Health Communism — Turn Illness Into A Weapon (Part 2)

Adler-Bolton & Vierkant revive SPK's radical call for solidarity

This is part 2 of my discussion of the book Health Communism: A Surplus Manifesto (Verso, 2022) by Beatrice Adler-Bolton and Artie Vierkant.

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Health Communism — All Care For All People (Part 1)

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“Illness—you point out—is the only possible form of life in capitalism. In fact, the psychiatrist, who is wage dependent, is a sick person like each of us. The ruling classes merely give him the power to “cure” or to hospitalize. Cure—this is self-evident—can’t be understood in our system to mean the elimination of illness: it serves exclusively as the maintenance of the ability to go to work where one stays sick.”

(Turn Illness into a Weapon: A Polemic Call to Action by the Socialist Patients’ Collective of the University of Heidelberg, 1972)

In this post, I focus on Adler-Bolton and Vierkant’s discussion of madness, the ideas of the Socialist Patients’ Collective (Sozialistisches Patientenkollektiv, aka SPK), and the antipsychiatry movement. Similar to part 1, I quote heavily from the original text, and I use headings to organize and emphasize the central points being made.

Turn illness into a weapon (image generated from DALL-E)

Asylums as sites of extractive abandonment

You will recall from part 1 that “extractive abandonment” is the process by which populations deemed surplus are made profitable to capital. Surplus consists of individuals who cannot participate in mechanisms of value production themselves, so systems are created to extract value from them.

Individuals with mental illnesses constitute one component of the surplus population. Adler-Bolton and Vierkant offer a history of psychiatric asylums by conceptualizing them as institutions engaged in the process of extracting value from the mentally ill (among other things). Psychiatric institutions were created not only to meet the natural needs of mentally ill people, but also as a way for the economic system to make money off of watching over, controlling, and studying them.¹ The evaluation, confinement, treatment, control, and research of mentally ill individuals within institutions generated both economic and scientific value for the people engaged in these tasks.

“The material horror of the practices visited upon those labeled mad/surplus must be understood not simply as some abstract, moral failing of society, but as a fundamental feature of our political economy.” (p. 80)

Sanist and carceral logic of mental healthcare

Sanism stigmatizes and marginalizes individuals facing mental health challenges based on societal fears and misconceptions that mental illness itself is a threat to social order, leading to approaches that prioritize control over compassionate care. Carceralism encompasses the idea of confinement, control, or punishment, often associated with institutional settings like prisons or psychiatric institutions. The phrase “carceral sanist logic” implies a way of thinking about mental health care that is centered around control, confinement, or punitive measures, with therapeutic considerations being secondary.

“Sanism is based on the fundamentally flawed notion that the mere existence of madness threatens the safety and order of society. As a result, the question of “what to do” about madness prompts “solutions” that give preference to coercive and carceral practices at the expense of the individual experiencing distress. The premise of sanism relies heavily on cultural mis/perceptions of danger and disorder, a sort of pre-limiting cultural imaginary characterized by the central political goal of exclusion, justified by pathology, and reinforced by professional medical expertise.” (p. 82)

“It is not that the individual’s state of mind is “unreasonable,” it is that our society is ill-fit to accommodate the complex needs of mad people under the incentive structures and fiscal restraints of capitalism. In fact, society is actively antagonistic toward mad people, using psychiatric frameworks to dictate how they may live, if they may be free, and sometimes, as is often the case in mad people’s encounters with state violence at the hands of police or doctors, how they must die.” (p. 84)

Deinstitutionalization

Adler-Bolton and Vierkant make the case that, despite the closure of asylums in the late twentieth century, the logic of extractive abandonment persists in the contemporary healthcare system.

