sketched: historical context is frequently lacking.

 

Galton in Context

“Empire of Normality” does not adequately situate Galton within the various strands of intellectual history that shaped his work. Consequently, it may give a misleading impression of the distinctiveness of Galton’s intellectual contributions, many of which are now very obviously infused with Galton’s classism, racism and misogyny. Such views are rightly seen as repugnant, and the point of contextualising Galton’s work is not to excuse them. Rather, the aim is to begin identifying how these views were culturally embedded and historically transmitted.

For example, Galton’s work of measuring and rank ordering individuals by ability is part of a lengthy history. Before Galton, this history goes back at least to Morton in the 1700s at Harvard, who estimated brain mass (as a proxy for intelligence) by measuring skull cavity volume. It proceeds through figures such as Lombroso and Broca in Europe and continues after Galton in the work of psychologists and others including Goddard, Terman and Yerkes^[5].

This history reveals how Galton’s use of anthropometry and craniometry, which led to his subsequent development of crude psychometric techniques, was prefigured by Morton’s work. It also shows that, no matter their basis, these rankings were remarkably similar: white men were at the top, skin colour got darker as the hierarchy descended, and women were often excluded.

This is no coincidence. Until abolition, the transatlantic trade in enslaved people from Africa, and the associated practice of slavery, were important drivers of this research. Some supporters attempted to justify the trade by proposing that darker skinned people actually come from separate, inferior or less able human species. This engendered a high-profile debate between so-called polygenists (‘many species’) and monogenists (‘one species’), and both sides sought evidence for their positions.

Despite its relevance this debate isn’t mentioned. “Empire of Normality” briefly locates Galton in his time, family (cousin of Darwin) and personal circumstances (extremely wealthy); notes some possible influence from phrenology; and makes some observations about the utility of Galton’s work for productivity and policing. However, Darwin and Quetelet aside, there is scant consideration of the intellectual fabric within which Galton was continuously enmeshed, and which nurtured certain amongst his scholarly tendencies whilst discouraging others.

This omission sometimes makes Galton’s achievements (influential and wide-ranging as they undoubtedly were) appear more uniquely ‘his’. For example, “Empire of Normality” (p.52) says that in 1883 Galton presented “his newly coined concept of eugenics… the science of improving stock […] to give to the more suitable races or strains of blood a better chance of prevailing”.

Although Galton was responsible for the word, he invented neither the concept nor its associated practices. In around 400 B.C. Plato’s ‘Republic’ described a system of deliberately matching ‘gold souls’ for procreation by using a rigged lottery (suggesting that state interference in such matters was seen as unacceptable). Around this time, too, both the Ancient Greeks and the Romans ‘exposed’ babies born with disabilities: they abandoned them outdoors, to die alone.

During subsequent centuries, and before Mendelian genetics were understood, many religions recognised the perils of inbreeding and outlawed marriage between close relatives. Conversely, farmers learned to cultivate certain crop strains, and selectively breed particular animals, so as to preserve or enhance desired characteristics.

As the 19^th century began, some opponents of slavery graphically described the forced breeding of enslaved people as one of its many abuses. Most described breeding to increase numbers, but as criticism mounted to its 1840s peak there were additional suggestions that some plantation owners were “attuned to ‘commercial eugenics’ and ‘stimulated breeding’”^[6]. By this time, too, it was also common for anxieties over heredity to inform discussions about the choice of marital partners^[7].

Then, between 1869-1880, the Oneida religious community in New York State introduced a selective breeding programme called ‘stirpiculture’ under which 58 children were born. Stirpiculture was influenced by the religious writings of Oneida founder John Noyes, agricultural selective breeding, Plato’s ‘Republic’, and concerns about heredity. It was later retrospectively justified with reference to Darwin and Galton^[8].

Rather than create a “new science” (p.52) then, it is possibly more accurate to say that Galton brought together and systematised already-existing ideas and practices; legitimated and elaborated them with reference to evolutionary theory; then named the resulting ensemble ‘eugenics’.

Seen this way, Galton is still hugely influential. But the intellectual accomplishment of eugenics cannot be attributed solely to his efforts. Its origins are simultaneously historically transmitted, culturally distributed and socially shared. They are perhaps as much a product of certain elements within what Marx called the ‘general intellect’ as of Galton’s individual acumen.

A similar view can be taken of what “Empire of Normality” calls Galton’s “obsessions” with heredity, genius and rank ordering by ability. Biographically, as “Empire of Normality” (p.46-8) recognises, these interests reflected Galton’s privileged background and elite education. Historically they would have been encouraged by arguments aired within the debate about polygeny versus monogeny. And contemporaneously, these interests would have resonated with concerns being raised in connection with degeneration theory.

Degeneration theory was influential and much discussed in the latter half of the 19^th century. It was widely endorsed by medical academics, including such eminent psychiatrists as Henry Maudsley^[9] and Kraepelin^[10].

The theory is usually traced to the 1857 work of Morel, a French psychiatrist, who proposed that frequent consumption of ‘poisons’ such as alcohol, hashish (cannabis) and opium made what were described as the ‘lower classes and races’ inherently prone to neurological and mental conditions.

Amongst individuals, these conditions were said to precipitate lunacy, idiocy, poverty, crime and prostitution. At population level, the result would be mental, physical and moral deterioration that cascaded and multiplied amongst offspring. Evolution would be pushed into reverse: degeneration^[9].

Whilst “Empire of Normality” (p.51) acknowledges that Galton feared “racial degeneration”, the probable synergies between his fears and this influential theory are omitted. In what follows it will help to recall that Galton’s eugenic proposals and fear of degeneration, no less than his interests in genius, heredity, measurement and ranking, were not merely personal quirks or obsessions. They had a simultaneous cultural aspect and were relevant to, if not provoked by, prominent intellectual debates.

 

Kraepelin and Galton

With this context established, “Empire of Normality’s” claims will now be assessed. Did Galton provide a paradigm, a metaphysical basis and experimental methods, that were taken up and expanded by Kraepelin in his work on psychiatric classification?

