I have tasked myself with mapping out my understanding of how therapy and mental health relate to politics. I don’t know how much of an original thought I have on the topic, but let’s see what happens.
Is therapy political?
In the sense that everything is influenced by politics in one way or another – yes, therapy is political. ‘Mental health’ is also political. Of course it is.
I’m not aware of any line that distinguishes between ‘political’ and ‘non-political.’ People imply a line exists without elaborating, but I believe no line actually exists in reality. There is only one world out there.
Specific details of this line would be helpful: vague affirmations that it ‘exists’ without these details, not so much. Get in touch if you can help me with this.
My Vested Interests
Since nailing a B in my Sociology A level, I’ve moved away from a view that relies on blaming a handful of evil people for all the world’s ills. My therapy training has played a part; I am now able to step into other people’s frames of reference. Nowadays I find it most helpful to look at things in terms of power dynamics and vested interests.
While I trained to become a therapist, I paid my bills by working as a debt advisor for the debt charity StepChange. During this time, I realised that I had developed an interesting vested interest from a selfish point of view. If the economy tanks or there is some huge disaster that traumatises loads of people, that could be great news for my job security!
I joked about it with friends, imagining a world where everyone had lost their jobs and felt depressed about it – while I sat in my hilltop castle, peering out, content that my services were in high demand.
As a therapist in private practice, I have a specific vested interest in earning enough to pay my bills. Potentially this could conflict with my aim of supporting people until they don’t need me anymore. If I ignore this interest, I might misinterpret my financial anxiety about a client ending as concern for their well-being, which would justify me to push for additional sessions.
Ethical practice requires vigilance in recognising vested interests in any situation and distinguishing between what is ethical and what personally benefits us.
Vested interests can be difficult to acknowledge. I am consciously aware of some vested interests, while undoubtedly, I’m not aware of others. Meanwhile, there are some on the edge of my awareness that I would rather not think about too much because it makes me uncomfortable.
For example: like many, I hold abstract ideals (e.g., ‘I should be vegan’) but tolerate dissonance when habits comfort me. I love cheese, so I tend to avoid thinking too much about animal suffering. I can’t even call myself a vegetarian, as I eat meat sometimes. I’m sure you can think of your own examples.
When trying to weigh up how to ethically navigate our lives, none of us exist in a vacuum as we’re all impacted by the culture around us. Therefore, we’re already invested in certain habits before we’re even aware of it, and this impacts how our perspective of the world develops in the first place.
Vested Interests in the History of ‘Mental Health’
As much as we like to think that our beliefs about the world are developed rationally using facts and logic, there is evidence to suggest the opposite – we tend to develop political beliefs which justify and explain our life circumstances and our feelings (Bellizzi, 2022). It takes effort to overcome this tendency and people would rather justify and hold on to any power and privilege they have, simply because they have a survival instinct to do so; losing power feels uncomfortable and disorienting. Maybe we all hold a perspective of the world that justifies the power and privilege that we already have – to some extent at least.
There are numerous examples of this playing out in the history of psychiatry such as ‘drapetomania’, a diagnosis given to slaves in the 19th century. The key symptom of ‘drapetomania’ was attempting to run away to escape their life of slavery. Obviously from our current perspective, a slave attempting to escape slavery is an understandable behaviour. However, in a system that is leveraged entirely on the idea that slavery is the natural order of things, anyone with a vested interest in maintaining slavery would need to frame the explanation for this behaviour as a problem within the slave, rather than within slavery itself.
It’s important to say that this isn’t necessarily conscious, and maybe the physician Samuel A. Cartright, who suggested the label, was honestly trying to understand the world as best he could. His entire social existence was so saturated with these power dynamics and vested interests that it’s possible he was blind to the influence they had on his perspective.
Another example is that in 1896, Freud argued that ‘Hysteria’ may be caused by people being sexually abused as prepubescent children (Freud, 2001). This was quite a radical and controversial insight, based on his observations from talking with numerous clients, many of whom were young women in the Viennese aristocracy. He soon after backtracked from this idea though, possibly when he realised that he was implying that members of the aristocracy sexually abused their kids (Herman 1997, Masson 1992).
