Politicians want to improve our worsening mental health with big psychiatric initiatives. The problem with this model, says historian of neuroscience Danielle Carr, is that it ignores the social and structural forces causing widespread mental suffering.
The biological body transforms in relation to an environment that far exceeds the medical interventions possible in a clinic. (zodebala / Getty Images)
It’s common for American politicians in the twenty-first century to speak gravely of an ongoing “mental health crisis,” which they are increasingly compelled to address through policy. The Bush administration explored technocratic solutions such as the Texas Medication Algorithm Project, designed to develop consistent guidelines for pharmaceutical interventions in treating mental illness. The Obama administration announced the BRAIN Initiative, a $110 million dollar project “to help researchers uncover the mysteries of brain disorders . . . like depression.” Both the Trump and Biden administrations’ efforts have been similar, focusing on countering the widespread mental anguish in our society primarily through the expansion of psychiatric interventions.
In a New York Times op-ed titled “Mental Health Is Political,” anthropologist and historian of neuroscience Danielle Carr asked, “What if the cure for our current mental health crisis is not more mental health care?” Carr argued that the conversation about mental illness frequently elides and displaces politics, ignoring the collective social and economic decisions that give rise to mental phenomena like anxiety, paranoia, and depression. Often the prevailing mental health discourse “puts the focus on the individual as a biological body,” writes Carr, “at the expense of factoring in systemic and infrastructural conditions.”
There’s no doubt that our collective mental health is suffering, and that the matter demands significant attention and robust policy solutions. But when political leaders undertake big policy initiatives designed strictly to increase targeted psychiatric provision, Carr suggested, they are also in a sense letting themselves off the hook for building a less crazy-making world.
Carr calls herself a “critic of psychiatry, in the sense that a literary critic writes in the service of a better possible literature.” Currently a professor at the University of California Los Angeles, she holds a PhD in anthropology from Columbia University, where she researched the history of twentieth-century brain science. Through her work, Carr identifies the pitfalls of status-quo neuroscience and psychiatry while urging us to imagine new ways of addressing mental illness and unease.
Carr sat down with psychotherapist and Jacobin contributor Chandler Dandridge to discuss psychiatry’s efforts to solve social problems, what a left vision of mental health treatment must entail, and why bipartisan politics offers no cure.
Your work calls into question some of the dominant assumptions about mental health, especially as it concerns the primacy of the biological in treating mental illness. As a leftist clinician, I’m especially interested in situating the social components connected to one’s condition properly alongside both the biological and psychological. Could you talk a bit about what liberal psychiatry and “mental health care” misses by focusing so much on the biological?
I think that concerns around mental health, which really are proxies for concerns about suffering, are integral to what we are doing as revolutionary-minded people trying to build a more just society. What’s united a lot of my thinking at a global level is the instinct that a left project cannot just import a conceptual vocabulary from liberals — and as a field, psychiatry is largely defined by a liberal conceptual vocabulary. It’s baked into the conceptual DNA of the field. So my work generally wants to push us to develop a different set of concepts for thinking about the question of suffering, psychiatric illness, affect and so on.
Concerns around mental health, which really are proxies for concerns about suffering, are integral to what we are doing as revolutionary-minded people trying to build a more just society.
Working from the biopsychosocial model is one way into thinking about how we can take a dialectical materialist approach to questions of “mental health.” But doing that is going to require problematizing some of the epistemological constructs that are at the heart of liberal psychiatry. What I mean by this is that positing disease categories is not a value-neutral act. There is no diagnosis from the “purely biological” vantage, especially in psychiatry. The most obvious example of this principle might be something like “drapetomania,” which was a psychiatric concept developed in the slave owning American South to describe the “mental illness” that escaped slaves suffer from. You look at that now, and the politics of epistemology there could not be more clear. The thing is, a psychiatric disease category is not just a name for a thing that really exists in the world. Built into that category are all kinds of ideas about causality — what kind of a thing “it” is, what’s causing this thing, and therefore what can be done to fix it.
Specifically to your question: the modern psychiatric diagnostic system is the Diagnostic and Statistical Manual (DSM), which really came to hegemony in the field in 1980. There was a big fight in 1980 around what categories would be included — for instance, would homosexuality continue to be seen as a psychiatric disease entity? — that resulted in some of the current blockbuster diagnoses like major depression, generalized anxiety disorder, and so on. The field’s adoption of the DSM system has shaped how you diagnose someone with a psychiatric disease. The way that you diagnose something like depression or anxiety is that you have a checklist of a particular number of symptoms. And if you meet a minimum number of those symptoms, then you get X diagnosis.