This question bears directly upon “Empire of Normality’s” claim to have identified a novel historical association between Galton and Kraepelin. Additionally, since the pathology paradigm is foundational to “Empire of Normality”, a negative answer would impact adversely upon the entire text.

Whilst “Empire of Normality” unambiguously asserts that Galton influenced Kraepelin in precisely these ways, little evidence is presented to support these assertions. “Empire of Normality” offers just two paragraphs from a lengthy paper by Kraepelin, published in 1922 by the Journal of Mental Science^[11] (originally published in German in 1918):

“By […] determining the range of normal variation, we shall obtain a standard for measuring morbid deviations – a standard that will be of value, not merely for pure science, but for many practical purposes, as for estimating school capacity, military fitness, business talent, and responsibility […] Thus we may gradually learn, not only to characterise numerically the various grades amid kinds of intellectual defect, but to obtain more exact expressions for insufficiencies and aberrances in other mental spheres. Only thus can the important forms of psychopathy that fade into one another be more clearly outlined”

“The psychiatric importance of such investigation on the large scale cannot be over­estimated. A mass psychiatry, having at its disposal statistics in their widest scope, must provide the foundations for a science of public mental health – a preventive psychological medicine for combating all those mischiefs that we group under the head of mental degeneracy.”

“Empire of Normality” characterises these paragraphs as “unmistakeably Galtonian” (p.54) although Galton is neither named nor cited. Surprisingly, given what is at stake, this is the only evidence that “Empire of Normality” presents in support of its claim that Galton influenced Kraepelin’s work on psychiatric classification. This raises four objections.

First, the quantity of evidence is infinitesimal, relative both to Kraepelin’s extensive writings and the scale of “Empire of Normality’s” claim. If Galton’s influence upon Kraepelin were as pervasive and significant as “Empire of Normality” says, we might reasonably expect more evidence.

Second, Galton’s influence is inferred rather than explicit: in fact, his name does not appear anywhere in Kraepelin’s lengthy paper. This is particularly troublesome given “Empire of Normality’s” failure to thoroughly contextualise Galton’s work. This failure makes it harder to judge what, if anything, is specifically Galtonian in these short passages.

Compounding this difficulty, “Empire of Normality” makes no attempt to show that Kraepelin’s suggestions are ‘unmistakeably Galtonian’: it merely asserts this as though it were self-evident. The assumption seems to be that in 1918 Kraepelin simply must have been inspired by Galton’s use of normal distributions and standard deviations, his interests in measuring and rank ordering, and his fear of degeneracy.

Notwithstanding the adjective ‘unmistakeably’ this assertion is speculative. What is more, each of Kraepelin’s suggestions might be plausibly explained on the basis of known facts about his life and work, without invoking Galton.

In an analysis that conceptually echoes certain aspects of “Empire of Normality”, philosopher Ian Hacking details how the word ‘normal’ acquired its modern meaning, beginning in the 1820’s in medicine:

“The normal was one of a pair. Its opposite was the pathological and for a short time its domain was chiefly medical. Then it moved into the sphere of – almost everything. People, behaviour, states of affairs, diplomatic relations, molecules: all these may be normal or abnormal.”^[12]

Kraepelin was medically trained during the 1870s and devoted his subsequent career to identifying and differentiating between psychiatric pathologies. This could have given him a straightforwardly medical, clinical, applied and non-Galtonian context for using concepts of both ‘normal’ and ‘deviation’ since, as Hacking further explains: “The pathological was defined as deviation from the normal. All variation was characterized in terms of variation from the normal state.”^[13]

Similarly, Kraepelin’s medical training and research could have sensitised him to the advantages of numerically grading and differentiating ‘intellectual defects’ and ‘forms of psychopathy’. Finally, Kraepelin’s endorsement of mass psychiatric testing could have reflected a desire to guard against the population-level deterioration predicted by degeneration theory. So it might have been Galton – rather than, say, Goddard, Terman or Yerkes – who inspired Kraepelin in these paragraphs; but the evidence is equivocal.

Third, there is a mismatch between the suggestions in this paper and the research Kraepelin actually conducted when developing his diagnostic system. Kraepelin tried to create a scientific basis for psychiatric classification based upon the convergence of detailed, longitudinal clinical observation, neuroanatomy and etiology (causation). Kraepelin established this approach before the second edition of his textbook was published in 1887, and it did not fundamentally alter in subsequent years^[14]. Consequently, during his career identifying and refining putative diagnostic categories, Kraepelin consistently worked with relatively small numbers of hospital patients. He never worked with populations, in the manner advocated in this paper.

And fourth, there is a troubling issue of chronology. The first version of Kraepelin’s psychiatric classification scheme was published in 1883, fully 35 years before this paper appeared in 1918. By then, Kraepelin’s work was nearly over. He retired from teaching in 1922 and died four years later. Speculative suggestions for future research, made in the twilight of his career, are not evidence that Kraepelin worked with Galton’s paradigm during the preceding four decades.

 

General Influence

Already, these objections make “Empire of Normality’s” assertion that Kraepelin took up and expanded Galton’s paradigm appear doubtful. But there is also an academic literature on Kraepelin. “Empire of Normality” alludes to this work (p.53) but says little about its contents, even though they are frequently relevant.

In this literature, Hoff^[14] names Wundt, Griesinger and Kahlbaum as intellectual influences upon Kraepelin. An analysis by Berrios and Hauser^[15] specifically exploring the development of Kraepelin’s early ideas also identified both Wundt and Kahlbaum, whilst a third analysis by Heckers and Kendler^[16] identifies Wundt, together with Schule, Kraft-Ebbing, and an anatomist, von Gudden. But none of these authors identify Galton as an influence. In fact, one even says:

“It will always be a cause of wonder to know how much further Kraepelin would have gone, had he applied more complex statistical techniques to his data. During this period Galton had already suggested ways of improving correlational analysis, but it is unlikely that Kraepelin knew of these”^[17]

So it seems that no general intellectual influence from Galton has been discerned. But “Empire of Normality’s” assertion contains two very specific claims: that Galton supplied Kraepelin with a metaphysical basis for his work, and with an experimental method.

