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Critical and Radical Social Work • vol 3 • no 1 • 103–17 • © Policy Press 2015 • #CRSW
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pioneers of the radical tradition
Peter Sedgwick: mental health as radical politics1
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Tad Tietze, [email protected]
University of New South Wales, Australia
This article examines the life, Marxist politics and critical psychiatric theory of Peter Sedgwick,
author of Psychopolitics (1982). Sedgwick critically engaged with the ideas of key anti-psychiatric
thinkers, including Goffman, Laing, Szasz and Foucault. His theoretical contribution – of the social
construction of health and illness, mental and otherwise – underpinned a focus on the politicisation
of medical goals within projects for social transformation. His ideas remain highly relevant to
modern psychiatric debates and controversies.
key words critical psychiatry • Marxism • anti-psychiatry • medicalisation • social construction
Introduction
Peter Sedgwick (1934-83) was a psychologist, academic, translator and revolutionary
Marxist activist who lived in Britain through periods of progress, crisis and reaction
– in both the field of mental healthcare and wider society – before his untimely
death. While working in various health settings, Sedgwick pursued a sustained critical
engagement with the ideas of thinkers associated with the anti-psychiatry movements
of the 1960s and 1970s – including Erving Goffman, R.D. Laing, Thomas Szasz and
Michel Foucault. He welcomed their critique of scientific positivism while rejecting
a tendency to annex psychiatric problems from health and illness in general.
In this article I outline Sedgwick’s personal story and his adult political commitments
and achievements. I survey his critiques of the anti-psychiatric thinkers before
elucidating his key theoretical contribution to critical psychiatry: the idea that all
health and illness is socially constructed, and therefore that conflicts over normality,
diagnosis and treatment can only be understood by locating their origins in conflictual
capitalist social relations. I address more recent criticisms of his main positions and
– through the example of the controversies surrounding the Diagnostic and statistical
manual of mental disorders: 5th edition (DSM-5) – consider how his ideas help us to
understand and orient thinking about the renewed crisis of mainstream psychiatry.
Life of a radical
Born in Southampton, England, in 1934, Sedgwick was brought up by his uncle
and aunt after his mother’s death from breast cancer when he was just one year old.
He was intelligent and studious as a child and went to Balliol College, Oxford, to
read Greats. Sedgwick’s burning interest in questions of mental health and illness
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was forged during his early years with his adoptive family. His adoptive mother ‘was
admitted, in a condition of extreme dementia, into the charge of a crowded and
custodial local mental hospital in which she quite shortly afterwards died’ (Sedgwick,
quoted in Lukes, 1983). It was only after this that Sedgwick learned that he had been
adopted. He later came to the conclusion that ‘the studious bookish part of me was
constructed as an elaborate defence system against a fairly horrendous world’ (Kuper,
2013). Sedgwick also suffered from debilitating physical problems, including a bowed
back and asthma (Mitchell, 2004).
It was at Oxford that he became involved with the Communist Party, and in
the aftermath of Khrushchev’s secret speech did not reject socialist values, instead
moving towards a more questioning and non-dogmatic commitment to working-class
self-emancipation. He became involved with the powerful movement for nuclear
disarmament that swept Britain at that time. He joined the Socialist Review Group/
International Socialists (SRG/IS) in the late 1950s, remaining a member until 1976.
Following his time at Oxford:
He became a psychologist at Liverpool University but was forced out of
this post when an article he had written about Durex’s monopoly of the
contraceptive industry led to a confrontation with his professor (and support
from his students). There followed jobs as a school teacher, an educational
psychologist, tutor at a psychiatric prison and research psychologist at an
Oxford hospital studying brain damaged patients. He then took up a politics
lectureship at York University, spent a year in New York, and, finally, a post
in both politics and psychiatry at Leeds University from 1974 until [his
death]. (Lukes, 1983)
While at Liverpool he met and married Edie in 1959. His daughter was born at the
end of that year and his son was born in 1961. Despite his personal struggles, Sedgwick
was widely considered to be an especially warm, generous and funny man, rarely
allowing the darkness he carried to colour his professional and political activities.
Sedgwick wrote for a wide variety of Left and mainstream publications, including
New Society, International Socialism, New Left Review, The Observer, The Guardian,
the Times Literary Supplement and New Statesman, as well as academic journals
such a Salmagundi, Psychological Medicine and Psychiatric Bulletin. Compared with
the overwrought stylistics of many writers on the revolutionary Left, Sedgwick’s
prose had a literary elegance, densely packed yet frequently witty and ironic. He
had a knack for puncturing received wisdoms, and would do so by mobilising an
encyclopaedic knowledge of the history of the Left and the workers’ movement.
