Demanding ‘more and better’ psychiatry: Potentially liberatory or worse than the disease? more

Demanding  ‘more  and  better’  psychiatry:  Potentially   liberatory  or  worse  than  the  disease?     By  Tad  Tietze     MBBS  (Hons),  FRANZCP   Conjoint  Lecturer,  School  of  Psychiatry,  University  of  New  South  Wales   Abstract   This  paper  takes  as  its  starting  point  Peter  Sedgwick’s  Psycho  Politics  (1982)  in   which  he  called  for  “more  and  better”  psychiatric  treatment  in  response  to   significant  “anti-­psychiatry”  movements  by  patients,  carers  and  clinicians.  In  the   30  years  since  he  wrote,  mental  health  services  have  been  dramatically  reshaped   by  neoliberalism  —  where  patients  are  “consumers”,  the  state  demands  greater   coercion  to  control  “risk”,  and  Big  Pharma  has  created  massive  new  markets  for   drug  treatments  —  while  public  resources  have  been  eroded.  Equally,  campaigns   around  psychiatric  treatment  have  often  been  delimited  by  and  adapted  to   hegemonic  neoliberal  frameworks.  Does  Sedgwick  offer  us  the  basis  for   challenging  these  reverses  and  building  resistance  that  can  provide  renewed   hope?  And  how  does  his  approach  square  with  arguments  that,  if  done  right,   modern,  scientific  psychiatry  can  itself  promise  liberation?     Introduction   Over  the  last  30  years,  mental  health  and  illness  have  been  dramatically  reshaped  by   neoliberalism.  Patients  have  become  “consumers”,  the  state  demands  greater  coercion   to  control  “risk”,  and  pharmaceutical  companies  have  created  massive  new  markets  for   their  drugs.  Publicly  funded  services  have  withered,  with  market  principles  introduced   to  drive  down  costs.  At  the  same  time,  patient  campaigns  around  psychiatric  treatment   have  often  been  delimited  by  and  adapted  to  hegemonic  neoliberal  frameworks  under   the  rubric  of  “consumer  empowerment”.  Within  psychiatric  science  itself,  the  biomedical   model  is  more  dominant  than  ever.     It  is  a  far  cry  from  the  1960s  and  1970s,  when  anti-­‐psychiatric  critiques  and  movements   seemed  to  have  mainstream  psychiatry  on  the  ropes,  attacked  for  its  bad  science,   ineffective  treatments  and  repressive  powers.  Yet,  despite  the  renewed  rise  of  critical   voices  both  within  and  outside  its  ranks,  the  psychiatric  establishment  prevails,  having   successfully  seen  off  those  powerful  challenges.     This  paper  will  trace  these  developments  by  examining  the  nature,  strengths  and   weaknesses  of  the  anti-­‐psychiatry  movements  of  the  past  through  the  theoretical   framework  developed  by  Peter  Sedgwick  in  his  book  Psycho  Politics  (1982)  and   elsewhere,  in  which  he  demanded  “more  and  better  mental  hospitals,  more  and  better   doctors  and  nurses”.  It  will  use  Sedgwick’s  insights  to  show  how  anti-­‐psychiatric  politics   were  vulnerable  to  neutralisation  or  co-­‐option  in  the  turn  to  neoliberal  capitalism,  in   particular  in  its  effects  on  mental  health  treatments.  Finally,  it  will  suggest  that  his  anti-­‐ capitalist  critique  is  a  necessary  basis  for  any  new  critical  praxis  that  challenges  not  just   mainstream  psychiatry’s  flaws  but  the  social  order  from  which  they  emerge.     Anti-­‐psychiatric  critiques  &  movements   Anti-­‐psychiatric  critiques  and  movements,  while  often  seen  by  mainstream  psychiatrists   as  a  monolithic  threat,  were  always  marked  by  considerable  heterogeneity.   Nevertheless,  it  is  possible  to  outline  three  basic  themes  that  cohered  them:     1. The  quality  of  the  “science”  of  psychiatry  when  compared  with  medicine  in  general   2. The  repressive  nature  of  psychiatric  practice,  with  its  ability  to  rob  patients  of  their   individual  rights  through  mechanisms  such  as  detention  and  forcible  treatment   3. The  value-­‐laden  nature  of  psychiatric  diagnosis  that  turned  deviancy  from   mainstream  norms  into  an  undefinable  entity  called  “mental  illness”.  