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For Diana
Our Psychiatric Future
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r: The Politics of Mental Health
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~ Nikolas Rose
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Copyright() Nikolas Rose 2019
The right of Nikolas Rose to be identified as Author of this Work has been asserted in
accordance with the UK Copyright, Dtlligns and Patents Act 1988.

Fitst publuhed in 2019 by Polity PrC$$ (

Polity Press ·
65 Bridge Street
Cambridge CB2 IUR, UK
Contents
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l O I Station Landing
Suite 300
Medford, MA o:uss, USA

All rights reserved, Except for the quotation of short passages for the purpose of criticism
and review, no part of this publication may be reproduced, stored in a retrieval $}'Stem
or transmitted, in any Conn or by any mcam, electronic, mechanical, photocopying,
recording or otherwise, without the prior pumiuion of the publisher.
Acknowledgements vii
ISBN-13: 978·0-7456-8911-1
ISBN-13: 978·0-7456-8912-S(pb)
1 What Is Psychiatry? 1
A catalogue record for this book is available &om the British Libraey.
. Our psychiatric lives 1
Everyone's little helpers 3
Library of Congress Cataloging-in-Publication Data Many psychiatries 5
Names: Rose, Nikolas s., author. Psychiatry defines the boundaries 6
Title: Our psychiatric future : the politics of mental health I Nikolas Rose. What mental disorder is 10
Description: Medford, MA: Policy, [2018) I Includes bibliographical Psychiatry as a political science
i:erercnces and index. · 14
Identifiers: LCCN 2018009173 (print) I LCCN 2018011035 (ebook) I ISBN The politics of psychiatry 16
9780745689159 (Bpub) I ISBN 9780745689lll'(hardback) I ISBN 9780745689128 - Critical psychiatry today 19
(pbl<.) .
Subjects: I MESH: Mental Health J Psychiauy I Health Policy Onwards ... 21
Classification: LCC RC454 (ebook) I LCC RC454 (print) I NLM WM 101 I DDC
616.89-dc23
LC record available at https://lccn.loc.gov/2018009173 :2 Is There Really an 'Epidemic' of Mental Disorder? 25
'The burden of brain disorders' 27
Typeset in 10.5 on 12 pt Plantin by
Servis Filmsctting Ltd, Stockport, Cheshire
Counting the costs 28
Printed and bound in Great Britain by Clays Ltd, Elcograf S.p.A. Burden today 33
From 'mental' disorders to 'brain disorders'. 36
The publisher haa used its best cndcavoun to ensure that the URI.a for external websites
refea:cd to in this book &IC correct and active at the time of going to prcsa. However, the So is there an 'epidemic'? . 38
publisher has no rcspon&ibility for the website:$ and can inake no guarantee that a site will
remain live or that the content is or will remain appropriate. 3 Is ltAII the fault of Neoliberal Capitalism? 41
Ev.:ry eft'orthas been made to trace all copyright holders, but if any have been Our unhappy present · 45
inadvcrtcndy overlooked the publisher will be pleased to include any necessary credits in The factory of unhappiness · 50
any subsequent reprint or edition.
Social capital · 53
For further information on Policy, visit our website: politYbooks.com loneliness 57
Stress 60
So. is it all the fault of neoliberal capitalism? 64

I
r>

c vi Contents
r
r 4 If Mental Disorders Exist, How Shall We Know Them?
Diagnosis as a social phenomenon
67
72
r Solution one: Define the phenotype 76
( Solution two: Firid the biomarker ' 82
r: Solution three: Straight to the brain 85
' Solution four: Beyorid diagnosis 89
r From diagnosis to formulation 91 Acknowledgements
f- 5 Are Mental Disorders 'Brain Disorders'? 94
Proven by psychopharmaceuticals? 99
~
Discovered in the genes? 102
( Visible in the brain images?, 108
c So are mental disorders brain disorders? 111

(, 6 Does Psychopharmacology Have a Future? 116 I have been thinking about the issues in this book since my time as
C How did we get here? 118 an undergraduate in the i 960s. I was struck by the contrast between
The drugs don't do nothing, but ... 122 the image of psychiatry in my course on abnormal psychology and
( · The pipeline is empty! 129 the experiences of my friends diagnosed with serious mental illness
( Beyond psychopharmacologyz 131 and undergoing treatment with antipsychotic drugs .. Later I became
involved with the critical psychiatry movement and with the work
( : 7 Who Needs Global Mental Health? 134 of 'concept houses' such as those run by the Richmond Fellowship,
(·,·. Grand challenge: No health without mental health?
The-debate
136 and I also taught an evening class with Peter Miller on the P-..c.ow~e.;.;rs~o~f _. _
141 psychiatry, which led to our edited volume The Power of Psychiatry,
(: Beyond the conflict? 143 published by Policy in 1986.[!n the 1980s at Brunel University I con-
.. All our futures?
e 147 vened a unique undergraduate programme which combined a degree
in sociology and psychology with a qualification as a psychiatric nurse
c 8 Experts By Experience? 150 - teaching the remarkable students and visiting them on the wards in
c. Mental patient movements
From 'on our own' to 'nothing about us without us'
153
157
the Maudsley and Bethlem Hospitals brought me face to face with
the challenges faced by dedicated psychiatric professionals, and gave
c The politics of recovery 161 me a clearer sense of the lives ofthose for whom they nied to care~
c. A new epistemology of mental distress
Have we moved beyond the monologue?
165
169
Over the intervening years, I have got to know many committed
and thoughtful mental health professionals who are painfully aw~re
c to
'".ti4
of the challenges they face in trying help individuals who are in
9 Is Another Psychiatry Possible? 173 distress, usually for reasons located not in their heads, but in the
l Manifestoes for the future 173 social conditions in which they find themselves.' I have spent some
(_ Seven answersto seven hard questions 181 l
time visiting mental institutions both in the UK and in a number of
Another psychiatry, another biopolitics 187 other countries. I have engaged with these iss'ues via my work with
( the Nuffield Council on Bioethics, the Science Policy Committee of
(_ Notes 199 the Royal Society and similar organizations, and my research in the
References 226 Social and Ethical Division of the Human Brain Project.' I have been
L Index 258 fortunate to have friends with first-hand experience of the ministra-
c tions of the mental health system, and who have worked collectively

c
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L.
 viii Acknowledgements
to find new ways of thinking about and responding to mental distress.
And I have Jived for more than 40 years with a partner diagnosed
with a severe and enduring psychiatric disorder. This book grows
out of that relationship, that history and debates too numerous to
mention. But while many people have helped me in developing my
arguments, only I am culpable for them.
I have touched o'n the questions I discuss here in other books -
notably in The Politics of Life Irself published in 2007, and in Neuro:
The New Brain Sciences and the Management of the Mind, written with
Joelle Abi-Racbed and published in 2013 - and I have tried not to
repeat myself; some of the things I address briefly here are given fuller
treatments in those earlier books. Most of the chapters that follow
arise from lectures that I have given since 2010. I would particularly
like to thank Dr Franco Rotelli in Trieste for persuading me to take
up the daunting challenge of giving the opening keynote lecture at
an International Conference in 2010 celebrating the life and work
of Franco Basaglia. That lecture - 'All in the Brain?' - morphed into
a rather different one, entitled 'What Is Mental Illness Today? Five
Hard. Questions', which I first gave at the University.of Nottingham
in 2013; I thank Hugh Middleton for inviting me. That led, in a
roundabout way, to Nick Manning joining me as a colleague at King's
College London, which has resulted in many fruitful collaborations
on the issues I discuss inthis book; he and I share the view that sociol-
ogy is a fundamental science when it comes to understanding mental
ill health. Some years ago I worked closely .with Ilina Singh on 'the
promises and perils' ofbiomarkers, and I draw upon ideas·developed
in that collaboratlon.<tks Fitz~kband Ilina Singh worked with me
on a related project ~ the Urban Brain Project - which helped me
develop a number of the ideas that have found their way into various
parts of' this book.' That project also led to a book with Des entitled
t {fjial Ci~: Mem,politan Life, Mental Health and -the Urban Brai~to
be published by Princeton University Press, some thoughts from
which are included in my final chapter. I have also benefited from
collaborations with Ayo Wahlberg which started many' years ago in
Copenhagen, continued in the BIOS Centre at the LSE, extended to
our work in China, and now to his research back in Copenhagen -
Ayo has generously given me permission to draw on sections of
our
joint paper,ahe Govemmentalization of Living: Calculating Global
Health>)ipubHshed in Economy and Socief:J' in 20i5, in chapter 2 of
this boc3i. I have learned a lot from the generous historical scholar-
ship on medicine, psychiatry and madness by Roy Porter: his voice
is much missed in current debates .. On general issues of 'the politics
Acknowledgements ix
of life', I have benefited ~µ~ he probably does not know
. this, from the work of'Q)1dier F~~mily Martin's work remains
an inspiration, to me as to many others, and her friendship is much (
valued. In many ways, this book grows out of the research on the (
genealogy of neuroscience that I conducted with Joelle Abi-Rached
for Neuro, and I thank her for being .the most excellent companion on
. that journey into the history of the present of neuroscience.
Among the other people who have invited me to lecture on these
topics, and whose challenging questions have contributed-sometimes
without them being aware - to these chapters are~~rvalh(f,)
Tulio Giraldi, Ilpo Helen, Lochlann Jain, Uffe Juul Jensen, Pat
O'Malley, Francisco Ortega, Andreas Roepstorff, George Szmukler,
Mariana Valverde, Catherine Waldby, Simon Wessley and Elizabeth
Wilson. I would also like to acknowledge the abiding influence on
my thought of the students who took my courses on psychiatry and
mental health at Brunel University, particularly Hilary Allen, .Edana
Minghella, Helen Griffin, Ben Thomas and Rob Tunmore. Thanks
also to all those students and postdoctoral fellows who have debated
. these questions withme over the last three. decades and more, many
of whom are now in senior academic positions. I cannot mention
them all, but especially would like to acknowledge Lisa Blackman,
Des Fitzgerald, Angela Filipe, Ian Hodges, Linsey McGoey, Sam
McLean, Leonie Mol, Tara Mahfoud, Sebastian Rojas Navarro,
Carlos Novas, Scott Vrecko and Ayo Wahlberg.'
Through. working with my undergraduate, postgraduate and
research' students; and· through my experience in many psychiatric
hospitals, wards and clinics, I have come to realize that, whatever one
may find in the thousands of texts on psychiatry and mental health,
whatever styles of thought arc dominant, and whatever technologies
of intervention are available, there are many dedicated professionals
working in our mental health system who, in spite of all the difficul-
ties and challenges they. face, and whatever their own conceptual
orientation, are just superb - and often lifesaving- clinicians. I would
like to pay special thanks here to Dr Nadia Davis ..
Across that half century of encounters with psychiatry, I have
learned most from people living under the description of severe and
enduring mental disorder. Through these friendships, I have. come to
know more of mental )!ealth and the politics of psychiatry than I ever
could have imagined.!..!3utI have 'also come to believe that the most
fundamental transformation in the power of'psychiatry will come not
from the discovery of the genetic or neurobiological basis of mental ../
illness, but because of the increasing recognition that the recipients b"T~~,~-'~
. . r•.LJ,.,,w~-"\91
--.
x Acknowledgements

1
of psychiatric ministrations, proclaimed to be for their benefit, are
increasingly acquiring a voice, and some power, in contesting the
ways that they are treated; to take this seriously requires a radical
rethink of the profession of psychiatry and of the organization of, and
power relations in, services for those in mental distressX{ would par-
. ticularly like to acknowledge Peter Campbell, Alison Faulkner and
Louise Pembroke, whose work in this area has been pathbreaking. What Is Psychiatry?
· Finally, this book would not have been written without my rela-
tionship with my partner of over 40 years, Diana Rose, who has
taught me more than she will ever know about psychiatry, madness,
,·· commitment, life and love. I dedicate this book to her.

r-·
'·. ilboui·.psycliktry,·~~ p~
This.is·~·bQO~· h;~
tllat i~ C~lll~-t~ play
,. so many .
in tlie' lives of of us across ihe world, .and the' challenging
of
q~estions the. perv~siveness. psychiatry rajses abo~t mental distress,
r about the promises and powers PI psycbiattj$tS, and about normality
r,.. 'on
itself. Wby focus 'psychiatry and not' ~eniai'health or mental
illness? In fact, of course, the two are inextricable: the very idea of
madness, mania, melancholy and more as illnesses is) in large part, a
function of the histoD' and reality of J:>S)'chiatry, because it .has shaped
fhow we have come to know these conditions;how we speak ofth._em_Q__
..._. Land how. we try tointervene upon them. To think of mental illness
.,·· or even, to use the phrase becoming common, 'mental health issues'
.... thus inescapably places us in relation with psychiatry. It is that rela-
t'
'- ' tionship~. OUt' relationship to psychiatry,;~at.is t;}le: ~O~S- o_f this _b,Ook.I
l l~ .va ...~.,: But what is psychiatry? This seems a simple question- the diction-
...... .
('

\" f
, t1 1 ary tells us that, psychiatry is the branch of medicine concerned with
(' .
~1, the causes, diagnosis, treatment and prevention of mental illness.2
, "'"l 3.
'-..·'
Yet a moment's thought tells us that psychiatry, even in this simple
x,v:; \ 1-?(.,.,, sense, is a rather special 'branch of medicine' not least because it
(
L Jrf.~~~. .
1
seems co have become a part of the lives of almost all of those who
ol".J. \At'../\ live in advanced liberal democracies and increasingly for some of
\ tµ.I' those in the developing world. 3 So Jet us begin. by exploring the. 'ter-
. ri~ory' ·of psychiatry to.d!ly)
(_
l Our psychiatric lives

l This sense that our everyday lives are increasingly intertwined with
l_ psychiatry becomes even stronger if we accept the description of