That he was able to demolish One-dimensional man (Marcuse, 1964) when Herbert
Marcuse was a darling of the New Left (Sedgwick, 1966) says much about his fierce
intellectual independence. Even a cursory glance at the page dedicated to his work
on the Marxists Internet Archive (https://www.marxists.org/) reveals his ability to
intervene incisively in debates around the nature of Stalinism, nuclear disarmament,
the travails of the British Labour movement and the New Left, socialist history and,
centrally for this review, the politics of mental illness. He is also known for translating
and editing Victor Serge’s Memoirs of a revolutionary (Serge, 1963) and Year one of the
Russian Revolution (Serge, 1972), helping to edit Midnight in the century (Serge, 1981),
and writing penetratingly on Serge’s politics (Sedgwick, 1984).
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While Sedgwick was for many years part of political currents that could broadly be
described as ‘Leninist’, his own politics after 1956 were decidedly more libertarian.
The SRG/IS was sufficiently open and inclusive that he was able to be a productive
contributor to its activities not despite but because of the creative tension that flowed
from such differences. The group’s founder and most prominent leader in that period,
Tony Cliff, would later claim: ‘Every organisation should have one Peter Sedgwick,
but no organisation would survive with two of them’ (Birchall, 2011: 175). It was
only when the IS declared itself the Socialist Workers Party that Sedgwick believed
that the group’s promise had been squandered by a grandiose turn to electoral work
in an increasingly right-wing climate (Sedgwick, 1976).
Following his departure he became involved in a number of Left regroupment
efforts, including helping to organise the influential ‘Beyond the Fragments’
conference in 1980. However, as the impact of Thatcherism became obvious, he
found himself fighting overwhelming depression, leading up to his premature death
in September 1983.
The challenge of ‘anti-psychiatry’
Sedgwick developed his critique of modern psychiatry in a series of papers and
articles in the 1970s, several of which were revised, expanded and elaborated on with
the help of editor Richard Kuper in the widely read Psychopolitics (Sedgwick, 1982).
Perhaps surprisingly, his main foils in this process were not defenders of psychiatry
but thinkers associated with the anti-psychiatry movement.
While ‘anti-psychiatry’ refers to a heterogeneous and often contradictory set of
ideas, politics and activities that rose to prominence in the late 1960s and early 1970s,
it is possible to identify some common themes, highly critical of psychiatric theory
and practice. First, there was a critique of psychiatry as being a branch of medicine
that relied on low-quality or absent ‘scientific’ evidence when compared with the
physical healthcare professions. Second, that mainstream mental healthcare was
basically repressive in nature, robbing patients of their individual rights via mechanisms
such as detention and forcible treatment. Third, psychiatric diagnosis was seen as
fundamentally value-laden in the way it turned certain types of social deviancy into a
poorly defined entity known as ‘mental illness’. Along with other political and social
developments in Western capitalist countries at the time, these movements drew on
and in turn influenced a series of scholars and thinkers who became associated with
anti-psychiatry as a phenomenon (Tietze, 2011).
Erving Goffman
One of the earliest influences on anti-psychiatry was the work of American functionalist
sociologist Erving Goffman, in particular with his books Asylum (1961) and Stigma
(1963). Goffman employed an ethnographic approach to his study of psychiatric
hospitals, coming to the conclusion that they were a type of ‘total institution’ in
which brutal and ineffective treatments had a tendency to render patients ‘dull and
inconspicuous’. However, Sedgwick noted, this apparently devastating critique of
mental healthcare was undercut by the deeply conservative substance of Goffman’s
theoretical stance, in which resistance to the social structures that oppressed people
was little more than part of the way those structures reproduced themselves intact.
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Sedgwick reasoned:
Goffman has no room for sense of the historical contingencies of social institutions.
This deficiency makes it absolutely impossible for him to use his insights,
either into particular local ‘settings’ or into the general quality of everyday
life, in any way which is critical: which issues, i.e., a demand for change in a
definite direction. (Sedgwick, 1974a: 38, emphasis in original)
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Further, Goffman’s attention to micro systems of social interaction led him to a kind
of ‘methodological localism’ that could not grasp the emergence of these specific
interactions from broader social relations and conflicts. This meant that he accepted
at face value various norms that were dominant in society in the United States in
the post-war era, and therefore saw phenomena such as mistreatment of mentally ill
people and stigma as merely the result of their deviancy from those norms.