The thing is, there’s no guarantee that any one person’s depression is going to look even behaviorally like another person’s, let alone neurologically. There are just too many ways you can hit the magic number in the checklist. Where one person might be eating a lot, another might be eating quite a bit less than usual. Where one person might be sleeping more than normal, another person will be sleeping less. This is not even getting into the question of comorbidity — and psychiatric disease entities are overwhelmingly comorbid. What this means is that at a neurological level, there is no guarantee that one person’s depression is going to neurologically or biologically be the same type of thing as another person’s. And this is not just me, Danielle, the critic of psychiatry saying this. This is what you will hear from any practitioner in the field who is keeping up with cutting-edge debates around this. There is a growing recognition that these disease entities are not necessarily biological entities. They’re conceptual entities.
Yet most mental health care is still fundamentally based in the clinic. Is this where mental health care belongs?
I want to say one thing first. The worst possible reading of my work would be to think that I am saying that psychological distress and psychiatric illness are not “real,” or that we should just run the deinstitutionalization experiment again, into the same kind of debacle. The Left should concern itself with the question of human suffering, which includes psychiatric suffering. However, when we talk about what kind of a thing is going to work to address population-level rises in suffering (which are being apprehended as psychiatric suffering), we have to think pretty seriously about what kind of a thing it is that we’re dealing with, and therefore what causes it, and what could fix it.
The Left should concern itself with the question of human suffering, which includes psychiatric suffering.
Let’s take, for instance, Los Angeles County. There’s been some noise here about reinstituting different types of legal mechanisms that let you involuntarily institutionalize people for long periods of time. These kinds of questions about the state, incarceration, and care are back on the table, and we need to be ready for them. I was reading a report from a Massachusetts state commission in 1984, which was set up to track the effects of deinstitutionalization, and what the report basically says is, “This has been a debacle.” First, a surprisingly high percentage of the patients had just straight up died in accidents like house fires, because they couldn’t take care of themselves. But what’s interesting is that a lot of the former patients they were able to find were either in and out of jail or the prison system, which is not equipped to provide psychiatric service, or bouncing around from shelter to flophouse to group home to the street. And many of the former long-term patients thought their situation was better in long-term institutions. What I’m saying here, as the first part of an answer to your question, is that we can’t ignore the fact that in a capitalist, alienated society, there are many people who simply will need long-term institutional care. I think that we should think about what that might look like, and what historical lessons we can take to make sure that that care is not, ah, fucked up.
However, when it comes to your question whether mental health care belongs in the clinic, let’s look at the way the clinic frames things. The clinic functions because you appear with a symptom, and the clinic then apprehends you as a body that has a medical problem. That’s what it was built to do, as an institution. And so the clinic looks at the symptoms, and as far as clinicians are concerned, the history of that symptom is more or less the history of one person’s body. What the clinic means by “history” is “there’s something wrong with your body, let’s take a quick history, and then let’s address this disease condition that is in your body.” That is quite clearly an insufficient imaginary to grasp population-level increases in things like suicide, depression, and despair.
You cannot disaggregate the question of mental health and try to turn it into something that’s only addressed in a clinic.
The point is that you cannot disaggregate the question of mental health and try to turn it into something that’s only addressed in a clinic and have that work at all. But I don’t think the answers are so mysterious, really: changes in infrastructure at the level of transportation, at the level of food security, at the level of the types of food that are available, at the level of education and housing, basic social policy stuff.
Psychiatry often presents itself as a field capable of solving social problems. How did this come to be?
One way into answering this question is to think about how disciplines are formed. Over the twentieth century American psychiatrists have to make all kinds of arguments about why states or capitalist foundations should invest in the things that a new discipline needs, like research facilities and university departments. Because psychiatry is always having to make the case for that kind of support, of course it has every incentive as a discipline to say, “Yes, you can solve social problems through psychiatry.” There’s certainly a place for psychiatry in any kind of left envisioning of what social services and medical services should look like. However, the problem is that psychiatry cannot fix social problems at large, population-level structural scales. It just can’t. It’s not the kind of thing that it’s good for. And so when we think about the role of psychiatry, I think there needs to be some limits on the ambit of psychiatrists’ claims. And those are the same kind of limits that I think we should begin thinking about for all kinds of essentially technocratic or technoscientific forms of knowledge, which are really good at solving the kind of problems that you might see under a microscope, but are not good at solving broad population-level questions about what kind of world we want to build.