 

Metaphysics

Historians Berrios & Hauser^[15] characterise Kraepelin’s metaphysics as Kantian, and (in his preference for localised order) reflecting his Bismarckian politics. The Kantian influence is attributed to Wundt. Orienting toward philosophy of science more so than history, Hoff^[14] identifies four metaphysical commitments within Kraepelin’s work: realism, psychophysical parallelism, experimentalism and naturalism. Naturalism and psychophysical parallelism are similarly highlighted by Heckers & Kendler^[16] who also cite Wundt as a source.

Galton is not mentioned as a possible source of Kraepelin’s metaphysics by any of these authors. Moreover, since “Empire of Normality” does not describe the metaphysical perspectives of either man the basis of this claim is unclear. It is difficult to understand how Kraepelin could have acquired his metaphysics from Galton, whilst seeming to have acquired them elsewhere.

 

Method

“Empire of Normality’s” other claim is that Kraepelin took up Galton’s experimental method. On this topic, “Empire of Normality” commends one book in particular:

“The influence of Galton on psychological and psychometric research has been well established elsewhere. The most notable work on this is Kurt Danziger’s book Constructing the Subject: Historical Origins of Psychological Research, which establishes how Galton’s theories and methods formed the basis for much research since this time.” (p.53)

Rather than focusing upon Galton specifically, as “Empire of Normality’s” description might imply, Danziger^[18]  actually gives a history of early psychological research methods overall. Galton is discussed on p.54-8, with numerous subsequent mentions throughout. Danziger acknowledges Galton’s significant influence on the evolution of modern psychological research, whilst simultaneously identifying many other factors. These include changes in economic and social orders; war and its consequences; other important scholars; institutional pressures; and commercial interests.

Danziger’s extended discussion of Galton appears within his description of three different styles of experiment in use at the dawn of modern psychology:

Wundt’s ‘Leipzig model’ relied upon introspection by trained participants who were schooled in reporting their own experiences. They were typically already in collaborative relationships with the experimenters, and even exchanged roles with them

The ‘clinical model’, pioneered by French scientists, focused on phenomena that were unusual or pathological. Detailed observations were made, frequently by doctors already known to participating patients.

Galton’s ‘anthropometric model’ involved quantitative data collected by expert experimenters with no relation to participants. Data was subject to statistical analyses that compared subjects against each other, and against aggregate values.

Danziger describes how the fledgling discipline of psychology gradually came to favour Galton’s method. His analysis of psychology journal papers published between 1894 and 1936 shows a steady decline in the Leipzig model and a corresponding rise in the anthropometric model.

Nevertheless, this dominance emerged in psychology, not psychiatry. Moreover, the process was gradual and took until the beginning of World War Two. So Danziger provides no support for “Empire of Normality’s” claim that Kraepelin adopted Galton’s experimental method (and besides, Kraepelin is not mentioned anywhere in Danziger’s substantial text).

Turning to the substance of Kraepelin’s work, his own primary research method – analyses of longitudinal observations of patients – exemplifies what Danziger called the clinical model. It was almost certainly acquired from Kahlbaum, who is known to have worked in the French tradition. Conversely, Kraepelin’s endorsement of formal psychology experiments is believed to reflect Wundt’s influence:

“Kraepelin [1883] described … how neuroanatomy and experimental psychology can support the pathological study and clinical characterization of mental disorders. The influence of his two mentors – the anatomist B. von Gudden and the experimental psychologist W. Wundt (1832-1920) – is unmistakable.”^[19]

It has been noted that Kraepelin is thought to have been ignorant of Galton’s correlational techniques. Nor did he use Galton’s anthropometric photographic methods to derive types of individuals. Neither did he conduct the kind of mass psychiatric screening which “Empire of Normality” characterises as Galtonian. Overall, the claim that Galton supplied Kraepelin with an experimental method lacks empirical support.

 

Eugenics

The two paragraphs from the 1922/1918 paper are the only evidence presented to back up the claim that Galton influenced Kraepelin’s work on psychiatric diagnosis. However, subsequent pages discuss Kraepelin’s concerns about mental degeneracy and racial hygiene. By calling them ‘eugenic’ “Empire of Normality” might seem to infer Galtonian influence over Kraepelin with regard to these concerns.

However, Kraepelin does not use that term: instead, he uses language and notions associated with degeneration theory. For example, the term ‘degenerate’ is used to describe persons, and alcohol and drug use are proposed to cause diseases. Any suggestion that Galton influenced Kraepelin with regard to eugenics must therefore be weighed against an alternative explanation: the appearance is an illusion created by the allegiance of both men to degeneracy theory.

 

The Pathology Paradigm: Conclusion

“Empire of Normality” doesn’t only characterise the pathology paradigm as Galtonian. It also restates the paradigm’s initial precepts so that they mirror Galton’s beliefs. With Galton and the pathology paradigm so closely identified, “Empire of Normality” needs a way to connect both to psychiatric diagnosis – if only because people given psychiatric diagnoses are centrally involved in neurodivergent activism.

“Empire of Normality” attempts to do this by arguing that Galton pervasively influenced Kraepelin’s seminal work on psychiatric diagnosis. However, no evidence is presented that demonstrates, or even strongly suggests, that Kraepelin ‘took up’ or ‘expanded’ Galton’s paradigm. Nor is there evidence that Galton provided a metaphysical basis, or an experimental method, that Kraepelin used when developing his system of psychiatric classification. Conversely, there are peer-reviewed papers which find that Kraepelin acquired his metaphysics and methods from other sources. “Empire of Normality’s” claim to have identified a novel connection between the work of these two men remains unproven.

Just as demonstrating a connection between Galton and Kraepelin would have made “Empire of Normality” coherent, not doing so renders it incoherent. It means that “Empire of Normality” doesn’t account for the place of psychiatric diagnoses within the pathology paradigm. It implies the possible relevance to the paradigm of a history of psychiatric theory and practice that “Empire of Normality” doesn’t include.

It also shows that “Empire of Normality’s” concept of the pathology paradigm must be inaccurate. The paradigm did not simply ‘emerge’ from history, intact and ready-made. Rather, the pathology paradigm is a product of history and thoroughly constituted by it. All of the paradigm’s details, features and characteristics are residual products of the various influences that interacted during its development.