R.D. Laing
Sedgwick’s approach to the Scottish psychiatrist and psychotherapist R.D. Laing –
probably the most celebrated figure in anti-psychiatry – was quite different. This
was in part because his subject’s oeuvre was marked by its frequent shifts in focus and
theoretical position: ‘The texts of his works are like the old Egyptian palimpsests,
manuscripts with the first draft rubbed away and, while still partly visible, written
over by another scribe – in this case Laing himself in a different ideological phase’
(Sedgwick, 1982: 69). It was Laing’s ability to hold a multitude of quite dissonant
critiques in tension that led many of those attracted to his ideas to see him as being
especially committed to their own particular preoccupations. Thus, he could be
republished uncritically in the Marxist journal New Left Review (Laing, 1962, 1964a,
1964b) at the same time as being seen as a guru of meditation.
In The divided self (1960), Laing drew on a study of psychotic patients he cared
for in Glasgow to declare that what others saw as symptoms and signs were in fact
mental states and behaviours that had understandable personal meaning when seen in
context. This relentless focus on individual experience soon made way for a concern
with family systems, first emerging in his revisions to the manuscript for The self
and others (Laing, 1961) that occurred in the light of working with families at the
Tavistock Clinic in London, as well as a deep engagement with Jean-Paul Sartre’s
existentialism. Laing argued that schizophrenia was the product of impossible ‘binds’
in which individuals were put by their families, to which the only rational response
was descent into madness.
Sedgwick noted that a lack of normal controls in his studies made it unclear whether
Laing was tackling communication problems specific to ‘schizophrenogenic’ families
or generally present in all families. But before such issues could be clarified, Laing
was already moving back to the realm of individual experience in the mid-1960s,
seeing psychosis as a ‘hyper-sane’ state of healing from psychic injury. This dovetailed
with running the therapeutic community Kingsley Hall and was perhaps most fully
summarised in The politics of experience (Laing, 1967). This represented a descent into
mysticism that was, paradoxically, tied up with the period of Laing’s most openly
anti-capitalist commitment. For Sedgwick the paradox is explicable in how Laing’s
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critique of a ‘crazy’ society leads there to be no social yardstick by which to judge
the greater validity of ‘normal’ or ‘psychotic’ experiences.
In the early 1970s, the Scotsman turned sharply ‘towards the criteria of everyday
commonsense in his approach to drugs, the family and mental illness’, thereby creating
the circumstances in which ‘the critic of Laing is now, indeed, faced with the task of
defending those elements of his work which their author now wishes to repudiate
or at least downgrade’ – especially his ability to undermine the ideologically loaded
categories that informed the turn to a more mechanistic and biologically reductionist
mainstream approach to mental disorder in the late 1970s (Sedgwick, 1982: 110).
The thinness of the radicalism was unsurprising because:
the main contention of Marx that ‘social being’ determines ‘social
consciousness’ was never accepted by Laing: if anything, ‘social being’, the
presence of structures of social organization which can be at odds with the
consciousness of the individuals comprising these structures, is dismissed by
Laing and his followers as the outcome of a plurality of ‘praxes’ or individualsubjective projects. (Sedgwick, 1982: 113-4)
Thomas Szasz
The Hungarian-born American psychiatrist, Thomas Szasz, meanwhile, took aim at
the core pretensions of his own profession and its very raison d’être. His most celebrated
work was an essay entitled ‘The myth of mental illness’ (Szasz, 1960), later republished
as part of a book of the same name (Szasz, 1961). For Szasz, mental illness was a ‘myth’
because, unlike physical illness, there were no ‘anatomical and genetic’ contexts to
judge someone ill, only ‘social and ethical’ ones. In this schema, physical medicine
was counterposed to psychiatry by being focused on the discovery of a pathological
‘lesion’ requiring medical intervention, which psychiatry, by definition, lacked.