You recently wrote a really sharp profile of Bessel van der Kolk, whom you describe as “the world’s most famous psychiatrist,” and the popularization of trauma science. In it you coin the term “traumatic literalism.” What do you mean by that phrase?
I mean the idea that trauma is literally a state of the body that can be mapped, through processes like fMRI or PET scanning, or all the variety of different brain imaging, or increasingly through the development of biomarkers. A biomarker operates by saying, “Here’s a state of the body that stands as an index of some disease entity.” In other words, the biomarker says, “This is what the disease really is.” A nonpsychiatric biomarker might be a particular gene that codes for a high risk of breast cancer. This works really well for things like breast cancer, where you have it or you don’t. It doesn’t work so well for things like trauma, which is a concept that is made out of history and politics.
My concern about this kind of traumatic literalism is that it operates according to the logic of the fetish. If you think about how Marx talks about the commodity fetish, a fetish works by erasing the conditions of its production. A fetish says, “This is that; this wheat is worth $10,” or “This money is value.” The commodity appears to us as this thing that seems to have an inherent value, but only because it has had its history, the social relations of labor and domination that created it, erased.
I think that there is a logic of the fetish that is at work in this traumatic literalism, whereby the trauma of an Israel Defense Forces soldier or an American soldier who participates in a massacre is seen as the same kind of thing as the trauma of a chronically abused child in the foster care system. I’m not trying to make a point here about which one is good and which one is bad — the point is that they’re seen as the same kind of thing.
In the piece you mention a moment in an interview where you had a disagreement with Van der Kolk over his insistence that “a nationwide program of early-childhood-attachment intervention could end mass incarceration.” What is your issue with this claim?
The problem with this claim is emblematic of the kind of conceptual mistake we make when we think that psychiatric expertise can, itself, fix social problems. It’s not that I think that early-attachment intervention is a bad idea, or even that it’s not the sort of thing that the state should fund. But the idea that mass incarceration is the result of children undergoing trauma that has biological ramifications — that is, that it causes some kind of defect in their bodies — that somehow causally determines they will commit crimes? This is essentially racist thinking. It backfills the story of mass incarceration as caused by biologically determined crime, rather than a political strategy by the ruling class to break racialized class struggle. I mean, it’s garbed itself in a kind of woke neo-Lamarckism, but it is quintessentially racist thinking. It rearticulates exactly the same sort of evo-biological racism that’s behind books like E. O. Wilson’s Sociobiology in 1975. This is the context in which, the next year, Foucault gives the Society Must Be Defended lectures, in which he argues that the core of race thinking is this idea that you can straightforwardly deduce political behavior from a state of the body.
You mentioned that trauma is a concept made out of history and politics. Throughout the twenty-first century we have seen a shift in this history and politics. I am wondering if you can talk about the way trauma was seen in 2003 versus 2023?
I would say that when it comes to the vicissitudes of the trauma concept from the War on Terror to, let’s say, #MeToo, something interesting happens. The large bolus of funding and the scientific cottage industry around the biology of trauma that sprang up during the war on terror installed a scientific apparatus, and a sort of common sense, that trauma has a biological reality that can be intervened in. And what this means is that there is a sort of racialization (in Foucault’s sense) of trauma. Now, normally what people mean by that is something like, “the fact that, on balance, black Americans suffer more traumatic experiences than white Americans,” which is certainly true. But what I mean is that this fastening of the trauma concept to a bodily state produces trauma as a form of racialization, even as the rise of things like genetic sequencing is contributing to a reversion to biologically essentialist ideas about race. It’s the idea that behind political behavior stands the real story: biology.
There’s certainly a place for psychiatry in any kind of left envisioning of what social services and medical services should look like. However, the problem is that psychiatry cannot fix social problems at large.
This is what I’m getting at when I say that I don’t think that it is an accident that Van der Kolk’s The Body Keeps the Score really takes off at the intersection of COVID — which is a broad politicization of biology in a way that we haven’t seen in American culture for quite some time — and the George Floyd uprisings. One of the ironies of the George Floyd moment was that, as part of their reactionary kneecapping of the moment, liberals doubled down on race as being the kind of thing you can figure out through getting a 23andMe. So in this sense, it makes sense that this is about the moment that middlebrow America becomes convinced that the way to understand a peaking social crisis is to say that people have a political problem in their bodies — that is, trauma.
Do you mark that at June 2020? Rather than, say, the Kavanaugh confirmation hearings? Or the Women’s March? Or even just Trump?
