Diagnosis — Unaccountable: Psychiatry’s history, present, and all of our futures.
Gendernaut and prophet, Alok, recently dropped this 👆 cautionary history of 19th and early 20th Century psychiatry. It’s replete with (cw, which applies to the whole of this article) institutional violence, racism, ableism & eugenics, bringing us tastefully up to the roaring 1920’s. It’s instinctive to hope this violence, institutional and strong, is stowed in the past. I mean, psychiatry has evolved since then, hasn’t it?
As we will see, psychiatry has changed a great deal in the last century. But not in the ways we suspect. The details have changed — how psychiatry does what it does — but it’s calamities are not detail-driven. They are structural problems. It seems training people in medicine and then asking them to treat emotional distress, while giving them absolute power over the distressed, is a terrible idea. The historical arc on this point is incandescent and upends our intuitions about history, medicine, and distress itself.
Before we travel back in time, let’s inspect a modern psychiatrist’s training regimen, the honest version:
Here is a sample of what follows:
Ok, let’s pick up where Alok left off — back to the 1930’s. (CW: Nazism, genocide.)
Hans Aspeger and the Nazis
The Nazis’ gas chambers were first used on Autistic (or “Asperger’s children”) and other institutionalised people with disabilities. After 2 years and 250 000 murders, the technology was moved to Auschwitz, which is the place that comes to mind when we now hear “gas chamber”.
We hear about Hans Asperger rounding up Autistic kids a few years before the Holocaust and it’s hard to associate his actions with psychiatry. That was nazism, not psychiatry, surely. We do the same when it comes to phrenology: “that was nazi science” we say, emphasising the “nazi” and whispering the “science”. Perversely we like uber-villains like Hitler, and in this case Asperger, because they take the heat off of the rest of us, and off institutions that still exist.
Nazis turned to the science of pathology to confirm their central tenet — that some people were worth more than others. Psychiatry, with its taxonomic and carceral power, came right up to the plate. Was Aspeger a monster, anomalous and rebellious, nothing to do with a principled branch of medicine? Or was he a leader in his field, doing exactly what psychiatry demanded of him? Our reflex to monsterfy him must be understood for what it really is; a trope in our internal cinema of history — the terrible monster is apart from the system they worked within. Nothing like us. Nothing like me.
Note that this is what we do when we wishfully account for violence by an individual’s “badness” or “monstrosity”. Hannah Arendt, who died a few weeks after I was born, demonstrated this in The Banality of Evil. And yet here I am, nearly half a century later, reminding people that the big violence is almost all cultural. Self-deception is hard to acknowledge.
Both the “lone villain” and the “lone genius” (in another form, “the great man”) theories of history are intuitive but worse than useless. They miss the complex structural forces that cause our actions. But let’s amuse that cinema for a moment and assume Asperger was a lone wolf. If we turn elsewhere in the annals of 20th Century psychiatry, we will find better things: specifically we will find experts helping people in distress to name and address their stressors. Won’t we?
1960’s housewives
In the postwar years the nuclear family was an engine for capital growth in the USA. White Dads were earning enough for the whole family. Meanwhile mum was embedded her new appliances in a suburban block, reproducing. It may have looked cute, but wealthy suburban women were being spiritually dessicated. The meaninglessness of their material wealth weighed heavy in their social isolation. And with distress comes a search for its cause. This couldn’t be the fault of America’s wonderful new society so it must be a sickness born within the woman. A kind of spontaneous generation, if you will. “Let’s get you to that nice doctor I met last week.” The culturally appropriate spirit doctors, psychiatrists, along with big pharma, were armed and helpful. Benzos had just arrived and they prescribed the shit out of them. Nothing wrong with your world, sweetheart, it’s your mind. Have a benzo.
This wasn’t the first moment that psychiatry medicated women’s non-compliance away and an epidemic of benzodiazepine addiction and withdrawal ensued. That secondary violence, just like the spiritual starvation that initiated it, was also blamed on its victims.
Psychiatric stigma stays around
When we speak of “housewives”, you don’t need to listen too closely to hear the pejorative in that term — as if women’s spiritual starvation at the hands of capitalist patriarchy were their own fault. Although the 1960’s was not the first moment that patriarchal capitalism dismissed, pathologised, or criminalised women’s suffering, it was perhaps the first time that psychiatry, pharma, and the patriarchy combined to do so. An apotheosis of sorts.