Sedgwick pointed out that, in the original edition of The myth of mental illness, Szasz
(1961) only attacks the ‘organicist’ faction of his profession, and even then mainly to
put forward his preferred views on human behaviour, individual responsibility, and
the benefits of private psychoanalysis. Yet in his later work, such as The manufacture of
madness (Szasz, 1970), he posited a radical opposition between two types of psychiatry:
The totalitarian pole is termed ‘Institutional Psychiatry’; it is characterised
by involuntary incarceration in mental hospitals, the use of psychiatric
concepts for the extralegal punishment of deviants, and the state’s investiture
of publicly employed physicians as agents of social order rather than of their
patients’ welfare. The opposite, benevolent extreme is offered in Contractual
Psychiatry: an arrangement founded on an informed consensus between
two freely choosing individuals, one a therapist and the other a client, the
former providing a service in the unraveling of certain moral problems and
the latter, in return, a monetary fee. (Sedgwick, 1982: 152)
Sedgwick was scathing of Szasz’ critique at two levels. First, there was the unreal
picture that Szasz painted of bodily medicine in order to sustain his extreme view
of what defines its object of intervention. This fantasy was necessary to Szasz so that
he could brush over the real-life complexities of institutional psychiatry, which even
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in the least sympathetic assessment does not conform to his one-sided description
of it, and which closely parallels the institutions and activities of physical healthcare.
Second, he punctured Szasz’ right-wing libertarian view of market transactions as
the apogee of therapeutic benevolence. Not only does the rejection of institutional
psychiatry leave no place for a whole range of patients with a multitude of problems
unable to afford to pay the cost of Szasz’ preferred model of care, but in many cases
their mental infirmities would render them unable to enter into such exchanges as
the informed equals that Szasz demands they must be. Finally, the shoehorning of
all psychiatric care into the psychoanalytic model of the regular ‘hour’ of therapy
makes little sense to many people’s problems. Szasz never faced up to the immense
inequalities of power inherent in his preferred psychoanalytic encounter, nor the
very real problems of psychotherapeutic coercion and exploitation, which have been
a source of repeated scandal.
Finally, Szasz’ hard-line rejection of ‘collectivism’ – dressed up in the form a
rejection of ‘statism’ – denied the irreducibly social nature of health and illness, and
evaded how society (as opposed to individuals) might do things differently in favour
of a narrowly market-juridical schema.
Michel Foucault
A preoccupation with how society shapes both mental illness and responses to it did
lie at the heart of French philosopher Michel Foucault’s (1961) pioneering work
Folie et déraison: Histoire de la folie à l’âge classique (translated and abridged as Madness
& civilisation; Foucault, 1965). For Foucault, concepts of mental health and illness
were purely sociohistorical constructs that shifted and changed over time but always
played a role in upholding existing power relations. In this view, the asylum and the
analyst’s couch were equally parts of systems of repression and control, which Foucault
later went on to explore in a variety of other social settings.
While Sedgwick praised Foucault’s critique of existing liberal histories of psychiatry
– which tended to see each new technical advance as bringing the field ever closer
to perfection – he was less convinced by the coherence and validity of Foucault’s
identification of ‘reason’ as the central driver of psychiatric advance. Madness &
civilisation is replete with historical detail, yet it remains poorly grounded in material
social facts in order to maintain its ‘overwhelming concern with the logic of “classical”
(i.e. seventeenth-century) diagnosis’ (Sedgwick, 1982: 140). Because he needs to make
the case for a ‘timeless bourgeois rationality which seeks the control of rebellious
Unreason quite outside the complex of social contradictions characteristic of different
periods’, Foucault misses minority psychiatric movements that contradict his central
narrative, as well as being unable to acknowledge what might (ironically) be termed
regressions to less mechanistic and more humanistic forms of treatment (Sedgwick,
1982: 142). In effect, the French thinker proposes a kind of anti-Whig history, ending
up with ‘anti-psychiatric romanticism’ that celebrates madness as a genuine but always
defeated enemy of irrational reason (Sedgwick, 1982: 147).