L
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t.
 2 What Is Psychiatry?
the scope of psychiatry which is now used by the World Health
Organization (WHO) and many other organizations. [For these
~ /r
bodies, notably when they compile their estimates of the prevalence
of mental disorders, the territory of psychiatry does not merely
Iii' include familiar conditions such as depression and schizophrenia; it
also covers neurodegenerative disorders such as Alzheimer's disease,
rlf,' ncludes complaints such as anxiety and panic, extends to relatively
~. "~~ ' recent diagnoses such as dyslexia as well as to conditions such as
\rt" addiction, substance abuse and obesity, which some might not think
~ . of as mental disorders at all.:)Taken together, estimates put the preva-
(,~ ,~ll'lence of such a wide array of conditions at over 25 per cent of the
v .~~ u adult population in the European Union in any one year, and 50
t(I' per cent over a lifetime - these are broadly the same for the United
States. 4 Indeed, perhaps the most often quoted recent figure for
Europe estimates that over a third of the European population each
year is afflicted with a potentially diagnosable 'disorder of thelbrain,',
even though many of these people never consult a psychiatriYor
receive treatment (Wittchen et al., 2011: 843) .[!f psychiatry is the
name we give to those diverse experts and practices which. deal with
these· conditions> it is clear that it is no longer a matter of concern
to a few unfortunate souls: over our lifetime> almost all of us are
potentially suitable cases for treatmen~ · · · · 'in the shadows', but are widely discussed, and that we now think are
But right away we have hit controversy! Should we accept these
· estimates? Who made them and how? There seems to be a lot of
drdt.y,. · slippage here- mental illn~ntal disorder, brain disorder- don't
,.,.,._:.~ we need much inore@re 1sion Can these conditions really affect
one in four - or even one 10 three - of us each year? And what is
~~.l'-fmphed by lumping· all these conditions together - surely anxiety
and Alzheimer's are rather different species of things? And in what
sense are these ~in d1s~rde~part from the banal fact that all
mental activity has neura correlates, is it really the case that these
diverse troubles share common mechanisms in the brain? Indeed,
are some of these things 'disorders' at all~urely obesity, which has
increased :gr~fatly in· i:haiWcountries over the past so Yeats; isa' matter .
oflifestyle; nota disorder;lefalciile'a diso'rdei'ofthcfbram. Can't the
same be said for all those mental health· issues that almost everyone
seems to suffer from at some time or another - mild depression and
. ~ - or even more severe conditions such as post-traumatic
QM~j;_t,,~ stress disorder and self-harm, which are on the increase, especially
"1"""~·I among women? Are these not best understood as fundamentally
social_problems, exacerbated by the stresses and strains _of eyeryday
life in our 24/7. society with its constant barrage of social media and
~~-,
,·
What Is Psychiatry? 3
so forth?5 And so on. Let us hold these thoughts for a moment, for
we will revisit all of them in later chapters. • .
For now> we have established one important thing - that whatever
psychiatry deals with, or wants to deal with, is no marginal matter. 6 If
you or I are not directly among the number directlyaffected, it is very
likely that a family lll~HJ~_er is.-: l!,.Sp~-qs~,.a _c~ild,.I)_ relative. Indeed,
a
when jf~oines 'to. children,. we are seeing woridwide increase in
thch1umb~ts di~_@Qs,ea)vith PF~.6l~µi( qf p~·avi~iir;· or·.~tte~tjon or
abiljty -~at. are~~-c;~m~~ .t9 be' P.SY,Chiatric, or'.at_ I~as_t :~01;1ght likely
to benefit from the attention, 9f .a psychiatrist: or a. related mental
· health professio:n!l'· Numbers vary greatly from country .to ..co~~try>
but a recent' estimate in the UK is that one child or young person in
every ten will suffer from a diagnosable mental health condition> with \
increasing numbers of young people being diagnosed with depression
or self-harming, leasJ.ing to the introduction of mental health pro-
grammes in schools(involving mindfulness and 'happiness lessons' ..:)
And this does not include those who are diagnosed with attention
deficit hyperactivity disorder, whose numbers in countries such as the
United States have been the subject of much controversy. And given TI ~J
our demographic changes, in which so many ofus are living longer, iu,.,,. ,;._., , __ ..,, • .-.
at the other.end of life there are the dementias that .are now no longer t ,.,vu:,·'
likely to afflict so many of us, our relatives and friends, as we ·age.8
It was once possible to think of psychiatry as a rather esoteric
activity> conducted by doctors and nurses, who were almost as weird
as those whom they treated, dealing largely with people locked away
in mental asylums, and extending outside the walls of the mental
hospital only to a few self-obsessed individuals receiving some kind
of psychotherapy. That is the image portrayed in the movies from the
1940s to the 1970s, from Spellbound and The__Snake Pit to One Flew
Over the Cuchoo's Nest or Morgan. -A Suitable Casefor Treatment. But
psychiatry now seems to be part. of almost everyone's life, in many'
cases quite _ literally. That is. to say, psychiatry is shaping· the. very
experience of living as its languages and diagnoses pervade the ways
we understand and respond to our problems and think of those of our
children, our relatives and our own life course. . · ·
l,
Everyone's little helpers
\.
I
Another crucial dimension of this psychiatric reshaping of our life
J
itself is the global reach of the most common psychiatric intervention
'
l
!
I
r·
4 ·what Is Psychiatry?
. \h~ !
,-. '),-tr\ - psychopharmaceuticals. While figures vary from country to
country, as a rough estimate about one person in ten in the countries
that are part of the Organisation for Economic Co-operation and
Development is taking a prescription pharmaceutical for depression,
anxiety or some other mental health problem at any one time; for
women, the figure is closer to one in six. 9 Once more, though, we
immediately enter controversial territory, How can we account for
the rise of the use of these drugs - not just the. tranquillizers that were
once such an object of cultural attention - 'mother's little helpers'10
,.. . - but now the antidepressants, · of which Prozac became the most
of
famous.'! In most of the· COUI\tnCS Where we have· data, use these
antidepressant drugs doubled in the decade from 2000, with the
greatest use in Iceland, ·Australia, Canada, Denmark and Sweden.12
' . And these drugs, initially celebrated because of their ·specificity for
depression, 'are now prescribed for a multitude of disorde~~ includ-
ing panic disorders, anxiety disorders, shyness and social phobia. No
country has seen a reduction in their use. Why has there been such
'-. a worldwide rise? Why are there such huge variations between coun-
e--, tries? Surely not because the conditions themselves 'show such huge
variations in' prevalence.[!lave. psychiatrists become so attached to
the prescription of these drugs because· their use seems to give them
. real treatments, and hence demonstrate the scientificity of their pro- ---1
. . __;-------- fessionaI-expertis-e,s:nci·a1iy-tl:femwith~tlierestofmeaicine?13.Do i1ie""
drugs work, or are they just 'placebos'? Are we not just medicalizing
normal problems of living, with psychiatrists 'in some countries more
keen to do this than in others? And why do these drugs appeal to so
many people? For while. it ~s still the case that some people, not just
those in psychiatric hospital but also some-living in tbecommunity,
are compelled or obliged to take such drugs, most do not do so under
,_.1
compulsion, but because they believe that they will, in some way,
help. Once more, hold onto these thoughts, for we shall certainly
. . .. \, come back to them in later chapters .
But for the moment, let me return to that simple dictionary defiai-
tion answer to the question 'what is psychiatry?' The dictionary defi-
nition is deceptive for many reasons - indeed, the very question itself
is misleading. Let me list four sets of reasons why, unfortunately, we
,.. need to make things more complicated.
.._,
What Is Psychiatry? 5
Many psychiatries .
First, of course, there is no one 'psychiatry' - psychiatry is heteroge-
neous with many different and sometimes incompatible conceptions
of mental disorder, and many different treatment practices.~e it is
true, today, that biological psychiatry is dominant, at least in the field
of Buro-American research, and that biological treatments, notably
drugs, have the widest coverage of all psychiatric interventions, most
practising psychiatrists .in clinics and hospitals, even though they
consider. drugs essential to their practice, are not simply 'biological'_
in their ways of understanding, diagnosing ~d treating disorders}
.We will spend some rune in this book considering the argument
made by some neurobiological researchers, and, also part of the ration-
ale for the heavily funded 'brain projects' that have been established
in Europe, the United States, .China, Japan and many other coun-
tries, !that mental disorders should be considered as diseases of the
brain.1~ut we also need to recognize that many psychiatrists, even
if.they accept the premise that the troubles they are dealing with have
I their roots in the brain, focus their diagnostic and therapeutic atten-
tion on matters that are normally thought of asmental rather than
cerebral - that is to say, on disordered or reP-etitive thought P-attems
d/
-;pl-~ _ .
I which may or may not have a biological basis, but which. they hope W-µ . ,, ~"
I can be ameliorated by cognitive therapies of v~~its ,j
.......~~~r V'rJI"<>~'¥°'
f many now recommend 'mindfulness', ·wliicnlias morphed rapidly J ~;."?',
, from something associated with esoteric practices of Buddhists to a <P.~ rt1 r ./~
! rather banal practice that aims to change the way we feel about stress- .._!Ir}. "~('.,.u".':~-
· ful experiences,15.and which has become an option in the toolbox of~"'~V..>J;
psychiatrists, psychologists, social workers - and indeed anyo~e who ~":. ~6' ~ "'
has access to the mternet or a smartphone. Those responsible for ;t: '-,V\r"
setting out policy guidelines, such as the National Institute for Health i.;..~.h
. and ~ __Excellen~(NICE) ~ ~e UK, oft~? advocate no~edi-f~'>1'-""'
\,VJC>Je. cal acnvines for~'and first episode conditions, such as lifestyle 1,s
changes, followed, if this is not effective, by psychosocial interven-
tions - though in many countries, drugs remain a first, not a last,
resort.
Of course, diagnostic and treatment guidelines for medical and
psychiatric professionals - where they exist - vacy from country to
country and change over time, and not everyone follows such guide-
lines. Indeed - and this is something that should always be borne
in mind - the diagnosis and treatment of mild mental health issues
often never reach psychiatrists at aJI. Most experiences of mental
6 What ls.Psychiatry?
distress are managed by families, friends and lay persons outside the
mental health system; indeed, what professionals term 'primary care'
is actually secondary care. further, when such distress does come
to the attention of a medical professional - a process much studied
by sociologists (for a classic study, see Smith, 1978) - it is often
managed in the general practitioner's clinic, where those reporting
troubling moods or feelings are usually given prescriptions for psy-
choactive drugs, because these are the most readily available options,
and because waiting lists for specialist consultations and psychologi-
cal interventions are Jong even in the countries where they exist at all,
except for those with the resources to payl In some countries, even
for those who are seriously distressed, and no doubt driven in part
by the rising costs of hospital treatment and the pressure on bed use,
'social' interventions are favoured, whereby a person is treated in his
or her own home and a multidisciplinary team monitors drug 'com-
pliance' or 'adherence' - people who do not take their prescribed
drugs tend to be seen as a serious problem in contemporary psychia-
try.111 In some cases - sadly, rare - a 'home treatment team' seeks to
ameliorate some of the social pressures, 'such as finance, .housing or
domestic violence, that may be exacerbating their mental distress.!?
Indeed, o.utstde the. hospital a,ri~ ~e~cally .c~~~oy~d -~)~~) .a )iost
of less medical' practices thrive, from. day centres· to recovery'houees,
where.biomeclical.approa~hes'play a minhnal roie; and iiiteiyeritions
are- gr(jund~d· dii:other conteptioiis. of the n,hire. of the problem at
hand. 'If one moves one's focus of attention away from the .'Global
Nord{ to India, China, Southeast Asia, . the rural areas of Latin
America and the many African countries where medical professionals
of any sort are very thin on· the ground, things· become even more
complex, and for most people 'care' - or its opposite - happens
outside any formal medical setting.18 Thus, while I focus in this book
on 'psychiatry' and will sometimes use that term to embrace all these
different practices for addressing 'mental disorders', it is necessary
to treat any statement that implies a singular psychiatry (including
mine) with a great deal of caution.
Psychiatry defines the boundaries
Secoi:id~.P~Y.~hi~fu. does '.not j~st' iinde~~iid and
treat, it also defines
and ·deiimits.·That is to say; p~chiatric categories and. practices of
c1,igtiosis,~~Ip .s~~ ~e boun.4arl~ :<a.ii(~eten)lur the boundaries) of -·
whcfis··or is not a suitable case fodw~~t kind of} treatment, Much
u • - • , • • • • ~ • ..•. : :
What Is Psychiatry? 7
(
discussion of. this question over recent years has focused on the
Diagnostic and Statistical Manual of Mental Disorders (DSM) of the
American Psychiatric Association (APA), which published its Jong
awaited fifth edition in 2013. Each new edition of the DSM has
included more categories of disorder, seemingly endlessly expanding
the kinds of conditions that are amenable. to psychiatric classifica-
tion and intervention. In the United States, a DSM diagnosis has
important practical consequences - for example, one has to have a
DSM diagnosis in order to be reimbursed for the costs of treatment
under medical insurance schemes. Further, until very recently, if they
hoped to get their research funded and published in the scientific
journals, psychiatric researchers were obliged to use DSM. diagnoses
in framing their grant applications, selecting the. subjects of their
research and presenting their findings.19. So, to some extent; such
manuals define the boundaries ·of the empire of mental disorder.
Thus, especially in the United States, many authors who are criti-
cal of what they see as the expansionist tendencies of psychiatry have
focused on the proliferation of categories of disorder in the DSM
the
and way in which.they frame diagnosis - a checklist approach
in which individuals are diagnosed with a particular · condition if
a
they have exhibited ce~in number of behaviours .over a. specified
°
period oftime.2 Critics point to the implicit value judgements in the
~ , applJ~!~On of such criteria, the.lack . of focus on the actual level of
i 0,-ll(~Q·~iinp_airm~!lt)Of the individual in particular situations, and to the Way
·· iJJ which t:fiis lack of precisi~n widens the net of those brought into
~mpire of psychiatcy'_1They argue that diagnostic imperialism
is leaclin1rrcrtlie psyc~tion of normal. variations in the human
conditionr of sadness. (Horwitz and Wakefield, 2007~f of .shyness (
(Lane, 2007), of anxiety (Orr, 2006) and much more. 2.1J .
··, It is certainly the case that diagnosis both extends and delimits
the empire of psychiatry, but we need to go beyond the DSM, and
indeed beyond diagnostic manuals altogether, to grasp this process. c
This is not least because, despite the critical attention that has been
lavished on the DSM, its history and its consequences; things are
I
a litde more complicated in the wild world of everyday life than
in the p~ges of the diagnostic textbooks. First; not· every country
'
uses the DSM. In Europe, a different .classification manual is used
- the International Classi.fication of Diseases.iwhich differs in many
respects22 - and, in many European countries with a national health
system of one sort or another, while a formal psychiatric classification
may be required, it plays little 'part in the decisions about how to treat
.•
an individual. Perhaps more fundamentally, although the formal
--~
~·
•...
c-
r: 8 What Is Psychiatry?
r- diagnostic classification system may be important when an individual
r· comes into contact with a medical or psychiatric service, the path to
contact is shaped by the beliefs about normality and pathology held
r,.. by many others - the individuals themselves, their families, teachers
or 'social workers, neighbours and employers. Research shows that
l these beliefs vary very widely both witliin and between countries,
r' not just as a result of widely differing mental health care systems and
c..:. the availability of trained practitioners, but also on such factors as
the age, ethnicity and social class of the 'pre-patient', the range of
r : available alternatives from herbal medicines to faith healing, and the
.,.--
r: prevailing social and cultural beliefs about the nature of the condi-
tion and the efficacy of various forms of intervention (Goldberg and
,,..
'-
What Is Psychiatry? 9
arguing that psychiatry defines the border between the normal and
the abnormal? This is tempting. But if one-third of the population is
diagnosable at any one time, and half of us over a lifetime, in what
sense is it 'abnormal' to receive a psychiatric diagnosis? Indeed,
one might almost say that it is 'abnormal, to live one's life without
coming into the remit of psychiatry: without talking to a medical or
other professional about one's mental troubles or conflicts; without
taking one or other of the multitude of psychiatric drugs - even if
only· a sedative - to help one sleep; without practising one of the
para-professional forms of mental self-help like mindfulness, even if
accessed for free via the internet.
We know that the idea of the norm, as it came into use in the late

[Huxley, 2003). l,',lonetheless, by·meanfof it~ auilioncy'.to confirm.·,..x nineteenth century, linked together the ideas of statistical normality,
'-
or deriy thes.e''other beliefs; thr9ug}) 'µie. giving' or':w.itlilioldingof a social normality and medical normality: the norm was the· average,
f"·
'- diagnosis:'or'even:anagre~eiit that someone is 'irt need' of treatment, ~.e ~es~rabl.e,the_heal~y, ~e lde~l.~i;id.~o,forth.P~rhaps; t~~~Y? this
1· w.oM in· h,el~iiig:"specify wha:t~th'ein~.'arid#i '.managing·th~m within :and s~9ng yei;sion 9f normality no Jonger_~C>!~s, or holds diffe.rentl}i: in dif-
ferent societies or iii different' sectors, Is it abnormal to feel hopeless
c
<,
outside' medical' institutions, 'psy~hiatry and 'psychiatric classification
:
systeitjs 'Play a signi~cant role in shaping. our unqe~t~ding ofnor- a·
in worlcf besei'by 'faniirie; conflict and injustice? Is it abnormal to
c:,.. . mality itself. : ' . . . . . . ' . ' .. . . .. . . . . . . . . . . . . . . .
I was tempted to put this more strongly and write that psychiatry
feel guilty for thinking unpleasant thoughts, or for actions undertaken
or not undertaken? Is my behaviour in polishing the taps or lining up
'-
: 'defines the boundaries of normality', but this would be too simple. the spice jars merely eccentric, or is it beyond the limits of normality?
r
__,;
It is true that psychiatry is sometimes defined as the study of psy- Is it abnormal to hear voices, or to experience strong thoughts that
\..
---·------~chopaihology, and ilie olo argument - that medical thought works,----!-- seem to come from outside? Is it normal to believe in a clivt..;:;ne_p_ow-er--·---
by establishing a division between the normal and the pathological that shapes one's fate? Clearly, normality- of what it is to be normal,
/ - remains true (Canguilhem, 1978). /i.Jut when it comes to the scope to think of oneself as normal, to be considered as normal by others -
......
r
of psychiatry today, can we stiU hold to the idea that, in some funda- leads to a set of rather profound questions .
'- mental way, to be diagnosed with. a mental disorder is to be classified We should probably accept that normality, today, is best thought
r : as 'pathological' - with all the cultural resonances of that term when of as a term of ascription, as perfmmative - that is to say, it is a term
i.. linked to mental illness: compulsive) extreme, uncontrolled, irrational, that is best understood in its uses. 23 So rather than. thirikjng of it as
r:
..._; dangerous and so forth~Perhaps this conception of psychopathology ha~g Som~ substantive mea.nmg>\ye should always ask who defines
who asnormal in relation to what critena;' in whaf p.ract:ices~ and with
r.
,,
still applies for severe mental disorders like schizophrenia, where
stigma and exclusion still flourish despite the best efforts of anti- · wh!it consequeii~es: We iiiight:be iempted'io-dispense with the term
'-
I
1 stigma policies and programmes to persuade people that mental altogether; were it not for the fact that any decision by a medical pro-
( yuA-<\,l-.i. ( "'(~illness carries no special threat orr@nt and is just an illness like any fessional) a teacher, a social worker, a family member or an individual
x..: other. And of course we know that the old idea of the psychopath still themselves that some kind of treatment is required invokes, even if
...... plays an important role in popular discourses even if the term and the implicitly, the judgement that something - a bodily feeling, a way of
( diagnosis are contesred within psychiatry. But whatever one might thinking, of speaking, of feeling, of acting- is not 'normal' for a par-
"- think of the diagnoses, few would consider mild depression, anxiety ticular person: for a man or a woman, a child or an adult, a member
L or panic disorders as 'pathological' even if, in formal terms, they are of this or that generation, of this or that ethnic group, a person with
(
often placed within the textbooks of psychopathology. these or those experiences and so forth. 24
\.... So should We think in terms of a less pejorative framing, sub- If anything, the issue of normality is becoming even more prob-
..... stituting the idea of abnormality for that of pathology, and hence lematic in medical thought, for every week seems to bring us new