So because “Empire of Normality’s” history of the pathology paradigm is flawed, its grasp of the paradigm itself must be mistaken. And since the pathology paradigm is the foundation of “Empire of Normality’s” neurodivergent Marxism, this has implications throughout the text.

 

Anti-Psychiatry

Background

Whilst anti-psychiatry is mentioned throughout “Empire of Normality”, this analysis will focus upon the sustained critique in Chapter 5. But first, some clarification is needed.

The term ‘anti-psychiatry’ has different meanings between the USA and the UK. In the USA ‘anti-psychiatry’ describes anyone who is critical of psychiatry. However, in the UK, where “Empire of Normality’s” author lives and works, its meaning is more specific.

In the UK anti-psychiatry refers to the movement that emerged in the 1960s, and – like other social movements of that decade – went into abeyance with the right-wing resurgence at the end of the 1970s. This historical movement was centred upon a small number of influential individuals: R.D. Laing, Thomas Szasz, Erving Goffman and Michel Foucault are amongst those most commonly named.

Even at the time both Laing and Szasz rejected this term, insisting that anti-psychiatry did not accurately describe their work or their aims. Contemporary UK critics also reject it, often describing themselves instead as critical psychiatrists, or simply critics of psychiatry. They identify many differences between the 1960s movement and their own efforts, for example with regard to the weight placed upon constructive critique and evidence-based alternatives to the psychiatric mainstream^[20].

Nevertheless, in contemporary online debates ‘anti-psychiatry’ is frequently used pejoratively by defenders of the psychiatric status quo, when referring to both contemporary and historical critics. Somewhat provocatively, perhaps, “Empire of Normality” does the same:

“…the anti­psychiatry movement, which waned towards the end of the twentieth century, is now growing in popularity again. In contrast to my analysis, this tradition sees psychiatry itself, and belief in the concept of ‘mental illness’, as the core problem” (p.18)

This, and statements elsewhere, imply that “Empire of Normality’s” arguments about anti-psychiatry apply to both contemporary critical perspectives and the 1960s movement. Yet contemporary critics are barely mentioned in “Empire of Normality” and there is almost no explicit engagement with their work (for possibly the sole exception, see the brief discussion of James Davies’ work on p.143). Chapter 5 only considers work produced by the historical movement from the 1960s and does not engage at all with more recent critical writing.

This narrow focus is both arbitrary and unhelpful. It excludes 50 years or more of empirical evidence that has accumulated since the 1960s and omits recent practical initiatives and novel conceptual work. Nevertheless, in order to make an even-handed evaluation of “Empire of Normality’s” position, this analysis will also focus upon the original, historical movement.

The core of “Empire of Normality’s” critique consists of four allegations, together with a historical example said to illustrate the political failure of anti-psychiatry: the large asylum closures. In order of appearance, the four allegations are that:

1. Anti-psychiatry was dominated by USA psychiatrist Thomas Szasz
2. Anti-psychiatry denied the reality of mental illness
3. To claim that mental distress is not medical illness is inherently right wing
4. Many anti-psychiatrists were (philosophical) idealists, rather than materialists: they supposedly assumed that ideas exert more power than do material influences

Each allegation will be assessed in turn. The ‘asylum closures’ example will then be evaluated.

Allegations

1.       Anti-psychiatry was dominated by Szasz

“Szasz’s engaging writing, precise arguments, and powerful rhetoric helped his analysis become the dominant counter­narrative” (p.73)

Thomas Szasz, with his extreme right wing libertarian politics, was the most controversial figure in the anti-psychiatry movement of the 1960s-70s. If “Empire of Normality” could establish that his ideas dominated the movement, those controversies might taint anti-psychiatry overall.

Yet the allegation that Szasz dominated the 1960s movement is contradicted by both empirical evidence and expert opinion. Histories of anti-psychiatry universally acknowledge its diversity of intellectual and political views. They rarely attribute overall dominance to Szasz or anyone else. Some histories describe a ‘hierarchy’ of influence: Laing and Szasz are typically together at the top; then Goffman and Foucault; then the rest. But on the evidence available it would be difficult to show that Szasz was uniquely dominant.

In part, this difficulty may reflect how the 1960s anti-psychiatry movement was geographically dispersed: so a writer who was more influential in one region – say Foucault in his native France – had less influence elsewhere. It may also reflect how the movement – which was hardly ever associated with street-level activism – had no decision-making body where dominance could be enacted. In any case, it reflects the great weight of empirical evidence and historical opinion. Szasz is overwhelmingly seen, not as dominant, but as one amongst a small number of highly influential anti-psychiatrists.

Lacking evidence to support this allegation, “Empire of Normality” uses four textual strategies to conjure an illusion of Szaszian dominance. An example of the first strategy appears in the quote above from p.73: straightforward assertion. The other three strategies are: developing a narrative that centres Szasz and only incidentally features others; devoting almost no space to the ideas of other anti-psychiatrists; and consistently using the adjective ‘Szaszian’ to characterise the entire movement (a strategy used throughout “Empire of Normality”).

 

2.       Anti-psychiatry denied the reality of mental illness

“[anti-psychiatrists] thought that denying the reality of mental illness, reducing mental illnesses to mere ‘labels’ … would liberate patients.” (p.82)

To ‘deny the reality’ of mental illness has two possible meanings. First, it could mean denying the actuality of the uncontrollable, debilitating anguish that characterises many forms of mental distress. Second, it could mean denying that this suffering is necessarily best understood as a medical phenomenon.

Of the most influential anti-psychiatrists, Szasz alone endorsed the first meaning. He was sometimes sceptical about the actuality of distress and accused those who considered themselves mentally ill of self-deception. None of the others shared these views.

But all of the most influential anti-psychiatrists endorsed the second meaning. Their reasons for doing so differed, often significantly. But they all questioned whether the profound suffering which psychiatry sees as mental illness is always best understood in medical terms.