The social construction of health and illness
Underpinning such critiques was Sedgwick’s commitment to constructing a rigorous
critical approach to mental health and illness based in close engagement with the
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revolutionary theory of Karl Marx. He laid out the basic shape of this method in
an article entitled ‘Mental illness is illness’ (Sedgwick, 1972a, emphasis in original),
in which he argued that the anti-psychiatrists had made a great contribution in
developing a ‘consistent and convergent tendency of opposition directed against positivist
method in the study of abnormal human behaviour’. Sedgwick defined positivism as:
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an approach towards the investigation of human pathology which, modelling
itself upon antecedents which it believes to be characteristic of the natural
sciences, (a) postulates a radical separation between ‘facts’ and ‘values’
(declaring only the former to be the subject-matter of the professional
investigator) and (b) suppresses the interactive relationship between the
investigator and the ‘facts’ on which he works. (Sedgwick, 1972a: 204)
Yet for all their radical dissection of psychiatry’s claims about the nature of mental
health and illness, ‘[i]t appears to me that none of [the critics] have begun by asking
the question: What is illness? Only in the light of an answer to this question could we
determine our answer to the question: Is mental illness really illness in the “medical”
sense?’ (Sedgwick, 1972a: 196, emphasis in original). Further:
The difference so forcefully argued by anti-psychiatric theorists, between
the ‘biological norms’ to which physical medicine appeals and the ‘social
norms’ which back up psychiatry, dissipates into nonsense as soon as we are
brought to see that ‘the medical enterprise is from its inception value-loaded;
it is not simply an applied biology, but a biology applied in accordance with
the dictates of social interest. (Sedgwick, 1974a: 28)
By broadening the scope of the entire inquiry, Sedgwick was following in the
footsteps of the medical epidemiologist, René Dubos, who had explored how social
and political change had historically produced the vast bulk of effective human
responses to ill-health. Biotechnological medicine focused on individual treatment
therefore formed merely a small (and not always successful) part of the overall story,
yet one that had become pre-eminent in the modern industrial era (Dubos, 1959).
By placing all of medicine (physical and psychological) in this context, Sedgwick
could simultaneously blow apart the positivist claims of the biological psychiatrists
and the shallow anti-positivism of the anti-psychiatrists.
It may prove possible to reduce the distance between psychiatry and other
streams of medicine … not by annexing psychopathology to the technical
instrumentation of the natural sciences but by revealing the character of all
illness and disease, health and treatment, as social constructions. (Sedgwick,
1972a: 210, emphasis in original)
That is: ‘Outside the significances that we voluntarily attach to certain conditions,
there are no illnesses or diseases in nature’ (Sedgwick, 1972a: 211, emphasis in original).
Sedgwick provided a series of examples where analogous biological occurrences were
differently categorised as illness or not depending on the social meaning ascribed to
them. For example, a twig snapping off would not normally be considered a form
of ‘illness’, while a human limb similarly broken would. Even within human society,
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definitions of health and illness change over time: tooth decay was once considered
normal yet now is seen as a disease process requiring both prevention and treatment.
And various symptoms and physical signs depend on social context for the way they
are defined: a man who finds himself increasingly weak and breathless on physical
exertion is considered as ill when young, but simply ‘ageing’ when in his nineties.
Thus, ‘all sickness is essentially deviancy’ from social norms, but of course only
certain types of social deviancy are considered to be illness (Sedgwick, 1972a: 213).
Sedgwick used these insights as part of arguing for the politicisation of medical goals.
He wrote: ‘Mental illness, like mental health, is a fundamentally critical concept: or
can be made into one provided that those who use it are prepared to place demands
and pressures on the existing organisation of society’ (Sedgwick, 1972a: 222, emphasis
in original). Such demands must not be limited to the reallocation of resources to
overcome gross disparities in access to healthcare, but also they should posit what
type of care would be needed. In a provocative review of Ken Loach’s film Family
life, which rejected psychiatric treatment from a perspective aligned with Laing
and David Cooper’s work, Sedgwick argued for ‘more and better mental hospitals,
more and better doctors and nurses – at the expense of armaments and the profits
of the rich’ (Sedgwick, 1972b). As Cresswell and Spandler (2009: 133, emphasis in
original) contend, this goes beyond the bounds of narrow biotechnical conceptions
of medical treatment:
Sedgwick is pro-medicine precisely to the extent that he envisages a radically
socialized medicine applicable equally to physical and mental health. Such
examples of socialized medicine include, ‘[t]he insertion of windows into
working-class houses’ and ‘the provision of a pure water supply and an
efficient sewage disposal’.
Sedgwick (1974b) was also sharply critical of how capitalism creates antagonism
between medicine as legally inspired, contractual and individualistic on the one hand,
and collectivist on the other. Writing in an era where the social provision of the
post Second World War welfare state was starting to be unwound, he underlined the
complicated double meaning of the word ‘collective’; that is, that due to collective
struggles from below, and that provided by the state and its social agencies from
above. As he addressed the Royal College of Psychiatrists, he presciently warned
that the Thatcherite Right’s ‘libertarian’ critique of psychiatric authority was a way
of breaking down collective provision without challenging the repressive authority
of the state itself (Sedgwick, 1983).