L
.
l
c
10 What ls Psychiatry?
diagnostic technologies- genetic technologies, scanning technologies
and so forth- that claim to reveal abnonnalities within the previously ·
invisible interior of the body or the brain: these are technologies that
claim to identify 'markers' showing that an individual is likely to
develop a disease long before they themselves feel symptomatic. Such
a person is suffering from a ~e-disease; he or she is 'presymptomati-
cally ill' (Rosenberg, 2006),1.l'or some researchers and policymakers,
the identification of these pre-diseases represents a great advance for
medicine; they are excited by the idea of identifying, treating and pre-
venting diseases before· they start to afflict the individual concerned~
For others, the hunt to identify and treat pre-diseases is simply a wid-
ening of the empire of medicine and psychiatry, treating individuals
who may never become ill at all, just because a test shows that they
have a probability - but not a certainty - of developing a disorder in
the future.2terhaps, then, normality has to be understood as having
a negative not a positive function, in the sense that, for psychiatry
and indeed more ,~nerally, normality is that which does not require
expert intervention. 2.!J.n these terms, there are few of us in the Global
as
North who.are normal in this sense, so many of us listen to experts
who advise. us to adjust our diets, take up exercise, take everything
from vitamins to cholesterol-reducing pharmaceuticals, to keep us
'normal'. We will return to this question of normality throughout this
· book, for it raises a host of medical, social and ethical challenges.
· · What mental disorder ls
Third, psychiatry and psychiatrists play a key role - though many
others are involved too -[ip establishing what kind of a thing mental
disorder is:\Is it - as it was for some in the early twentieth century - a
matter of Thstincts badly managed, of habits poorly trained? Is it a
· matter of the dynamic forces in the unconscious as it was ., and still
is - for psychoanalysis and the many related 'dynamic' psychothera-
pies?m it an understandable and perhaps even normal reaction to
difficult social circumstances, poverty, racism or traumatic events, as
many social scientists have long arguedU:s it a matter of dysfunctional
patterns of cognition to be corrected by cognitive therapy? Is it an
outcome of 'toxic stress' in childhood, to be countered by interven-
tions directed at dysfunctional families? Or is a mental disorder, as is
increasingly argued, a brain kind of thing, ultimately understandable
in terms of neuronal processes?
Many psychiatrists and neuroscientists believe the issue is now
What Is Psychiatry? 11
(
settled - the key to understanding mental disorders is the recognition
. that, at root, they are brain disorders. I have already mentioned the
'big science' brain projects under way in Europe, the United States, (
China, Cuba, India and many other countries. The hope is not just
. that these will reveal "how [the brain's] roughly 86 billion neurons
and its trillions of connections interact in real time ... [and] revolu-
tionize our understanding of how. we think, feel, learn, remember»,
to quote Francis Collins in his National Institutes of Health (NIH)
fpirector's Blog entitled 'Launching America's Next Moonshot';j
it is also that they will transform "efforts to help the more than
1 billion people worldwide who suffer from autism, depression,
schizophrenia, epilepsy, traumatic brain injury, Parkinson's disease,
Alzheimer's disease, .and other devastating brain disorders". One
can find the same rhetoric in the funding of Europe's Human Brain
Project - despite the fact that little of the research within that 'project
focuses directly on mental disorders28 - and in statements from the
US National Institute for Mental Health (NIMH). Thus Thomas
Insel, when he was Director of the NIMH, stated unequivocally that
"[m]ental disorders are biological disorders involving brain circuits
that implicate specific domains of cognition, emotion· or behaviour",
and his successor, Josh Gordon, asserts: "psychiatric disorders are
disorders of the brain, and to make progress in treating them we
really have to understand the brain ... {if we can] get at questions of
how neural circuits produce behaviour (this] may soon generate new
treatments fol," psychiatric disorders". (quoted from Abbott, 2016)
- although he does· admit that we have no idea of which circuits are
involved or how they might be modified.P , · · · ·
Of course, not all agree. For example, in the UK, the British
Psychological Society (BPS) was' speaking for many psychologists
when it argued that we should turn our attention away from the
brain towards the complex .psychosocial experiences that lead to
mental distress, and that these should underpin approaches to treat-
ment. 30 U\nd, as I have already stressed, psychiatry is a heterogeneous
domain, arid much clinical practice is agnostic about, and sometimes
uninterested in,. questions concerning the fundamental detenni-
~~n~ ~~ bi~logi.c~l mechanisms o(U!~ conditions under treatmentJ
~onethe,less, I-~ w_e ~~~d- a<!~P~:.~ "path-dependent' theory of
~tu~ wl\en.i~CPP1~~ to _S{').Dle~ni.Hkc; psychiatry. 'ntat:is..t9 say, there
}fe ;01ariy, diff.er~~ p_a9}s, th~t .re~e.~rc:b, ~a.n,..~k.~~ .a,nd, hence. many
different 'trutl:i~~:~a~ res~a~~ ~an,bring into, the g<;>m;iin of.potential
truths. I. s.a,j )Ii~P?.m.a~ __o~ potential. truths' because; of course, the
re~~~s and firidi~~ of re~.eartji are constantly subject tocontestation
\
 12 What Is Psychiatry?
and they have to go through. complex social. probesses before they.
r-. become accepted facts (Fleck~ 1979 [193'5]; Latour, i987).'':i3ur if
something is notresearched at all, it cannot enter into the domain of
,,...... · potential truths. If it is on the pathnot taken, it cannot become even
,- a candidate scientific fact. Uyiost research in psychiatry depends·upon
,.. .
funding, and so the paths of research are shaped by the interplay
between the research priorities and predictions of funding agencies,
and the interests, priorities and calculations of researchers themselves
who are applying for fundy If the key funders· make it a priority
c--'
to seek the brain bases of psychiatric disorders, it is not surprising
to find that a very significant proportion of research ori psychiatric
disorders focuses on these neurobiological processes. As a result,
r: neurobiological processes and mechanisms are the most likely to
' come into the domain of potential truths as far as mental disorders
~. are concerned.
,,. The priorities, methods and findings of psychiatric research shape
not just what we know, but how we should try to know what mental
disorders are. There are various reasons for the molecular path that
r has been followed by much psychiatric research since the 1980s -
that is to say, the focus on molecular mechanisms in the brain and
the attempts to understand mental disorders in terms of anomalies
or malfunctions in those molecular mechanisms (for more detail,
see-Rose-an-d-Abi;;Rac:h-ec1;--2013):-or-course, iliis'moleciilarization•
has been characteristic of biomedical thought more generally - the
belief, that is to say, that life is not mystery but mechanism, and that
..... pathological processes are best understood in terms of disorders or
anomalies in fundamental biological processes of the human body,
('.
and that, if one can 'reverse· engineer' the pathology to identify the
'-..· molecular mechanisms that underpin it, one can and should target
... _.l
(' effective treatments on those molecular mechanisms (Rose, 2007b).
While this@ecjijar style of thaughTh biology dates to the 1930s
(Kay, 1993), from the 1950s onwards it was undoubtedly boosted
,· by the discovery, byFranklin, Watson and Crick, of the double helix
......
r: structure of DNA, and the ways that· DNA sequences code for the
..._. elements of proteins that make up the molecular structure of human
organs including the brain. ·
,..
(
As far as psychiatry is concerned, other factors also come into
"-) play. Notably, there was the belief that if psychiatric drugs developed
since the 1950s work, it is because their constituent molecules lock
onto molecules in the neurotransmitter system in the brain - notably,
( .
"-- the locations on neurons that are responsible for transmission. of
nerve impulses across the synapses.31 So if drugs such as lSD mimic
'.._;
l
What Is Psychiatry? 13
psychiatric symptoms by interfering with the normal system of neuro-
transmitters> and if the early drugs for severe psychosis, such as
chlorpromazine, turned out to modify neurotransmission, and if the
first drugs developed to treat depression - such as iproniazid and
. imipramine - lilso worked on the neurotransmitter system, then it
seemed pretty obvious. that this is where resear<:11 should. foc;u£i Of
I
course, this had to be laboratory research, and, given that 1t was very
difficult ethically to experiment on humans, researchers had to work
with animals, which seemed to rule out any attention to a mental
domain. lMost researchers gave little thought to the mental Jives of
mice; rats or even macaques on which they experimented, assumed
that they could produce models of mental disorders in such animals -
arutjety, depression and so forth - and believed that the mechanisms
they studied in such model animals were evolutionarily conserved ,
and hence similar, if not identical, in humans;)
This belief in the biological basis of mental disorder was coupled
with the pervasive conviction, going .back many centuries in lay
understandings, formalized in theories of 'degeneracy in the late
nineteenth century, in the eugenics of the first half of the twentieth
century and in innumerable studies of lineages and of twins, that
there was a strong hereditary element in mental disorders, and hence
a genetic basis> .so cleai:'ly one should study the genetics of these
molecular mechanisms. Of course, much more was involved in the
growing belief that mental· disorders had a biological basis, to be
searched for at the molecular level, but for present purposes the
point is. straightforward: whatever had its effect on mental disorder
- whether genetics, family upbringing, adverse events, poverty and
trauma - it must do so via its effect on the molecular mechanisms of
the brain. And, as a corollary, if one wants to treat mental disorders,
the most direct route is to act on those molecular mechanisms to
correct their malfunctions, and the best way to do this is via· drugs.
Hence. much of this research involves sometimes controversial part-
nerships of various sorts between researchers based in hospitals and
universities and the commercial companies that produce drugs and
other treanaentsfor profit. The priorities that are identified for such
research, the hypotheses that are thought worthy of examination,
··· the research methods that are thought appropriate - such as animal
experiments or clinical trials - in other words the investigatory 'set-
ups' that are used in psychiatric research: these all shape what counts
as truth and what will come to count as truth about the nature of
mental disorders.
14 What ls Psychiatry?
Psychiatry as a political science
Fourth, psychiatcy is intensely political. Indeed, psychiatcy, since.
its inception in modern form. in the mid-nineteenth century, has
been a political science (Rose, l 996c). The rise of the asylum gave
psychiatry and psychiatrists a unique role - the capacity to com-
pulsorily confine and treat individuals who had broken no law,
but had transgressed· norms of order, control, civility, cognition or
desire - a capacity which it retains despite the 'death of the asylum',
and even though this is now constrained by subsequent legislation
and rights-based regulation. 3% The power of psychiauy to detain and
compulsorily treat was central to the critique of psychiatcy from the
1950s onwards, which I will discuss later in this book. But it would
be a mistake to identify the politics of psychiatry with the problems
of the asylum, important as· that has been. Outside the asylum, in
the second half of the nineteenth century, psychiatric practitioners
were central to arguments about degeneracy and its sociopolitical
implications •. As arguments about the prolific br~eding of degenerat~s
morphed into eugenic strategies in the early years of the twenti-
eth century, many psychiatrists. accepted that there was a constitu-
tional and heritable commonality between those who were mentally
deranged and those who were feeble minded, alcoholics, prostitutes
and a whole family of problematic type~ of person - we should not
forget that the first of thosewho were 'euthanized' in Nazi Germany
were· the inhabitants of mental asylums (Proctor, '1988)~ But the
political role of psychiatrists was by no means all 'negative' .: seeking
to confine or constrain. Eugenics also had its 'positive side' - encour-
aging the healthy to breed. And beyond eugenics, psychiatrists were
key players in the mental hygiene movements in the first half of the
twentieth century, making the link between poor mental hygiene and
all manner of problems of maladjustment among children, factory
workers, military personnel and others and seeking to maximize the
mental health of the population (Rose, l 985a: 'chs 6-8). ·
As the movement for the closure of asylums spread across inany
countries iri the 1980s, we saw an increase in the number of psychiat-
ric and quasi-psychiatric institutions across. the territory that became
termed 'the community' (I discuss this in detail in Rose, 1986, from
which the following paragraph is derived). Psychiatric medicine
moved out from the asylums to psychiatric wards in general hospi-
tals, special hospitals, medium secure units, day hospitals, outpatient
clinics, child guidance clinics, prisons, children's homes, sheltered
What Is Psychiatry? 15
housing, drop-in centres, community mental health centres, domicil-
.iacy care by community psychiatric nurses and, of course, the general
practitioner's surgery. And psychiatric practitioners, in alliance with
psychologists and social workers, concerned themselves with infertil-
ity, pregnancy, birth and the post-partum period; infancy; childhood
at home and at school; sexual normality, perversion, impotence and
pleasure; family. life, marriage and divorce, employment and unem-
ployment, mid-life crises and failures to achieve; and old age, terminal
illness and bereavement. Wherever problems arise e- in our homes, on (
the streets, in factories, schools, hospitals, the army, courtroom or
prison - experts with specialist knowledge of the nature, causes and
remedies for mental distress are on hand to provide its diagnoses and (
propose remedial action. As I argued in 1986, it would not be too
much of an exaggeration to say that, by thattime, we were living in a
'psychiatric society' (for a related argument about the United States
that informed my own approach, see Castel et al.; 1979). . ,.
Critics of 'deinstitutionalization' argued that this process was leaving
hundreds of severely disturbed individuals to fend for themselves on
: ~e streets, .not only at risk to themselves, but, more importantly, a
risk to others: the mad person figured "as the sign of a community
that doesn't care, as a threat ro a community that naturally cares for
itself, as an instance of the uncaring nature of a fiscally straightened
state, as an object of pity and of fear" (Rose, l 996c: 3). Psychiatrists'
capacity to treat was, it seemed, less important than their capacity to
. assess. and manage the risk that those with mental illness supposedly
posed to others, despite the fact that, in reality, that risk was far lower
than for many others (Szmukler and Rose, 2013). Both within the
criminal justice system - where: psychiatric reports play a key role in
the decision as to the appropriate ways to deal with potential offenders
- and outside it - where every Individual in touch with mental health
services is subject to risk assessment and .risk management - the
expertise of the psychiatrist is. required .(Rose, 2016). In the criminal t:
justice SY,Stem, psychiatric risk assessments may determine a verdict
- murder or manslaughter on grounds of diminished responsibil-
ity - but much more frequently their risk assessments determine the
sentence, especially in jurisdictions that have. a separate sentencing
hearing, and they also play a part in decisions over parole and early
release. Outside the criminal justice system, .Psychiatric evaluations
of risk shape decisions over whether an individual should be admitted I
-,
to a psychiatric facility, the level of security that is required, whether
he or she should be confined or treated against their will, as well as \.
the timing and nature of discharge. Today, while the mongers of fear
I.
\
r
r 16 What Is Psychiatry? What Is Psychiatry? 17
'
have retreated to the shadows, a different political problematic has Lovell, 1987: 9). But Basaglia, like Michel Foucault, whose Folie
emerged. Psychiatric estimates of the current and future prevalence et deraison: Histoire de la Jolie a l'age dassique was also published in
of mental disorders and brain disorders are linked to questions of 1961, asked questions about the social functions of the asylum and
economic productivity in a knowledge economy, on the. one hand, its carceral form, and hence about the sociopolitical role of the psy-
and concerns about the economic burden of care for the afflicted, on chiatrists who were its custodians, and the knowledge that grounded
the other. This is what is termed, in a phrase I profoundly dislike> 'the their claims to expertise. To put the matter concisely, these critics
,· burden of brain disorders'jwhich we will discuss in the next chapter. argued that psychiatry was a highly normative discipline, and its role
was one of social protection: to control those who deviated from or
transgressed social norms, in particular refusing the twin obligations
The politics of psychiatry of production and consumption, simultaneously delegitimating their
beliefs or actions as symptoms of illness, and normalizing them, or at
Is psychiatry today, at its root, a political practice? This question least muting their resistance, by incarceration and/or treatment with
c returns us to a controversy that has been rumbling since at least
the end· of the Second World War: Is. psychiatry, despite the pro-
powerful 'chemical coshes' - drugs used primarily for the purposes
of control within institutions and management of conduct outside it.
fessed therapeutic vocation of its practitioners, fundamentally tied Many psychiatrists were prepared to accept that their expertise
to practices of social control? The radical Italian psychiatrist, Franco could be used for_purposes of political repression. This was the widely
he
c Basaglia, put this most clearly: psychiatry,
the tension between control and care (for an excellent introduction·
argued, was riven by accepted view of the role of psychiatry in the Soviet Union as a means
of, and a: legitimation of,. the incarceration of dissidents. Psychiatric
r to Basaglia's work, see Scheper-Hughes and Lovell, 1987). Basaglia .
was writing at a time when, in Italy and many other countries, psychi-
diagnoses, notably Andrei Snezhnevsky's diagnosis of 'sluggish
schizophrenia' (van Veren, 2009), were used not just to confine
attic practice was inextricably linked to the involuntary confinement those who opposed the political regime in psychiatric hospitals, and
of patients in the custodial mental hospital. In the Italian case in not only to treat them with powerful psychiatric drugs against their
C--·-·---- th.-e~19=6=o~s-,-w~h-e-n~B~a-s-agl-ia-ca_m_'_e_d_o_u_t_hi_ .•s'-m'-'=.o""'st==--w~el;;.;l-'-kn=o;;;:;;wn=-w..;;.o""'r'""k--'i=n'-----s----W1~.l=1,~b~u_,._t_a~l-so---'-to~d-en-y~th-e-m-i1egal rights when they were di"-·s_c_h-arg-e-d,-----
,.· the transformation and eventual closure of the Gorizia psychiatric and effectively rob them of the chances of employment and much
hospital in northeast Italy, the sinillarities of the hospital to a prison more .. But outside the Soviet Union, did contemporary psychiatry
were clear. In Erving Goffman's terms, they were 'total institutions' have a similar function of constraining, controlling and medicalizing
- his analysis, published in 1961 in Asylums: Studies on the Social those whose views, beliefs, conduct and form of life were considered
( Condition of Mental Patitrnts and Other Inmates, was based on a year deviant and threatening to order and civility?
...... of observations in a psychiatric hospital in Washington> DC - that As will have been clear from my argument thus far, this would
(
l.i
. stripped those confined within them of the material, symbolic and be to greatly simplify a very heterogeneous set of practices that go
(_:, practical elements of personal identity 'and subjected them to the under the heading of psychiatry. Nonetheless, from its inception in
rules of the institution, transforming them in body and in soul from the mid-nineteenth century> the asylum was utilized as part of an
(
...__ persons to inmates (for an intriguing discussion, see Hacking, 2004). apparatus for the compulsory incarceration of troublesome individu-
( The horrors of the asylums in the mid-twentieth century had .been als - those found troublesome by their families, their spouses, their
...__.
revealed in earlier studies, such as Albert Deutsch's The Shame of the communities or various authorities. Across the twentieth century, the
States (1948) . and portrayed in movies such as The Snake Pit (also power of psychiatry to detain individuals against their will, and often
released in 1948), and while Goffman theorized its mode of action to subject them to harsh 'treatments', remained, and, even when
l on those within it, Basaglia sought, in a range of ways, to "restore a unspoken, the shadow of compulsion fell over all voluntary decisions
c subjectivity to the way in which patients were viewed ... he would
take the side of the patient, as a person who suffers and is oppressed
to accept hospitalization and treatment. There can be no doubt that
we can see many instances> historicaily and more recently, when
L [entailing] a refusal of accepted ways of organizing suffering, and an psychiatric language and powers have been utilized for frank control
involvement in transforming the patient's iifc" (Scheper-Hughes and of norm-violaters. Think, for example, of the psychiatrization of
~-·
c
(

L..