“… some of the key functions of the asylum system persist; deinstitutionalization did not destroy carceral sanist logic but instead redistributed the asylum’s responsibilities into a vast, chaotic network of private and public entities.” (p 95)

“If there is a direct descendant of the asylum system it is the nursing home, a punitive, fundamentally carceral setting built on the same principles of social management described earlier. But the asylum system has many lesser descendants… Just as catchall almshouses transmogrified into siloed, categorically segregated institutional care, “old” institutions gave rise to a public-private continuum of contingent phenomena that serves few interests beyond the cost-benefit fueled reproduction of capital. Long-term care encompasses a wide variety of corporations, services, products, and relations; from institutionalized skilled nursing care, personal care, and in-home services and supports to unpaid informal care labor from family or kin.” (pp. 96-97)

“Attempting to profit off long-term care is like trying to squeeze blood from a stone. And so the dynamics of the “old” warehousing model of congregant confinement and maximized austerity continued despite the “end” of the era of institutionalization.” (p. 97)

“If there is a direct descendant of the asylum system it is the nursing home, a punitive, fundamentally carceral setting…” Adler-Bolton and Vierkant

The Nature of Madness, Illness, and Disability

Adler-Bolton and Vierkant walk a fine line between recognizing madness as historically and socially situated (and not a category with a biological essence) while also recognizing that any account of madness/mental illness that frames it only in terms of capitalism or social control is inadequate.

“It is important to note that when we refer to madness, we refer not to some specific biocertifiable category but to a shifting and diffuse set of sociologically and historically situated definitions. While we categorically refute assertions that have attempted to label madness as merely “a product of capitalism” or as categorizations of difference premised only on “control,” the historical construction of madness as an expansive category for collective social difference or “deviance” is important to confront.” (p. 81)

They do not elaborate on what sort of metaphysics of psychopathology allows for this. From my perspective (Adler-Bolton and Vierkant may very well disagree), the historical construction of madness is entirely consistent with work in philosophy of psychiatry that rejects naturalist and essentialist accounts of mental illness in favor of normative, pragmatic accounts that nonetheless acknowledge that these categories are value-laden assortments of a variety of neurobiological mechanisms that are amenable to scientific inquiry. My assessment of Health Communism would have been far less positive if Adler-Bolton and Vierkant had not offered this qualification. Their account of the social construction of madness needs to be complemented with an account of psychopathology that also recognizes the reality of the neurobiological mechanisms and processes that underpin these categories, and for that purpose, I recommend the work of Derek Bolton (What is Mental Disorder?, 2008) and Peter Zachar (A Metaphysics of Psychopathology, 2014). (See my interviews with Bolton and Zachar from the Conversations in Critical Psychiatry series.)

Adler-Bolton and Vierkant make it clear that recognizing the social construction of these categories doesn’t make them illusory; the individuals, their disabilities, and their needs are very real and require healthcare. There is a genuine risk that those who are content to ignore these categories will disregard the material needs of those so classified. In fact, this is the precise route that contemporary “critical psychiatry” has taken. By refusing to recognize psychiatric conditions such as ADHD and autism, critics who dismiss the reality of these disabilities have nothing material to offer the individuals experiencing them.

“… illness, disability, and madness are categorically social constructions ill-fitting the bodies these labels are used to demarcate as burden. But it is not that these categories do not exist. The categoric dismissal of these labels, as practiced in particular by some critics of health and capital in the mid-twentieth century, can also produce a categoric dismissal of the bodies that have been so marked. We have seen social movements, in refuting the stigmas capital places on these biocertifications, in fact abandon the material needs of the surplus in a fit of utopian zeal, as though because capital has shaped them, merely stating that they do not exist will in and of itself undo capital’s violence. The sociological constructions that constitute these stigmatized categories, and all stigmatized categorizations under capital, must instead be celebrated.” (p. 208)

It is important to note here that the social construction of illness and disability applies not just to madness but to all illnesses and disabilities. This places an important constraint, as the account has to be flexible enough to accommodate the biological reality of conditions such as Kaposi sarcoma, diabetes mellitus, silicosis, and systemic lupus erythematosus, even as it recognizes the socially constructed nature of illness and disability.

“The categoric dismissal of these labels, as practiced in particular by some critics of health and capital in the mid-twentieth century, can also produce a categoric dismissal of the bodies that have been so marked.” Adler-Bolton and Vierkant

The Distinction Between Mental and Physical Illness

Following SPK, Adler-Bolton and Vierkant rejected any fundamental distinction between mental and physical illness when it comes to the experience of disability and the necessity of care.