1     These  themes  can  be  seen  in  the  work  of  four  key  thinkers,  whose  work  remains  a   touchstone  for  anti-­‐psychiatric  critiques  today.     Firstly,  writing  from  the  late  1950s,  North  American  sociologist  Erving  Goffman   developed  a  trenchant  ethnographic  examination  of  psychiatric  hospitals,  with  their   often  brutal  and  ineffective  treatments  and  tendency  to  render  patients  “dull  and   inconspicuous”  (Goffman  1961).  Secondly,  in  the  1960s  Scottish  psychiatrist  and   psychotherapist  R.D.  Laing  argued  that  schizophrenia  resulted  from  impossible  “binds”   people  were  put  in  by  their  families  and  society,  and  therefore  it  was  really  society  and   not  the  patient  that  was  pathological  (Laing  1964).  Also  writing  in  the  1960s,   Hungarian-­‐American  psychiatrist  Thomas  Szasz  claimed  that  mental  illness  was  a   “myth”  because  unlike  physical  illness  there  were  no  “anatomical  and  genetic”  contexts   to  judging  someone  mentally  ill,  only  “social  and  ethical”  ones.  He  hit  out  at  how   psychiatrists  could  deprive  people  of  their  liberties  simply  by  bestowing  a  spurious   diagnosis  (Szasz  1960).  And  finally,  French  philosophe  Michel  Foucault,  in  a  more   complex  line  of  reasoning,  posited  that  concepts  of  mental  health  and  illness  were   purely  social-­‐historical  constructs  that  shifted  and  changed  over  time  but  always  played   the  same  role  in  upholding  power  relations.  That  is,  the  asylum  and  the  psychoanalyst’s   couch  were  equally  just  parts  of  systems  of  repression  and  control  (Foucault  2001).     Anti-­‐psychiatric  ideas  were  often  seen  as  a  radical,  liberatory  antidote  to  a  reactionary   mental  health  system.  Their  popularity  was  tied  up  with  counter-­‐cultural  and  social   movement  activity  erupting  across  Western  nations  at  the  time.  These  movements’  calls   for  personal  and  social  liberation  within  a  nascent  anti-­‐systemic  outlook  meant  that   society’s  treatment  of  deviant  behaviour  soon  attracted  their  attention.  New  Left  Review   ran  some  of  Laing’s  (1964)  writings  and  its  editors  waxed  lyrical  about  his  revolutionary   import.       Moreover,  anti-­‐psychiatry  ideas  were  not  just  disembodied  phenomena  but  were  taken   up  by  real  movements  of  psychiatric  patients,  their  friends  and  relatives,  and  at  times   reforming  clinicians.  As  one  history  of  such  movements  in  the  United  States  points  out   (Tomes  2006:  722-­‐3),  in  the  period  1950-­‐70  deinstitutionalisation  led  to  advocacy  that   was  still  mainly  led  by  clinicians  but  from  around  1970  a  psychiatric  “survivor”   movement  developed  in  the  setting  of  radical  social  movements  of  the  1960s,  looking  to   patients  themselves  to  build  a  new  type  of  mental  health  system  based  on  self-­‐ empowerment.  McLean  notes,  “Intellectually,  the  movement  was  nurtured  by  the   consciousness  raising  of  the  feminist  movement,  the  societal  critiques  of  the  radical   therapists,  the  labelling  arguments  of  the  gay  liberation  movement,  and  the  philosophies   of  self-­‐help  movements”  (2000:  823-­‐4).  In  the  spirit  of  the  times,  one  of  the  first  patient                                                                                                                             1  As  McLean  (2000)  summarises  it:  “The  movement  was  overwhelmingly  antipsychiatry,  anti–medical   model,  and  opposed  to  forced  treatment  and  involuntary  commitment.  Participants  located  mental  illness   not  in  individual  impairments  but  in  oppressive  social  conditions.”   groups  to  spring  up  in  the  United  States  called  itself  the  Psychiatric  Inmates  Liberation   Movement  (McLean  2000:  822).  