R.D. Laing, for example, often worked with people experiencing the intense mixtures of agitation and confusion that psychiatrists describe as florid psychosis. Laing used existential philosophy to develop innovative strategies for establishing therapeutic relationships with these patients, and challenged the prevailing orthodoxy by arguing that their distressing experiences were meaningful. Laing never questioned the actuality of these difficult, debilitating experiences, but nor did he dismiss them as mere everyday unhappiness: he just refused to frame them medically^[21].

 

3.       To claim that mental distress is not medical illness is inherently right wing

“Marxist critics … saw Szasz’s views as a highly reactionary denial of mental illness … Szasz’s arguments were driven by and reproduced his hard­right libertarian politics” (p.73; p.79)

Although this allegation names Szasz alone, it has a general quality. Moroever, “Empire of Normality” readers are meant to be persuaded by now that Szasz uniquely dominated the movement. So despite being framed with sole reference to Szasz it seems to be aimed at the whole movement.

Medicalised notions of distress-as-illness are most often associated with right wing political positions, so this allegation might appear puzzling. “Empire of Normality” attributes it to the Marxist critic Peter Sedgwick.

Sedgwick observed that sharply distinguishing mental from physical illness, as Szasz does, is both conceptually and practically difficult. Social norms, for example, inform decision-making in both general medicine and psychiatry. He was also concerned that anti-psychiatry pitted patients against medical professionals, making them less likely to form alliances and campaign together. Most relevant to “Empire of Normality’s” allegation, though, is Sedgwick’s opinion that “…without the concept of illness – including that of mental illness … – we shall be unable to make demands upon the health service facilities of the society we live in.”^[22]

Whilst this is a reasonable opinion, a thoughtful re-evaluation of Sedgwick’s work proposed that this concern was overstated. This is because, in the years since Sedgwick first expressed this view, demands not dependent upon notions of illness have been successfully made. The example given is the Hearing Voices Network (HVN), which does not see voice-hearing as a medical illness. Yet HVN groups have successfully engaged health services in productive dialogues, sometimes producing real benefits. This lead to the conclusion that, to make successful demands “’Illness’ may do that job, has done that job, could do that job. But it is not the only way, especially if its deployment alienates … individuals and organizations”^[23].

Sedgwick aside, the best way to assess whether an idea is inherently right wing is surely to examine how it has actually been used. “Empire of Normality” (p.75-79) says there is evidence that refusing to see distress in medical terms has enabled right-wing agendas, such as legitimising cost-cutting in mental health services, and facilitating hospital closures.

“Empire of Normality” fails to mention that this same idea has facilitated research into the social, cultural and material drivers of mental distress. Amongst other things, it has challenged the legitimacy, and threatened the profitability, of the co-dependent pharmaceutical and psychiatric industries. It has encouraged greater recognition of the impacts of trauma and abuse and fostered new conceptual frameworks. It has also underpinned service users’ demands for alternatives to standard psychiatric treatment. These uses of the idea that mental distress is not a medical phenomenon cannot readily be seen as right wing.

 

4.       Many anti-psychiatrists were idealists

“Many of the anti­psychiatrists believed that the ‘myth’ of mental illness and psychiatric ‘labels’ were the core problems. They were what Marx called idealists, taking the power of psychiatric control to come from belief in the ideas of psychiatry.” (p. 82)

This allegation does not mean that anti-psychiatrists strived, perhaps unrealistically, towards an ideal or utopian future. The allegation is meant in the philosophical sense that they supposedly imagined that ideas constitute reality and impel social change. Put simply, this would imply believing that abolishing psychiatric labels and rejecting illness concepts would, by itself, eliminate psychiatric oppression.

In political circles, to be idealist in this philosophical sense is a grave error. Famously, Marx inverted Hegel’s dialectic to make material conflicts and contradictions, rather than incompatible or opposing ideas, the drivers of historical change. So without exception Marxists favour the opposing philosophical stance to idealism: materialism.

At the same time, most Marxists accept that neither idealism or materialism can usually be discerned absolutely. In fact, allegations of ‘vulgar’ or ‘crude’ materialism are almost as damaging as allegations of idealism. Most often we encounter tendencies, mixtures, hybrids. These demand assessments of the overall balance of idealist and materialist elements within complex explanations – a dialectical materialism^[24].

From the text it is not clear what evidence “Empire of Normality” has for these allegations of idealism. In any case, there is considerable evidence that anti-psychiatry was not simply idealist. David Cooper, who coined the term anti-psychiatry, was well known as a Marxist who had joined the armed struggle against apartheid in South Africa. And whilst Laing often avoided political issues and experimented with mysticism and religion, interviews show that he was influenced by Marxism too:

“This is what I thought then and still feel now. Practical material contradictions, not logical contradictions, which clashed with each other in terms of the historical process, seemed to me the only motor of history that I had come across”

“There are statements about the society that we live in and the socio-economic conditions and material things and how these form, and the decisive factor of division in modern society into class. There’s a class of people who do this and get exploited for doing it … I’m a Marxist in that sense”^[25]

In addition to what Laing said, we might also look again at what he actually did. To be clear, Laing’s work, both psychologically/therapeutically and politically, was inconsistent: he is not being promoted as an icon. Nevertheless, his work with people in extreme states of distress did not only involve ideas. It included deliberate changes in embodied relational practices – different ways of physically being with patients. These therapeutic innovations might have been imbued with utopian idealism, but were not idealist in the philosophical sense.

 

Example: the asylum closures

“Empire of Normality” illustrates what it says are the adverse political consequences of anti-psychiatry with a history of the closure of large asylums and hospitals. “Empire of Normality” describes how the closures led to homelessness, drug use and other social problems, and claims that anti-psychiatry was partially responsible for these adverse outcomes.

“Empire of Normality” says that its history of the asylum closures encompasses the UK as well as “much of Europe and the United States” (p.77). In these respects, it includes one quote from Sedgwick talking about Britain, and a brief mention of Basaglia’s work in Italy. However, both the content of the narrative and the character of the sources indicate that “Empire of Normality’s” history is actually largely specific to the USA. As will be shown, closures in the UK mostly happened later and the UK process unfolded quite differently (and in Italy was different again).