In the closing sections of Psychopolitics, Sedgwick (1982) reviewed the changing
face of mental healthcare, considering these shifts in their national contexts and with
careful attention paid both to wider political-economic changes and the specific
political currents within clinician and patient social groups. The task for the Left
was to find ways to creatively bring together these diverse currents, which he saw
as already present in embryo, but which the Left had too often been at best inept at
working with let alone providing relevant help to.
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Criticisms of Sedgwick
Psychopolitics made a considerable impact on discussions of the politics of mental
health and illness. However, while aspects of Sedgwick’s argument were often
acknowledged and even appropriated (eg, Klerman, 1977), and continue to appear
in influential critical psychiatry writings (eg, Greenberg, 2010, 2013), there have
also been criticisms of his overall position.
One objection to Sedgwick’s ‘terrible’ idea that all health and illness is socially
constructed is that it ‘confuses the idea that we value something with the idea that
our explanation of how it works is evaluative’ (Murphy, 2006: 83-4). Such a view
falls prey to exactly the positivism that Sedgwick criticised more broadly – that the
activity of science in elucidating how processes in nature work can be separated from
the normative presumptions that lead scientists to inquire into these processes and
then shape the methods of inquiry employed.
A more sophisticated charge has been made by Wakefield (1992), whose influential
‘harmful dysfunction’ analysis of mental disorders treats these as existing ‘on the
boundary between biological facts and social values’. Wakefield contends that ‘the
fact that all disorders are undesirable and harmful according to social values shows
only that values are part of the concept of disorder, not that disorder is composed
only of values’. He argues that Sedgwick provides no consistent guide as to how
to differentiate (health) disorders from other forms of social deviancy, and that this
results in his being unable to critically analyse ‘incorrect diagnoses’ such as the historic
labelling of runaway slaves and Soviet dissidents with mental illness. In addition,
situations where there is an ongoing dispute about the disorder status of a particular
problem (eg, attention deficit hyperactivity disorder [ADHD] or alcoholism), ‘[t]he
complex factual arguments presented by both sides in these debates clearly indicate
that judgments about disorder depend on much more than values’ (Wakefield, 1992:
375-7).
Yet Sedgwick did not dismiss the facts presented in favour or against whether
something is considered to fall within the health-illness spectrum and whether it
represents disorder. Rather, as a historical materialist, he saw ‘facts’ as indissolubly
bound up with the human social practices in which they were apprehended and
‘discovered’. He was making an ontological point: that human conceptions and the
material reality they described were not the same thing. Thus, arguments about the
‘medical’ status of some social problem – or even if it is a ‘problem’ at all – can only
be understood in a historically grounded appreciation of the society in which such
debates occur. Sedgwick wrote of such definitions emerging because of the human
interests they serve – but he also dissected the complex and often antagonistic ensemble
of social interests that operate in any particular historical epoch. The implicit charge
of relativism levelled at Sedgwick therefore does not apply. Unlike even an erudite
analyst like Peter Conrad, whose accounts of medicalisation detail the competing
social interests influencing such processes but refrain from making judgements about
whether medicalisation is valid in each case (Conrad, 2008), Sedgwick based his
judgements in an immanent critique of existing society. Except, perhaps, for his brief
dalliance with a Kropotkin-influenced view of alternative healthcare systems at the
end of Psychopolitics, his judgements are grounded in the impossibility of drawing up
blueprints for healthcare in an idealised future social order. This does not restrain
him from making judgements about, say, the extreme individual libertarian views of
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someone like Szasz, on the basis that beneath the arguments lie determinate social
interests, expressing themselves as absolute principles or objective facts when in fact
they cannot be separated from the historically specific social purposes they reflect
at the level of ideas, whether or not such mediations are consciously understood by
those making them. In the end, Wakefield’s goal of a methodology that can come
to objective conclusions about what is or is not a mental disorder cannot be satisfied
precisely because he wrongly presumes that the answer can be judged independent
of such interests. While standing against positivism at one level, Wakefield invites it
back in at another.