Nowadays it is routine legal practice to discredit a witness, particularly if feminine, by calling upon a psychiatrist for some acronyms. “BPD”, “ASD”, “ADD”, and her list of medications. This is she’s just on her period but with a stethoscope.
Look, maybe psychiatry had a few hiccoughs. But it’s not like it serves pathology to every marginalised group, does it?
1970’s and 80’s gay and trans people
We like to imagine conversion therapy as some kind of exorcism performed by a priest. But that’s not it at all. Gay conversion therapy (wherein a deviant is brought to heel by force of operant conditioning) was brought to you by psychiatry. And it wasn’t a renegade homophobe working alone. It was the standard treatment. Indeed, conversion therapy was apt to the task: To fix reprobates. When moralists can’t demand the church “redeem this sinner”, nor say “lock up this criminal” to the cops, then they say “disappear this pathology medically” to psychiatry. That is psychiatry’s larger, but subtextual, obligation.
In the 60’s, 70’s and 80’s, queers celebrated their legal right to exist at Mardi Gras and Pride. Just as the cops took a break from queer bashing, society pushed back with civilized violence: Micro-agressions, legally sanctioned discriminations, and verbal and sexual violence that the police were more than happy to overlook (or to participate in when off-duty). This kind of violence is unmentionable in polite society. It happens. It’s felt. But it’s not acknowledged by the perpetrators. In many cases they are unconscious that they are doing it. Bring it to their attention too rapidly and they often turn away and pretend you haven’t spoken at all. Gaslight city. This is distressing and disabling. Enter psychiatry.
Psychiatry picks up where the cops leave off. “You’re experiencing depression”. These pills will help. Tricyclic antidepressants, de rigueur at the time, might as well have been a punch in the face for all the good they did. Their side-effects sketched a longer list than their intended effects.
If it wasn’t poisoned pills, it was electric shocks and lobotomies. They were the norm in 20th Century psychiatry. Attention! There is our mindless historical cinema trope again: “Weren’t they barbaric back then!” It wasn’t just “back then”. Torture (conversion therapy, ECT) and eugenics were normal and they still are. I should know. I’m a sterilized trans woman who avoided conversion therapy as a child by masking both my neurodivergence and my gender. Both of my parents were licensed diagnosticians and one was a carceral agent of the state. Had I revealed myself to them I would have been before a conversion therapist when I was too young to advocate for myself. Wait, what? There was conversion therapy for neurodivergents too? Yes, there was. And there still is.
1980’s, 90’s, 2000’s, 2010’s, 2020’s ABA
At raisingchildren.net.au the benefits of ABA are advertised:
Applied Behaviour Analysis (ABA) is an approach to understanding and changing behaviour. It’s not a specific therapy itself, but a range of different strategies and techniques that can be used to help autistic people learn new skills and behaviour.
When they say “learn new skills and behaviour”, they mean “perform operant conditioning on Autistic people when they fail to mask”. ABA is conversion therapy for Autistic people. Here is a simple example of that:
Many Autistic people avoid eye contact. They describe it variously as “overwhelming”, “painful”, “distressing” and the like. I am Autistic, and while I can (uncomfortably) maintain eye contact with someone who is speaking to me, I cannot speak and look in my interlocutor’s eyes at the same time. When I try to do so, I lose track of what I’m trying to say. In addition, my breath shortens, and I feel pain in my neck, which if I persist turns into a sharp headache. It’s distressing to try. So I don’t. The dominant culture where I live permits this but mistrusts it. So when young Autists in ABA behave as I do, therapists punish them. The practioner might torture them “passively” (withholding attention, toys, or even food), or “actively” (some stimulus the person finds distressing). I get it. Mum and Dad want little Nicky to grow up trusted and adored and ABA aims to achieve that, assimilating Autists into neuronormative culture. Sounds neat. But so does waterboarding if you call it “enhanced interrogation technique”.
The central problem with ABA, like that with psychiatry itself, is not in its techniques, though they are distressing to learn about as an Autistic person, but in its framework. Just like psychiatry at large, the ABA practitioner’s goal is to “normalise”, not to encourage. To suppress, rather than liberate.