l
18 What ls Psychiatry?
homosexuality and the use by some psychiatrists of deeply unpleasant
technologies of behaviour modification in an attempt to eliiriiri11te the
deviant erotic desires of homosexuals (Bayer, 1981). Or consider the
heavily heterononnative use of psychopharmaceuticals for women
who either refused or found it difficult to conform to the forms of life
allotted to them (Chesler, 1972; Metz!, 2003), or the 'protest psy-
chosis' - the diagnosis of schizophrenia for young black Americans
demanding their civil rights (Metzl, 2010). Or consider the racial
stereotypes embodied in the overuse of the diagnosis of schizophrenia
for young black men in the UK (Littlewood and Lipsedge, 1997).
These examples could be proliferated.
More generally, risk assessment in the UK has become a routine
part of the work of all psychiatrists, not just those working in specialist
forensic services. «Psychiatrists are increasingly called upon to guard
the entry and exit points to a new range of quasi-psychiatric institu-
tions that seem to offer a solution to the problems thrown up by such
public fears and political responses generated by the 'community
psychiatry"' (Rose, 2002: 18).33 Some of the most egregious exam-
ples of this have been modified; Thus the institutions set up to detain
those deemed to have 'Dangerous and Severe Personality Disorder'
- a term introduced in a UK government document in 1999 but
which did not correspond to any known psychiatric diagnosis - have
now been subsumed within ordinary psychiatric services, and the
infamous 'indeterminate sentences for public protection', for those
considered likely to remain dangerous when their sentences had been
served, have been abolished. 34 However, several thousands of those
sentenced in this way still remain in detention, and the number of
persons detained under mental health legislation in the UK continues
to rise. In the year 2015/16 the total number of detentions under the
Mental Health Act 1983, as amended by the Mental Health Act 2007,
increased by 9 per cent co 63,622, compared to 58,399 in 2014/15.
As the offjcial report noted, «This compares with an increase of 10
per cent between 2013/14 and 2014/15 and is the highest number
since 2005/06 (43,361 detentions) a rise of just under a half over the
period." Further, the use of Section 136, which enables individuals
to be. institutionalized in 'a place of safety' increased by 18 per cent
over the previous year to 22,965. "At the end of March 2016, 25,577
people were subject to The ·Act of whom 20,151 were detained in
hospitals".« 30 per cent of whom were detained in private hospitals.35
We cannot ignore the continuing presence of coercion within
the psychiatric system: the statistics demonstrate quite clearly that
the 'control' functions of psychiatry, its 'social protection' role. in
What Is Psychiatry? 19
managing troublesome individuals, remains active and indeed may
be increasing. Nonetheless, many problematic cases .of the. use of
psychiatric power to compulsorily detain and treat do not relate to
either norm-violation or the control of those who might pose a risk
(
to others, but to more mundane, if no more acceptable, instances of
institutional management and pacification of troublesome individu-
als. Even the use of lobotomies or leucotomies from the 1930s to
the 1970s - psychosurgical operations which resulted in massive and
damaging changes in personalityfor those subject to them - while to
be deplored, cannot really be interpreted in terms of sociopolitical
control of deviant, dangerous or politically problematic behaviour.
These desperate remedies - like the shock therapies using malaria,
insulin or electrically induced convulsions (ECT) - arose from a
deadly combination of psychiatrists' genuine, if misguided, wish to
find a physical basis for their practice, together with the vaunting
ambitions and willing blindness to consequences of a few charismatic
practitioners (Valenstein, 1986). But what of today?
Critical psychiatry today
\
When.Peter Miller and I put together our collection on The P()Wer of
the
Psychiatry in 1980s, we suggested that any comprehensive politi-
cal analysis of psychiatry should not confine itself to a condemnation
. of the 'hard end' of coercion and compulsion, but should locate the
carceral asylum and those desperate .remedies within a wider set of
psychiatric practices, spreading way beyond the asylum, whose func-
. tion is not - or not only - the political or social control of deviance,
· · but is to define, inaintain or restore a particular notion of mental
health (Miller and Rose, 1986). I think it is from this basis that we
can begin to analyse the political role of psychiatry in the twenty-first
century. But to take that position isto also to stand at a distance from r
some of the themes that underpin contemporary critical psychiatry.
I have already touched on many of these in this chapter, but now let
me tum to them directly. . · .
We can start by returning to our dictionary definition: psychiatry is
the branch of medicine concerned with the causes, diagnosis; treat-
ment and prevention of mental. illness. As will have become clear, if
psychiatry is merely a 'branch of medicine', it is one that appears to
many to have been, and to still be, a uniquely problematic one. No
doubt there are many critics ofobsretrics and gynaecology, of oncol-
ogy and of many other 'branches of medicine' concerning the way
c 20 What Is Psychiatry? What Is Psychiatry? 21
(
c that experts treat their patients, for the difficulty of accessing effec-
tive treatments, and the ways that pharmaceutical companies, and
in the world of work. In locating the origins of so many disorders in
neurobiological anomalies, they suggest that it ignores or neglects the
('
I the medical device industry, make vast profits from human sickness damaging neurobiological consequences of austerity, the demeaning
r
,-··
and frailty. But few· would argue that these 'branches of medicine'
are fundamentallyillegitimate, serve sociopolitical rather than thera-
practices now forced on the benefit seeker, the job seeker, the asylum
seeker, the disabled person subject to work capability assessments.
peutic functions, offer pseudo-remedies for invented diseases, and In reindivid~g a disorder already individualized by our con-
,·
\
should not exist. Yet ever since the birth of modem psychiatry in the
mid-nineteenth century, it has been the topic of complaint, criticism,
temporary form of political economy, they contend that psychiatry,
along with the other psy disciplines, merely repeats, in a revised-form,
c,
,. sometimes ridicule. . the tension between care and control that has run through it since its
In the 1960s and l.970s, its very foundations came under attack inception 'in the .mid-nineteenth century. .
'---- from all sides. -From right-wing libertarians such as Thomas Szasz, In · the following chapters we will see that while many of these
c who thought the very idea of mental illness was a myth, that psychia- criticisms are overstated and overgeneralized, and some are frankly
r trists were peddling spurious diseases and ineffective treatments, and
that those treated by ·psychiatry were not sick, but merely unable to
wrong, most have some grains of truth, and some accurately target
flaws at the very heart of contemporary psychiatry. Yet, I will suggest,
r,,. cope with the demands of living (Szasz, :1962). From those on the
left who· regarded psychiatry as a political practice for the control
there are segments, forces, explanations and practices within the
heterogeneous domain of this 'discipline of mental health' that offer
'- of those who deviated from social norms, doing the state's business hints of an alternative. As I conclude this book, I argue that we can
r under the guise of medicine (Baruch and Treacher, 1978). From identify some lines of escape, some hints that another psychiatry -

r:
c. those who believed that psychiatry was actually in the control of
the pharmaceutical industry, part of a vast machinery of 'disease
· no less evldence-based, no less rigorous, no less neurobiologically
informed, indeed far more attuned to the reality of the ailment - is
\.
mongering', inventiµg diseases for the sole, or main, purpose of indeed possible.'
increasing potential markets for financial exploitation by the dru~..!!g~--l--------------------------------
c. '----------ccc:,rnJ5a:ni'es-(Moyniliiinan,rCasse1s,"'200'5)~From iliose wlio thouglit
r·i
...... that, while major mental disorders were a reality, psychiatry had Onwards.~.
;'. expanded beyond its legitimate borders, medicalizing the ordinary
..... travails of human existences, such as inattentiveness in kids, shyness It is necessary to resist the temptation to set out all the arguments of
in adolescents, anxieties in parents, stress in business people, sadness
'-' in everyone (Conrad ·and Schneider, 1992). And, above. all, from
a book in its first chapter. I have tried to identify some of the multiple
dimensions that map out the territory of contemporary psychiatry
"'\... .. .. those who felt that, despite all its pretensions to be based on biomedi- and to raise some of the problems that we will explore in this book. I
, ... i cal science, psychiatry's truth claims were invalid, lacking objective will do this by addressing a number of 'hard questions' about mental
"- knowledge of the conditions it claimed to be able to diagnose, and disorder today- hard questions, because, in my view, there are no
c its treatments today were as ineffective and harmful as_ the purging, easy answers .
..._ . bleeding, cold baths, spinning chairs, malaria shock, lobotomies and I start, in chapter 2, with the numbers. In the face of numerous
electro-convulsive therapies of the past (lngleby, 1981 ). · estimates of the size and burden of mental disorders that seem to
(
,.: Today, these criticisms often merge with a more general distaste for show that there are alarming numbers of people across the globe
the politics of the present, characterized by· its critics as 'neoliberal- living with a diagnosable mental disorder, even if they do not seek, or
-, ,
ism' (Cohen and Timimi, 2008; Moncrieff, 2008b).36 That is to say, cannot access, treatment, I ask whether we can "trust these estimates:
l many argue that psychiatry today, in diagnosing increasing numbers 'Is there really a global "epidemic" of mental disorder?' ··
( of individuals with psychiatric disorders, masks the origin of those In chapter 3, I consider the view of those who claim that there is
"-. ,'
disorders in the political practices associated with neoliberalism: the indeed a high and growing level of mental distress, but argue that
' I.... celebration of markets, competition, individualism, personal respon- this is as much a politiea! and economic issue as a 'psychiarric and
sibility and self-improvement through individual entrepreneurship therapeutic one. Those who argue this way link the rise in diagnoses
.....
l'
L,.

(._
 22 What' Is Psychiatry?
of psychiatric disorders to a decline in the conditions of life for
many of our fellow citizens, often attributed to political· and eco-
nomic strategies termed 'neoliberalism' and the linked phenomena of
'globalization; - with the movement of jobs from the Global North
to the Global South - 'marketization' - the celebration of market
individualism, competition and choice in all areas of life, not merely
those of production and exchange - and the attacks on welfare states .
and their associated provisions of social security, in the name of
autonomy, self-reliance and the like. In this chapter, then, I ask the
hard question: 'Is it all the fault of neoJiberal capitalism?'
In chapter 4, I return to the issue of what mental disorder 'is' and
ask a version of the question made famous many years ago by David
Rosenhan: 'If sanity and insanity exist, bow shall we know them?'
(1973: 250). Focusing specifically on the question of diagnosis, I
ask: 'If mental disorder exists, how shall we know it?' and I evalu-
ate the argument that changes in diagnostic practices, in particular
those associated with the APA's DSM, have played a key role in the
expansion · of the territory of psychiatry over the last half century,
transforming many .·of·the· ordinary·vicissitudes of-life ....- sadness,
shyness, childhood irritability and so forth - into psychiatric catego-
ries and hence increasing the number of us who are 'suitable cases
for treatment'. I also consider the linked argument that we can, and
----- - - -- ---- ·- .... -should,-seek to-find-genetic or neural~biomarkers~-that-would.enable _
precise and objective diagnosis, enable early identification of those at
risk of future mental pathology, and allow us to develop 'precision
medicine' in psychiatry. It seems difficult to argue against the hope
that biomarkers might enable those at risk of a mental disorder to be
identified while they were still well, andtherapeudc measures put in
place to prevent, or at least ameliorate, the problem. Yet we shall see
that the issue is not as simple as it seems. · some, represents a new wave of psychiatric colonization. We examine
In chapter 5, we consider the increasing emphasis on the role of
neurobiology in understanding mental disorders, and the increasing
focus on the brain in psychiatric research in Europe, North America
and indeed across the world, Few, today, would resist the idea that
brains are involved in mental distress, anxiety, despair, thought dis-
ruption; voice hearing and alt the other symptoms now placed in
the category of mental disorder. But of course; brains are involved
in almost everything that humans think; feel and do! To speak of
'the brain' is to paint with a very broad brush the millions of neural
circuits among the 100 billion or so nerve celJs in the adult human
brain and the l 00 trillion synapses or connections among these cells,
circuits evolved over millennia, developed from conception onwards,
What Is Psychiatry? 23
. and changing at. timescales ranging from the millisecond to the
. decade as a result of the transactions with body, milieu and physi-
cal, interpersonal, social and symbolic environment. And to accept
that brains - inwhatever sense we anatomize them- are involved in
mental distress is neither to argue that disruptions in these circuits
are the origin or cause of mental distress, nor that treatment should
be directed towards them. I therefore ask: 'Are mental disorders
"brain disorders"?' .· .
In chapter 6, I ask a question that may seem· paradoxical given (
that the rates of prescription of psychiatric drugs seem inexorably to
· be rising worldwide: 'Does psychopharmacology havea future?' For
while drug use is on the rise, there are increasing doubts about the
efficacy of these drugs, the founding hypotheses as to their modes of
action are now discredited, and the large pharmaceutical companies
are withdrawing from psychiatric drug development as they have had
little success in bringing new and more effective drugs to market for
any psychiatric condition, and are moving to invest in more profitable
products.
.: -In chapter. 7, I examine the Movement for Global Mental Health
(MGMH), . and the claim that mental disorders are not merely a
growing problem in wealthy industrialized nations, but also a major \
if largely unrecognized cause of undiagnosed illness .and untreated
_ .suffering_in_low~and_middl~income-countries,-where~psychiatrists----
. are few and far between, arid the treatment of sufferers is . often
represented as one of neglect and isolation, often downright cruelty.
Critics suggest that, knowingly or not, the MGMH is based upon a
culturally specific Euro-American model of mental health problems,
mistakenly believes that 'Western' definitions of illness and practices
'of intervention can be generalized to non-Western cultures and, for
this debate, and what it can tell us about the politics of mental
health today, and ask 'Who needs global mental health?' For the
issues raised - for example, those of the universality. of diagnoses,
of interpretation of clinical trials claiming to show the efficacy of
particular treatments, of the ways in which social, economic, political
and cultural factors shape the emergence, expression, experience and
consequences of mental i1l health=do not merely have relevance for
the psychiatric future in low- and middle-income countries, They tell
us· a great deal about the ways in which we understand and. govern
l
those who are perceived to fail at the tasks of living what has come to
be considered a normal life. .
. In chapter 8, I ask what the place of the patient is· in the psychiatric
\
,·
24 What Is Psychiatry?

2
system - that is, the user, the survivor, the consumer in the mental
health system. I place this in the. context of the powerful passage
in Michel Foucault's preface to his book Madness and Civilization
r:
(1967), where he argues: "The constitution of madness as a mental
illness thrusts into oblivion all those stammered imperfect· words
without fixed syntax in which the exchange between madness and
reason was made r. The language of psychiatry, which is a monologue · ls There Really an 'Epidemic' of
ofreason about madness; has been established only on the basis of
that silence." Foucault was writing 60 years ago. Have things changed
Mental Disorder?
in our current world of empowerment, citizenship., recovery and the
r: like? And if so, what are the challenges that confront us today?
This forms the prelude to chapter 9., where I discuss whether, in
the light of the critical analysis in earlier chapters, another psychiatry
is possible, and outline some of the key dimensions of an alternative:
that is to say., I ask: 'Is another psychiatry possible?' The total cost of disorders of the brain [in Europe] was estimated at
€798 billion in 2010. Direct costs constitute the majority of costs (37%
direct healthcare costs .and 23% direct non-medical costs) whereas
~- . the remaining 40% were indirect costs associated with patients' pro-
duction losses. • •• In terms of the health economic burden outlined
in this report, disorders of the brain likely constitute the nwnber one
economic challenge for European health care, now and in the future.
~-
...... J'
.
Gustavsson et al., 2011: 720

It seems that Americans are in the midst of a raging epidemic of mental

illness, at least as judged by the increase in the nwnben treated for it.
The tally of those who are so disabled by mental disorders that they
qualify for Supplemental Security Income ($SI) or Social Security
Disability Insurance (SSDI) increased nearly two and a half times
between 1987 and 2007 - from one in 184 Americans to one in sev-
....... enty-six. For children, the rise is even more startling - a thlrty-five-fold
increase in the same two decades. Mental illness is now the leading
·,·.-· cause of disability in children, well ahead of physical disabilities like
cerebral palsy or Down syndrome, for which the federal programs
were created: ..• A large survey of randomly selected adults, sponsored
by the National Institute of Mental Health (NIMH) and conducted
between 2001 and 2003, found that an astonishing 46 percent met
criteria established by the American Psychiatric Association (APA) for
-. , having had at least one mental illness within four broad categories at
some time in their lives ... What is going on here?" ·
Angell, 2011: 20

Claims about the large numbers of adults and children suffering from
..... mental disorder are becoming familiar.1 Mental health and govern-
ment websites in the UK and the United States regularly report that
'~-