Very  soon  the  anti-­‐authoritarian  bent  of  some  activists   led  them  to  break  ties  even  with  sympathetic  clinicians.     In  response  to  this  frontal  assault,  the  mainstream  of  psychiatry  felt  under  siege.  At  first   it  tried  to  ignore  it,  but  by  the  1970s  was  moving  to  clean  up  its  act.  Yet  it  managed  to  do   so  in  a  way  that  rehabilitated  much  of  what  was  being  attacked  in  the  first  place.  How   did  such  an  apparently  radical  critique  get  subverted  so  thoroughly?     Sedgwick’s  critique  of  anti-­‐psychiatry   Writing  before  rise  of  neoliberalism,  British  socialist  and  clinical  psychologist  Peter   Sedgwick  pointed  to  limitations  in  anti-­‐psychiatric  critiques  that  can  help  us  understand   how  they  left  themselves  open  to  being  neutralised  by  hegemonic  mental  health   systems.  To  do  this  he  deployed  Marx’s  materialist  method  of  analysing  social   phenomena,  contradictions  and  change  rather  than  suggesting  that  psychiatry  was   uniquely  rotten,  as  many  of  its  critics  did.     In  an  approach  that  garnered  significant  criticism  on  the  Left,  even  in  early  writings  he   argued  for  “more  and  better  mental  hospitals,  more  and  better  doctors  and  nurses  —  at   the  expense  of  armaments  and  the  profits  of  the  rich”.  This  was  at  odds  to  anti-­‐ psychiatric  views  like  those  expressed  in  the  David  Mercer  play  Family  Life  (later  a  Ken   Loach  film),  which  tells  us  “that  all  that  these  hospitals,  doctors  and  nurses  do  is  to   brainwash  potentially  revolutionary  people  through  the  use  of  drugs  and  electro-­‐shock”   (Sedgwick  1972).     He  praised  anti-­‐psychiatrists’  demolition  of  scientific  positivism  in  psychiatry.  He   described  the  latter  as  “an  approach  towards  the  investigation  of  human  pathology   which,  modelling  itself  upon  antecedents  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  she  or  he   works.”  Positivist  diagnostic  entities  catalogued  in  textbooks  were  thus  held  to   correspond  to  some  external,  objective  reality  in  nature  (Sedgwick  1982:  21-­‐2).     The  anti-­‐psychiatrists  were  correct  to  both  reject  psychiatric  diagnosis  and  treatment  as   value-­‐neutral,  and  treat  them  as  social  constructions.  But  Sedgwick  differed  with  them   in  that  they  mostly  turned  a  blind  eye  to  concepts  of  health  and  illness  in  general,  rather   than  just  the  mental  varieties.  In  a  key  passage  he  argued,  “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.  For  social  constructions  they  most  certainly  are”  (ibid:  29).     By  making  this  point  Sedgwick  is  not  denying  the  existence  of  phenomena  in  the  natural   world  that  humans  label  as  “diseases”  or  “illnesses”;  rather,  “[o]utside  the  significances   that  we  voluntarily  attach  to  certain  conditions,  there  are  no  illnesses  or  diseases  in   nature”  (ibid:  30).  For  example,  the  illness  known  as  influenza  consists  of  the  interaction   between  various  biological  organisms  in  the  context  of  a  certain  environment,  but  its   designation  as  an  illness  arises  from  the  social  meaning  it  possesses.  There  are  many   similar  interactions  between  organisms  in  nature  that  humans  don’t  call  diseases   because  they  have  no  such  social  import.     It  is  important  grasp  that  for  Sedgwick  this  was  not  about  relativism.  Rather,  definitions   of  health  and  sickness  were  always  the  product  of  specific,  historical  social  processes,   whose  meaning  could  only  be  judged  if  one  also  had  a  theory  of  social  structure  and   change.  “All  sickness  is  essentially  deviancy”  from  social  norms,  which  themselves  must   be  understood  concretely  (ibid:  32).  This  allowed  him  to  focus  attention  back  on   conflicts  over  ideas  and  practices  of  a  society  itself.  