“Many confuse this group as a movement only of psychiatric patients, but SPK importantly saw no boundary between their work and work centering other chronically ill, sick, queer, trans, non-normative, dying, I/DD, or physically disabled people. Instead, SPK sought to remove the division between mental healthcare and healthcare, uniting all patients in solidarity—to unite everyone by rejecting the taxonomic categories of illness-diagnostics under the present system. Rather than distinguish between types of illness or states of being, SPK placed all health, “good” or ill, on a continuum of illness under capitalism. It is through this broad unifying gesture that SPK sought to unite the surplus class under the same banner in a way that had been impossible when organizing only the working class. If we are all ill under capitalism, then we can all awaken into the struggle to abolish what makes our collective illness unacceptable within society.” (p. 154)

“SPK importantly, and in sharp contrast to the anti-psychiatry movement, did not differentiate between “bio/physical” illness and “mental” illness, reflecting a remarkable approach to understanding illness and disease from the perspective of patients rather than through the materially distanced observation of patients.” (p. 177)

“To differentiate between the bio and mental symptoms was a false game, SPK argued, because under capitalism, it only served to pathologize the pathology itself.” (p 177)

This position stands in contrast to contemporary critical psychiatry, which posits a sharp distinction between mental and physical illness. SPK’s argument is consistent with Robert Chapman’s criticism of the “comparativist” approach. The comparativist critique embraced by critical psychiatry takes somatic medicine to be objective and scientifically valid, while considering psychiatry to be subjective, value-laden, and scientifically invalid. Chapman makes a persuasive case that the theoretical commitments of the comparativist critique are untenable and harmful. This is articulated quite well in the abstract of his 2023 article for Philosophy, Psychiatry, & Psychology:

“The contemporary form of critical psychiatry and psychology focused on here follows Thomas Szasz in arguing that many of the concepts and practices of psychiatry are unscientific, value-laden, and epistemically violent. These claims are based on what I call the ‘comparativist’ critique, referred to as such since the argument relies on comparing psychiatry to what is taken to be a comparatively objective and useful somatic medicine. Here I adopt a Sedgwickian constructivist approach to illness and disability more generally to argue that the theoretical commitments of the comparativist critique are not just untenable, they are also epistemically harmful in much the same way criticals identify in psychiatry. This is because they commit to an unrealistic understanding of bodily health that reifies the ‘normal’ body in ways that are harmful for those who fall outside bodily, neurological, gendered, sexed, and racialized norms. Far from being a merely theoretical problem, I show how maintaining these commitments routinely contributes to the at least partial, and unintentional, marginalization of neurodivergent, disabled, and LGBTQI identity, agency, and history in critical psychiatry discourse and practice. I conclude that, although some of its critique of mainstream psychiatry is pertinent, the problems with Szaszianism’s core theoretical commitments are likely to be incompatible with critical psychiatry’s liberatory aims in the long run.”

Including mental illness within the fold of illness and disability is also important for Adler-Bolton and Vierkant because it brings solidarity instead of division. The mentally and somatically ill are aligned in their sociopolitical interests and needs; they have both been marked as “surplus” by capital.

What went wrong with “antipsychiatry”?

Adler-Bolton and Vierkant describe antipsychiatry as follows:

“Anti-psychiatry, or “critical psychiatry,” was a movement that began in the 1960s primarily among psychiatric professionals in the United States and United Kingdom who sought to delegitimize the carceral and coercive components of standardized psychiatric practice.” (p. 155)

“Uniting the many disparate analyses that fell under the general umbrella of anti-psychiatry, democratic psychiatry, critical social psychiatry or meta-psychiatry is the central idea that madness was not an individual’s biological destiny but a socially determined phenomenon at the population level.” (pp. 155-156).

They note, “The anti-psychiatric project was influential, but failed to deliver on any of its promised goals to patients.” Why? Adler-Bolton and Vierkant discuss many reasons.

“The anti-psychiatric project was influential, but failed to deliver on any of its promised goals to patients.” Adler-Bolton and Vierkant

• As noted above, antipsychiatry relied on a comparativist critique to attack psychiatry that was untenable and politically harmful.

• “As a social movement, it died as its founders died: by the end of their careers, most anti-psychiatrists had never made the transition from theory to action, and many had drifted toward a kind of apolitical spiritualism at best and outright libertarianism at worst.”

