Radical PsychologyWinter 2005
Mental Health Care After Capitalism
Note: An edited version of this article also appears at ZMag.
The only way to protect and promote the health of a nation is to redistribute the wealth and power among its people.
-- Salvador Allende Grossens, MD, Former President of Chile
Mental Health Care under Advanced Capitalism
Health care is in profound crisis in the United States. In the
wealthiest country in the world, over 40 million people lack basic
health insurance coverage. Even for many who have insurance, adequate
mental health services are insufficient. Public health care for the
poor and indigent is chronically under-funded and the private health
care industry, in cooperation with powerful insurance interests,
actively works to block all efforts at progressive health care reform.
Nonetheless, in the United States, as in many other countries, the
struggle for comprehensive health care as a fundamental right continues
to be waged on many fronts.
To fight this system we first have to understand it. The work of Michel Foucault showed us how modern societies, and the people who live in them, are constituted by and through institutions, practices and ideologies of power. Foucault insisted that the behavior of individuals is not merely the expression of their own internal psychic makeups, but also the consequence of the action on them of modern forms of power, and the way that action is internalized through the processes of thought and consciousness.
Foucault's
power analysis is useful for understanding how mental health treatment
under advanced capitalism works. It provides a framework for examining
the three dominant components of social power characteristic of
advanced capitalism and how these factors influence the provision of
mental health services. These three primary components of power are:
1. Economic power
2. Political/institutional power
3. Ideological or discursive power
Economic Power
Under capitalism, mental health systems are driven by market economics and the profit motive. Most decisions about who gets services, what kind of services they get, and their quality and quantity, are determined by access to or control of money and other resources. While the wealthy have unlimited access to the best mental health services available, millions of poor and working class people have little or no access to services of any kind.
Political/Institutional Power
Under capitalism, mental health services are furnished through a vast system of powerful institutions, dominated by a hierarchy of elite experts, administrators and doctors who are overwhelmingly white, male and heterosexual. These institutions are powerful mechanisms for the social control of the population. They use clinics, hospitals, "treatment" and medication to restrain and discipline what they consider to be "deviant" forms of behavior and impose on individuals and communities regimes of social conformity and passivity.
For much of the 20th century in the United States, the seriously mentally ill were confined to state hospitals while those suffering less extreme forms of mental illness received little or no treatment at all. Forty years ago, under a process labeled "deinstitutionalization" many of these state hospitals were closed and their patients were sent back into society at large. However, adequate funds were never allocated to provide services for these individuals, and the treatment they received was limited and inadequate (McCubbin, 1994). Adrift without necessary social support, many of these former patients drifted into alcoholism or drug addition and were unable to successfully integrate into their communities.
In the last
twenty years, the conditions experienced by the seriously mentally ill
in the United States have worsened considerably. Today, many mentally
ill individuals are found living on the street, or in homeless shelters
or prisons. An estimated 6 to 14% of persons incarcerated in prisons
and jails in the U.S. are mentally ill (Human
Rights Watch, 1999). Social control of the seriously mentally ill
has become less a medical issue and more and more a police matter.
Meanwhile, for persons suffering other less serious forms of mental illness in the United States, over the last 40 years psychotropic medications and prescription drugs in general have all too often become the dominant or only form of treatment. While this approach undoubtedly benefits some individuals, the primary beneficiary of this over-reliance on drugs is the powerful pharmaceutical industry and the web of corporate entities that make up the medical industrial complex.
Ideological/Discursive Power
The dominant discourses on mental health and mental illness under capitalism are biological/medical models that treat most forms of mental illness as "pathologies." Ignoring the economic, political and social causes of a number of widespread mental health problems, these discourses "blame the victim" when individuals deviate from the narrow range of accepted behavioral norms. Such discourses reinforce peoples' problems and, once they are internalized, keep them locked into self-subjugating social narratives (Prilleltensky & Gonick, 1996).
The combination of these three forms or faces of power structure capitalist mental health service systems in such a way that they are incapable of providing the kinds of care and treatment that a just and equitable social system requires.
An Alternative Model for the Provision of Mental Health Services
Envisioning
"another world is possible" requires envisioning an alternative model
for the provision of mental health services for all in a post
capitalist social system. Some of the essential elements of such an
alternative model can be described as follows.
The Economics of Post-Capitalist
Mental Health Services
In a post-capitalist society, all health care, including mental health care, would be a basic human right, not a socially limited privilege. Services would be provided to the entire population based on need, not on ability to pay. Mental health care will focus on prevention and the social causes of illness as well as the treatment and care of the ill.