Who’s it for?
In a way, the client of psychiatry is not who we think it is. Although psychiatry is sold as a service to divergent people, we might do better to think of it as a service to “normal” people — helping them to feel comfortable about divergent folk. Psychiatry’s bread is not buttered by its inmates. That is done chiefly by the state via the medical-industrial-carceral complex. How, then, does psychiatry service it’s real client? At least three techniques stand out:
- Squashing the square human into a round box (ABA, Anti-psychotic medications, stimulants for ADHD “take this, it will help with your executive function”)
- Sedating or incarcerating trouble makers (“take this, it will calm you down”)
- Promising to “manage” divergent unrest via taxonomy and private care.
Hypercapitalism & divergent distress
I can attest that the built environment has become immeasurably more hostile to Autistic me during the last 20 years. Supermarkets now, for example, maintain aisles that I cannot peruse without disability aids — the combination of lighting, hissing from speakers, and signage melts me right down. This might seem like a loss for the supermarket operator, but it’s the opposite. The owner of the franchise knows from their efficiency manual that the most efficient extraction of profit from consumers comes when the consumers are all the same. “Normalising” people and extracting from them are the same project. So it is not by accident that unconventional people feel uncomfortable in hyper-capitalist spaces. Stand for a moment in head office: How can you mass-produce something if everybody’s needs are different? You can’t. If you’re big enough, however, you can make sure that everybody who buys from you is the same by making your space intolerable to freaks. When you are the only option left, the freaks will have to fall in line or starve. Literally. This is not, of course, how these ideas a framed at head office. There, too, euphemism conceals the rot.
Being accustomed to capitalists extracting profit from human bodies, we don’t register the violence of all this. Instead we see the emotional fallout — the wailing weirdos showing up in droves to the psychiatrist. They must be defective, right? It couldn’t be their environment. Epidemics of Autism, ADHD, Depression, Snowflake Sydrome. An epidemic of disability. It can’t be the environment. It must be a DISEAAASE!
And psychiatry says literally that — that distressed people are diseased: “Autism Spectrum Disorder”, “Attention Deficit Hyperactivity Disorder”, “Major Depressive Disorder”.
The naming of the disease is a moment many distressed people welcome. “Wow, thank you, everybody else said I was crazy and now you’re saying… that I’m crazy but with a label. Thank you.” Ending confusion is a relief. What that person doesn’t yet know the measure of is the dependence and stigma they’ve just signed onto.
Meds? Not for Autism sorry. But if we can diagnose you with one of these other things in this here book of spells then we can absolutely mess with your neurochemistry. And we will! ADHD! yes, there’s some crossover there (now that it’s Wednesday), especially if we can zoom in on your “Executive Dysfunction”.
The emperor has no clothes. None.
It has recently become abundantly clear (previously it was clear but with a lower abundance coefficient) that shrinks’ best sales pitch of the last 30 years was unmitigated nonsense. The theory that a “chemical imbalance” was the cause of depression was as philosophically non-sensical as it was untrue. But it sold the most successful psychiatric medications of all time and we love drugs. Especially the peer-reviewed kind. We lapped it up. Again and again.
There comes a point in swimming through all this history where one asks, “is anyone going to take responsibility for all of this bullshit?”
It’s no doubt not lost on you that psychiatry has a peculiar power. It seems to be able to choose which diversities are “disordered” and which can be left alone. I mean, what’s to stop psychiatry naming “Left Handed Disorder”, or “Black Skin Disorder”, or “Homosexual Disorder”. Oh right. It did. Serving the opprobrium of its day. Check out the this move from the 1850's:
Drapetomania was a supposed mental illness that, in 1851, American physician Samuel A. Cartwright hypothesized as the cause of enslaved Africans fleeing captivity.[1]: 41 The official view was, slave life was so pleasant, that only the mentally ill would want to run away.
Distress, it turns out, has something to do with our social conditions.
Looking at the organism
Although psychiatry’s science of distress has shifted its focus over the years, the field it is inspecting has remained the same: the organism. Yet distress for a social animal is most often social in origin. And with its one-organism policy, seeing a psychiatrist for your distress is like seeing a mechanic for your groceries. We don’t want to admit our distress is structural so we keep going back to the mechanic. This whole thing is getting very silly.
