Mental illness has extended well beyond being a clinical concern to becoming a dramatically epidemiological problem. Which discipline is best positioned to study and explain this epidemiological transition when even basic questions about aetiology, disease course and methods of treatment remain hotly contested? Taking seriously scientific examinations that question the validity of mental illness diagnostics and treatment, Bruce Cohen takes a sociological approach to ask what are the social drivers of the rapidly increasing rates of mental illness? Psychiatric Hegemony explains how and why psychiatric discourse escaped from the clinic and spread throughout the masses to achieve hegemonic status in neo-liberal society. Anti-psychiatry literature is swelling with well-reasoned arguments about the sweeping impact of the pharmaceutical industry on the spread of this discourse. In his explanation of how we arrived at an expanded political economy of mental illness, Cohen applies a structural analysis at an even deeper level. He skilfully puts together a compelling argument that neo-liberal capitalism is the central driver. Aligning expertise and science with the needs of capitalism, psychiatric discourse has become a primary tool for neo-liberal social control, which is increasing the penetration of diagnostic labels and psychiatric interventions into the everyday experiences of individuals. To some readers, Psychiatric Hegemony might seem like an exaggerated account, but that does not refute the insights to be gained by entertaining the central polemic. Questioning how the mental health enterprise serves both the economic and ideological needs of capitalist society ensures that we work towards more ethical modes of attending to human suffering. Cohen applies Marxist theory to mental illness at multiple levels of analysis: from mental health in schools and the workplace to the policing of women’s behaviour and the pathologisation of social and political dissent. Cohen draws upon a wealth of data and case examples from history, the educational system, the work environment and service sector, as well as a detailed textual analysis of the various iterations of the Diagnostic and Statistical Manual of Mental Disorders (DSM) from version one (published in 1952) through to version five (published in 2013). Cohen situates each edition of the DSM within the wider political context of its publication to demonstrate how categories and symptoms of mental disorder increasingly mirror the dominant norms and values of capitalist society. The growth of neo-liberalism has been accompanied by corresponding shifts in psychiatric discourse and mental illness classifications in response to changing socio-political dynamics. Today, individuals who are unable to fulfil or comply with the emotional labour of their work, gender or academic requirements are pathologised in ways that reflect the needs of neo-liberal capitalism for productive, disciplined, self-governing citizens. The mental health enterprise has become a major conduit for neo-liberal subjects to meet these demands at school, at work, or even at home. Informed by the available evidence, and with perhaps the most comprehensive application of Marxist theory to the area of mental health, Cohen confidently makes bold claims that will prompt specialists in the field to rethink their models of aetiology, epidemiology and treatment. A Marxist structural analysis of mental health is likely to pique the interest of only the most open-minded professionals working in the field. Ultimately, however, if the validity of mental illness is to be determined rigorously, then the mental health industry will have to respond to the concrete challenge put forward by Bruce Cohen in Psychiatric Hegemony. Cohen’s engaging writing style, persuasive case examples, and perspicacious arguments render the polemic convincing and easy to understand. But perhaps the neo-liberal critique of the proliferation of psychiatric diagnoses is low hanging fruit for sociological analyses of medicalisation. The aetiology of mental illness is little understood, the clusters of symptoms associated with individual disorders are continually contested, and the best methods of treatment are heavily disputed. A space has been left open for the fruitful application of critical social theory. That is not to dampen my praise of Cohen’s hard-hitting blow to the tenets of the psychiatric enterprise, but to highlight that this work is but the beginning. The next challenge is to apply a similarly rigorous structural analysis to the care and prevention of communicable and non-communicable diseases where aetiology, diagnostic measurements, and pharmaceutical treatments are scientifically well-established, clinically fine-tuned and rolled out globally. Social consensus around biomedical explanations should not be an excuse for languor or complacency. That diseases such as tuberculosis, malaria and type 2 diabetes persist despite the availability of effective pharmaceuticals is a clear indication that critical social theory needs to be factored into aetiological and epidemiological investigations beyond mental illness. Allowing the remit of science to be oriented unwittingly by neo-liberalism compromises the objectivity of research findings, the robustness of disease models and the efficacy of interventions. Cohen’s contribution to psychiatry and social theory is worthy of being taken further. Hopefully Psychiatric Hegemony will inspire a wide range of scholarship that informs both the social and biological sciences, and that will one day perhaps even make a difference to the health and well-being of diverse populations worldwide. © The Author 2017. Published by Oxford University Press on behalf of the Society for the Social History of Medicine.
Social History of Medicine – Oxford University Press
Published: Feb 1, 2018
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