A  materialist  approach  was  not  a   matter  of  technologising  illness  or  medicalising  morals,  but  of  the  politicisation  of   medical  goals:     [W]ithout  the  concept  of  illness  —  including  that  of  mental  illness  since  to   exclude  it  would  constitute  the  crudest  dualism  —  we  shall  be  unable  to  make   demands  on  the  health  service  facilities  of  the  society  we  live  in  (Sedgwick  1982:   40).     Thus,  “more  and  better”  care  did  not  mean  “more  of  the  same”  but  a  challenge  to  the   priorities  of  capitalist  psychiatry,  as  part  of  a  wider  challenge  to  the  system  itself.       Sedgwick’s  approach  has  multiple  merits.  By  defining  mental  illness  as  “real”  but  socially   (rather  than  biologically)  constructed,  his  approach  can  explain  the  emergence  of  new   illnesses  as  part  of  social  processes,  and  help  us  understand  what  social  functions  they   serve.  It  can  cut  through  debates  about  whether  certain  illnesses  are  bona  fide  by   locating  their  attribution  within  a  wider  context.  And  it  can  explain  how  diagnosis  and   treatment  can  play  contradictory  roles,  not  just  as  instruments  of  elite  rule  (as   suggested  by  anti-­‐psychiatrists)  but  also  as  essential  aids  to  subaltern  resistance.       Importantly,  his  writing  was  also  a  riposte  to  the  medical  (and  methodological)   individualism  that  was  uncritically  accepted  by  most  of  psychiatry’s  detractors.  Rather   than  framing  diagnosis  and  treatment  in  terms  of  a  simple  battle  between  the  labelled   individual  and  their  oppressor,  he  located  their  contradictions  in  social  struggles.  Contra   Szasz’s  libertarian  invocation  of  the  absolute  right  of  the  individual  to  determine  their   fate,  Sedgwick  responded  that  personal  rights  couldn’t  be  separated  from  the  struggle   for  social  freedoms.  Similarly,  the  attribution  of  deviancy  to  individual  patients  could   not  be  resolved  by  determining  that  they  “really”  had  nothing  wrong  with  them   biologically,  but  by  interrogating  the  social  function  of  the  attribution  (and  thereby  also   explaining  its  ability  to  shift  and  change  with  social  change  itself)  (Sedgwick  1973).     By  freeing  himself  of  these  unresolvable  debates,  Sedgwick  could  both  argue  for  reforms   in  the  here  and  now  (“more  and  better”)  but  also  point  to  the  need  for  a  thoroughgoing   critique-­‐in-­‐practice  of  society  as  a  whole.  Such  a  critique  can  serve  as  a  guide  through   developments  produced  by  neoliberalism.     Neoliberalism  and  mental  health   1. Neoliberal  biopsychiatry   Biological  psychiatry  emerged  long  before  the  renaissance  it  was  afforded  by  the  project   to  put  the  profession  on  a  firmer  “scientific”  footing,  in  1980,  with  publication  of  the   American  Psychiatric  Association’s  Diagnostic  and  Statistical  Manual  of  Mental  Disorders,   3rd  Edition  (DSM-­‐III).  Despite  its  obvious  weaknesses,  biological  reductionism  continues   to  dominate  psychiatry  because  of  its  fit  with  the  needs  of  the  dominant  social  order:  Its   claim  to  provide  “value-­‐free”  scientific  legitimacy  to  social  problems,  its  basis  in  medical   individualism  mirroring  the  appearance  of  ontological  individualism  within  markets,   and  its  usefulness  as  a  conscious  tool  used  by  elites  to  mystify  and  enforce  hierarchical   social  relations  (Cohen  1993:  511-­‐2).      Nevertheless,  with  the  shift  away  from  post-­‐WWII  “welfare”  politics  that  were  already   being  dismantled  when  Sedgwick  wrote,  there  has  also  been  a  massive  expansion  of  this   model  to  completely  overtake  all  other  modalities  of  explanation  and  treatment.  This   has  been  synergistic  with  the  transformations  wrought  by  neoliberalisation,  understood   here  in  David  Harvey’s  words  as  a  “project  to  achieve  the  restoration  [capitalist]  class   power”  in  response  to  the  economic  crisis  and  subaltern  resistance  of  the  1970s  (Harvey   2005).  