These things are all in the works, right? They are all different ways of fastening one’s political project to the epistemology and politics of the body. But take, for instance, during the Kavanaugh trial: remember Christine Blasey Ford’s line “indelible in the hippocampus”? What is that if not traumatic literalism? And the point of traumatic literalism is to say: This claim cannot be contested. This trauma, this experience has left some sort of literal and indelible mark on the body. And this is going to be the basis for our political claim. Now, I don’t think that that’s wrong or not wrong. But as someone who’s interested in historical epistemology, I think it’s interesting.
I thought this over and over during the Trump years, that the potential upside might be that the center would be radicalized. In hindsight, this was true, except so often they got radicalized into being even more centrist. So something like the Women’s March did radicalize people, but it just as often radicalized them into doubling down on centrist categories like a conceptualization of woman as a political category stripped of race, class, or different types of things that purport to be captured by a language of intersectionality that can be more or less radical.
I mean, is the legacy of George Floyd really going to be just completely cynical HR seminars? One of the most horrifying things about the past month of wanton destruction in Gaza, backed by a wall-to-wall alliance of the institutions of US civil society, is that it’s clear liberals totally failed to abstract any generalizable principles about race and oppression from the George Floyd moment. In fact, in the end, it just made them more racist — more doubled down on a kind of racial essentialism, and thus more vulnerable to getting hacked by the cynical deployment of identity discourse Israel is using now. And now it’s exactly the same kind of people who, during George Floyd, would insist that militant action during protests was “problematic” because it was allegedly caused by “white anarchists” co-opting “black protest” (it wasn’t) that look at a fascist ethnostate openly conducting a genocide and find themselves unable to apply a single lesson from 2020 other than “There are certain things you’re no longer allowed to say about black people.”
It sounds like you are saying that the Democratic Party will not save us?
The Democratic Party and its politicians, inclusively, are not going to save us. And they have no incentive to behave differently than they have been behaving without a real threat that we won’t line up and vote for them again. Particularly given what’s going on in Gaza right now, and the total indifference of the entire establishment to it — we need to have a renewed conversation on the Left about what voting strategy looks like right now.
It is almost perverse to find a silver lining to the level of death and violence that is being meted out, funded by US tax dollars, and overseen by the international community. However, I have never seen this level of public outcry against what has been an ongoing human catastrophe, an artificially constructed human catastrophe for Palestinians. The naked violence that the Israeli state is wreaking, with absolutely no regard for things like international law, is highlighting that in some ways power is weakest when it shows its hand in violence. The American public is seeing it in a way that is not totally muzzled by the lies of different state mouthpieces like the New York Times. It is my hope that the suspicion that is cast on the apparatuses of the American state by this can be generalized.
“Mental health” has never been more popular. Your Van der Kolk piece headlined trauma as “America’s favorite diagnosis.” Could you talk about this moment we are in and its opportunities for building our movement.
I think that our job is to provide alternate conceptual vocabularies that posit different forms of causality, and different forms of intervention or different imaginaries of the types of collectivity that could heal, that could recalibrate someone’s biology. We need to move into the opening that is presented by the rise of mental health or trauma talk in relation to the ongoing and worsening catastrophe of the present.
We need to move into the opening that is presented by the rise of mental health or trauma talk in relation to the ongoing and worsening catastrophe of the present.
We are in a moment now in which many of the criticisms of psychiatry that were characteristic of the late ’60s and early ’70s are being recapitulated. I think we can look back at the antipsychiatry movement and say that, while there were gains here and there — especially around the destigmatization of homosexuality, or installing different forms of patient protections in psychiatric treatment — ultimately the gains that were made were overtaken, co-opted, and folded into the consumerization of American medicine. This is the legacy that it falls to us to inherit, to deal with, and to contest.
The antipsychiatry movement’s biggest failure was that it took the biological to be the opposite of the political, rather than a site where politics happens. Where it did its best work was in imagining different institutions of care that were not necessarily divorced from different projects of the welfare state. But the problem was that the Left had not built enough power to ensure that those alternate modes actually came into being. Long-term care facilities were dismantled in the name of establishing community mental health clinics — and they did this first part, but then the community mental health clinics never quite got around to being funded.
When we look into the future, and when we think about what a left project for resuscitating a robust critique of psychiatry would be, I think that the lesson that we have to take is that a dialectical materialist approach is an approach that takes biology seriously, but understands that the biological body transforms in relation to an environment that far exceeds the medical interventions possible in a clinic.Original post