A very different kind of complaint comes from Cresswell and Spandler (2009),
perhaps the key inheritors of Sedgwick’s psychopolitical approach, who argue that
more recent struggles by psychiatric service users against the validity of ‘illness’
attribution undermine Sedgwick’s unitary, anti-dualistic conception of illness. In
particular, they point to movements of people who self-harm and hear voices, and
their struggle to de-medicalise their ‘symptoms’:
The mobilization of such groups has revolved around the discursive ensemble
‘trauma/abuse/distress’ rather than the Sedgwickian ensemble ‘illness/
disease’. Such frameworks attest to the importance of personal histories of
trauma and abuse, as well as iatrogenic degradations experienced within the
mental health system itself. (Cresswell and Spandler, 2009: 138)
This misses how Sedgwick explained why it is that ‘however illness is specified
from culture to culture, the attribution of illness appears to include a quest for
explanation’ and how illness arises historically alongside practice of treatment and
is indissolubly tied up with it (Sedgwick, 1972a: 216). Even if illness is reframed as
‘trauma/abuse/distress’, as long as individuals seek to address their suffering through
engagement with some kind of treatment process, the shift entailed in the renaming
of their problems is at most a move away from dominant biotechnological medical
paradigms to other healing paradigms, each with their own explanatory frameworks
and treatment practices. Their critical rejection of mainstream psychiatry’s illness
claims is thus coupled to uncritical belief that a terminological change breaks beyond
socially constituted conceptions of health and illness in general.
Cresswell and Spandler also argue that Sedgwick’s critique of Szasz elides how
physical medicine and psychiatry are qualitatively different because determinations of
health and illness are directly bound up with the state-sanctioned, coercive imposition
of treatment in psychiatry. Yet this is unsustainable on two grounds. First, much of
psychiatric practice has for decades expanded well outside the narrow remit of lockedward practice, with no clear boundaries between these realms. Second, their claim does
not acknowledge the wide range of coercive practices in physical medicine, which
Sedgwick already alluded to. From the impossibility of ‘informed consent’ when there
are large asymmetries of knowledge and power between doctors and patients, to the
informally non-consensual treatment of severely ill patients in emergency and acute
medical settings, to the use of various legal instruments such as ‘guardianship’ orders
to impose treatment and control on patients found to lack decision-making ‘capacity’,
the individual freedom of patients being treated by physicians and surgeons is often
only apparent and partial. The strength of Sedgwick’s critique is that he historicises
these issues and forces us to think about the problems with modern healthcare in
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general, and the society that spawns it, rather than a focus on the problems of the
mental health field in isolation.
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The DSM-5 and ‘the bereavement exclusion’ in Sedgwickian
perspective
The richness of Sedgwick’s contribution to the politics of mental health means that his
work can be creatively applied to a wide variety of modern developments and issues,
both strictly within disciplines of healthcare and in relation to wider social action.
To conclude with one prominent example, while his work only hinted at the
increasing centrality of diagnosis to the legitimacy of mainstream psychiatry,
Sedgwick’s theoretical innovations provide a powerful framework for understanding
controversies surrounding the recently released psychiatric ‘diagnostic bible’, the
Diagnostic and statistical manual of mental disorders: 5th edition (DSM-5), published by
the American Psychiatric Association – and for strategically orienting radical political
projects in relation to such struggles over the boundaries of normality. (For other
applications of Sedgwick’s ideas, see Spandler, 2007; Cresswell and Spandler, 2009;
Tietze, 2011, 2014.)
The revision of the DSM was initiated in 2002, with hopes that psychiatric diagnosis
could move beyond the ‘atheoretical’, descriptive approach codified in the DSM-III
(1980). Its protagonists naively imagined that advances in neuroscience would be
robust enough to underpin diagnosis based on brain biology. As the revision process
progressed, concern grew about the project’s lack of transparency, ties between the
pharmaceutical industry and leading DSM participants, and the likelihood that the
revision would broaden criteria to medicalise ever-more normal human traits. When
the psychiatrist who had helmed DSM-IV, Allen Frances, broke ranks with his former
colleagues and waged a public campaign against the ‘diagnostic inflation’ of DSM-5,
he gave confidence to a wide range of patients, clinicians and professional groups to
speak out against the manual (Frances, 2013).
One of the especially contentious changes was the removal of the ‘bereavement
exclusion’ from the diagnosis of major depressive disorder (MDD). Analysis, by
members of the DSM-5 mood disorders workgroup, of scientific studies comparing
episodes of MDD with episodes of low mood associated with the loss of a loved one
indicated that there were no essential differences between the two presentations apart
from the presence or absence of grief. That is, normal grief often met MDD criteria
of five symptoms over more than two weeks. Once the proposal was publicised it
became the subject of sharp criticism in the public sphere.