'-
 26 Is There Really an 'Epidemic' of Mental Disorder?
about one quarter of the adult population will experience at least one
diagnosable mental health problem in any one year, and around 50
per cent over a lifetime; and that 20 per cent of children will have a
mental health problem in any one year. International organizations
tell us that approximately 450 million people worldwide have a mental
health problem, and that mental disorders are rapidly becoming one
of the world's leading causes of ill health.2 We used to count the
number of mentally disordered persons in terms of the populations
of mental hospitals, yet even at their peak these numbered hundreds
of thousands across Europe and the United States, not millions.3
How have we come to such a view of the prevalence of these condi-
tions in our own times? Is this an acknowledgement of the scale of
disorder that has long existed across the world, but is only now fully
recognized - after all, we would not be surprised by these figures
if they referred to the prevalence of <physical' - non-psychiatric -
disorders? Or does this provide evidence of the rising numbers of
those who are ailing-Crom mental disorders in developed, developing
and less-developed regions alike: a genuine epidemic! whose causes
we need to. identify and address?
Further, what are we to make of the fact that those who produce
these and other similar estimates argue that the majority of those
whom experts consider to be suffering with a mental disorder are not
____________ . _ diagnosed.and.have.neither been.giv.en,_nor_hav.e_sought,_psychiatric
· help (Kohn et al., 2004; Rebello et al., 2014; WHO, 2017)? Does this
so-called <treatment gap' imply that we must demand a rapid increase
in the numbers of psychiatrists and in the availability of mental health
treatment, especially in those countries where such professionals and
facilities are rudimentary? Or is this)- as some critics have suggested,
a gross overestimation, a sign of the 'psychiatrization' of more and
more features of everyday existence, an inflation of figures by those
who .seek to benefit directly or indirectly from extravagant claims
such as these?
Here is the first hard question that we must consider in this book, and
the first dilemma with-which we must struggle: is there really a global
'epidemic' of mental disorders? Is there really so much undiagnosed
mental disorder demanding more research, programmes of disease
awareness for professionals and lay persons alike, an increase in psy-
chiatrists and practitioners of-community mental health and so forth?
Or are psychiatrists too ready to diagnose disorder for normal varia-
tions in mood or behaviour, and prone to overestimate the prevalence
of disorder? If so, what are the forces that are leading psychiatrists to
make these estimates? Let us begin by considering the phrase that is
Is There Really an 'Epidemic' of Mental Disorder? 27
currently popular to describe these numbers: <the burden of brain
.disorders'. For two things are implied by this phrase, in addition to
the numbers themselves. The first is that these disorders are to be (
understood as <burden' - a weight, a load, an encumbrance. And the
(
·' second is that these disorders are matters of (the brain'.
"Iheburden of brain disorders'
. . . . (
The idea that mental pathology was a burden - rather than an indi-
vidual affliction, a family misfortune or a public danger- took shape
in the late nineteenth century, with the widespread acceptance of
the idea that disorders ranging from tuberculosis __ to insanity were
symptoms of a heritable trait of degeneracy that hampered the .overall
power of a nation and ~ts ability to succeed in international competi-
tion for territory and resources (Pick, 1989). This burden was partly
a matter of expenditure, and partly a matter of fitness. On the one
hand, supporting all those defectives, lunatics, alcoholics and others
· · with a weakened and degenerate constitution imposed a financial cost
on the healthy, who contributed through their taxes. On the other,
a population whose fitness was weakened by an increasing number
of degenerates would lose out in the imperialist struggle between
______ nations._This-made-it-imperative-to-identify-those-burdensome-indi---------
viduals and, if possible, to curtail their numbers, in the first instance
by limiting their tendency to-spawn.so many genetically tainted off-
spring. A particular concern was with those termed 'feeble minded',
who often passed among the normal population without clear visible
signs of their inferiority, but who also reproduced their kind in large
numbers, indeed larger than those of the civilized population who
were limiting the size of their families. This eugenic style of thought,
grounded intellectually in the work of Francis Gal ton (1904), took .a
lethal tum in Nazi Germany - and one that was carefully calculated
in Reichsmarks, A famous illustration in Volk und Rasse, published
in 1935, shows a healthy Aryan labourer carrying a beam on his
shoulders with a caricatured mentally defective individual sitting at
one end and a caricatured Jew at the other. The text reads: "You
are sharing the load. A genetically ill individual costs approximately
50,000 Reichsmarks by the age of sixty" (Burleigh, 1994; Proctor,
1988). 5 However, eugenic ideas also underpinned policies of identi-
fication and segregation - and sometimes sterilization "".' of the feeble
minded and other sociaUy undesirable individuals in Britain, the
United States, and in countries from Mexico to Japan; it continued
r: 28 Is There Really an 'Epidemic' of Mental Disorder?
in attenuated form in the Nordic countries until the mid-1970s and
in China until· the end of the twentieth century (Broberg and Roll-
Hansen, 1996; Dikotter, 1998; Dowbiggin, 1997; Stepan, 1991).
Of course, now is not then. Today's use of the term 'burden'
in calculating the costs of mental disorders or brain disorders to
our economies does not partake of the same eugenic or political
rationale, and .the conclusions drawn from the estimates that experts
produce are exactly the opposite .:. they are not used to demand
exclusion and elimination of the unfit, but to press for treatment and
~~~·: inclusion to reduce the burden of mental disorder on themselves,
--\
\'{.·
r: their families andcommunities, and the directand indirect costs to
the economy, Nonetheless, 'many .who are diagnosed with mental
,,.. disorders find the language of burden insulting and demeaning - and
'··
/
many of those - including the present author- whose loved ones are
so diagnosed do not consider that their relationship is one of burden.
Perhaps we should look at this from a very different perspective.
r: Could these conditions - however they are described - be the price
that' some of us pay for the demands that are made upon us by·
r: contemporary societies? That is to say, might many of those living
'-··
under the description of mental disorders thrive in other cultural
conditions, even though, for whatever reason, they lack the fortitude,
,.~ the desire, or the resources required to live a life of freedom, choice,
,._,---- ·------r...,.e-sp-o,--n,...,sioility,ancnnclusion via wage labour? And might we think
of our relationship with those who are diagnosed with mental health
problems not in terms of burden, but in terms of care and solidarity?
Such a relationship would entail the recognition that we ourselves
might have been in that situation, and under those diagnoses, in
the past and might very well be in the future. I shall return to these
........ ethical and political questions later. For now, let me focus on the
ways in which, today, the prevalence of these disorders has come to
be construed as a governmental problem and framed in the language
.......• of burden.
Counting the costs
....
( The European Brain Council took its report, 'Cost of Disorders of
.......
the Brain in Europe 2010', to the European Parliament on 4 October
2011.6 The experts who contributed to that report estimated that
around one-third of citizens of theEuropean Union suffered from
'-·. a diagnosable 'brain disorder' in any one year, most of whom were
,., undiagnosed and untreated, and that the total cost of such disorders
'v
l.
Is There Really an 'Epidemic' of Mental Disorder? 29
to Europe in 2019 was €798 billion (Gustavsson et al., 20ll). One
of the coauthors succinctly summarized the report's main argument
for the Parliament: "People don't die. from them, rather they live in
a· disabled state for most of their lives ..That's why disorders of the
brain are so costly" (Ies Olesen, cited in Andersen, 2011). How did
mental disorders come to be framed in these economic terms and
seen as "so. costly"? . .
For many years it was routine for those working in psychiatry
to complain about the relative lack of investment in research into
mental disorder compared with other conditions such . as cancer.
But, as Ayo Wahlberg has argued (Wahlberg and Rose, 2015), partly
a result of .the shift among epidemiologists and health economists
from calculating the cost of dying from disease to calculating the cost
of living with it, problems of mental health and neurological disease
have gained a newfound prominence in global efforts to set health
priorities. Central to this shift in priorities has been the consolidation
of psychiatric epidemiology as a subfield of epidemiology, and its
shift of focus, in step with the rest of epidemiology, from the numbers
themselves - the mapping of disease incidence and prevalence - to
the calculation of 'disease burden',
The Second World War marked something of a turning point in
the way_ in which P.§Y.Chiatr}'. conceived of its sociaJ_y_o~.111i.QJ)_._Prior~-----
to the outbreak of war, to oversimplify, psychiatry. was divided
between the asylums - the institutions which enclosed and isolated
both the inmates and the asylum superintendents - and the growing
variety of provisions outside the asylums, whether these were psychi-
atric units in general hospitals, outpatient clinics or indeed private
psychotherapy. During the war, in both the UK and the United
States, psychiatrists were iti.volved in the selection of personnel, in
techniques of training, in strategies for the maximization of both
military and civilian moral, as well as the treatment of 'problem
cases'. In the British army, psychiatric discharges made up over 30
per cent of all discharges for medical reasons. It became clear, both
to professionals and to the politicians, that psychiatry should no
longer focus all its attention on the confinement of a small number of
severely disordered persons. "To fulfil the task that society required,
it needed to shift its attention to the detection and treatment of those
. large numbers of the population who were now known to be liable
to neurotic breakdown, maladjustment, inefficiency, and unemploy-
. ability on the grounds of poor mental health" (Rose, 1986: 62-3).
Given this changed perception of the extent of mental disorder
in the non-institutionalized population, it is not surprising that, in
 30 Is There Really an 'Epidemic' of Mental Disorder?
the decades following the end of the Second World War, there were
innumerable studies of the 'prevalence' of. (mental illness', 'mental
distress', 'mental morbidity' and the like - in short, of what was to
become psychiatric epidemiology. In a review of psychiatric epide-
miology published in "1964, Michael Shepherd and Brian Cooper
attribute this new postwar concern not to eugenics, but to "the
unprecedented interest taken in the mental health of both the mili-
tary and civil populations during the conflict" and to "the post-war
renewal of interest in the psychosocial components of morbidity and
the emergence as a separate discipline of social, or 'comprehensive
medicine?' (Shepherd and Cooper, 1964: 279). What was surprising,
however, given that eugenic thought was still active in the late 1940s
and early 1950s, is the fact that eugenic arguments seeni to have
played no part in these studies.
The abiding concern from the 1950s to the 1970s, rather, was
with the extent of the 'unserved' population. Mortori Wagenfeld, in a
paper published in 1983, reviewed the studies that had been carried
out in the United States and their implications. There was "the 1954
survey of the· entire non-institutionalized Baltimore population, in
which it was determined that atany given point in the year, 10% of
the total population (all ages) had a mental disorder classifiable by
the ICDA [International Classification of Diseases, Adapted for Use
in the United States]"; there was the Midtown Manhattan Study of
1954 which found that "23% of the adult population (age, 20-59
years) were affected by serious psychiatric impairments at any point
in time"; and there was the· 1967 study in New Haven, Connecticut,
which "found a point prevalence mental disorder rate of about 16%
in- the adulrpopulation (age;' 20+ )" (Regier ec··at:;"1978: 687}.'These
studies were heavily criticized because of the vagueness of their object
- they used different definitions and categories, raising the question
"Just what was being measured?" (Wagenfeld, 1983: 171).
· Nonetheless, by the early 1980s, it was widely believed that some 15
· per cent of the adult non-institutionalized population suffered from
mental disorder, much of which was unrecognized and 'unserved' by
mental health services (Regier et al., 1978). Some were contending
that the United States - and indeed the whole world - was facing a
pandemic of mental disorder (Kramer, 1983);7 The 1978 Report
from President Garter'sCommission on ·Mental Health was of the
view that, in the words of the president, "one. in seven Americans
needed mental treatment of some kind at any particular moment". 8
The report estimated that while some 15 per cent of the general
population needed access to mental health services, the majority did
Is There Really an 'Epidemic'. of Mental Di~order? 31
not succeed because of discrimination, fragmentation of services,
-..
"';·
.and lack of official concern and of coordination between services
for physical health and those for mental health. This was linked to a (
more general question about the specific population groups that had (
been 'unserved' by the community mental health policies since the
Community Mental Health Centers. Act of 1973 '(Grob, 2005; US
Government, 1978).
In the years that followed, epidemiologists radically increased their
estimates of those afflicted by mental health problems. From the (
1990s forward, surveys in the United States (Kessler et al., 1994; ,
Kessler et al., 2005) arid in Europe (Wittchen et al., 1994; Wittchen
l
and Jacobi, 2005) were regularly estimating that 25 per cent of the
adult population not receiving psychiatric attention could be diag-
nosed with a mental disorder in any one year, and 50 per cent in a
lifetime. It is important to ask ourselves how these increased esti-
mates were reached.
The method used by Kessler and his colleagues - which has
remained basically unaltered since their first report in 1994 to the
present - was based· on an interview conducted in the National
Comorbidity Survey (NCS) of the non-institutionalized civilian r
population of the United States, which was designed "to study the (
comorbidity of substance use disorders and nonsubstance psychiat-
'
ric disorders" (Kessler et al., 1994: 8).~ A randomly selected set of l
households are chosen and members interviewed using a research ·\'
..diagnostic interview schedule which is designed to be administered by
nonclinical interviewers, and which evaluates subjects on categories
based on the DSM. For instance, the baseline study administered in
1990-2 asked questions of the form "Have you ever had.2 weeks or
longer when you lost the ability to enjoy having good things happen
· to you, like winning something or being praised or complimented?"
or "Has .there ever been 2 weeks or more when nearly every day
you felt worthless?" - that is to say, questions that took the form of
,--
the DSM checklists of symptoms. The answers are used to decide
whether that individual should be allocated to a diagnostic cat-
egory.10The authors are clearly aware of criticisms about the validity
of such a method based on self-reports and classified using a check-
list methodology, but argue that,' if anything, it underestimates rates
of psychiatric disorders, for instance arguing .thar non-respondents
have elevated rates of lifetime and current psychiatric disorder, and
pointing out that they apply various corrective measures to adjust
the data as well as checks on interviewer performance. However,
it is clear that the summary statements> for example "Nearly 50%
r·
'
t:
r 32 Is There Really an 'Epidemic' of Mental Disorder? Is There Really an 'Epidemic' of Mental Disorder? 33
r:
of respondents reported ·at least one lifetime disorder, and close to
' Burden today
r 30% reported at least one 12-month disorder" (Kessler et al., 1994:
8) - are rather misleading, since the respondents did not report
( disorders at all, but merely responded positively when asked if they It was in the early 1980s that studies of the prevalence of mental
~- had had various kinds of experiences. And, while the surveys do ask, disorder ceased to be just a matter of counting the numbers of cases
in certain cases, questions that require the interviewee to decide in different countries or cities and plotting their distribution against
r· whether, for example, a fear of some activity or event was 'unrea- standard variables such as density or level of deprivation. Instead- or
'
r sonable' and they also ask whether the interviewee has consulted a
medical professional, clearly theassessment of unmet need is not
as well -there were attempts to estimate the costs of mental disorders
- in particular of depression- to society. And this was to become the
~ based on any clinical evaluation. . . new meaning of 'burden'.
r-, One of the researchers on the earliest of these studies was Hans- Alan Stoudemire and colleagues (1986) were among the first to
Ulrich Wittchen, who spent periods of time with Kessler and his frame a paper in these terms. "Despite the ubiquity of depression as a
c colleagues at the NIMH each year between 1981 and 2000. It
was Wittchen, based at the Max Planck Institute of Psychiatry in
clinical entity," they write, "few systematic attempts have been made
to approximate the economic burden that this form of mental iliness
r Munich, and later at the Technische Universitiit Dresden, who places on American society" (1986: 387). In estimating burden, they
(•
'-.
took the lead in the analogous studies in· Europe. While the exact suggested, one needs not only to take account of the direct treatment
details of their methods are a little unclear, it 'appears that panels costs, such as doctor and hospital costs, pharmaceuticals and so
(. of experts were used to evaluate available evidence from existing forth, but also to include the indirect costs arising from time lost
r
r:
epidemiological' publications that used DSM or /CD (Iniernational
Classification of Diseases) criteria. After the epidemiological data was
from productive work due to the illness "and the relative dollar value
of that lost time" (1986: 387), which of course includes estimates of
-; compiled into tables, experts from various countries were asked to time lost in respect of those individuals with the condition who are
review the tables and state how much confidence theY.:--::h::a;.:::d~1=·n=-=th==e:c....__.._ n:.:.o.;:...t=-in==-=re~ce=ipt of treatment. The authors conclude:
C' .)

prevalence estimates (Wittchen and Jacobi, 2005). The estimate

r: ..
that they arrived at based on these methods was quite close to that These economicngures, alongwith emergingepidemiologicdata, dem-
'r of Kessler et al., namely: onstrste the magnitude of depression as a public health and socioeco-
'- nomic problem ()f major proportions for our society.These data further
r
_that about 27% (equals 82.7 million ... ) of the adult BU population, emphasizethat timely recognitionand administrationof currently avail-
'-· able treatments for depressionmay result not only in decreasedhuman
18-65 years of age, is or bas been affectedby at least one mental disor-
C: -. der in the past 12 months.Takinginfo account the considerabledegree sufferingand reduced morbidity,but aJso potentiallydiminish the drain
(
of comorbidity (about cine third had inore than one disorder). the on our overallsocioeconomicresourcescausedby this illness.The figures
'-;
most frequent disorders are anxiety disorders, depressive,somatoform alsoprovidea basisfor calculatingthe potential cost savingsto societyby
(.': and substance dependence disorders.When taking into account design, decreasingthe morbidity and monality of the illness by assuringrapid
sampling and other methodologicaldifferencesbetween studies, little and effectivetreatment for affectedindividuals.(1986: .393)
r
'- evidenceseems to exist for considerable cultural or country variation
c
r
... Only 26% of all caseshad any consultation with professionalhealth
care services,a finding suggestinga considerabledegree of unmet need.
The authors remark that "the full economic burden of depression
would include riot only the costs calculated here but also would
take into account pain and suffering experienced by the individual
'-(_: (Winchen and Jacobi, 2005: 357)
involved and/or his family and friends" (1986: 388). But it would not
What differentiated the Wincbeµ studies most clearly from those be until the early 1990s that the costs of the nonfatal outcomes of
c of Kessler and his colleagues were two key moves: first, to make an
explicit attempt to estimate 'burden' and, second, to group neuro-
depression and other inental disorders would come to be calculated
in assessing this personal, familial and interpersonal impact.
l_, logical and psychiatric disorders together as 'brain disorders', Let me In 2003, when Wang, Simon and Kessler reviewed the literature
(

'-'
of
consider each these moves in nun. , · on the economic burden of depression and the cost-effectiveness

l.
l-
c
34 Is There Really an 'Epidemic' of Mental Disorder?
of treatment, they assigned discussion of the "personal costs that
depression exacts from afflicted individuals, families and communi-
ties" to "earlier research", and focused on economic calculations of
burden, pointing out that "[i]n the past decade, research on the social
consequences of depression has begun to focus on the economic
costs" (Wang et al., 2003: 22). They attributed this change of focus