For the last time, Derrick, it’s not about good intentions
Many people hear all this and think “but the psychiatrist I know is a good person. They just want to help.” and they’re not wrong. But wow, bro, way to misunderstand harm! Good intentions are true OF EVERYBODY, not just those who land themselves in the “helping professions”.
Psychiatrists are so immune from feedback they don’t even do their own apologising. Devoted apologists come running when you dare poke a question in psychiatry’s direction. Just check out the comments on this Instagram Post: The contributors will say and do literally anything to protect their shrink. It’s all quite spiritual.
This army of apologists is populated from all corners, but perhaps the most ferocious defender of psychiatry is the late-diagnosed ADHDer. For 3 or 4 decades they struggled and nobody could tell them why. I’m one of these people myself. It’s confusing to fail at time, school and money with no obvious excuse. And so when they found legal meth and a diagnostic hug from the shrink, they thanked… psychiatry. Honey, those things are GATEKEPT by psychiatry, not “provided” by it. And it’s not “your biology” that distresses you, it’s the capitalism. And here’s the banger — that’s not the fault of shrinks. That’s how the state has set up the game. We look for individual fault though, because carceral logic doesn’t just effect our political enemies. It lives in our bodies too.
In short, accountability in psychiatry is nil. And unaccountable enterprises don’t get better, they defend.
Let’s forget about reforming this industry for a little minute and notice what it is that brings someone before a psychiatrist in the first place. Perhaps then we can think clearly about redirecting that person to a useful place.
Distress
An Autistic Black person in distress in public in the USA has some decent chance of being shot by the police. For people lucky enough to avoid jail or death, sufficient distress may find them in front of a psychiatrist. Some distress makes sense. I injured myself and I can’t leave the house for 3 weeks? That’s obviously distressing. There are words to describe it that EVERYBODY would agree upon. No need for a psychiatrist. What about if I’m distressed by something that I cannot consciously name. Or worse, when I do name it, the people around me say it’s not real. Let’s take a look at that.
Minority stress
Take what is in someways a typical nuclear family with 4 members; Dad, Mum, Kiddo1 and Kiddo2. Now let’s exaggerate some of the power and privilege by noting that Dad is white, a legal citizen, abled-bodied, neurotypical, employed, cis-gendered, and heterosexual. Mum is the same in some respects but marginalised in that she’s undocumented, brown, and illegally employed. Kiddo 1 is brown, documented and gay. And kiddo 2 is brown, undocumented, physically disabled, neurodivergent (dyslexic and Autistic), intersex and trans and bisexual. Kiddo 2’s safety, as you might be able to imagine, relies on them masking themself differently in different contexts. With their family they mask only their gender and their sexuality. With their peers and teachers at school they mask their transness, sexuality, documentation, or intersex identity. And in other places they go, they have to assess on-the-go what to hide. (If this sounds like a meaningless shopping list to you, read it again slowly and sit a while.) Kiddo 1, on the other hand, has only their sexuality to mask and masks it in all contexts. Mum has to mask her documentation status and employment conditions in most environments, and Dad wears no masks at all, except when he decides to have an affair and to keep it a secret. His only shame is by choice.
When Dad experiences some disappointment at work, or when he’s triggered by something at home, unpacking the the cause of his distress is a relatively simple matter. There’s little invisible violence landing on him and his interlocutor needs very little elaboration from him to understand and hold space. For example, when his direct boss dismisses him rudely one day, he struggles with that moment and, upon being asked later “what’s got you in a huff?”, he has little difficulty in stating “my boss was rude to me and it cut deep.” Mum, on the other hand needs another brown, undocumented mother and wife to catch her story and provide adequate witness. Most documented folk don’t understand what the fear of deportation feels like. And deficits like that exist for each axis of her marginalisation. Without those intersections present in her comforting friend, she has a great deal of invisible violence to “explain” before they can do very much witnessing at all. Moreover, her distress takes place at a higher rate and a higher intensity than Dad’s. We’re going to look at the kids now so get out your calculator.