Nowadays, to say that childhood sexual abuse can lead to ‘mental health’ difficulties is an obvious statement. But there were strong vested interests to counter such insights – especially from those who were abusers themselves. Presumably Freud decided that it wouldn’t be worth the impact on his career to upset so many powerful people. He later developed the Oedipus/Electra complex in 1899, which instead suggested that kids were in fact sexually attracted to their parents (Freud, 1999).
A third example includes the historical diagnosis of ‘Masochistic Personality Disorder’ specifically applied to women who remained in abusive relationships, a sleight of hand which again involves blaming the victim, rather than placing the problem within the perpetrator, or even the system that enables it (Herman, 1997). The label frames the issue as residing within the victim rather than arising from their traumatic circumstances. This is true for the label “personality disorder” more broadly, which is still in use today.
These are examples of two injustices: the original injustice itself, and then the injustice of a narrative created to obfuscate the original injustice.
Systemic power is often blind to itself. There will always be an inherent inertia for any system, or an individual benefitting from a system, to genuinely reflect on that system’s nature, because to do so would pose an existential threat to that system. (A ‘system’ in this sense could be a literal organisation like a private company, church, school, or even a family unit. It can also be something more nebulous and abstract like the cultural ‘system’ of white privilege, patriarchy, heteronormativity, and so on.)
Vested Interests in the ‘Mental Health’ System Today
Spotting current examples is inherently more difficult because we have less of a vantage point. Nevertheless, there are interesting observations to be made when considering instances where particular forces have:
- Enough power to shape the narrative around ‘mental health’.
- A vested interest to do so in a particular way.
Example One: Pharmaceutical Companies
Multi-billion-pound pharmaceutical corporations have a vested interest in hustling essentialist narratives about broken brains/chemical imbalances because their drugs can then be viewed as the profitable solution to diagnosed ‘mental health problems’ on an ongoing basis; powerful organisations have very profitable motivations for emphasising a biological narrative in this way.
I often come across people who have been told that their brain has a chemical imbalance, and yet no tests exist to measure any such supposed imbalance. As many people already know, they will have no test because no psychiatric disorder has been linked to any single biochemical disturbance at all. This is acknowledged by David Kupfer, who chaired the taskforce that produced the DSM-5:
“In the future, we hope to be able to identify disorders using biological and genetic markers that provide precise diagnoses that can be delivered with complete reliability and validity. Yet this promise, which we have anticipated since the 1970s, remains disappointingly distant. We’ve been telling patients for several decades that we are waiting for biomarkers. We’re still waiting.” (Kupfer, 2013)
Psychiatrist Professor Joanna Moncrieff explains how the ‘chemical imbalance’ idea remains prevalent anyway simply because of how often it is put out there, and is often even echoed by others:
“The message is repeated on numerous company websites, despite the fact that it cannot be clearly substantiated with scientific evidence. Information produced by professional bodies and charitable groups also promotes this view and it is reported by the media as if it were established fact. This is how psychiatric knowledge has come to be distorted by commercial interests.” (Moncrieff, 2008. p.257)
In the book Merchants of Doubt, historians of science Noami Oreskes and Erik M. Conway show clearly how tobacco and oil corporations have deliberately sowed public doubt in relation to the dangers of smoking and climate change, respectively. Tactics included only publishing research data that favoured their interests, attacking individual researchers that disagreed with them, funding think tanks to promote ideas that were favourable to them, and encouraging ‘balanced’ reporting to create the illusion of significant scientific disagreement where none existed. In the case of tobacco, these tactics delayed the dangers of tobacco becoming widely known amongst the public for decades, and in the case of global warming there is still an ongoing struggle to convince many people (Oreskes & Conway, 2010).
It doesn’t seem beyond the realm of possibility that pharmaceutical companies would deliberately disrupt the conversation in similar ways, and indeed James Davies in his book Sedated gives evidenced examples of them selectively publishing research data on the efficacy of their drugs (Davies, 2022). Furthermore, pharmaceutical companies have, with relative opacity, funded influential mental health charities, patient groups, psychiatric research and leading professional psychiatric organizations—notably including the publisher of the Diagnostic & Statistical Manual of Mental Health Disorder (DSM). All of which raises significant ethical concerns.