Defending the proposed change, workgroup member Dr Stanley Zisook told The
New York Times: ‘Depression can and does occur in the wake of bereavement, it
can be severe and debilitating, and calling it by any other name is doing a disservice
to people who may require more careful attention.’ In the same article, Wakefield
countered that ‘[t]his would pathologize [millions of Americans each year] for behavior
previously thought to be normal’ (Carey, 2012). Wakefield co-authored a scathing
critique of the scientific papers the DSM-5 experts had been using to defend the
proposed change (Wakefield and First, 2012). Lending its authority to the criticism,
the leading medical journal The Lancet (2012: 589) would later editorialise that ‘grief
is not an illness; it is more usefully thought of as part of being human and a normal
response to death of a loved one’. One group of critics took the arguments to their
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Tad Tietze
logical conclusion and stated that misery should be ‘de-medicalised’ and that ‘what
are, frequently, essentially moral and political – not medical – matters [must be put]
back at the centre of our understanding of human suffering’ (Rapley et al, 2011: 5,
emphasis in original). Despite the controversy, however, the bereavement exclusion
was ultimately removed in the DSM-5.
An analysis of the dispute based in Sedgwick’s approach would have elucidated the
social forces and interests at play: from pharmaceutical companies, psychiatrists and
providers of psychological therapies seeking to expand their potential consumer base,
to clinicians, patients, carers and employers wanting quick resolution of distressing
symptoms, to clinicians and large sections of the public concerned that a normal
process of grief would now be pathologised and treated as abnormal. It would note
the institutional reasons for the American Psychiatric Association to press ahead with
a new edition of its manual despite the lack of significant scientific advance to justify
it, in particular the need for publishing royalties to prop up a professional body with
declining membership and less access to industry sponsorship in the wake of scandals
involving drug company payments to leading academic psychiatrists (Frances, 2013).
Yet this would also warn against a simple rejection of the medicalisation of
bereavement. As Sedgwick himself argued regarding previous debates on the issue:
The example [of a bereavement causing symptoms] is revealing in several
ways. A doctor may prescribe some form of minor tranquilliser to relieve
some of the effects of a bereavement, even though depression of activity and
feeling following the death of a close relative would scarcely be regarded
as constituting a ‘mental illness’. Bereavement has, however, also been
reported as a significant precipitating event in the onset of actual psychiatric
illnesses.… The line of division between a ‘bereavement’ and a ‘psychiatric
illness following bereavement’ would seem to depend on our culturallyderived expectations about how to mourn properly. (Sedgwick, 1974a: 33fn)
For Sedgwick, an ever-present danger was the rejection of all ‘medical’ treatment of
distress when the cause of such distress did not conform to the narrow biotechnical
determinism that dominates medicine in late capitalism. The solution to the failures
and contradictions of modern mental healthcare was neither to deny the illnessness of illness (ie, to ‘de-medicalise’ it), nor to technologise it further. Contra those
who worry that the psychiatric relief of distress provides ‘analgesia at the expense of
understanding’ (Jureidini, 2012: 190), Sedgwick argued:
I myself am perfectly happy to see as many mentally-ill persons as possible
treated, fully and effectively, in this society; for no matter how many
maladjustments may become adjusted through expert techniques, the
workings of capitalism will ever create newer and larger discontents, infinitely
more dangerous to the system than any number of individual neuroses or
manias. (Sedgwick, 1972a: 224)
The politicisation of medical goals was for Sedgwick, therefore, a profoundly
humanist orientation, one that demanded the greatest possible care for the suffering
individual, indissolubly tied to a profoundly critical social practice. As the capitalist
mode of production delivers social destruction worse than at any time since the
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Great Depression, with healthcare facing devastating cuts while capitalist rationalities
in medicine push technological rather than social remedies for people’s suffering,
Sedgwick’s legacy is one worth preserving and extending in order to strengthen
real-life political struggles over the future of health and illness.
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Note
1 This article draws in part on Tietze, 2013, which was delivered as part of a panel on
‘Peter Sedgwick’s legacy: politics, psychiatry & freedom’. It has also been inspired by the
contributions of my fellow panelists Ian Birchall, Mick McKeown and Richard Kuper.
I would also like to thank Helen Spandler and Elizabeth Humphrys.
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