• “Few among the group grounded their theories in the building of solidarity with either patients or broader society, and most framed psychiatric liberation as an individual right. Their resistance was decidedly professional and still distanced from their objects of liberation: the patients themselves.”

• “Anti-psychiatry rarely crossed the transom of the expertise barrier, remaining firmly grounded within the realm of institutional critique from the level of doctor, therapist, and hospital administrator, rarely from within the more hallowed dungeons of the asylums.”

• Anti-psychiatrists were generally opposed to or skeptical of psychiatric treatment.

SPK, in contrast, took a different position. SPK saw no boundaries between mental and physical in the illness experience. SPK was politically active. SPK was led by patients and sought solidarity between professionals and patients. SPK embraced treatment but sought to liberate care from the carceral and sanist logic of the system.

“Unlike their contemporaries in the anti-psychiatry movement like Cooper, Laing, and Szasz, who rejected the use of certain therapies and pharmaceuticals, SPK radically and wholly embraced treatment, and felt that, above all else, care should be self-directed and synergetic: a dual dialectic between doctor and patient working in collaboration and producing forms not just of care but also of solidarity.” (p. 172)

“SPK argued that “science has to be freed from its parasitic, thoroughly life-denying, and anti-human function,” and that it was necessary to “carry on science for sick people (because there aren’t any other kind), so that they put science in the hands of those who need science to be freed … that means in the hands of the sick.”” (pp. 172-173)

Reorienting the doctor-patient relationship

There are moments when I wish I could care for patients without having to serve as the gatekeeper of medical services and accommodations and without having the power over them that I currently do. SPK wished for something similar and turned it into a manifesto. The idea that this power imbalance is not inevitable but a consequence of our particular sociocultural arrangements is one of great appeal to me, even as I recognize it as utopian in its aspirations.

“SPK praxis establishes the patient-doctor relationship as one that must be reoriented, rejecting the relation in which the doctor has total authority over the patient as an object, and instead embracing a collaborative approach to care and therapeutics.”

“SPK refused the distinction of “patient and doctor as two individuals who are naturally separated.” Instead, they saw a “dialectical unity” of which there was the capacity in each patient-doctor relationship for revolutionary solidarity and struggle. The goal was to end the practice of care as a property regime and to do that by first breaking the boundaries imposed on care by the artificial scarcity of gatekept expertise. Under capitalism, SPK argued, these roles of doctor and patient would always be in conflict—the key to revolution was finding a way to get people the care they needed without the coercive structures of health-capitalism.” (p 153)

“Capitalism, SPK argued, requires the continual destruction of the means by which we can build solidarity between doctors and patients, intentionally partitioning doctors and patients into separate classes. To unite the doctor and patient in a true dialectical relationship of collaboration is to declare revolt against the capitalist political economy of health. The division between doctor and patient was a means by which to undermine solidarity, and SPK argued that this was precisely why the class identities and care relationships between doctor and patient are so heavily mediated by institutions and systems of surveillance. This fracture results in a healthcare relation optimized for processes of extractive abandonment and not for the process of care, rendering the doctor into the signifier of state power and the patient into “pure object.”” (pp. 153-154)

Improving the lives of individuals with mental illness requires improving societal conditions for everyone

“… living and sanitary conditions in asylums, often cited as one of the precipitating reasons for deinstitutionalization in the late twentieth century, were the subject of public exposés and state inquiries as early as the beginning of the nineteenth century, with official inquiries in 1815–16, 1827, 1839, and from 1842–44. Scull notes of these public debates that, ultimately, “improving the conditions of existence for lunatics living in the community would have entailed the provision of a relatively generous pension or welfare payments to provide for their support; implying that the living standards of families with an insane member would have been raised above those of the working class generally.” This analysis, we argue, remains true today with only degrees of difference, and forms a compelling reason for “worker” and “surplus” to join their demands and move toward mutual liberation.” (p. 88) (my emphasis)

I wrote in part 1, “How can how all care for all people exist in a world where the boundaries of healthcare are actively constructed and negotiated, and scarcity exists outside the boundaries? A radical abundance of healthcare can perhaps only exist in a world that has radical abundance of everything we may desire.” The passage quoted above illustrates this dilemma quite well. When so many workers in society are making barely enough to survive, it’s not possible to provide mentally ill individuals with a standard of living that ensures their well-being. A society that doesn’t care for the homeless or the working class will not be able to care for the ill or disabled either. There is a good reason that disability payments, as they currently exist, all but ensure a continued life of poverty for the individuals receiving them.