to the growing recognition of the "sheer magnitude" of the economic
burden, and to the social policy debate, · especially in the United
States, about the extent of health insurance coverage for mental dis-
orders in the light of necessary decisions about the allocation of scarce
resources. And indeed it is in cost-benefit terms that they cast their
argument - concluding that the current inadequate· and insufficient
treatment practices compound the economic burden of depression,
but that aggressive outreach and improved quality of treatments,
which were currently resisted by primary care physicians, health care
systems and purchasers of care, were, in fact, cost effective.
It was soon argued that this question of the burden of mental dis-
order was not merely a 'Western' problem or a problem of developed
economies or societies: . it was global .. Actually, this transnational
concern dates back to the. first global burden of disease (GBD) · study
initiated by the World Bank in 1992 .. Reflecting on that study in
1993, its authors note: · · · ·
The results of the 1990 GBD study confirmed what many health
workers had suspected for some time, namely, that noncommunicable
.. diseasesand-Iniuriee- were· a significant cause 'of health: burden ·in· all
regions .. ; Many diseases, for example, neuropsychiatric diseases and
hearing loss, and injuries may cause considerable ill health but no or few
direct deaths •.. Neuropsychiatric disorders and injuries in particular
were major causes of iost years of healthy life as. measured by DALYs
[disability·adjusted life years], and were vastly underappreciated when
measured by mortality alone. {World Bank, 1993)
Although questions of psychiatric disorders tended to languish
in the background in.earlier .global estimates, depression features
in the vecy first paragraph of the summary to an analysis of the data
published in 1996: "The next two. decades will see dramatic changes
in the health needs of the world's populations. In the developing
regions where four-fifths· of the planet's people live, noncommuni-
cable diseases such as depression and heart disease are fast replacing
the traditional enemies, such as infectious diseases and malnutrition,
as the leading causes of disability and premature death" (Murray et
al., 1996: I). ..
Is There Really 811 'Epidemic' of Mental Disorder? 35
This new prominence was, at least in part, a consequence of the
.move from death to life, that is to say, from counting the conse-
quences of disease in terms of the brute fact of death to counting (
consequences in terms of impaired lives. This study used a new
measure of burden, the DALY, to niake its estimates (Wahlberg and
Rose, 2015). The DALY expresses in a single figu~e both years of life
lost to premature death and years lived with a disability of specified
severity and duration. One DALY is one lost year of healthy life. The
study concluded that, in both developed and developing. countries,
depression in the middle years of life was the single most burden-
' some illness,' accounting for at least twice the burden imposed by
any other disease. It argued that traditional approaches to measuring
the economic costs of disorders had seriously underestimated the
burdens of mental illnesses, such as depression, alcohol dependence
and schizophrenia, because they took account of deaths, but not of
disabilities; and while psychiatric conditions are responsible for little
more than 1 per cent of deaths, they account for almost 11 per cent
:'
.c ,
of disease burden worldwide. .
· · . : . In 2001, the WHO published what was to become the foundational
document of the new approach - Menuzl Health: New ·understandi"ng,
New Hope: ..
Today, some 450 million people suffer from a mental or behavioural
disorder, yet only a small minority of them receive even most the
basic treatment. In developing countries, most individuals with severe
· mental disorders are left to cope as best they can with their private
burdens such as depression, dementia, schizophrenia, and substance
·· • · ,. · dependence .• ,. Already, mental ·disorders represent four of the. 10
leading causes of disability worldwide. This growing,bw:den amounts
to a huge cost in terms of human misery, disability and economic loss.
Mental and behavioural disorders are estimated to account for 12%
of the global burden ofdisease, yet the mental health budgets of the
majority of countries constitute less than I% of their total health expen-
ditures. The relationship between disease burden and dlseasespending
-Is dearly disproportionate. More than 40% of countries have no mental
health policy and over .30% have no mental health programme. Over
90% of countries have no mental heal tit 'policy that includes children
and adolescents. (WHO, 2001: 3)
These figures, so stark and compelling, seem to speak for themselves
of the need for political action. Indeed, the following words of the
WHO report became iconic: "By the year 2020, if current trends for
demographic and epidemiological transition continue, the burden
I.
r
(•
36 Is There Really an 'Epidemic' of Mental Disorder?
of depression will increase to 5. 7% of the total burden of disease>
becoming the second leading cause ofDALYs lost. Worldwide it will
be second only to ischaemic heart disease for DALYs lost for both
sexes. In the developed regions, depression will then be the highest
ranking cause of burden of disease" (WHO, 2001: 30).
From 'mental disorders' to 'brain disorders'
In studies up to the time of the 2001 World Health Report> the object
of calculation was variously referred to as mental disorders, behav-
ioural disorders, neuropsychiatric disorders, or in terms of specific
"'" psychiatric categories such as depression. When the European Brain
,,, Council (BBC) was established in 2002, it decided that one ofits first
tasks should be to provide decision-makers with an
accurate estimate
r-,
of the cost, or 'burden', of neurological diseases and mental disorder -
to bring together data on mental disorders and neurological disorders
'· . 'under one hat', as Jes Olsen, president of the EBC, put it in 2005. It
therefore embarked on a study; funded by the Danish pharmaceuti-
cal company Lunbeck, that it called 'Cost of Brain Disorders in
Europe'. This led to a· whole series of publications, gathered together
as a special issue of the European Joumai of Neurology, edited by
,.,...
..._;----------Analin-Sol>ocla et al:-(2C>C>5)~Tlie work was jointly commissioned by
the European College of Neuropsychopharmacclogy (BCNP), and
/ Hans-Ulrich Wittchen was central to the work of both organizations.
The report of the ECNP, included · in the special issue, was
called
-,'
the 'Size and Burden of Mental Disorders in Burope' (Wittchen and
Jacobi, 2005). But the executive summary of the special issue marks
clearly the move to a reframed object - 'brain disorders':
·-· . Brain disorders (psychiatric, neurological and neurosurgical diseases
. ...
/
· together) figure amongst the leading causes of disease and disability.
Yet, the knowledge of the epidemiological and economic impact of
brain disorders has been relativelylittle researched in Europe. WHO
'--. data suggest, however, that brain disorders cause 35% of the burden of
all diseases in Europe .•.
'-· · There are an estimated 127 million Europeans currently living with
'- .. a brain disorder outof a population of 466 million. Toe total annual ·
cost of brain disorders in Europe was estimated to €386 billion in 2004.
'·· Direct medical expenditures alone totalled €135 billion, comprising
inpatient stays (€78 billion), outpatient visits (€45 billion) and drug
costs (€13 billion). Attributable indirect costs resulting from lost work-
days and productivity loss because of permanent disability caused by
,.........•
,.__.
Is There Really an 'Epidemic' of Mental Disorder? 37
brain disorders and monality were €179 billion, of whl~h the mental
disorders are the most prevalent. Pirc<:~ non-medical costs (social ser-
vices, informal care and other direct costs) totalled €72 billion.
Mental disorders amounted to €240 billion and hence constitute 62%
of the total cost (excluding dementia), followed by neurological dis-
eases (excluding dementia) totalling €84 billion (22%). Neurosurgical
diseases made up a smaller traction of the total cost of brain disorders
in ~urope, i~aching a. cost of €8 billion . . • ·
The huge cost and burden of brain disorders calls for increased
efforts in, research, health care and teaching. (Andlin-Sobocki et al.,
2005: x-xi) ·
By 2011, on the basis of further analysis, Hans-Ulrich Wittchen
and his colleagues upgraded these figures, estimating that "each year
38.2% of the EU population suffers from a mental disorder ... this
corresponds to 164.8 million persons affected", a total cost of "dis-
orders of the brain in Europe" that they put at €798 billion in 2010.
Their recommendations followed as night follows day:
Political action is required in light of the present hlgb cost of disorders
of the brain. Funding ·of brain research must be increased; care for
patients with brain disorders as well as teaching at medical schools and i
other health related educations must be quantitatively and qualitatively
.improved, including psychological treatments. The current move of the
pharmaceutical industry away from brain related indications must be
halted and reversed. Continued research into the cost of the many <lis-
---1!
orders not included in the present study is warranted, It is essentialthat !
i
not only the EU but also the national governments forcefully support
·these initiatives .. (Gustavsson et al., 2011: 720)
of
The quantification of the burden 'living with disease> generated
grids of epidemiological visibility through which these brain disorders
gained a new-found prominence in developed countries, underpin-
ning demands for increased political action and funding for research.
But in addition, estimates of the burden in low- and middle-income
countries, as in the regular WHO reports, fonned a crucial rhetorical
underpinning for those seeking to promote intervention on mental
disorders in those regions:
Depression is the leading cause of disability as measured byYearsLived
with Disability (YLDs) and the fourth leading contributor to the global
burden of disease in.2000. By the year 2020, depression is projected
to reach second place in the ranking of Disability Adjusted Life Years
(DALYs) calculated for aU ages, both sexes. Today, depression already
is the second cause ofDALYs in the age category 15-44 years for both
sexes combined. (WHO, cited in Reddy,2010: l)
38 ls There Really an 'Epidemic' of Mental Disorder?
As a result, from a virtual absence in global health priority setting
agendas, Prince et al. described a "recent rapid increase in the vis-
ibility of the [global mental health] field": · culpable for ignoring it, someone must be. held responsible, or to
About 14% of the globalburden of disease has been attributed to neu-
ropsychiatric disorders, mostly due to the chronically disabling nature
of depression and other common mental disorders, alcohol-use and
substance-use disorders, and psychoses. Such estimates have drawn
attention to the importance of mental disorders for public health ...
[Still] the burden of mental disorders is likely to have been under-
estimated because of inadequate appreciation of the connectedness
between mental illness and other health conditions. (2007: 859)
These arguments led to the development of a powerful movement
to address "the grand challenge in global mental health" (Collins et
al., 2011) focused on schizophrenia, depression, epilepsy, dementia,
alcohol dependence and other mental, neurological and substance-
use disorders which are now thought to constitute 13 per cent of
the total global burden of disease. As the Movement for Global
Mental· Health· gained-traction, some' began to' argue that-mental
health should be recognized as the most important challenge for
global health.11 Indeed, some went further. Vigo et al., for example,
argued that, if the estimates were corrected in five problem areas
- overlap between psychiatric and neurological disorders; the group-
ing of suicide and self-hann as a separate category; conflation of
ait .chronic pain, syndromes. with.musculoskeletal. disorders; .. exclu-
sion of personality disorders from disease burden calculations; and
inadequate consideration of the contribution of severe mental illness
to mortality from associated causes - "the. global burden of mental
illness accounts for 32.4% of years lived with disability {Yl.Ds) and
13.0% of disability-adjusted life years (DALYs) .... Our estimates
place mental illness a distant first in global burden of disease in terms
of YLDs, and level with cardiovascular and circulatory diseases in
terms ofDALYs" (2016: 171).
So is there an •epidemic'?
Let us be clear: numbers· are political. Numbers are seldom; if ever,
merely collected, train-spotter style. Numbers are· assembled to be
used in arguments ...... to make arguments, to try to settle arguments,
sometimes in an attempt to depoliticize a disagreement by turning
it into a technical question, more often to politicize something that
Is There .Really an 'Epidemic'
. . of .Mental Disorder? 39
has, in someone's eyes, not got the attention it deserves. Look how (
many suffer, look how many die: it is a scandal. Someone must be
assume responsibility, for doing something about it. When psychi-
atric researchers 'do the math' in such arguments ...,. mental illness
, versus cancer, mental illness· versus HN ... - it is not always an
edifying spectacle as each group musters and organizes the evidence
for the importance of 'its condition' to argue for-more funding, more
research, more attention. The ambition of the researchers does not
depend on the precise figures - it is to force home to policymakers,
research funders, pharmaceutical companies, educators and indeed·
the public that there is a genuine need for urgent action to pay
attention to a very large amount of untreated illness that is not only
causing individual misery and many related familial and social dif-
ficulties, but is also a heavy cost on economies, in both developed
and less developed nations. We might adapt the term introduced by
Howard Becker (1963) for this kind of labour: these advocates. are
'moral entrepreneurs', not in· the sense of crusading for public and
· · political action to. address. a form of deviant conduct that outrages
their own moral principles, but in the sense of seeking to highlight a
..
t: wrong or an injustice to. a groupof persons that should create moral
outrage, and demanding that those in authority direct their attention,
their policies and. their funds to try to rectify it.. · ...
But to. say that numbers are political, and are mobilized in 'the
.service of moral.objectives, is.notto say thatthey are untrue.la As
William Alonso and. Paui Starr point out in the Introduction to
their. edited volume The Politics. of Numbers, acts of quantification
are 'politicized' not in the. sense that they are corrupt; though they
may be, but because "political judgments are implicit in the choice
of what to measure, how to measure it, how often to measure it,
and how to present and interpret the results" (19_87: 3). Further,
to quote Starr, while «me characteristics· of people are myriad and
subtly varied", statistical systems, such as the ones we have been
discussing, reduce complexity, incorporating this myriad into a single
domain and, very often, generating a single number that will appear
in headlines, in speeches and in reports (1987: 40). In the process,
l.
they shape our images of our society through ·the reality they seem
and
to disclose, and in this arid riiaiiy other" cases, they frame high-
light' certain domains as problems requiring attention, paradoxically
simultaneously depoliticizing it, making it appear as simply a recogni-
tion of an objective reality, not the subjectivity of a political choice.
And in a present in which statistics have become indispensable to
r·
( 40 Is There Really an 'Epidemic'of Mental Disorder?

r
3
government, they not only create a domain that requires government, '
,·~:
r but also create a means of judging success and failure.
So we should treat.the numbers with care. And this is especially the
r,....
case when, eswith so many of the estimates of the prevalence of dis-
orders that I have discussed here, the numbers do not include those
who have sought medical attention for their mental distress, but only
those whom experts believe could, would and should be included as Is It All the Fault of Neoliberal
suffering from a diagnosable disorder, if only they were picked up by
medical 'personnel, if only they were diagnosed correctly. This leads
Capitalism?
us to a further hard question: how shall we distinguish a mental dis-
,· order from ordinary variations in human mood, emotion, cognitions
and desires? How shall we 'diagnose' those who are suitable cases for
C, treatment? If mental disorders exist, how shall we know them? ·
Before we tum to that question, we need to set the scene by
C., · asking another -:- one that is raised by many critics of our present · I want to argue that it is necessary to reframe the growing problem
social and political arrangements. Is there something in our current of stress (and distress) in capitalist societies. Instead of treating it as
social, economic and political system that is leading so many of our incumbent on individu~ to resolve their own psychological distress,
r fellow citizens to the forms of distress .that are diagnosed as mental instead, that is, of accepting the vast privatization of stress that has
r. disorders? In other words, is 'neoliberal capnalism' at the root of the
'epidemic' that these numbers seem to reveal? This is our next hard
taken place over the last thirty years, we need to ask: bow has it become
acceptable that so many people, and especially so many young people,
are ill?The 'mental health plague" in capitalist societies would suggest
question.
that, instead of being the only social system that works, capitalism is
(.) ..;__-"-------------~ inherently.dysfunctional,.and-that-the.cost-of-it-appearing-to-work-is-------
very high.
Fisher, 2009: 19
(
'-
( Neoliberalism is creating loneliness. That's what's wrenching society
'- .· apart. What greater indictment of a system could there be than !lll epi-
demic of mental illness?Yet plagues of anxiety, stress, depression, social
phobia, eating disorders, self-harm and loneliness now strike people
..__.-.
(
down all over the world. The latest, catastrophic figures for children's •
mental health in England reflect a global crisis. There are plenty of see-
C: ondary reasons for this distress, but it seems to me that the underlying
cause is everywhere the same: human beings, the ultrasocial mammals,
l' whose brains are wired to respond to other people, are being peeled
(_ apart .•. Though our wellbeing is inextricably linked to the lives of
others, everywhere we are told that we will prosper through competitive
l .. self-interest and extreme individualism ••• Of all the fantasies human
(_ beings entertain> the idea that we can go it alone is ihe most absurd and
perhaps the most dangerous. We stand together or we fall apart.
l, · Monbiot, 2016

r We have known> at least since the birth of social medicine in the

nineteenth century, that there are social determinants of ill health
42 ls It All the Fault of Neoliberal Capitalism?
(Rosen, 1974). Through the pioneering work of Michael Mannot
and many others, it is now beyond doubt that these social conditions
- not just inadequate diet, polluted water and bad sanitation, but
also poverty, unemployment, social isolation, insecurity, inequali-
ties in status, power and control - affect mental health as much as
physical health (Marmot and Bell, 2012). Indeed, Marmot begins his
compelling book The Health Gap (2015) with an anecdote about his
experience in psychiatry in the 1960s. A senior psychiatrist working
in outpatients is confronted with a depressed woman who cries every
day and feels Jife is not worth living. She explains that her alcoholic
husband has started to beat her again, her daughter is pregnant, her
son is in prison - and much more. The psychiatrist tells the woman
to stop taking the pills she is currently on, prescribes some different
medication, and sends her on her way. That is all. For Marmot, "It
seemed startlingly obvious that her depression related to her life
circumstances" and it was not enough for the psychiatrist to say - as
he did - that there was little he personally could do about that; it
was not only that we "should be paying attention to the causes of
her depression", but.there.is something.that can be done about those
causes (2015: 2). Sadly, more than half a century on, this anecdote
reflects a reality that is repeated hundreds if not thousands of times
a day, in the Global North and increasingly in the Global South. No
wonder, then, that Marmot ends the Introduction tohis book with a
call to action, quoting the Chilean poet Pablo Neruda: "Rise up ...
against the organisation of misery" (2015: 21).
So do the figures on the prevalence of mental distress, however
it is categorized, reflect the personal consequences of the 'organiza-
tion of· misery' that· characterizes· the -political management of so
many societies in our contemporary world? We know from many
empirical studies, especially those in low- and middle-income coun-
tries, that there are consistently strong associations between poverty
- in particular, food insecurity, poor housing, financial stress and
similar indicators of a precarious and demanding form of life - and
'common mental disorders' {Lund .et .al., 2010). The WHO's 2014
report; Social Determinants of Mental Health, written by a group that
included Marmot, 1 makes these points forcefully. The report points
to systematic reviews which consistently show that common mental
disorders such as· depression and· anxiety "are distributed according
to a gradient of economic disadvantage across society" (Campion et
al., 2013), and that in low- and middle-income countries there was
a consistent relation between common mental disorders and poverty
(Lund et al., 2010). · transfer of inequities" (WHO, 2014: 27).
Is It All the Fault of Neoliberal Capitalism? 43
As the report also recognizes, these studies raise important questions (
about how to define and measure poverty, and which dimensions are
most significant (Lund, 2014; Bums, 2015). Education, food insecu- (