“Empire of Normality” describes how large asylum and hospital closures were already happening on a notable scale in the early 1960s (which was true of the USA, but not the UK.) Because anti-psychiatry had from the first characterised the asylums as oppressive and abusive, the movement was generally supportive. However, anti-psychiatry’s impact was largely confined to political discourse. As asylums were shut down the movement did not significantly shape the services that followed, and saving money frequently took precedence over enhancing care.

“Empire of Normality” describes how former inmates were relocated to smaller institutions that were sometimes themselves coercive or abusive; how some began, or returned to, using recreational drugs; and how some ended up homeless or in prison. Summing up, “Empire of Normality” says that “Szaszian ideology turned out to be useful for the ruling class rather than helping to resist the dominant system” (p.78) and “the fact remains that the most dominant form of Anglo-American anti­psychiatry – stemming from the work of Szasz – was misguided, and its politics failed to liberate its subjects” (p.79).

It is easy to imagine that alternative institutional provision for former asylum inmates was often sub-standard, and even sometimes abusive. Still, many people would question whether remaining in the large asylums would have been a better alternative. In any case, this USA-focused history, and the responsibility it confers upon anti-psychiatry, is not quite what it seems.

Historian Michael Staub^[26] describes a backlash against anti-psychiatry in the USA during the 1970s, as part of a wider reaction against the culture and politics of the previous decade. This rejection of anti-psychiatry was seized upon and amplified in the mid-1980s by supporters of the Reagan administration. Their aim was to prevent the USA ‘homelessness crisis’ of that time from being associated with the neoliberal policies – often called ‘Reaganomics’ – that were its cause.

One influential policy was enacted shortly after Reagan took office in 1981, when federal housing benefits for people with disabilities were cancelled. Many people with severe mental health difficulties, including former asylum residents, were affected. The APA warned in 1982 that “individuals who were having their benefits removed included ‘large numbers of schizophrenics and other chronically mentally ill persons’”. Other experts echoed these concerns, stating that “almost certainly many of the individuals who lost their benefits joined the ranks of the homeless.”^[27] The administration remained intransigent. As a consequence of this and other neoliberal policies, by the mid-1980s USA homelessness surged and many people with severe mental health difficulties were affected.

Faced with intense criticism, Reagan’s team issued straightforward denials that homelessness had actually increased. This strategy proved ineffective so another way to deflect responsibility was sought. They then began to both talk up the failings of the asylum closures, and to blame these failings on anti-psychiatry. Superficially at least, this explained the substantial numbers of mentally distressed people amongst the homeless.

This neoliberal propaganda effort succeeded. In fact, says Staub, it was so successful that by the 1990’s “it became a matter of some generalized consensus that anti-psychiatric theories in the 1960s and 1970s might be held at least partially accountable for the homelessness crisis in the 1980s”^[28] Neoliberal propaganda therefore influenced how the USA asylum closures are uncritically understood today.

In a different way, neoliberalism was influential for the UK asylum closures. Shutting down the large hospitals and asylums had been seen as desirable by UK governments since at least the 1950s, pre-dating the anti-psychiatry movement. But despite numerous recommendations little action was taken. At sporadic intervals, abuse scandals both caused public outrage and led to renewed calls for closure of the large institutions. By the 1970s, though, change was favoured by the National Health Service. The national charities Mind (mental health) and Mencap (intellectual disability) had also begun campaigning on this issue.

The Thatcher government, the first in the UK to implement large-scale neoliberal policies, initially took office in 1979. At that point relatively few large hospitals and asylums had shut down, but closures began to gather pace following the publication of governmental ‘Care in the Community’ circulars, in 1981 and again in 1983.

At around the same time changes to benefit regulations made it easier for people to reclaim the costs of their care from the social security system^[29]. The amended regulations also adjusted how properties and personal savings could be inherited, without the costs of social care being charged against them^[30].

As their effects became clear, these changes quickly sparked a boom in new, small, privately run residential care homes. Business-minded healthcare professionals identified a lucrative emerging market and opened their own ‘community care’ facilities. In the years that followed, not just in mental health but across the entire health and social care sector, significant numbers of people vacated the large asylums and hospitals and took up places in these new facilities – albeit at considerable cost to central government.

In fact, spending rose so much that by the late 1980s some in government began to view it as unsustainable. Yet the care homes were “exactly the kind of small businesses of which Mrs. Thatcher approved”, exemplifying, perhaps, neoliberal ideals of entrepreneurship and diminished state provision. Additionally, any viable gatekeeping procedure would have given more power to local authority social services, which “was anathema to Mrs. Thatcher”. So on both grounds Margaret Thatcher is said to have personally blocked attempts to limit this spending^[31].

UK governments clearly never intended to de-medicalise the lives of asylum residents and dismantle psychiatry, and nor did anyone working or campaigning in mental health at the time seriously expect this to happen. The asylum beds were always to be partially replaced by units in District General Hospitals. Commenting at around that time, contemporary critic Lucy Johnstone made the distinctly non-Szaszian observation that:

“although these units do have some advantages, they can also be seen as a further victory in the medical profession’s campaign to establish psychiatry as just another branch of medicine, to be assimilated with its new drug treatments into the traditional medical world of wards, beds, nurses, and medicines’^[32]

Thus, in the UK a complex of material, institutional and financial factors, animated by neoliberal economic policies, was the primary influence upon the timing and nature of the asylum closures.

As in the USA, these same policies also caused the prison and homeless populations to increase. An overview of UK research into single homelessness during this period^[33] identifies rising unemployment, cuts in social security and family restructuring as structural drivers of the increase. Housing market changes, and particularly the consequences of Thatcher’s ‘right to buy’ for council house occupiers, also contributed significantly^[34].

Amongst other influences upon homelessness that it categorises as ‘individual’ the research also identifies mental distress, and notes – again, like the USA – the rising prevalence of drug and alcohol problems. But these problems are not attributed, even in part, to anti-psychiatry.

Moreover, across the entire UK health and social care sector, the closures of the large institutions happened over roughly the same period and in broadly similar ways. And in mental health, one result was arguably to align the field more closely with general medicine. It seems clear, then, that any influence from anti-psychiatry was negligible. The main drivers of rising homelessness, incarceration and drug dependency were neoliberal economic policies, not anti-psychiatric theories.