Given my own experience working in a forensic psychiatric setting, I am reminded of how the porous boundary between jails and state psychiatric hospitals in the US all but ensures that the quality of life that patients experience in state psychiatric facilities is not substantially better than what they experience in jails or prisons. The quality of life in jails exerts a downward pull on the quality of life in state psychiatric hospitals, ensuring that the two remain in proximity. The fates of the two are linked. A society that doesn’t care for the well-being of those who are arrested and imprisoned cannot care for the well-being of the mentally ill in any meaningful way; conversely, improving the lives of the mentally ill requires us to improve the lives of the poor, the homeless, and the incarcerated as well.

Illness is the only possible form of life under capitalism

How should we understand this provocative assertion by SPK? The first thing to keep in mind is that SPK had a tendency for hyperbolic rhetoric. (As Sasha Durakov Warren puts it, “There is much confusion around what the SPK actually said, due in part to their proclivity for falsifiable hyperbole and crude sloganeering.”)

SPK’s notion of illness is a broad one, playing a similar role as “alienation” does in Marxist thought. Probably the most straightforward way to interpret it is as follows: in capitalist systems, nearly all of us are forced to work under conditions that take us beyond our own physical or mental limits. To sell one’s labor without ownership of the fruits of that labor is a process that inevitably results in mental and physical degradation.

Adler-Bolton and Vierkant qualify the statement as follows: “It is not necessarily the case that we are all sick. But none of us is well. The truth of the distinction that capitalist states draw in their demarcations of worker/surplus is that in the eyes of capital, we are all surplus.” (p. 211)

Turn illness into a weapon

The realization that capitalism makes us vulnerable to illness, that illness is disruptive to work and offers a reprieve from labor, that capital is interested in health only to the degree it keeps workers productive or restores the ability of the ill/disabled to work, that capitalism extracts value from the mad, the ill, the disabled, even as it abandons them, provides a foundation for radical solidarity.

Sasha Durakov Warren explains the notion as follows:

“Illness, insofar as it is an expression of the real contradictions that permeate our social world, is also a form of protest, a rejection of one’s conditions and the expression of the need for transformation. At that point, one can manage it, repress its call, or “turn illness into a weapon.”… Under capitalism, we are all on fire. Every person burns from the social contradictions degrading their physical and mental integrity. How does one appropriate that burning and turn it into a destructive flame against our conditions? That was the sole question of madness for the SPK.”

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Some readers may say, “I’m not really into all this communism talk. What takeaways do you have for me?”

Allow me to reiterate a few important points without mentioning communism or capitalism.

• Psychiatric institutions (and a host of other community institutions, such as nursing homes) exist not simply to care for the individuals in those institutions, or even just to control or confine them. They are institutions that extract economic and academic value from the processes of care and control; the lives of disabled people are made of use to the system. The process of extracting value also leads to a warehousing model of austere living conditions for the patients, because that’s the only way to generate profit from the limited amount of public money that is designated for each individual.

• Disability, illness, and madness are socially situated, but they are also real experiences with material needs that necessitate care. (I’d say they are value-laden assortments of neurophysiological and psychological processes.) The antipsychiatry approach of delegitimizing the mental while essentializing the physical is a philosophical and political failure. What is needed is a shift towards more collaborative forms of care in which patients are empowered and take an active role.

• It is not enough to conceptualize health as an individual right. The right to health and life includes a right to treatment that, if taken seriously, forces us to question systems that are based on the idea that care needs to be rationed and on self-fulfilling beliefs that healthcare resources are necessarily scarce.

• Improving the lives of individuals with mental illness requires improving societal living and working conditions for everyone, including the poor, the homeless, the incarcerated, and… yes, even the psychiatrists. This recognition provides a radical basis for socio-political solidarity.

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1. And in some cases, value was generated from the actual physical labor of the mentally ill individuals within institutions.