rity, housing, social class, socioeconomic status and financial stress
all exhibit a relatively consistent and strong association wii:h common
mental disorders, while other simpler variables, such as income and
employment, . were more equivocal. Nonetheless, the fundamental
· finding - "that the poor and disadvantaged suffer disproportionally
from common mental disorders and their adverse consequences"
(WHO, 2014: 16)- is confirmed by many other studies dating back
· to the early years of this century, both in low resource settings (Patel
et al., 2010; Patel and Kleinman, 2003; Fryers et al., 2003) and in
countries in the Global North (Fryers et al., 2005).
Key to the analysis in the WHO report is the idea of 'stressful
experience' (2014: 13). The authors of the report recognize that
stressful experiences do not always lead to merital disorders, and such
· disorders can occur in the absence of such experiences. However,
they point to research highlighting the relationships between mental (
.., disorders and "the level, frequency and duration of stressful experi-
ences and the· extent to which they are buffered by social supports
in the community", and they suggest that those "lower on the social
hierarchy" are more likely to be subject to such experiences, and
have access to fewer buffers and supports (2014: 17-18). They par-
ticularly point to evidence on the importance of prenatal experiences ,·
and early life, the deleterious effects of stress ors in early childhood on
· gene expression and neural mechanisms, and the consequences for
poor physical and mental health of cumulative exposures to stressors
over time, especially those arising from prolonged or frequent intense
adversity (Shonkoff et al., 2012) -what has become known as 'toxic
stress'. 2 The report suggests that such stress can be "buffered by social
support provided by loving, responsive and stable relationships with a
caring adult" (WHO, 2014: 18). It seems that the roots of mental dis-
order may begin even before birth, with adverse prenatal experiences
if mothers-to-be are young, socially or economically disadvantaged,
experiencing a hostile or violent environment or themselves suffer-
ing from mental health problems. And while schooling and home
support throughout childhood can build 'emotional resilience', this
too is less likely for children in families living in poverty and stress-
ful circumstances: hence, the report authors argue that efforts to
support poorer families, especially those where adults themselves are
suffering poor mental health, will "help disrupt the intergenerational
(
 44 Is It All the Fault of Neoliberal Capitalism?
It is easy to interpret these arguments as a reprise of earlier views
on 'the cycle of deprivation' now rewritten in neural terms. The
idea of the intergenerational transmission of social problems has a
long history>3 but it was reactivated in the UK in a 1972 speech by
the then Secretary of State for Social Services> Sir Keith Joseph> in
which he used this phrase and went on to ask: "Why is it that> in
spite of long periods of full employment and relative prosperity and
the improvement in community services since the Second World
War> deprivation and problems of maladjustment so conspicuously
persist?" This question was answered with reference to the personal,
parental and cultural characteristics of the families whose children
themselves went on to a life ofdeprivation marked by high levels
of crime> and mental and social pathologies (Welshman> 2007). In
the United States, the idea of a: 'cycle of disadvanrage' that began
in early childhood and led to the reproduction of poverty, disadvan-
tage, low school achievement and associated social problems took
shape in the 1960s, as part of President Lyndon Johnson's. so-called
War on Poverty. A panel of experts developed a .programme focused
specifically on the needs of disadvantaged preschool children> which
"became the blueprint for Project Head Start {launched in 1965]
designed to help break the cycle of poverty by providing preschool
.,. ...... children of low-income families with a comprehensive program to
... ;
·-------------=m-e,_e.,....ilieir
t emotional> social; nealth, nutntional> and psychological
needs".4 ·
· In the 1970s, the view of many who researched and debated these
issues was that these arguments about the transmission of poverty
and deprivation across th~ generations led, in fact, to policies directed
at poor families themselves rather than at the social conditions that
thrust them into .povercy· CWedge and Prosser, 1973; Rutter and
-· Madge, l 976f Deacon, 2003). While the 2014 WHO report does
lay emphasis on the importance of pregnancy, early childhood and
family life to "give every child the best possible start", it dearly seeks
to go beyond the idea of the family as the primary site of intervention:
its first key message is: "Mental health and many common mental
disorders are shaped to a great extent by the social, economic and
physical environments in which people live." The report musters a
compelling array of evidence to show that actions are required across
of
the life course at the level both communities and countries) includ-
ing "environmental) structural and local interventions" which will
"not only prevent mental disorders but also promote mental health
in the population" (WHO> 2014: 8). ..
But if it has long been true that people are made sick by the condi-
Is It All the Fault of Neoliberal Capitalism? 45
nons under which they have to make their lives, is there something
about our present situation that is driving more and more of us> not
just in the wealthy West, or the Global North> but also in less devel-
oped countries of. the Global. South> into states of anxiety> stress,
depression, social phobia> eating disorders, self-harm, suicide ... ?
What is it in our current 'organization of misery' that could be to
blame? Could it be because of the rise of policies in so many regions
of the world that seek to limit state expenditure, to transfer provisions
of everything from health services to old age pensions to the private
'for profit' sector> to deregulate the economy, to celebrate the free
market and competition, and - crucially - to promote the ethics of
individualism, entrepreneurialisin and relentless self-advancement?
. Is neoliberalism to blame?
Our unhappy present
It certainly seems to be the case that the diagnosis of the so-called
'common mental disorder' is on the rise; in the UK, surveys and
reports show considerable increases in recent years. A study by Barr
et al. (2015) of the prevalence of individuals aged· 18-59 report-
ing mental health pJ'()blems in thJLQuarterly Labour Force Suivey; _
showed that there had been a significant increase since 2008, that
the pervasive inequalities between those with low and high levels of
education widened over this period and that the increases were great-
est in those who were unemployed. On the basis of statistical analysis
of the trends, Barr et al. ruled out the effects of decline in wages or
unemployment itself, and concluded that the overall picture was. one
in which there was "a large increase in the proportion ofthe·working
age population facing the multiple disadvantages of being out of
work>·having a low level of education and reporting a mental health
problem"> which> they suggested> might well be linked to changes in
welfare and austerity policies implemented since 2010 (2015: 329).
Increases in mental health problems in the UK were widely publi-
cized in September 2016, when the Guardian ran an article entitled
'Mental illness soars among young women in England' reporting on
an official study that has been carried out for the National Health
Service (NHS) every seven years from 1993. This found that "12.6%
of women aged 16-24 screen positive for PTSD, 19. 7% self-harm and
28.2% have a mental health condition» - all of these having increased
greatly for women, but at a lower rate for men, between 2007 and
2014.6 We might blame some of this rise on the problematic status
46 Is It All the Fault of Neoliberal Capitalism?
of psychiatric diagnosis that I discuss elsewhere in this book, and on
the increased willingness of people to frame distress in this way. The
authors noted that this was a problem when it comes to interpreting
results of this sort. But even supposing that the actual increase in
mental distress in women is half of that reported, these results suggest
that something consequential has happened in the lives and circum-
stances of young'women over the seven-year period in question. In
this particular case, many commentators did not 'blame austerity' or
neoliberalism, but pointed to sexual violence, childhood trauma and
the pressures of social media, all of which might be thought to be
greater for young women than for young men.
More generally, the NHS study also reported that since 1993 when
the survey was first conducted, the proportion of the overall popula-
tion with a common mental disorder (CMD) had risen from 6.9 per
cent of 1 ~4-year-olds in 1993 to 7. 9 per cent in 2000, then to 8.5
per cent in 2007 and to 9.3 per cent in 2014: overall, "one adult in
six had a common mental disorder: about one woman in five and one
man in eight. Since 2000, overall rates of CMD in England steadily
increased in womenand remained largely stable in men" (McManus
et al., 2016: 8). Of course, one could identity.many potential social
causes of these increases: while most of those who speak of 'neolib-
eralism' date its emergence to the dosing decades of the twentieth
century, 2008 is often cited as the start of the 'financial crisis' that led
to the UK governments and many others in Europe and the United
States cutting welfare and other .state services, and introducing 'an
age of austerity'," Thus, tellingly, the study· also found that most
mental disorders "were more common in people living alone, in poor
physical health, arid not employed. Claimants of Employment and
Support Allowance (ESA), a benefit aimed at those unable to work
due to poor health or disability, experienced. particularly high rates
of all the disorders assessed."8 Indeed, one person in eight receiv-
ing BSA screened positive for bipolar disorder, a third for attention·
deficit hyperactivity disorder (ADHD), and almost half of people in
this category had attempted suicide at some point.
Studies in other countries also seem to show that anxiety, depres-
sion and the use of psychiatric medication is on the increase, at least
in some groups. As far as depression is concerned, as early as 1989,
Klerman arid Weissman reviewed a number of large epidemiological
and family studies carried out in the United States, Sweden, Germany,
Canada and New .Zealand using similar diagnostic instruments, and'
found "an increase in the rates in the cohorts born after World War
II; a decrease in the age of onset with an increase in the late teenaged
Is It All the Fault of Neoliberal Capitalism? 47
and early adult years; an increase between 1960 and 1975 in the rates (
of depression for all ages; a persistent gender effect, with the risk of
depression consistently two to three times higher among women than (
men across all adult ages ... and the suggestion of a narrowing of
the differential risk to men and women due to a greater increase in
. risk of depression among young men" (1989: 2220). While they do
not wish to disregard genetic factors, Klerman and Weissman point,
somewhat inconclusively, to a range of potential environmental and
cultural factors that might be.involved. . · ·
On the basis of a survey of adults in the United States conducted
in 1988 and 2000,, Twenge (2015) found that, despite some increases
in reports of depressive symptoms, such as feeling everything was
an effort, there were no significant differences in the numbers of
adults reporting that they felt depressed. However, as we will see in
more detail in chapter 6, the following decade saw a huge increase in
the use of the so-called 'antidepressant' drugs across all the OECD
(Organisation for Economic Co-operation and Development) coun-
tries, from Korea, through France, Gennany and Spain, to Iceland, (
although with very :large ..differences between them. The quantity
of antidepressant prescribing varies· widely between countries, for
example, in 2010, when more than six.times as many antidepressants
per person were prescribed in Iceland than in Estonia. And while the
United. States is not included· in the OECD analysis, the National
Center for Health Statistics reported that 11 per cent of Americans /
aged .12 .and over. were taking antidepressant medication in 2008,
and that antidepressant:prescriptions were most frequent amongst
persons aged between 18 and 44. Compared to the period from 1988
· to 1994, the rate of antidepressant use in the United States among all
ages had increased nearly 400 per cent by 2008 (Pratt et al., 2011).
& far as young people in the United States are concerned, Olfson
and colleagues report that "[tJhe percentage of youths receiving any
outpatient mental health service increased from 9 .2 % in 1996-1998
to 13.3% in 2010-2012 ... the absolute increase in annual service \.
use was larger among youths with less severe or no impairment";
they also found that there were significant overall increases in the
use of psychotherapy for youths, and.in psychotropic medications,
including stimulants (for the treatment of ADHD), antidepressants,
and even antipsychotic drugs (2015: 2029). 9 Twenge and colleagues
(2010) looked at 'real-time reports' of psychiatric symptoms in
young people in the United States and found large generational
,.. increases in psychopathology among collegestudents between 1938
and 2007 and among high school students between 1951 and 2002
.~-.
-,
(
Another random document with
no related content on Scribd:
 Fig. 5. Types of spears.

Others devote much attention to the shaping of the spear by

scraping and rasping its surface. Exceptionally straight and
smoothed mulga spears were made by the Barcoo natives of the
Durham Downs district and by the Dieri (b), whilst on the north coast,
the Crocker Islanders’ spears are deserving of the same comments;
the latter, in addition, are decorated by a few delicate engravings in
the form of circumferential rings and wavy longitudinal bands
composed of short parallel transverse lines. The Arunndta groove
the spears lengthwise with a stone adze.
An improvement on this type is rendered by the cutting of a
pointed blade at one end of the spear (c). Some of the best
specimens come from the eastern Arunndta in the Arltunga district.
The blade is symmetrically cut, sharply edged, and smooth; the
remaining portion of the spear is grooved longitudinally throughout
its length.
All the above-mentioned types of spear are thrown by hand.
A straight, single-piece, hard-wood spear is made more effective
by splicing a barb on to the point with kangaroo or emu sinew (d).
The barb being directed away from the point, the spear cannot be
withdrawn without forcibly tearing it through the flesh of the animal or
man it has entered. The natives living along the Great Australian
Bight, from Port Lincoln to King George Sound in Western Australia,
used to make this the principal weapon; the spear was up to twelve
feet in length, perfectly straight and smooth, and was thrown with a
spear-thrower.
A rare and perhaps unique variety was found at Todmorden on the
Alberga River in the possession of an Aluridja. It was a simple, one-
piece, bladed spear, like that described of the Arltunga natives, but it
had two wooden barbs tied against one and the same side of the
blade with kangaroo sinew, one above the other, at distances of
three and six inches, respectively, from the point.
The hard-wood spears may have the anterior end carved, on one
or two sides, into a number of barbs of different shape and size. The
simplest and most rudimentary forms were to be met with among the
weapons of the practically extinct tribes of the lower reaches of the
River Murray, including Lake Alexandria. The shaft was of mallee
and by no means always straight and smooth; its anterior end, for a
distance of from twelve to eighteen inches, had from five to six
medium-sized, thorn-like barbs or spikes, which were directed
backwards and cut out of the wood, on one or two sides. More rarely
one would find spears with a three-sided serrature, consisting of
something like two dozen small barbs, directed backwards,
extending in three longitudinal lines over a distance of about fifteen
inches; at the top the serrated lines merged into a single strong
point. Vide Fig. 5, e, f, and g.
 PLATE XXIV

A “boned” Man, Minning tribe.

“He stands aghast, with his eyes staring at the treacherous pointer, and
with his hands lifted as though to ward off the lethal medium....”

The most formidable weapons of this kind are those still in daily
use as hunting and fighting spears on Melville and Bathurst Islands
(h). The head of this type has many barbs carved on one side, and
occasionally on two diametrically opposite sides. There are from ten
to thirty barbs pointing backwards, behind which from four to eight
short serrations project straight outwards, whilst beyond them again
occasionally some six or more small barbs point forwards. The
spears have a long, sharp, bladed point. The barbs are
symmetrically carved, and each has sharp lateral edges which end in
a point. The size of the barbs varies in different specimens. Many of
the spears are longitudinally grooved or fluted, either for the whole
length or at the head end only. Usually these weapons are
becomingly decorated with ochre, and may have a collar of human
hair-string wound tightly round the shaft at the base of the head.
Some of the heaviest of these spears are up to sixteen feet long,
and would be more fitly described as lances.
The most elaborate, and at the same time most perfect,
specimens of the single-piece wooden spears of aboriginal
manufacture are the ceremonial pieces of the Melville Islanders.
These have a carved head measuring occasionally over four feet in
length and four inches in width, consisting of from twelve to twenty-
five paired, symmetrical, leaf-shaped or quadrilateral barbs, whose
sides display a remarkable parallelism. The barbs are surmounted
by a long tapering point emanating from the topmost pair; and very
frequently one finds an inverted pair of similar barbs beneath the
series just mentioned. Occasionally, too, the two pairs opposed to
each other at the bottom are fused into one, and a square hole is cut
into the bigger area of wood thus gained on either side of the shaft
(i).
 The structure may be further complicated by cutting away the point
at the top, and separating the paired series of barbs by a narrow
vertical cleft down the middle (j).
We shall now turn our attention to spears whose head and shaft
are composed of separate parts. In the construction of these, two
principal objects are aimed at by the aboriginal, the first being to
make the missile travel more accurately through space, and in
accordance with the aim, the second to make the point more cruel
and deadly. Whereas, with one exception, all the single-piece
spears, so far discussed, are projected or wielded with the hand
only, in every instance of the multi-pieced spears, a specially
designed spear-thrower is used for that purpose.
The native has learned by experience that weight in the forepart of
the spear will enable him to throw and aim with greater precision.
One has only to watch the children and youths during a sham-fight to
realize how well it is known that the heavier end of a toy spear must
be directed towards the target whilst the lighter end is held in the
hand. Green shoots of many tussocks, or their seed-stalks, and the
straight stems of reeds or bullrushes, are mostly used. They are cut
or pulled at the root in order that a good butt-end may be obtained,
and carefully stripped of leaves; the toy weapons are then ready for
throwing. One is taken at a time and its thin end held against the
inner side of the point of the right index finger; it is kept in that
position with the middle finger and thumb. Raising the spear in a
horizontal position, the native extends his arm backwards, and,
carefully selecting his mark, shies his weapon with full force at it.
The simplest type of a combination made to satisfy the conditions
of an artificially weighted spear is one in which the shaft consists of
light wood and the head of heavier wood (k). Roughly speaking, the
proportion of light to heavy wood is about half of one to half of the
other. The old Adelaide tribe used to select the combination of the
light pithy flower-stalk of the grass-tree with a straight pointed stick of
mallee. The western coastal tribes of the Northern Territory construct
small, and those of the Northern Kimberleys large spears composed
of a shaft of reed and a head of mangrove; the former being four or
at most five feet long, the latter from ten to twelve. The joint between
the two pieces is effected by inserting the heavier wood into the
lighter and sealing the union with triodia-grass resin or beeswax. The
Adelaide tribe used the gum of the grass-tree.
The River Murray tribes used to make the point of the mallee more
effective by attaching to it a blade-like mass of resin, into both edges
of which they stuck a longitudinal row of quartz flakes.
The Northern Kimberleys natives accomplish the same object by
fixing on to the top end of the mangrove stick a globular mass of
warm, soft resin, in which they embed a stone spear-head (l). In
certain parts of the Northern Territory one occasionally meets with a
similar type of spear, but such in all probability is imported from the
west.
The popular spear of central Australian tribes consists of a light
shaft fashioned out of a shoot of the wild tecoma bush (T. Australis),
which carries a long-bladed head of hard mulga wood. The junction
is made between the two pieces by cutting them both on a slope,
sticking these surfaces together with hot resin, and securely binding
them with kangaroo tendon. The bottom end is similarly bound and a
small hole made in its base to receive the point of the spear-thrower
(m).
As often as not the blade has a single barb of wood bound tightly
against it with tendon.
It is often difficult to find a single piece of tecoma long enough to
make a suitable shaft, in which case two pieces are taken and neatly
joined somewhere within the lower, and thinner, half with tendon.
The shoots, when cut, are always stripped of their bark and
straightened in the fire, the surfaces being subsequently trimmed by