That  is  because  it  has  suited  the  economic  interests  of  powerful  institutional   actors  such  as  private  health  insurers  and  pharmaceutical  manufacturers  seeking  to   expand  markets,  and  governments  seeking  to  limit  costs  of  public  services  through   narrowly  defined  and  easily  administered  therapeutic  approaches  (Cohen  1993:  516).     Big  Pharma  has  been  able  to  extend  the  notion  of  “chemical  imbalance”  to  produce   massive  increases  in  the  prescription  of  psychotropic  drugs  for  a  much  wider  range  of   conditions  than  previously  obtained  (Moncrieff  2006).  Psychotropics  are  now  among   the  most  profitable  drugs  in  the  world.  To  achieve  this,  Big  Pharma  has  preyed  on  real   life  stresses  faced  by  ordinary  people  in  a  society  becoming  harsher  and  less  collective.   In  part,  it  has  achieved  this  through  utilising  the  ideology  of  happiness  through   individual  consumption,  where  people  are  always  expected  to  seek  an  idealised,   contented  norm  of  inner  experience  that  is  always  frustrated  by  their  actual  existence   (Moncrieff  2009).       The  positivism  (and  empiricism)  that  underpins  DSM  diagnoses  and  related  treatments   also  matches  the  reduction  of  health  service  activities  to  ones  that  can  be  measured  for   efficacy  and  cost-­‐effectiveness  by  randomised  controlled  trials,  excluding  more   complicated  (and  perhaps  more  effective)  psychotherapeutic  and  social  modalities   because  they  are  not  readily  amenable  to  such  quantitative  analysis.  This  then  allows   mental  health  services,  whether  public  or  private,  to  be  subordinated  to  monetary,   market  imperatives  (Plastow  2010b;  Plastow  2010c).     By  locating  such  tendencies  in  the  social  system,  Sedgwick’s  approach  can  track  the   changing  definitions  and  boundaries  of  health,  illness  and  treatment  while  remaining   anchored  in  the  social  system  being  analysed.  For  example  we  can  now  understand  both   the  struggle  for  Vietnam  veterans’  suffering  to  be  acknowledged  by  governments  in   terms  of  Post-­‐Traumatic  Stress  Disorder  as  a  fundamentally  radical  subaltern  act  (Neale   2001:  185-­‐9),  but  also  understand  the  later  use  of  the  category  by  private  medical,   pharmaceutical  and  insurance  interests,  as  well  as  governments,  to  define  the  veracity   or  otherwise  of  workplace  injuries  in  the  service  of  elite  interests  (Summerfield  2001).   Similarly,  the  use  of  medications  to  treat  depression  can,  depending  on  the  context  and   circumstances,  be  part  of  trying  to  cover  up  anger  at  the  state  of  society  or  it  can   represent  a  genuine  attempt  to  provide  relief  to  those  suffering  from  those  social   problems,  even  if  only  partial.  In  both  cases  Sedgwick  encourages  a  critical  practice  that   seeks  to  bring  out  the  best  from  existing  scientific  knowledge  while  eschewing  a   moralistic  rejection  of  all  psychiatric  treatments  as  useless  or  worse.       2. Neoliberalism  &  social  control   The  process  of  neoliberalisation  on  the  one  hand  stresses  the  roles  of  individual  market   actors  to  freely  engage  in  commerce,  but  on  the  other  hand  it  is  accompanied  by   authoritarian  tendencies  that  seek  to  modulate,  pacify  or  even  eliminate  deviancy,  here   designated  as  failure  to  meet  the  expectations  of  modern  work  and  consumer  life   (Moncrieff  2009:  242).  As  Terry  Eagleton  describes  the  ideal  neoliberal  subject:   “Capitalism  needs  a  human  being  who  has  never  existed,  one  who  is  prudently   restrained  in  the  office  and  wildly  anarchic  in  the  shopping  mall  (2003:23).”      Growing  social  inequality  and  distress  result  in  systemic  responses  to  increase  social   control,  often  through  invocation  of  the  paradigm  of  “risk”  (See  Callinicos  2007:  303-­‐4   for  a  general  discussion  of  risk).  