Davies describes a comprehensive UK government report on the influence of the pharmaceutical industry – the ‘House of Commons Health Select Committee Report on the Pharmaceutical Industry’. This report, written in 2005, revealed that the pharmaceutical industry aggressively marketed drugs, often using misleading information that minimized harms and exaggerated benefits (House of Commons Health Committee, 2005).
Furthermore, the committee found significant financial ties between the industry and supposedly independent medical doctors. The report concluded that the regulatory agency (now The Medicines and Healthcare products Regulatory Agency, or MHRA) had become “too close to the industry,” with “common policy objectives, agreed processes, frequent contact, consultation and interchange of staff”. It called for an overhaul of the regulatory system to ensure that industry works in the public interest. However, none of the substantive reforms recommended have been enacted and there has been no independent review of the MHRA.
Of course, some people do find drugs helpful. As Davies explains though, over 20% of the UK adult population take a psychiatric drug in any one year, and the numbers are only set to increase. Placing this figure alongside the emerging clinical and scientific data revealing their poor outcomes and the harms psychiatric drugs often cause, their commercial success cannot be explained by their therapeutic efficacy .
Example Two: Psychiatric Diagnosis
The discussion of pharmaceutical companies feeds in neatly with the vested interest created by the veneer of scientific rigour offered by psychiatric diagnosis, and the power the professionals gain from this veneer.
No psychiatric disorder has ever been linked conclusively to any biochemical disturbance. Unlike ‘physical conditions’, where symptoms suggest what confirmatory tests are required to reach a diagnosis, there are no tests which can confirm psychiatric diagnoses. I have personally met and worked with numerous people who think that their psychiatric diagnosis is largely used as a means for professionals to feel as though they understand them without needing to listen to them.
It isn’t just diagnostic processes that have problems – the construction of diagnostic labels themselves has also been roundly criticised for lacking a scientific basis, and this has been acknowledged by many of the people actually involved in the creation of the labels.
As Theodore Millon, a figure involved in the creation of the DSM-3, put it: ‘There was very little systematic research [guiding the creation of the DSM], and much of the research that existed was really a hodgepodge – scattered, inconsistent, and ambiguous. I think the majority of us recognised that the amount of good, solid science upon which we were making our decisions was pretty modest.” (quoted by Spiegel, 2004)
Professor Donald Klein, another leading figure in the development of the DSM-3, put it like this:
“… we were forced to rely on clinical consensus, which, admittedly, is a very poor way to do things… We thrashed it out, basically. We had a three-hour argument… If people were still divided, the matter would be eventually decided by a vote.” (Davies, 2013, pp.29–30)
Needless to say, the idea of voting on scientific truth is absurd. Voting belongs to the realm of politics, rather than science.
Renee Garfinkel, a psychologist who participated in two DSM advisory committees, expressed it like this:
“What I saw happening on these committees wasn’t scientific – it more resembled a group of friends trying to decide where they want to go for dinner. One person says, ‘I feel like Chinese food’, and another person says, ‘No, no, I’m really more in the mood for Indian food’, and finally, after some discussion and collaborative give-and-take, they all decide to go have Italian.” (Davies, 2013, p.30)
Robert Spitzer, another key figure in the development of the DSM, later in life acknowledged that the widespread medicalisation of distress through the manual was met with delight by pharmaceutical companies, as it created a vast and highly profitable market for their products (Snyder, 2016). This commercialisation of ‘mental illness’ has not only shaped public understandings of ‘mental health’ but has also led to a complex network of funding that impacts the very institutions tasked with understanding and treating ‘mental health conditions’.
Bessel van der Kolk (2015) explains that even prior to the release of the DSM-5, findings published in the American Journal of Psychiatry indicated that it lacked the capacity to yield consistent and replicable results— a major scientific shortcoming. He highlights that the American Psychological Association (APA) had previously generated around $100 million from the DSM-IV and was expected to earn a similar amount from the DSM-5, which begs the question: Did these financial incentives create pressure to meet publication deadlines, even in light of these issues and a broad consensus that the new edition marked no substantial improvement over its predecessor?
Diagnosis of course can be a personal choice that some people find helpful and gain relief at least temporarily. Furthermore it can be useful for practical purposes – such as access to services, benefits etc. But internally people may not wish to define their problems in this way.