Fo Kiddo 1, a friend with some special experience (child, queer, brown) is needed. And kiddo 2 needs a miraculous confluence of circumstances in order to share just a small part of their burden. Kiddo 2, more to the point, weathers a constant barrage of normative violence — microagressions, disapproval, threats, and typically from people who mean no harm but don’t know any better. Kiddo 2 is constantly assessing whether to address those harms (fight), whether to hide (freeze), whether to run (flight), or whether to blend in (fawn). Their attentional window is steamed up with calculus about what to do. It is, in the modern vernacular, a lot. Kiddo 2 is experiencing minority stress.
Managing those threats is not the same as managing a corporate job while white, cis and abled, or missing out on sleep because your newborn. It is a constant flight-fight pressure on the nervous system without witness or release, and leads to chronic distress. If they avoid jail or the morgue, this kid is likely to land in a psychiatrist’s office eventually. What happens next depends largely on how much of the invisible violence can be rendered visible inside the psychiatrist’s frame. And I hope by now it is becoming clear that a frame which only contains causes “from within” the subject is worse than useless. It is more gaslight. The amiability of the psychiatrist is neither here nor there. It’s their framework that matters, not their intentions.
Theorists have attempted inroads into the psychiatric canon. Minority stress is itself a term coined by a psychiatrist in 2002. Despite 20 years and an introduction from an insider, psychiatrists still don’t have this frankly ubiquitous explanator in their scriptural framework. This is not to say there aren’t individual shrinks and other therapists screaming for a revolution. They are. But their cries are not reaching the parliament. Why is that?
This “from within” idea is mandated by psychiatry’s foundations — shrinks are doctors of medicine. Medicine looks at an organism, not at a social system. And while it’s true that human distress can be caused by broken legs and viruses, that’s not the kind of distress that sends people to psychiatrists. Psychiatric patients are victims of social violence and psychiatrists have no special skills there. So the answer for psychiatry is pretty simple. Abandon the medical model and embrace the social one.
Oh, what was that? Psychiatry is well powered in medical science and has no particular claim to expertise in social violence? Marginalised people themselves are the experts there? Well we can’t very well empower psychiatric patients. They’re crazy.
It turns out that empowering marginalised people is a solution to all kinds of modern problems, particularly when it comes to repairing harm to the natural world. And it turns out that human beings and their cultures are a part of the natural world, not apart from it.
Australia is not the only place on earth which displays the pattern illustrated above. Indigenous custodians, it turns out, are not only custodians of the land, but custodians of the culture which heals it.
Traditional custodians, indigenous people, have been overlooked, criminalised, pathologised, genocided, and “saved” by settlers. And now, in the final throws of the planet, we notice that they maintain the cultures who can heal it. It’s not a coincidence that divergent people of all kinds have been also been overlooked, criminalised, pathologised, genocided, and saved. The police have led the state’s charge against indigenous people. Psychiatry has led it against neurodivergent people. And both of these “social puzzles” of present day distress are not really puzzles at all. Divergent people, People of Colour, Disabled people, Queer people, Indigenous people, are helped when they are given access to power. The psychiatric hug is not an empowering one. It is historically and presently a disempowering one, a eugenic one, a genocidal one, a pathologising one. We fix this by empowering psychiatric survivors to build alternatives.
My sterilization — modern eugenics and how to fix it
I promised to come back to this. To tell you about how the eugenic threads of psychiatry’s power played out in my trans story. But it turns out I’m too fucking tired. I’ve been writing all weekend and not about daisies. I have nothing left. It doesn’t matter though. It’s incredibly simple to discover. Even with a search engine that privileges cisness and hides state violence, searching for “eugenics in trans health care” is incredible simple. You just have to want to know.
Which leads mercifully to our conclusion. Psychiatry’s coercive and violent past is actually its present. When we gag at the horror of historical events we default to statements like “weren’t they barbaric back then. Monsters!” That is a reflex in service of the status quo. It is a little piece of the bullshit that lives in all of us. It’s not only “back then”. It’s now. And they weren’t monsters. They were people. Just like us, working inside structurally violent institutions. So how can we reform psychiatry? We can’t. It’s set up wrong. The power is in the wrong hands. Give that power back to the marginalised people in distress. In the case of psychiatric care, here is what that looks like.