Society as a whole would allocate adequate and appropriate resources to health care, rather than leaving it to the market to determine where and in what amount mental health care services would be provided. Likewise, society would devote sufficient resources to institutions of higher learning for training programs for physicians, psychologists, social workers and other health care professionals. Such programs will emphasize health care delivery as a public service rather than a lucrative private career.
The
Institutional Character of
Post-Capitalist Mental Health Services
In life after capitalism, mental health institutions will no longer be
organized according to the models promoted by the medical-industrial
complex described earlier. No longer will care be dictated by social
control imperatives or corporate profit motives. Instead, the
institutional goal of mental health systems will be to facilitate the
fullest development of the potentials of each and every individual,
consistent with his or her physical and mental capabilities. Rather
than viewing patients as objects to be
manipulated and controlled for the benefit of capital, individuals in
health care systems will be viewed as subjects,
working alongside physicians and other health care workers toward their
individual and collective empowerment.
Geographically, post capitalist mental health services will be
furnished through a decentralized system of full service neighborhood
clinics which will guarantee a continuity of care, and a close
connection between providers and the communities in which they work.
In addition to
institutional and geographical changes, a post-capitalist social system
will inaugurate other transformations in the way that mental health
services are provided. Health care providers themselves -- particularly
physicians -- will no longer be exalted as revered experts, dominating
a hierarchical system that reinforces their privileges and distances
them from the patients with which they work.
Post-capitalist mental health practitioners will be guided by new
principles in their relationships with clients and families. They will
see themselves as helpful allies in a joint project with patients and
families. The North American psychologist William
Madsen has identified the following commitments as key to these new
relationships (1999):
First, approach clients, their families and communities as unique
micro-cultures and learn what they can teach you. Clients' behavior and
action need to be understood through their own lenses.
Second, abandon the approach of identifying pathologies in
favor of one that elicits competencies.
Persons with mental health problems have skills, resilience, and
capacities to grow. Treatment is not possible without recognition and
reliance on these strengths.
Third, work in partnership with clients and families. Clients must be active and invested subjects in their own treatment.
Finally,
engage in empowerment
practice. Empowerment practice involves ways of thinking and
acting that acknowledge, support and amplify people's own participation
and influence in the decisions that affect their lives. Mental health
care providers must make themselves and their work accountable to their
clients.
Discourse/Knowledge in Post-Capitalist Mental Health
If, as
Foucault showed us, knowledge is a form of power, then the development
and application of knowledge in a post capitalist society must be
radically different than it is under capitalism. Today, as noted
earlier, mental health theory and its discourses serve to objectify and
discipline individuals and communities that deviate from accepted
social norms and to pathologize persons with serious forms of mental
illness.
Post-capitalist
mental health theory will have to make a profound break with this
tradition. It must find ways to liberate both practitioners and clients
from the oppressive social control model. It is too early to describe
the full range of alternative approaches that will be available to
mental health workers in a post-capitalist society. Even so, activists
in various countries are already attempting to identify theoretical
constructs that represent a genuine break with the dominant
contemporary discourses. The Australian family therapist Michael White has developed one
approach that I find particularly useful (1990).
White's
theoretical model is an alternative to the way that capitalist mental
health discourses dehumanize people by reducing them to their
illnesses. He notes that these discourses often reinforce the problems
that led people to seek treatment in the first place and keep them
locked in self-subjugating social and personal narratives. His
alternative model assists clients both by enabling them to externalize
their illnesses and by inviting them to participate in the construction
of new and liberating narratives and stories about themselves.
Working
together with clients as helpful allies, practitioners assist them to
externalize and confront their problems by examining their lives in
their full social contexts. This practice, by distinguishing and
separating individuals from their illnesses, enables them to actively
participate in the emergence of new personal narratives, different
versions of their past, present, and future, and new self-images and
ways of living.
This
alternative mental health theory and practice draws inspiration from
the political/educational work of Paulo Freire (1973).
As Freire demonstrated, individuals do not gain critical awareness by
being "empty vessels" to be filled with knowledge or ideas by outside
experts. Instead, they can come to truly understand themselves and
their world and to consciously act in it only through a process of
praxis involving reflection -- action
-- reflection. This method is as applicable in the context of
mental health treatment as it is in popular education. By employing
Freire's techniques of problem posing, and of analyzing problems from a
matrix of personal, cultural and institutional perspectives, mental
health service providers can work with clients to facilitate their
individual and collective empowerment.