 

Sedgwick on Szasz

“Empire of Normality’s” chapter on anti-psychiatry closes with a summary of Sedgwick’s analysis of Szasz’s anti-psychiatry. Like the allegation that it is inherently right wing to claim that mental distress is not mental illness, the arguments here seem intended to indict anti-psychiatry in general (if only because Szasz’s ‘dominance’ is presumed).

Unlike that allegation, however, this summary is specific to Szasz. The allegation regarding disbelief in distress as mental illness could plausibly be levelled at almost any sceptic of psychiatry. By contrast, this summary is only sensible in relation to Szasz’s work. Since this restricts its relevance, both historically and for contemporary critical work, it will not be analysed in great detail.

Briefly, then, “Empire of Normality” describes Szasz’s support for neoliberalism; his extreme individualism; his view of bodies as mechanistic and sharply distinguishable from minds; and his assumption that (in contrast with psychiatry) bodily normality and abnormality are objectively identifiable, by means of which “Empire of Normality” says “he fully bought into the underlying logics of the pathology paradigm” (p.82).

This final point requires elaboration. In assuming that bodily normality is objective, Szasz overlooked how ‘normal’ only makes sense by contrast with something considered ‘not normal’, or abnormal. What is more, Szasz seemed ignorant of how the criteria by which normality and abnormality get assessed are frequently value-laden and discriminatory, for example along racial lines^[35]. As “Empire of Normality” puts it, often these criteria “are intertwined with racist, patriarchal, and capitalist logics” (p.81).

But what does this signify? One implication is that an extreme right-wing libertarian, born in 1920, probably held assumptions that were racist, sexist and exploitative: but this hardly seems like a momentous discovery. Alternately, perhaps this is the basis for “Empire of Normality’s” claim that anti-psychiatry as a whole is inherently “reactionary”(p.10)? If so, something both more widely applicable and supported by empirical evidence seems to be required.

More significant, maybe, are the implications for the pathology paradigm itself. Szasz was an influential figure: did his assumption of objective bodily normality feed into the pathology paradigm? To reliably answer this question, “Empire of Normality’s” account of the pathology paradigm would first need to be revised, to take account of the unproven claim that Galton influenced Kraepelin’s work on psychiatric diagnosis. Any implications of Szasz’s arguments might then be identified.

 

Anti-Psychiatry: Conclusion

In this chapter “Empire of Normality” consistently misrepresents anti-psychiatry. As noted earlier, this misrepresentation even extends to using this term to identify contemporary critics who explicitly reject it. “Empire of Normality” neither names these contemporary critics nor gives examples of their work (excepting, again, on p.143) perhaps because this would challenge “Empire of Normality’s” portrayal.

Despite misrepresenting anti-psychiatry in all of these ways, none of the four allegations that “Empire of Normality” makes about the movement can withstand scrutiny. Three allegations (1,3,4) are – if not refuted – at least robustly challenged, by evidence and/or expert opinion.

The second allegation – that anti-psychiatry denied the reality of mental illness – confuses two meanings. With respect to the first meaning, the only leading anti-psychiatrist who can be interpreted as sometimes denying the full reality of suffering was Szasz. But the second meaning – the widely-held view that mental distress is not most helpfully seen as a medical illness – was overwhelmingly endorsed by anti-psychiatry. It is less an allegation than a defining characteristic.

“Empire of Normality’s” history of the asylum closures is unconvincing. It glosses over significant differences between the USA, the UK and Italy, subordinating them (along with ‘much of Europe’) to a singular narrative. Unusually for a Marxist account, this narrative emphasises the influence of anti-psychiatric ideas but omits the material influence of neoliberal economic policies: it tends toward idealism. Ironically, this renders it uncannily reminiscent of propaganda, first promulgated in the mid-1980s, which was designed to conceal neoliberalism’s adverse impacts.

 

Discussion

Perhaps inevitably, this review raises questions it cannot answer. Why do “Empire of Normality’s” arguments seem to require distortions of the evidence? Do “Empire of Normality’s” flaws suggest a fundamental weakness in the neurodiversity position? Are Chapman’s misrepresentations calculated and deliberate, or careless and accidental?

Even the most concise answer to any one of these questions would demand a lengthy essay, if not powers of telepathy. Instead, this discussion will merely explore some probable consequences of “Empire of Normality’s” flaws: what are their likely effects? Whilst this might seem to imply access to authorial motives, what follows is a textual analysis. Access to the writer’s intentions is neither claimed nor implied.

Textually, many of “Empire of Normality’s” flaws have the effect of streamlining and simplifying the narrative. For example, “Empire of Normality’s” history of the pathology paradigm is shorter, simpler and more compelling because of the claim that Kraepelin’s work on diagnosis was influenced by Galton.

With this claim, “Empire of Normality’s” history of the pathology paradigm hinges dramatically upon the unexpected discovery of an intellectual connection that supposedly went unnoticed for over a century. The story of this discovery can be told in a largely biographical manner: first one famous man; then another; then their common ground. Despite entirely lacking evidence, this claim forms the basis of an appealing, accessible history.

Other likely effects are less helpful to “Empire of Normality”. For example, some contemporary arguments by neurodiversity activists have close parallels with arguments advanced historically by the anti-psychiatry movement^[36]. Yet “Empire of Normality’s” dismissal of both the historical anti-psychiatry movement and contemporary critics, including those with lived experience, will likely obstruct opportunities to identify, evaluate and learn from these connections.

Taking a wider perspective, “Empire of Normality’s” dismissal of contemporary critical perspectives risks the unjustified stereotyping and discrediting of a movement with many achievements to its name, not least Mad in the World’s continuing contribution to debate. Examples include dismantling the ‘chemical imbalance’ myth; the promotion of information and support for psychiatric drug withdrawal; Open Dialogue; the Hearing Voices Movement; trauma-informed care; and much else that has changed people’s lives for the better.

