Peter Sedgwick: Psycho Politics, Pluto Press, 1982, £4.95.
I can still see Ellie clearly, even after nine years. In her mid-twenties, she had already had numerous admissions to psychiatric hospitals, mainly for attempting suicide. When I knew her, she had been admitted yet again, after another attempt. She was bright, very unhappy, obviously insightful about her situation and, equally obviously, not psychotic. During an afternoon's discussion, when she described her fairly horrendous childhood, I asked her why she rarely talked about her feelings. ‘Oh, you never tell psychiatrists how you feel’, she said, ‘You only tell them what they want to hear.’ Over the years, various experiences in psychiatry have reminded me of this comment. Reading Peter Sedgwick brought it to mind once again.
Some twenty years ago, Enoch Powell, then Minister of Health, talked about the coming demise of the asylum. A new Mental Health Act had been introduced, as an attempt to safeguard the rights of the mentally ill, and the era of community psychiatry was nigh. The intervening years were to see many things, from the defeat of the United States in Vietnam to the emergence of Thatcher, Reagan, Friedman and Co. The asylums, however, are still with us, a grim reminder of society’s response to the mentally ill. Traditional psychiatric practice continues unimpeded in most of them. Electric Shock Treatment (ECT) is still prescribed, perhaps with less gusto than before, but prescribed nevertheless. A few papers have been written by psychiatrists suggesting that the effects of ECT are at best transient and possibly valueless, even damaging — a couple of recent ones caused near riots at the Royal College of Psychiatry, Ever increasing numbers and quantities of drugs are being prescribed for an ever-growing number of conditions; and more and more cases are reported of iatrogenic diseases (ie illness caused by the treatment itself). Finally, the last few years have seen the return of brain surgery, previously discredited, this time under the cover of ‘more accurate’ neurological diagnosis.
These trends had long been integral parts of psychiatric practice by the time the anti-psychiatrists caught the public imagination. Here at last were a group of people who really identified with the mentally ill, who were exposing the rigidities and the dehumanisation inherent in the system, who even went so far as to see insanity as the only sane response in an insane world. Their ideas influenced popular consciousness to a surprising degree. Even today they underlie many of the concepts of the radical critique of psychiatry. From the destruction of the individual in the institution to psychiatry as social control, from McMurphy’s rebellion to Mary Barnes’ journey through madness, many of the key symbols have been provided by anti-psychiatry. Yet, despite all this the situation of the mentally ill has remained, at least overtly, quite unchanged. For Peter Sedgwick the answer to this is clear. He blames the ineffectiveness of anti-psychiatry squarely on the anti-psychiatrist.
Sedgwick finds their message dangerous, the more so because it was so uncritically accepted. His severest criticisms are reserved for Laing, but he hardly leaves the others unscathed. Foucault's notion of a ‘golden age of permissiveness towards insanity’ is rightly challenged. So is his idea of the triumph of Reason exemplified by ‘the rigid sectarian rules of the institution.’ It would, however, have been well to consider his argument that the shame formerly applied on the leper has been to this day awoken and applied afresh on the deranged minds’.
Sedgwick shows Szasz to be an elitist and a reactionary behind his liberalism. The comparison with Herbert Spencer is particularly apt. Yet surely socialists of all people must come to terms with Szasz's idea of a psychiatric practice based purely on consent. Goffman’s essential conservatism and his inability to offer a critique of the macro-social organisation in which the asylum is located are rightly exposed. It is hardly true, however, that the asylum is so dismally compelling only ‘because it symbolises an ancient, indefinitely renewed tradition of neglect whose liquidation, in the face of many entrenched moral and material interests, will require a large and concentrated effort’ (p 62).
As for Laing, he is given two chapters, in the course of which he is quite completely demolished. His later conversion to mysticism, his recanting of his earlier ideas on the family processes in the genesis of schizophrenia, his distancing himself from his previous collaborators are all held up for our attention. The Laing of Facts of Life is undoubtedly a quite different creature from the Laing of Politics of Experience. Yet how does his later interest in Buddhism devalue his initial work on schizophrenia? That some, or even many people on the Left saw him as some sort of a revolutionary, reveals as much about them as it does about him. And his later conversion to Le Boyer childbirth and ‘umbilical shock’ does not invalidate his earlier ideas about family processes.
For Sedgwick, the insidious effect of these theorists’ work was to establish a New Left fallacy that mental illness was simply an artefact of capitalism and one fated to disappear with its demise. This caused trade unions to pursue selfishly sectarian policies. The rejection of the medical model confused and distracted the consumers/patients with the result that they often stayed away from the one place where adequate help was available — the psychiatric hospital. The concern with civil liberties in the final analysis led to ‘an all-round condemnation of the psychiatric enterprise itself”.
For Sedgwick, this is a matter of some importance, for throughout the book runs the assumption that mental illness is indeed an illness. Well, this may be so. If it is, however, the nature of the illness/es, has been poorly defined and even less well understood by psychiatrists. And even here, the occasional moves away from physical treatments to other modalities, the attempts to tighten diagnostic criteria, were at least partly their responses to the pressures generated by anti-psychiatry. Psychiatry remains a confused and confusing field. Most often we are still told what we want to hear and all too rarely what ‘they’, the patients, feel. Every new diagnostic criterion in the final analysis serves to blur the boundaries even further. Every fresh ‘insight’ from Neurology, Genetics, Psychology or whatever, compounds the confusion. Mental illness may be illness, but perhaps the medical model is not the best means of studying it.
As for prescriptions, Sedgwick suggests something along the lines of the Belgian village of Geel where 58 per cent of the population of Belgium's mental institutions live. They are strictly selected by the medical authorities and live as boarders with various families. The hospitals screen them, organise their outings, their work and hobbies, and readmit them if it becomes necessary. The hospitals also provide them with precise instructions for their host household, which include whether they may walk in twos unaccompanied (apparently two-thirds may not). They are strictly forbidden all sexual contact and are fairly widely discriminated against in bars and public places, ‘but not stared at’.
Sedgwick sees this as a major step forward, but from his description the transition to the community does not seem to have changed their experiences much; indeed, many patients have more sexual and social freedom in some British psychiatric wards. Although they are rarely on drugs or in contact with doctors after placement, the initial selection and screening is strictly in medical hands. In fact all the freedoms they do (or don't) enjoy are under medical control. Ironically, this exercise in community psychiatry shows the degree to which medical control extends over patients’ lives. And that, above all, was what the anti-psychiatric movement was all about.
TUKI ZUTSHI is a psychiatric registrar who has worked in a number of mental hospitals.