How We Can Begin Organizing Now for a
Post-Capitalist Mental Health Alternative
I leave it to my colleagues from around the world to describe what is
happening in their own countries to advance the struggle for
alternatives to capitalist health care models. Here are some of things
we can and are doing in the United States to prepare for life after
capitalism in regard to mental health care. I hope that these
experiences will be of use to activists in other countries.
Mental
health care providers and clients can fight the logic of the current
system in a number of different ways. These include the following:
1. Providers can start by rejecting the wealth of monetary and
institutional privileges associated with being physicians,
psychologists and social workers. They can fight the oppressive
hierarchies characteristic of hospitals, clinics and governmental
health bureaucracies. They can support strong, progressive labor unions
of hospital and clinic workers where they exist and help to organize
them where they do not.
2. Providers can begin to master forms of empowerment practice and
integrate them into their work in order to guarantee that clients and
families involved in mental health system have real power in
determining their course of treatment (see McCubbin and Cohen, 2003). They can
actively participate in community and neighborhood organizations that
embody empowerment practices and are fighting to develop popular forms
of struggle and resistance to capitalist oppression and exploitation.
3. Providers can promote the reform of university and college
programs which train physicians, psychologists and social workers to
ensure that these programs incorporate radical critiques of the
existing system and raise with students the idea of post capitalist
alternatives. As someone who teaches social work in a graduate college,
I am particularly aware of the importance of introducing empowerment
theory and practice into student consciousness about mental illness and
mental health.
4. Given their wealth and social status, doctors and psychologists
wield a great deal of power in capitalist countries. Progressives among
them should be actively participating in organizations and associations
of other physicians, social workers and mental health providers to
insist that these groups intervene in economic and political struggles
for universal health care and the reform of health care systems and
institutions.
5. Recipients of mental health services, their families and
friends constitute a significant community of interest. Given their
knowledge of the workings of mental health systems, and their stake in
their improvement, this community should be encouraged to get involved
in efforts to reform mental health systems, expand access to health
care, and ensure that public programs receive necessary funding and
institutional support.
6. A number of different studies have demonstrated that participation in community organizing and political action is good for people's mental health (Martinez, 2004). It contributes to psychological well being and individual empowerment, and teaches participatory competence, causal importance and self-efficacy that can materially and spiritually enhance participants' lives. For all these reasons, providers should encourage clients to become active in community and political struggles as part of their treatment plans.
In the United
States we have an unfortunate tradition of separating our work and our
politics. Or, more specifically, of treating our work practice as if it
were essentially non-political.
This is, of course, an illusion. All work is political. All mental
health assessments and interventions are political. The job of
progressive health care activists is, first, to recognize the political
nature of everything we do, and secondly, to seek out and practice
those forms of politics that will ensure the best possible health care
system for all people everywhere.
In Brazil, after many years of struggle, the Workers' Party candidate
was elected president in 2002 under the slogan, "Hope over Fear." We
are a long way from electing someone like Lula to be president of the
United States, but this slogan can inspire us in our own efforts to
make sure that "health care for all" becomes a reality. "Another world
is possible!"
References
Freire,
P. (1973). Pedagogy of the oppressed.
New York: Seabury.
Human Rights Watch. World report 1999.
Available: http://www.hrw.org/worldreport99/usa/
Madsen,
W. (1999). Collaborative therapy
with multi-stressed families: From old
problems to new futures. New York: Guilford, 1999.
Martinez,
D. B (2004). Therapy for liberation:
The Paulo Freire methodology.
Unpublished manuscript.
McCubbin,
M. (1994). Deinstitutionalization: The illusion of disillusion. Journal
of Mind and Behavior, 15, 35-53.
McCubbin, M., & Cohen, D. (2003).
Empowering practice in mental health social work: Barriers and
challenges. GRASP Working Papers
Series, 31. Montreal: University of
Montreal (GRASP). Available: http://www.grasp.umontreal.ca/documents/WP-An-31.pdf
Prilleltensky, I., &
Gonick, L. (1996). Polities change, oppression remains: On the
psychology and politics of oppression. Political Psychology, 17,
127-148.
White, M., & Epston, D.
(1990). Narrative means to
therapeutic ends. New York: Norton.
Note about the author: Dawn Belkin Martinez is a clinical social worker and teacher of social work practice at Simmons College School of Social Work. She is also a community activist working on making the connection between imperialist war abroad and the war against the poor here in the United States. Her current research examines political organizing among Latino immigrants as an empowerment practice. Email: dawn.belkin-martinez@simmons.edu