The new edition of Peter Sedgwick’s Psychopolitics is welcomed by Lucette Davies, who finds its analysis is as important today as ever

Peter Sedgwick’s book Psychopolitics, first published in 1982 and now in a new edition, offers a critique of popular anti-psychiatry thinkers with an impassioned plea for an alternative to the psychiatry of today.

I was interested in this book as I wanted to understand the concepts promoted by the anti-psychiatry movement. Having experienced appalling psychiatric treatment, I felt tempted by a knee-jerk reaction towards supporting anything anti-psychiatry. But I also understand the sheer turmoil and terror that mental distress can cause. I know something has to exist to support and assist those living through it. I also believe society has a moral duty to care for those afflicted by mental distress. And, I have been shocked by the failure of many NHS campaigns and other prominent left-wing organisations to take this on in any serious way.

Sedgwick dissects the work of Erving Goffman, R D Laing, Michael Foucault and Thomas Szasz, all popular anti-psychiatry thinkers. He writes that: ‘nobody, situated now, at the fagend of a century that has seen the coming and passing of innumerable avant-gardes of critical promise, should underrate the importance of this cohort of anti-psychiatric writers and thinkers’ (p.4).

Sedgwick is critical of the under-current of conservative thinking in the thinkers he discusses, and rejects the approach that physical medicine and psychiatry can be easily separated. He is critical of those who use the civil liberty of an individual to deny collective responsibility. However, he clearly acknowledges the significant contribution these writers have made towards an understanding of mental illness. He touches on the fact that as a writer he understands the great pain that mental distress can cause. His arguments come across as more meaningful than others I have read because of this.

Each of these great writers and thinkers which Sedgwick discusses at length approach their view of psychiatry from very different angles. Their arguments are disparate in nature and their political positions varied. Sedgwick describes his book as being directed against what he takes to be their shared error.

In chapter one, he discusses at length what it means to be ‘ill’. If a person gets tired easily it could indicate illness, but possibly not if they are 92. He gives the example that a person with a stabbing pain in their shoulder may not be ill if the pain follows their husband hitting them with a rolling pin (p.30). This use of wry humour gives the reader a sense of his humanity. Clearly illness, including physical illness, relates to how a person presents in relation to how they are expected to present.

Erving Goffman

Sedgwick goes on to compare the concept of illness in the mentally ill and physically ill. He rejects the arguments of Goffman who takes physical illness for granted, but argues that the ‘identification of mental illness depends on a specific social context’ (p.39). Goffman’s theory implies that the labelling of an individual with a mental illness is designed to reduce any social deviancy. And their ‘subsequent treatment enables society to punish these lapses of decorum and demeanour’ (p.39).

Goffman’s political position is that the ruling classes should be left firmly in place. And ‘that their dominion is indeed necessary for it gives us status’ (p.49). He describes them as providing the ‘solid buildings of the world with our personal identities residing in the cracks’ (p.49). He argues that it is only within these cracks that we are able to expand ourselves.

Sedgwick finishes his examination of Goffman’s theories with the statement: ‘It is illegitimate to offer a micro-sociological discussion of experience which takes the macrostructure of social organisation for granted and that in attempting so sharp a separation between the personal and the political, Goffman has joined the slumberers, and is thus in no position at all to watch other people snoring’ (p.57).

R D Laing

He then moves onto the work of R D Laing who compelled attention through the sixties and early seventies. Using a blend of psychoanalytical and existential concepts, Laing focused his attentions largely on those diagnosed with schizophrenia. His intellectual development resulted in changes of approach, and a rejection of old ideas in favour of new ideas throughout his career.

Laing displays an understanding of schizophrenia and an affinity with psychotic patients. Sedgwick reports that Laing claims to ‘find great difficulty in detecting signs and symptoms of illness in psychotic patients since their behaviour actually appears to him as meaningful and appropriate rather than odd or irrelevant’ (p.65).