Perhaps the most obvious possibility is that these flaws might erode trust and confidence in other elements of “Empire of Normality”, including Chapman’s argument that to achieve ‘collective liberation’ the ‘reactionary and outdated’ anti-psychiatry tradition must be rejected in favour of “a more radical politics of neurodiversity, directed against the Empire of Normality itself”(p.19).

It remains to be seen how these possibilities will play out. Certainly, this review has demonstrated that some of “Empire of Normality’s” most important arguments contain substantial flaws. Their presence suggests that “Empire of Normality’s” eventual impact – upon both psychiatry and anti-psychiatry – might be at best superficial, as it perhaps becomes apparent that the Empire has no clothes.

 

Every effort has been made to represent “Empire of Normality” (and other sources) accurately. Minor omissions or mis-readings of course remain possible. Readers will decide whether any such errors are of sufficient magnitude to neutralise the concerns identified.

 

References

1. Shakespeare, T., Disability Rights and Wrongs Revisited. 2014, Abingdon: Routledge.
2. Johnstone, L., & Boyle, M., The Power Threat Meaning Framework: Towards the identification of patterns in emotional distress, unusual experiences and troubled or troubling behaviour, as an alternative to functional psychiatric diagnosis. 2018, Leicester: British Psychological Society.
3. Walker, N., Autism and the Pathology Paradigm, in Notes on the Neurodiversity Paradigm, Autistic Empowerment, and Post-Normal Possibilities, N. Walker, Editor. 2021 originally 2016, Autonomous Press: Fort Worth, Texas. p. (ebook).
4. Boyle, M., Schizophrenia: a scientific delusion? 2nd ed. 2002, London: Routledge.
5. Gould, S.J., The Mismeasure of Man. 1981, Harmondsworth: Penguin.
6. p.120 in Stanley, A.D., Slave Breeding and Free Love: An Antebellum Argument over Slavery, Capitalism, and Personhood, in Capitalism Takes Command: The Social Transformation of Nineteenth- Century America, M. Zakim and G. Kornblith, Editors. 2012, University of Chicago Press: Chicago. p. 119-144.
7. Waller, J., Ideas of Heredity, Reproduction and Eugenics in Britain, 1800–1875. Studies in the History and Philosophy of Biology and Biomedical Sciences 2001. 32(457-489).
8. Richards, M., Perfecting people: selective breeding at the Oneida Community (1869–1879) and the Eugenics Movement. New Genetics and Society, 2004. 23(1): p. 47-71.
9. Billinger, M. Degeneracy. Eugenics Archives n.d. (accessed 26/3/2024). Available from: https://www.eugenicsarchive.ca/.
10. Hoff, P., Kraepelin and Degeneration Theory. European Archives of Psychiatry and Clinical Neuroscience, 2008. 258: p. 2-17.
11. Kraepelin, E., Ends and Means of Psychiatric Research. The Journal of Mental Science, 1922. LXVIII(281): p. 115-143.
12. p.160 in Hacking, I., The Taming of Chance. 1990, Cambridge: Cambridge University Press.
13. p.164 in Hacking, 1990
14. Hoff, P., The Kraepelinian tradition. Dialogues in Clinical Neuroscience, 2015. 17(1): p. 31-41.
15. Berrios, G. and R. Hauser, The Early Development of Kraepelin’s Ideas on Classification: a conceptual history. Psychological Medicine, 1988. 18: p. 813-821.
16. Heckers, S. and K. Kendler, The Evolution of Kraepelin’s Nosological Principles. World Psychiatry, 2020. 19: p. 381-388.
17. p.820 in Berrios and Hauser, 1988.
18. Danziger, K., Constructing the Subject: historical origins of psychological research. 1994, Cambridge: Cambridge University Press
19. p.382 in Heckers & Kendler, 2020.
20. Middleton, H. and J. Moncrieff, Critical psychiatry: a brief overview. BJPsych Advances, 2019. 25(1): p. 47-54.
21. Laing, R.D., The Divided Self: an existential study in sanity and madness. 1960, Harmondsworth: Penguin.
22. p.41 in Sedgwick, P., Psychopolitics. 1982, London: Pluto Press
23. p.142 in Cresswell, M. and H. Spandler, Psychopolitics: Peter Sedgwick’s legacy for the politics of mental health. Social Theory & Health, 2009. 7(2): p. 129-147.
24. Timpanaro, S. Considerations on Materialism. New Left Review 1974 [cited 1/85; Available from: https://newleftreview.org/issues/i85/articles/sebastiano-timpanaro-considerations-on-materialism.pdf.
25. p.90; 308-9 in Mullan, B., Mad To Be Normal: conversations with R.D.Laing. 1995, London: Free Association Books.
26. p.184-8 in Staub, M., Madness Is Civilisation: when the diagnosis was social, 1948-1980. 2011, Chicago: University of Chicago Press.
27. p.184 in Staub, 2011.
28. p.187 in Staub, 2011.

29. Means, R. and R. Smith, Community Care: policy and practice. 1994, Basingstoke: The MacMillan Press Ltd.
30. Lewis, J. and H. Glennerster, Implementing the New Community Care. 1996, Buckingham: Open University Press.
31. p.6 in Lewis & Glennerster, 1996.
32. p.185 in Johnstone, L., Users and Abusers of Psychiatry. 2nd ed. 2000 (1^st ed. 1989), Hove: Brunner-Routledge.
33. Fitzpatrick, S., Kemp., P & Klinker, S. (2000) Single homelessness: an overview of research in Britain. JRF/Policy Press, Bristol
34. AGS Support (2023) The History of Homelessness in the UK. Available from: https://agssupport.co.uk/the-history-of-homelessness-in-the-uk/
35. Creadick, A., Disability’s Other: the production of ‘normal’ men in midcentury America, in Phallacies: Historical intersections of disability and masculinity, K. Brian and J. Trent, Editors. 2017, Oxford University Press: New York. p. 25-43.
36. Dyck, E. and G. Russell, Challenging Psychiatric Classification: healthy autistic diversity and the neurodiversity movement, in Healthy Minds in the Twentieth Century: in and beyond the asylum, S. Taylor and A. Brumby, Editors. 2020, Palgrave Macmillan: London. p. 175-191.