The  latter  seeks  to  reduce  the  social  determinants  of   illness  and  health  to  “risk  factors”  which  must  then  be  controlled  at  the  level  of  the   individual  person  (Henderson  2007:  82).  Such  a  calculus  leads  to  an  increase  in   preventative  actions,  including  detention  and  coercive  treatment  —  such  as  has  been   seen  with  the  introduction  of  forcible  medication  in  the  community  in  the  UK  despite  the   lack  of  an  evidence  base  for  its  effectiveness  (Churchill,  Owen  et  al.  2007).       At  a  less  extreme  level  there  is  the  use  of  medicalisation  to  regulate  socially  undesirable   affects  or  behaviours,  whether  through  drug  therapy  for  disruptive  children  for  their   ADHD  or  to  ameliorate  the  productivity-­‐sapping  effects  of  depression  on  labour  power.   Sometimes  the  medicalised  approach  results  in  workers  no  longer  capable  of  fitting  in  to   modern  workplaces  being  put  out  to  pasture  on  disability  pensions,  robbing  them  of   meaning  in  life.  Again  Sedgwick  allows  us  to  break  free  from  circular  debates  about   what  the  “objective”  basis  of  these  problems  is  locating  them  in  a  contradictory  and   conflictual  social  reality.     3. Neoliberal  co-­‐option  of  patient  movements   Perhaps  most  importantly,  Sedgwick’s  critique  of  medical  individualism  and  an   individual  rights  agenda  among  anti-­‐psychiatry  movements  helps  explain  how  quickly   they  turned  from  radical  rejections  of  the  existing  mental  health  system  to  incorporation   within  it.  The  reform  movement’s  high  point  was  undoubtedly  in  Italy,  where  radical   psychiatrist  Franco  Basaglia  successfully  campaigned  for  “the  1978  Italian  National   Reform  Bill  that  banned  all  asylums  and  compulsory  admissions,  and   established  community  hospital  psychiatric  units  which  were  restricted  to  15  beds”   (Rissmiller  and  Rissmiller  2006:  864).  This  spurred  a  “democratic  psychiatry   movement”  that  saw  similar  reforms  in  several  countries,  but  thereafter,  almost   everywhere  the  movement  petered  out,  mostly  shifting  its  focus  to  consumer  advocacy.     The  early  movement’s  focus  on  individual  “empowerment”  was  wedded  to  a  consumer   perspective,  especially  in  the  United  States  where  consumer  politics  were  a  significant   force.  As  McLean  (1995:  1067)  explains,  “  ‘Consumer  empowerment'  substitutes   an  empowerment  defined  in  terms  of  one’s  power  to  exercise  choice  within  the  mental   health  system  for  an  empowerment  originally  conceived  as  deriving  from  one’s   independence  from  that  system.”     The  self-­‐help  ethos  of  many  patient  groups,  an  understandable  reaction  to  state   “welfarist”  policies  that  “encouraged  passivity  and  professional  ‘policing’  of  social  and   family  life”,  could  easily  be  turned  to  encouraging  the  privatisation  of  care  arrangements   within  families  and  voluntary  organisations  (Henderson  2005:  249-­‐50).  Very  often  the   problems  inside  existing  services,  driven  by  hierarchical  management  structures  and   limited  funding,  would  simply  replicate  themselves  inside  consumer-­‐managed  non-­‐ government  organisations.  There  would  also  be  conditions  placed  by  governments  on   the  flow  of  funds  to  ensure  that  the  organisations  muffled  their  criticisms  of  state  policy   (McLean  2000:  838).     An  account  of  the  way  that  an  Australian  government  moved  from  welcoming  consumer   activists  “inside  the  tent”  before  then  applying  neoliberal  prerogatives  to  their   functioning  is  instructive:     When  corporate  rationalisers  in  periods  of  Labor  government  were  concerned   with  the  state’s  legitimation  imperative  of  popular  support  for  health  services   reform,  the  democratising  efforts  of  activist  groups  were  encouraged  and  their   policy  role  embraced.  