Sedgwick describes some paragraphs in Laing’s book Sanity, Madness and the Family by saying: ‘The blindness of these passages is unbelievable’ (p.77). He goes onto explain that Laing is ‘attacking any human relationships which have built into them any anticipation of exchange, or some sense of limit that will be violated if that exchange in unreciprocated’ (p.77).

Laing describes schizophrenia as being as ‘one stage in a natural psychic healing process, containing the possibility of entry into a realm of hyper-sanity’ (p.81). And, that schizophrenia was in some patients ‘no more than the first step in a two-way voyage which led back again into a new ego and an existential rebirth’ (p.82). He criticized psychiatry for simply frustrating this natural process, and opened the Kingsley Hall therapeutic community in 1965 to provide a ‘sympathetic setting for the schizophrenic’s cyclical voyage’ (p.82). This became part of a network of therapeutic communities known as the Philadelphia Association.

Sedgwick describes Laing as having a sympathy with mysticism that followed naturally from his solidarity with schizophrenia (p.86). Although his work in the mid-60s contained an aspect of social radicalism, Laing later went on to ‘repudiate any taint of socialism’ (p.89). Laing disappointed many on the left wing with this, as they had hoped for something far greater than he ever gave them. But far from making any substantial theory of social significance on wider social relations, Laing limited himself to theories about how people interact with those nearest to them in the family.

Laing attempted to reduce the boundaries between those suffering from a psychotic episode and those who weren’t. His claims of success at Kingsley Hall and other similar therapeutic communities were dismissed by the general secretary of the National Schizophrenia Fellowship. Sedgwick states that: ‘it is implausible to suppose that the great bulk of people who have to manage their outbreaks of schizophrenic illness only have to do so because they have not had the privilege of experiencing a spell of existential rebirth in one of the Philadelphia Association’s households’ (p.107). The people who self-referred to the Philadelphia Association were generally white and middle class.

Foucault and Szasz

In chapter five, Sedgwick goes onto the dissection of the work of Michael Foucault, and in particular his book Madness and Civilisation, an examination of the history of madness from 1500 to 1800. Foucault charts Western society’s treatment of the mentally ill, including clinical practices such as blood-letting, and cold water shock that, in today’s world, most people would view as horrific. Sedgwick describes the early work of Foucault as according ‘all too well with the glorification of mania and the dismissal of scientific logic.’ He describes Foucault’s goal of a dialogue with unreason as ‘an admirable one’. But Sedgwick goes on to say that ‘unlike Foucault, we propose that it actually be implemented, through specific transformations in the structures – social, political, economic and therapeutic – of latter-day capitalism’ (p.127).

The last of the thinkers to whom Sedgwick turns his attention is Thomas Szasz. Sedgwick describes the work of Szasz as ‘uneven, occasional, lacking even in the structure of schematic overstatement’ (p.130). He describes Szasz as focusing on the concept that people learn to follow rules in either a socially acceptable, or socially deviant manner (p.131). This game-theory of mental illness replaces a theory that mental illness stems from an organic disease of the brain. His beliefs separate the concept of ‘institutional psychiatry and contractual psychiatry.’ He rejects the use of involuntary incarceration into mental hospitals, and argues that doctors should not involve themselves with social change in any way. Instead he supports the concept of contractual psychiatry, where a therapist and client freely choose an arrangement where the client is paying for the service of the therapist.

Sedgwick argues that Szasz has ‘taken the most indefensible compulsory hospitalisations and presented them as though they were typical hospitalisations’ (p.134). He also ignores the fact that many people, including those in a psychotic episode enter psychiatric hospitals on a voluntary basis. And that neurotic patients can also be compulsorily admitted to hospitals. Sedgwick also points out that Szasz’s belief in contractual psychiatry as safe and ‘pre-designed to pose no serious ethical problems for therapist or client’ ignores the fact that a ‘well-known consequence of emotional illness is an extreme dependency that is often manifested towards the therapist’ (p.135).

Sedgwick describes Szasz as being politically, psychologically and philosophically a ‘libertarian’. He likens this to the American ‘libertariat’ as a ‘celebrant of competitive business enterprise’ (p.138). In other words, he adheres to the goals of free-market economics, which in today’s world is the cause of increasing levels of mental distress and decreasing levels of services to support people who are suffering.

