Psychiatric Psychodrama

“The maddening ambiguity of our position is what leads to the titular psychiatric psychodrama. One cannot reconcile oneself to psychiatry because it constantly pulls in two directions – it presents one with an ideological narrative that speaks of humanism and pluralism, and a material structure that witnesses biomedical hegemony. At some level this profession just does not make sense to itself, its own ideology out of whack with the plain facts of its own existence. There are those who are tempted to focus only on the positives, and see in this a story of triumphant progress towards a scientific future. And there are those who are inclined to see in it a story of eternal recurrence, single message mythologies ever reinventing themselves. But both of these perspectives are too tidy to capture the phenomenon. For this story is of a profession in contradiction with itself.”

The above passage is a modification of a particularly memorable paragraph from Liam Kofi Bright’s brilliant article “White Psychodrama.” I have rephrased it in appropriate places so that it refers to psychiatry rather than whiteness and racial inequality. As I was reading Bright’s paper, I couldn’t help but think of the parallels of the situation with the discourse around psychiatry, which is subject to its own peculiar “culture war” and polarized responses to a variety of issues – hence all the fuss around “antipsychiatry” and “critical psychiatry.” The extent of the analogy is limited, but nonetheless, I hope, illuminating in some way. Vigilance is warranted. I am drawn to this idea of a profession “in contradiction with itself,” a profession that struggles to make sense of the divide between what it aspires to in practice and the actual state of care provided to the average person. 

A crucial piece of this analogy is that this divide exists due to broad social, political, and economic structures that cannot be modified simply by a change in the ideological attitudes of psychiatric practitioners. In psychiatry’s case, the lack of adequate funding and resources for mental health services, a shortage of trained professionals, stigma surrounding psychiatric conditions, rampant and unchecked influence of the pharmaceutical industry, managed care bureaucracies that make it more and more difficult for clinicians to spend time with patients, reimbursement structures that do not incentivize psychosocial care, society’s aversion to risks posed by various psychiatric states (suicide, violence, public disruption, etc.), and social conditions (poverty, unemployment, homelessness, etc.) that ensure a continual state of misery and stress in the population – basically all the absurdities and dysfunctions of late-stage capitalism – are fundamental obstacles that prevent meaningful transformations in psychiatric practice. The focus of psychiatric culture wars, however, is on relatively superficial matters – the merits of psychiatric diagnoses, the efficacy and harms of psychiatric medications, the coercive and dehumanizing nature of inpatient psychiatric care, the concept of “mental disorder”, etc. These are important issues as well, but the degree of polarizing attention devoted to these issues stands in stark contrast to the sociopolitical structures that are arguably the actual drivers of biomedical hegemony.    

I won’t summarize Bright’s article here aside from referring to some pertinent points, so I strongly recommend that readers read it. The central thesis is that deep tensions between widely held normative aspirations of racial equality and pervasive and readily observable material facts about our society produce distinct character archetypes. These include the Repenter, the Represser, and the People of Color (PoC) Intelligentsia. Bright offers a fourth archetype of “Non-Aligned” as an ideal to aspire to as a means of reconciliation for folks seeking a way out of this dynamic. The Repenter and the Represser are understood to be elite White characters, for the most part, given that culture war polarization is largely a dynamic within elite White America. PoC Intelligentsia are people of color who have become advocates and allies of Repenter and Represser ideology respectively as a way to gain access to the resources and institutions of elite White America. The analogy of character types extends poorly to psychiatry, but to a limited extent, we can think of the Repenter and the Repressor as agents within the psy-medical complex, representing the professionals who are politically conscious and engaged. In place of PoC Intelligentsia, we have patients and service users intelligentsia. This over-simplification is far from exhaustive and ultimately unsatisfactory. In particular, we are not taking into account other powerful groups and institutions in the society whose relationships with the psy-complex varies considerably.

The Repenter type in psychiatry responds to the history of the profession with an overwhelming sense of guilt and alleviates this guilt by engaging in vocal and performative criticisms of contemporary psychiatric practices and constant exhortations that the profession has lost its soul. All the while, the Repenter will either work outside the public system, such as private practice, catering to those who can afford such services, thereby contributing to existing inequities in care for the most vulnerable members of the society, or will work within the public system such that their day-to-day practices are by and large indistinguishable from those of their colleagues, both situations further aggravating their guilt and the need for performative action. The Represser rejects any admission of guilt and sees it as a sign of irrational self-hatred. They will emphasize the progress that has been made in the field, the growth in scientific knowledge, and the availability of interventions and evidence of efficacy and safety from randomized controlled trials. They will highlight the horrors patients had to endure prior to the arrival of modern psychopharmacology, and reassure themselves that although things could be better, we are not doing so bad after all. Patients and service users – at least the ones who are sufficiently engaged in this politics – are largely devoid of power and representation, but opportunities arise for them to align themselves with either the Repressers or the Repenters, and use their lived experiences to support the narratives of the two groups.

“… the culture war is sustained by a material inequality that no one is seriously trying to fix. Repenters and Repressers are both responding to discontent generated by an ideology-reality mismatch, but neither of them wishes to either ideologically justify the material inequality or give away their property and superior opportunities.” “The matters disputed are sufficiently complex, and the historical narrative sufficiently contradictory, that there will always be the possibility of reasonable disagreement.” [Bright]

This brings us to the fourth archetype of the Non-Aligned. The Non-Aligned person views the culture war with a certain detachment, because from their point of view the institutions engaged in this culture war are “fundamentally addressing the wrong questions.” The interest of the Non-Aligned is in making progress towards the eradication of structural inequalities. The Non-Aligned sees the ideological projects of the culture war with a certain skepticism. They realize that many on-going projects of reform are simply serving Repenter or Represser goals, and the Non-Aligned would prefer to divert attention and resources to projects more likely to make a difference.

As a positive example of a Non-Aligned project with both intellectual and material elements, Bright mentions climate reparations advocated by Táíwò. When I think of the Non-Aligned archetype in mental health, I think of someone like Nev Jones, who has been working endlessly to promote “building a pipeline of [mental health] researchers with significant psychiatric disabilities and intersecting lived experiences frequently studied in public sector services research, including homelessness, incarceration, comorbid health problems, structural racism, and poverty.” (2021) This is a strategy that is orthogonal to the issues of psychiatric culture wars but more likely to positively reshape the structural landscape of psychiatric research. The Trieste model of mental healthcare, a product of Basaglia and Democratic Psychiatry movement, strikes me as another example of a Non-Aligned response, directly tackling sociopolitical structures. Hearing Voices Movement is also a positive example with both intellectual and material elements, from which many patients and service users have benefitted. There are many other good examples as well, but these suffice to illustrate the point.

Bright argues: “we must cultivate dispassion towards culture war flashpoints. Repenters, Repressers, and many of the PoC intelligentsia, will insist we ought care deeply about these issues. And there are genuinely good arguments for affective engagement with political injustices. But, where our own agenda of securing republican freedom by changes to the material base does not independently confirm their concerns to be of interest, these affectively charged flashpoints are nothing more than a distraction.”

Something of this dispassion towards culture war flashpoints is perhaps much needed in psychiatry as well.