But  when  governments  shifted  to  a  focus  on  efficiency  and   economic  and  managerial  objectives  rather  than  democracy,  community  activist   groups  came  under  pressure  to  redefine  their  role  more  narrowly  in  accordance   with  neo-­‐liberal  and  managerialist  paradigms.  Having  long  accepted   their  designation  as  “consumer  groups”,  they  tempered  their  commitment  to   radical  reform  of  the  health  system  in  favour  of  participation  in  the  mainstream   policy  process  (Lofgren,  Leahy  et  al.  2011).       These  shifts  did  not  mean  that  all  activists  abandoned  their  suspicion  of  mainstream   mental  health  services.  In  the  United  States  there  were  deep  splits  in  the  movement  over   support  or  opposition  for  forcible  treatment.  But  those  attracted  to  “consumer”  rather   than  “survivor”  politics  focused  on  “advocating  for  more  treatments  and  greater  access   to  them.”  Former  patients  moved  from  picketing  meetings  of  the  American  Psychiatric   Association  to  sitting  on  panels  at  them  (McLean  2000:  825).  Similarly,  health   authorities  saw  the  benefit  of  promoting  organisations  of  family  members  of  the   mentally  ill,  finding  them  willing  to  argue  for  more  research  into  narrow  biomedical   explanations  of  deviant  behaviour  and  even  coerced  treatment.  These  carer   organisations  were  often  better  organised  nationally  than  groups  of  patients  and  ex-­‐ patients  themselves  (ibid:  828).     Consumer  activism  was  not  just  problematic  because  of  its  use  of  neoliberal  terminology   and  its  incorporation  into  existing  power  institutions.  It  also  exacerbated  class   differentials  in  the  type  of  care  patients  received.  Not  only  would  working-­‐class  and   poor  people  tend  to  receive  drugs  rather  than  intensive  therapies  for  their  problems,   but  their  very  experience  of  “consumption”,  and  the  promised  “choice”  and   “empowerment”  it  could  deliver,  came  with  minimal  ability  to  control  other  aspects  of   their  lives  (ibid:  830).       The  rights  agenda  that  drove  large  sections  of  the  patient  movement  therefore  left  it   open  to  incorporation  in  a  neoliberal  framework.  Understandable  rejection  of   paternalistic  mental  health  services  in  the  post-­‐WWII  “welfare  state”  era  was  utilised  by   authorities  willing  to  cede  limited  individual  rights,  but  only  within  a  tightly  controlled   market  framework.  As  with  other  liberation  movements  of  the  era,  a  mixture  of  legal   reforms  and  incorporation  into  existing  corporate  and  state  structures  seemed  to   provide  a  way  forward  for  activists.  But  instead,  their  aspirations  were  reduced  to  once   again  being  mere  participants  in  a  system  out  of  their  control.   Conclusion   Although  he  published  Psycho  Politics  at  the  very  start  of  the  neoliberal  era,  Peter   Sedgwick  was  able  to  develop  a  critique  of  existing  psychiatry  that  could  serve  as  a   useful  approach  to  resisting  the  logic  of  neoliberal  transformations  of  mental  health  and   illness.  He  would  not  have  been  surprised  by  mainstream  psychiatry’s  ability  to  claim  it   now  stood  on  firm  scientific  footing  with  the  positivist,  narrowly  biomedical  counter-­‐ revolution  ushered  in  with  the  DSM-­‐III.  Neither  would  he  have  been  shocked  to  see   individual  rights  agendas  moulded  into  safe  channels  through  consumer  empowerment   strategies,  while  authoritarian  policies  gradually  bubbled  back  into  view.  And  he  would   have  rejected  the  naïve  hope  that  the  explosion  of  medical  diagnoses  for  all  kinds  of   human  distress  could  be  resolved  through  interventions  (psychiatric  or  anti-­‐psychiatric)   divorced  from  a  social  substrate.     Despite  the  difficulties  involved  in  creating  such  unity,  Sedgwick  always  highlighted  the   need  for  genuine 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