The politics of mental health

In his final chapter, Sedgwick offers a review of various mental-health movements and the issues involved. He discusses the inequalities of treatment accorded to the psychiatrically ill of different classes. Lower classes are less likely to receive therapeutic interventions, and more likely to be incarcerated in psychiatric hospitals, sometimes with no treatment at all (p.166).

Knowing this already, I was surprised to read that Sedgewick finds an undercurrent of conservative thinking in these figures of the anti-psychiatry movement. The people most likely to be suffering mental distress in today’s world are from a lower socio-economic background, they are more likely to be physically disabled, or from other minority groups. They are often the victims of the most atrocious abuse in psychiatric services and the harsh conditions of hospitals that are far from conducive to overall well-being. They are also amongst the people most likely to suffer austerity measures and various forms of discrimination compounding their mental distress. Surely any attack on psychiatry should come from a perspective of fighting this gross discrimination against the suffering of people who are at the bottom of the ladder? You would think that would hardly be the approach of conservative thinkers, but perhaps this might account for their limitations.

Sedgwick goes on to describe various movements of people who fight for better psychiatric services around the world. He states clearly that: ‘It would be senseless to deny the part played by wide-ranging economic factors in shaping the course of psychiatric history’ (p.177). He also states that: ‘The entry of political argument into the discussion of alternative mental-health systems is seen as an illicit and irrational intrusion’ (p.179).

He quotes the director of Britain’s largest therapeutic community, the Henderson Hospital, as saying: ‘During the Second World War, it was both politically and economically expedient to foster the development of the therapeutic community to preserve manpower for the war effort’ (p.181). He writes that at the time of the book’s publication, therapeutic communities with world-wide reputations such as the Henderson Hospital, had been placed in serious jeopardy. They were only being kept open ‘with the mobilisation of considerable public and expert pressure on their behalf.’ The Henderson Hospital did in fact finally close its doors in 2008.

Sedgwick charts the work of movements such as MIND, various trade unions and patient’s groups like the Mental Patient’s Union (MPU) in Britain. However, despite all these efforts, now in 2022, we have a rising number of people being diagnosed with a mental illness with a decreasing likelihood of recovery. Psychiatric services are being cut to the bone, as is the welfare provision for those affected.

A different mental-health care is possible

In some senses, psychiatry can be distinguished from general medicine. There are differences, and more current books, such as those written by Dr James Davies, discuss the remarkably unscientific nature of current-day psychiatry. Psychiatric services will always be needed. However, the statistics on what is happening today, the overall cost to society as a whole, and our own moral values should compel us to call for immediate changes to the psychiatric system. The harsh realities of mental illness should concern us all, as it is hard to imagine that many people would not know somebody who has suffered from mental distress.

I find it unlikely that there could simply be one theory or model of mental illness and treatment that is universal. Sedgwick’s book revealed the complexity of issues that surround mental-health treatment. Still today, we can learn a lot from reading about the work of these prominent thinkers. How our mental-health system should be designed is certainly not clear, neither is it an impossible task to improve it. It should be a major area of concern for those on the left as an essential component in any sort of society of equality and fairness. But sadly it isn’t, and I believe it to be a major failing of the left in general.

It would have been an excellent end to the new edition to have an update on mental health in Britain today (Sedgwick himself died in 1983). But the book finishes with Sedgwick’s account of the remarkable success story of Geel in Belgium.

The town of Geel has for 700 years allowed the mentally disabled to live with families as ‘guests’ and be welcomed into the community. The words mentally ill or psychiatric are never uttered. People have come to Geel from all over Europe, and it has been a remarkable success. Guests are expected to adhere to the same standards of behaviour as everyone else, although there is an understanding that they may have difficulties. The hospital at Geel serves as a place where people can go, if at times they need to. Even today several hundred people live in this ‘family care system’.

Perhaps to conclude by demonstrating that the care of the mentally ill can be delivered successfully is the most powerful point with which Sedgwick could finish.