scraping.
A very common type of spear, especially on the Daly River, and
practically all along the coast of the Northern Territory, is one with a
long reed-shaft, to which is attached, by means of a mass of wax or
gum, a stone-head, consisting of either quartzite or slate, or latterly
also of glass. The bottom end is strengthened, to receive the point of
the thrower, by winding around it some vegetable fibre (n).
 The natives of Arnhem Land now and then replace the stone by a
short piece of hard wood of lanceolate shape.
If now we consider the only remaining type—a light reed-shaft, to
which is affixed a long head of hard wood, with a number of barbs
cut on one or more edges—we find a great variety of designs. The
difference lies principally in the number and size of the barbs; in
most cases they point backwards, but it is by no means rare to find a
certain number of them pointing the opposite way or standing out at
right angles to the length of the head. These spears belong
principally to the northern tribes of the Northern Territory.
The commonest form is a spear having its head carved into a
number of barbs along one side only, and all pointing backwards (o).
The number ranges from three to over two dozen, the individual
barbs being either short and straight or long and curved, with the
exception of the lowest, which in many examples sticks out at right
angles just above the point of insertion. The point is always long and
tapering. These spears are common to the Larrekiya, Wogait, Wulna,
and all Daly River tribes.
 PLATE XXV

1. Dieri grave, Lake Eyre district.

2. Yantowannta grave, Innamincka district.

 The same pattern of barbs may be found carved symmetrically on
the side diametrically opposite, or, indeed, it may be cut in three
planes.
An elegant, but rare, type is found among the weapons of the
Ponga Ponga, Mulluk Mulluk, and Wogait tribes on the Daly River. Its
hard-wood head is long and uniformly tapering from its point of
insertion to its sharp tip. On one side there are very many small
barbs, diminishing in size from the shaft upwards; as many as one
hundred barbs have been counted; they point either slightly
backwards or at right angles to the length (p).
A spear in use on the Alligator River, and in the districts south and
west therefrom, has the barbs along the edge of the anterior moiety
directed backwards, whereas those of the posterior portion point
forwards. And occasionally one finds the barbs arranged
asymmetrically on two sides of the spear-head.
Finally, a rather remarkable type will be referred to, which belongs
to the Arnhem Land tribes, or rather to the country extending from
Port Essington to the Roper River, including Groote Island and
smaller groups lying off the coast. It is a neat and comparatively
small spear, about eight feet long on an average. The head, instead
of possessing a number of barbs, has a series of eye-shaped holes
cut along one of its sides, which give the impression of being so
many unfinished barbs, or so many barbs with their points joined
together (q). The major axes of the holes are parallel and directed
backwards; there may be up to thirty holes present. Occasionally
there are a few real barbs cut near the shaft end of the head; or a
number of incomplete barbs may there be cut with their axes turned
towards the front of the spear. The point is always sharp and stands
back somewhat from the level of the uncut barbs.
For special purposes, like fishing, two or three of the simple-
barbed prongs are frequently affixed to a reed shaft with beeswax or
resin, and vegetable fibre. This combination is met with all along the
coast of the Northern Territory. The natives know very well that the
chances of stabbing a fish with a trident of this description are much
greater than with a single prong. As a matter of fact, a barbed spear
with less than two prongs is not normally used for fishing purposes,
yet a plain, single-pronged spear is often utilized when there is none
of the other kind available.
The Australian aboriginals do not poison their spears in the
ordinary sense of the word, but the Ponga Ponga and Wogait tribes
residing on the Daly River employ the vertebræ of large fish, like the
barramundi, which have previously been inserted into decaying
flesh, usually the putrid carcase of a kangaroo, with the object of
making the weapon more deadly. The bones are tied to the head of a
fighting spear. This is not a general practice, however, and the spear
never leaves the hands of the owner. The natives maintain that by so
doing they can kill their enemy “quick fella.”
 CHAPTER XXII
SPEAR-THROWERS

Principle of construction—How held—Some of the common types described—

Other uses.

To assist in the projection of a spear, the aboriginal has invented a

simple apparatus, which is commonly referred to as a spear-thrower
or wommera. In principle it is just a straight piece of wood with a haft
at one end and a small hook at the other. In practice the hand seizes
the haft, the hook is inserted into the small pit at the bottom of the
spear, and the shaft is laid along the thrower and held there with two
of the fingers of the hand, which is clasping the haft. In this position,
the arm is placed well back, the point of the spear steadied or made
to vibrate, and, when the native has taken careful aim, the arm is
forcibly shot forwards. The missile flies through space, towards its
target, but the thrower is retained by the hand.
One of the simplest types was made by the tribes living along the
shores of the Great Australian Bight. It consists of a flat piece of
wood, about three feet long, roughly fluted lengthwise and slightly
sloped off at either extremity. At one end a mass of resin forms a
handle, in which, moreover, a quartzite or flint scraper is embedded.
At the other end a wooden peg is affixed with resin against the flat
surface of the stick. Both surfaces of the implement are flat or slightly
convex; at Esperance Bay they are rather nicely polished, the wood
selected being a dark-coloured acacia. Towards the east, however,
as for instance at Streaky Bay, the inner side, i.e. the one bearing
the hook or peg, becomes concave and the outer side convex. On
Eyre Peninsula, the old Parnkalla tribe made the spear-thrower
shorter but wider, and its section was distinctly concave.
Northwards, through the territories of the Kukata, Arrabonna,
Wongapitcha, Aluridja, Arunndta, and Cooper Creek tribes, the
shape becomes leaf-shaped and generally of concave section, with
a well-shaped haft and broad flint scraper; the peg is attached with
resin and sinew. Within this same area, another type is less
frequently met with, which is of similar shape, but flat; it is really used
more for show purposes, and for that reason is usually decorated
with engraved circles and lines, which during some of the
ceremonies are further embellished with ochre and coloured down.
The last-named is the prevalent type, which extends westwards as
an elongate form through the Murchison district right through to the
Warburton River, where it is again broader. In both the areas
mentioned, the inner surface of the spear-thrower is deeply incised
with series of parallel, angular bands made up of transverse notches.
In the south of Western Australia, the shape remains the same, but
the incised ornamentation disappears.
Yet another variety comes from the old Narrinyerri tribe and from
the lower reaches of the River Murray, where it was known as
“taralje.” It is a small, flat, spatulate form, elongated at both ends, the
lower (and longer) prolongation making the handle, the upper
carrying a point of bone or tooth deeply embedded in resin. The
inner side, against which the spear is laid, is flat, the outer surface
being convex. The handle is circular in section and is rounded off at
the bottom to a blunt point. The convex side is occasionally
decorated with a number of pinholes, arranged in a rudely
symmetrical pattern.
All through the northern districts of the Northern Territory and the
Northern Kimberleys, the principal type is a long light-wood blade,
tapering slightly from the handle end to the point and having
comparatively flat or slightly convex sides. A handle is shaped by
rounding off the ends and cutting away some of the wood
symmetrically on each side, a few inches down. A clumsy-looking
peg is attached to one of the flat surfaces at the opposite, narrower
end with beeswax. The peg is made big on account of the instrument
being exclusively used to propel the reed-spears, which are naturally
hollow, and consequently have a large opening or pit at the bottom
end. This type of thrower is nearly always decorated in an elaborate
way with ochre. When used, the thrower and spear are held by the
right hand in such a way that the shaft of the latter passes, and is
held, between the thumb and index finger, the remaining fingers
holding the handle of the thrower. Vide Plate XIV, 2.
A spear-thrower used exclusively for projecting the small variety of
reed-spear is known to the Larrekiya, Wogait, Wordaman, Berringin,
and a few other coastal tribes of the Northern Territory. It consists of
a rod of hard wood, four feet or so in length, tapering a little towards
either end. A lump of resin is attached to one end, and, whilst warm
and plastic, is moulded into a blunt point, which fits into the hole at
the bottom of the spear. At about five inches from the opposite end,
a rim of resin is fixed, and from it a layer, decreasing in thickness, is
plastered around the stick to near the extremity. When using this
thrower, the hand is placed above the resin-rim, and the shaft of the
spear is held by the thumb against the top of the middle finger,
without the aid of the index finger. In addition to this, its principal
function, the thrower is often used for making fire, the native twirling
its lower point against another piece of wood.
A variety of the above type is found in the Gulf of Carpentaria
country, on the MacArthur River, which has a tassel of human hair-
string tied with vegetable fibre immediately below the rim of resin
around the handle.
One of the most remarkable of all spear-throwers is made by the
Larrekiya, and other Northern Territory tribes, consisting of a long,
leaf-shaped, and very thin, flexible blade, flat on one side and slightly
convex on the other. The peg is pear-shaped, and is fixed with
vegetable string and beeswax. The handle is thick and cone-shaped,
and covered with a thin layer of resin or wax. It is ornamented with
rows of small pits, which are pricked into the mass while warm with
the point of a fish bone or sharpened stick. The instrument is so thin
and fragile that only experienced men dare handle it. At times the
blade is curved like a sabre.
In addition to serving as a projecting apparatus, most of the hard-
wood spear-throwers with sharp edges are used for producing fire by
the rubbing or sawing process; those of concave section also take
the place of a small cooleman, in which ochre, down, blood, and
other materials are stored during the “making up” period of a
ceremony.
Any of the flat types of spear-thrower may be used for making fire
by the “sawing process.” The edge of the implement is rubbed briskly
across a split piece of soft wood until the red-hot powder produced
by the friction kindles some dry grass which was previously packed
into the cleft. The spark is then fanned into a flame, as previously
referred to (page 111).
 CHAPTER XXIII
BURIAL AND MOURNING CUSTOMS

Customs depend upon a variety of circumstances—Child burial—Cremation

disavowed—Interment—Graves differently marked—Carved tomb-posts of
Melville Islanders—Sepulchral sign-posts of Larrekiya—Platform burial—
Mummification of corpse—Skeleton eventually buried—Identification of
supposed murderer—Pathetic scenes in camp—Self-inflicted mutilations—
Weird elegies—Name of deceased never mentioned—Hut of deceased
destroyed—Widowhood’s tribulation—Pipe-clay masks and skull-caps—
Mutilations—Second Husbands—Collecting and concealing the dead man’s
bones—Treatment of skull—Final mourning ceremony.

The burial and mourning ceremonies, if any, attendant upon the

death of a person, depend largely upon the tribe, the age, and the
social standing or status of the individual concerned. Old people who
have become “silly” (i.e. childish), and who in consequence do not
take an active part in any of the tribal functions or ceremonies, are
never honoured with a big funeral, but are quietly buried in the
ground. The reason for this is that the natives believe that the
greater share of any personal charms and talents possessed by the
senile frame have already migrated to the eternal home of the spirit.
As a matter of fact, the old person’s spirit has itself partly quitted the
body and whiles for the most time in the great beyond. For precisely
the same reason, it often happens that a tribe, when undergoing
hardship and privation brought about by drought, necessitating
perhaps long marches under the most trying conditions, knocks an
old and decrepit person on the head, just as an act of charity in order
to spare the lingering soul the tortures, which can be more readily
borne by the younger members. These ideas exist all over Australia.
When infants die, they are kept or carried around by the mothers,
individual or tribal, for a while in a food-carrier, and then buried
without any demonstration. The extinct Adelaide tribes required of
the women to carry their dead children about with them on their
backs until the bodies were shrivelled up and mummified. The
women alone attended to the burial of the child when eventually it
was assigned to a tree or the ground.
But at the demise of a person in the prime of his or her life, and of
one who has been a recognized power in life, the case is vastly
different. Both before and after the “burial” of the corpus, a lengthy
ceremony is performed, during which all sorts of painful mutilations
are inflicted amongst the bereaved relatives, amidst the
accompaniment of weird chants and horribly uncanny wails. Before
proceeding with the discussion of the attendant ceremonies,
however, we shall give an outline of the different methods adopted in
Australia for the disposal of the dead.
Cremation is nowhere practised for the simple reason that the
destruction of the bony skeleton would debar the spirit from re-
entering a terrestrial existence.
The spirit is regarded as the indestructible, or really immortal,
quantity of a man’s existence; and it is intimately associated with the
skeleton. The natives tender, as an analogy, the big larva of the
Cossus or “witchedy,” which lies buried in the bark of a gum tree. As
a result of its ordinary metamorphosis, the moth appears and flies
away, leaving the empty shell or, as the natives call it, the “skeleton”
of the “dead” grub behind. It is a common belief on the north coast
that the spirit of a dead person returns from the sky by means of a
shooting star, and when it reaches the earth, it immediately looks
around for its old skeleton. For this reason the relatives of a dead
man carefully preserve the skeletal remains, carry them around for a
while, and finally store them in a cave.
 PLATE XXVI

1. Aluridja widow.

2. Yantowannta widow.

Stillborn children are usually burnt in a blazing fire since they are
regarded as being possessed of the evil spirit, which was the cause
of the death.
The simplest method universally adopted, either alone or in
conjunction with other procedures, is interment.
Most of the central tribes, like the Dieri, Aluridja, Yantowannta,
Ngameni, Wongapitcha, Kukata, and others, bury their dead, whilst
the northern and southern tribes place the corpse upon a platform,
which they construct upon the boughs of a tree or upon a special set
of upright poles. The Ilyauarra formerly used to practise tree-burial,
but nowadays interment is generally in vogue.
 A large, oblong hole, from two to five feet deep, is dug in the
ground to receive the body, which has previously been wrapped in
sheets of bark, skins, or nowadays blankets. Two or three men jump
into the hole and take the corpse out of the hands of other men, who
are kneeling at the edge of the grave, and carefully lower it in a
horizontal position to the bottom of the excavation. The body is made
to lie upon the back, and the head is turned to face the camp last
occupied by the deceased, or in the direction of the supposed
invisible abode of the spirit, which occupied the mortal frame about
to be consigned to the earth. The Arunndta quite occasionally place
the body in a natural sitting position. The Larrekiya, when burying an
aged person, place the body in a recumbent position, usually lying
on its right side, with the legs tucked up against the trunk and the
head reposing upon the hands, the position reminding one of that of
a fœtus in utero.
The body is covered with layers of grass, small sticks, and sheets
of bark, when the earth is scraped back into the hole. But very often
a small passage is left open at the side of the grave, by means of
which the spirit may leave or return to the human shell (i.e. the
skeleton) whenever it wishes.
The place of sepulture is marked in a variety of ways. In many
cases only a low mound is erected over the spot, which in course of
time is washed away and finally leaves a shallow depression.
The early south-eastern (Victorian) and certain central tribes place
the personal belongings, such as spear and spear-thrower in the
case of a man, and yam-stick and cooleman in the case of a woman,
upon the mound, much after the fashion of a modern tombstone. The
now fast-vanishing people of the Flinders Ranges clear a space
around the mound, and construct a shelter of stones and brushwood
at the head end. They cover the corpse with a layer of foliage and
branches, over which they place a number of slabs of slate. Finally a
mound is erected over the site.
The Adelaide and Encounter Bay tribes built wurleys or brushwood
shelters over the mound to serve the spirit of the dead native as a
resting place.
 In the Mulluk Mulluk, when a man dies outside his own country, he
is buried immediately. A circular space of ground is cleared, in the
centre of which the grave is dug. After interment, the earth is thrown
back into the hole and a mound raised, which is covered with sheets
of paper-bark. The bark is kept in place by three or four flexible
wands, stuck into the ground at their ends, but closely against the
mound, transversely to its length. A number of flat stones are laid
along the border of the grave and one or two upon the mound.
In the Northern Kimberleys of Western Australia, when an
unauthorized trespasser is killed by the local tribes, the body is
placed into a cavity scooped out of an anthill, and covered up. In a
few hours, the termites rebuild the defective portion of the hill, and
the presence of a corpse is not suspected by an avenging party,
even though it be close on the heels of the murderers.
The Dieri, in the Lake Eyre district of central Australia, dispense
with the mound, but in its place they lay a number of heavy saplings
longitudinally across the grave. Their eastern neighbours, the
Yantowannta, expand this method by piling up an exceptionally large
mound, which they cover with a stout meshwork of stakes, branches,
and brushwood lying closely against the earth (Plate XXV, 1 and 2).
One of the most elaborate methods is that in vogue on Melville
and Bathurst Islands. The ground immediately encompassing the
grave is cleared, for a radius of half a chain or more, and quantities
of clean soil thrown upon it to elevate the space as a whole. The
surface is then sprinkled with ashes and shell debris. The mound
stands in the centre of this space, and is surrounded by a number of
artistically decorated posts of hard and heavy wood, or occasionally
of a lighter fibrous variety resembling that of a palm. Each of the
posts bears a distinctive design drawn in ochre upon it; several of
the series in addition have the top end carved into simple or
complicated knobs; occasionally a square hole is cut right through
the post, about a foot from the top, leaving only a small, vertical strip
of wood at each side to support the knob (Fig. 14). The designs are
drawn in red, yellow, white, and black, and represent human, animal,
emblematical, and nondescript forms.
 The Larrekiya erect a sort of sign-post, at some distance from the
grave, consisting of an upright pole, to the top of which a bundle of
grass is fixed. A cross-piece is tied beneath the grass, which projects
unequally at the sides and carries an additional bundle at each
extremity. The structure resembles a scarecrow with outstretched
arms, the longer of which has a small rod inserted into the bundle of
grass to indicate the direction of the grave. Suspended from the
other arm, a few feathers or light pieces of bark are allowed to sway
in the wind and thus serve to attract the attention of any passers-by.
When the body is to be placed upon a platform, it is carried, at the
conclusion of the preliminary mourning ceremonies, shoulder high by
the bereaved relatives to the place previously prepared for the
reception of the corpse. A couple of the men climb upon the platform
and take charge of the body, which is handed to them by those
remaining below. They carefully place it in position, and lay a few
branches over it, after which they again descend to join the
mourners. The platform is constructed of boughs and bark, which are
spread between the forks of a tree or upon specially erected pillars
of wood.
The Adelaide tribe used to tie the bodies of the dead into a sitting
position, with the legs and arms drawn up closely against the chest,
and in that position kept them in the scorching sun until the tissues
were thoroughly dried around the skeleton; then the mummy was
placed in the branches of a tree, usually a casuarina or a ti-tree.
Along the reaches of the River Murray near its mouth, the
mummification of the corpse was accelerated by placing it upon a
platform and smoking it from a big fire, which was kept burning
underneath; all orifices in the body were previously closed up. When
the epidermis peeled off, the whole surface of the corpse was thickly
bedaubed with a mixture of red ochre and grease, which had the
consistency of an ordinary oil-paint. A similar mummification process
is adopted by certain of the coastal tribes of north-eastern
Queensland.
The Larrekiya, Wogait, and other northern tribes smear red ochre
all over the surface of the corpse, prior to placing it aloft, in much the
same manner as they do when going to battle. The mourners,