In light of the lack of scientific basis for these labels, I believe people should have the right to step back from psychiatric diagnosis or avoid it entirely. When this isn’t an option, I see it as an abuse of power that serves to comfort and empower the professional rather than the service user.
Conclusion
People are not fixed; they are always in process. I don’t pretend to fully understand someone’s experience. In fact, the way I work relies on the openness to the person-in-process that specifically comes from acknowledging that I don’t know.
It would be comforting to strip away the complexity and the not-knowing, and wrap everything up in a neat package. But I think to alienate someone from their own process and meaning-making is a violent action, and is exactly what happens when professionals choose to monopolise the meaning of someone else’s experience using unscientific, decontextualised diagnoses.
If we listen to people on an ongoing basis, then we can build forms of support collaboratively, using their frame of reference and preferences as a guide. These things might change, which is why our understanding and our support should be organic, collaborative and based on an ongoing dialogue. If nothing else, this would drastically reduce the trauma that the mental health system itself causes.
I wrote this in an attempt to solidify my understanding of why this kind of mental health system doesn’t exist already, despite countless people over many decades speaking out about the trauma that the ‘mental health system’ causes them, and the mounting evidence which suggests that ‘mental health difficulties’ may be seen as adaptations people need to make to cope with extremely distressing or difficult experiences. Exploring these kinds of vested interests has helped me to understand this better.
I don’t have all the answers, but surely the first step is to become aware of the problem. A ‘mental health system’ that is fundamentally person-centred might threaten the profit margins of numerous powerful organisations, but it would also eventually lead to uncomfortable questions about current societal conditions – pervasive issues like poverty, financial precariousness, isolation or the underfunding of support services, and in turn the traumas (like child abuse) they perpetuate.
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References:
Bellizzi, K. M. (2022, August 11). Cognitive biases and brain biology help explain why facts don’t change minds. The Conversation. https://theconversation.com/cognitive-biases-and-brain-biology-help-explain-why-facts-dont-change-minds-186530
Davies, J. (2013). Cracked: Why psychiatry is doing more harm than good. Icon Books.
Davies, J. (2022). Sedated: How Modern Capitalism Created our Mental Health Crisis. Atlantic Books.
Freud, S. (1999). The interpretation of dreams (A. A. Brill, Trans.). Wordsworth Editions. (Original work published 1899)
Freud, S. (2001). The aetiology of hysteria. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 3, pp. 1-20). Hogarth Press.
House of Commons Health Committee. (2005). House of Commons Health Committee: Fourth report: The influence of the pharmaceutical industry (HC 42). https://publications.parliament.uk/pa/cm200405/cmselect/cmhealth/42/4202.htm
Herman, J. L. (1997). Trauma and recovery: The aftermath of violence – from domestic abuse to political terror. Basic Books. (Original work published 1992)
Kupfer, D. (2013, May 3). Chair of DSM-5 Task Force discusses future of mental health research. [News release.] American Psychiatric Association. https://www.madinamerica.com/wp-content/uploads/2013/05/Statement-from-dsm-chair-david-kupfer-md.pdf
Masson, J. (2003). The assault on truth: Freud’s suppression of the seduction theory (Original work published 1984). Farrar, Straus & Giroux.
Moncrieff, J. (2008). A straight talking introduction to psychiatric drugs. PCCS Books.
Oreskes, N., & Conway, E. M. (2010). Merchants of doubt: How a handful of scientists obscured the truth on issues from tobacco smoke to global warming. Bloomsbury Press.
Snyder, A. (2016). The biggest misuse is that pharmaceutical companies are moving the goalposts for mental health. The Lancet, 387(10034), 2339. https://doi.org/10.1016/S0140-6736(16)00182-3
Spiegel, A. (2004, December 26). The dictionary of disorder. The New Yorker. https://www.newyorker.com/magazine/2005/01/03/the-dictionary-of-disorder?currentPage=all
Van der Kolk, B. A. (2015). The body keeps the score: Brain, mind, and body in the healing of trauma (UK ed.). Penguin Life.
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Mad in the UK hosts blogs by a diverse group of writers. The opinions expressed are the writers’ own.