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The Culture of Therapy: Psychocentrism in Everyday Life

Heidi Rimke University of Winnipeg Deborah Brock York University

Has life got you down? Do you have trouble getting out of bed in the morning? Have you stopped eating? Or perhaps, you are unable to stop eating? Do you have trouble falling asleep at night or staying asleep? Have others expressed concern about your mental or emotional state? Have you wondered whether your sexual desires are normal? Do you experience feelings of helplessness, meaninglessness, worthlessness, or powerlessness? Are you worried about having an addiction to something, such as television, video or computer games, the Internet, sex, food, alcohol, shopping, a relationship, texting, pornography, sports, or anything else? You have probably encountered questionnaires with questions similar to these while reading a magazine, watching television, or surng the Internet. Perhaps a psychiatric association, pharmaceutical company, or government agency has posted them. The questions act as a set of identiable warning signs for the readers self-reection. These might then create a crisis in the readers sense of normalcy, suggesting to the reader that s/he may be suffering from a treatable mental or emotional disorder, requiring professional help. However, far from referring to exceptional conditions, such lists include common feelings and practices, some of which all of us may experience at some points in our lives. Indeed, as this chapter will discuss, virtually every form of human behaviour has been classied within the normal/abnormal dichotomyand there appears to be no end in sight to the growing index of human dysfunctions, disorders, and diseases. The growth of human scientic discourses is the most signicant driving force behind what can be understood as the shrinking spectrum of normalcy in contemporary Western societies. The idea that some people are psychologically sick or disordered reects the growth of the pathological approach, a distinctly Western and recent historical phenomenon, in which it is assumed that personal problems are individual and caused by biological and/or psychological factors. Everyday terms such as psycho, messed up, crazy, and nuts reect the current popularity of the therapeutic ethos of our time and place. We come to think of ourselves as not smart enough, attractive enough, rich enough, skinny enough, fullled enough, sexy enough, successful enough, or healthy enough; that we must smarten up, straighten out, grow upso that we can measure up. Our cultural beliefs and practices about what it means to be a human being in the early 21st century hinge on the idea that there is this objective thing called normal that we should all strive for.
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However, the notion of normal has a history. It has not always been a part of everyday life. Nor are Western or North American ideas and discourses about what is normal found in other societies, as Kleinmans (1991, 2006) cross-cultural research on mental illness demonstrates. As you have learned in previous chapters, the emergence of the idea of normal is key in understanding the establishment of modern systems of discipline. Discourses of normalcy and abnormality have been inserted into the very subjectivities of people through techniques of domination and self-regulation derived in large part from the human sciences. Therefore, the psy discourses (psychology, psychiatry, psychotherapy, etc.) wield enormous inuence in shaping our everyday lives and practices in the early 21st century. The general popularity of psy discourses, which attempt to explain human problems by identifying their psychological or psychiatric origin, is particularly evident in the growing consumption of self-help material and prescription drugs for mental and emotional reasons. The now-pervasive presence of psy in our everyday lives and practices as Westerners can be seen in the widespread acceptance of a particular psychotherapeutic ethos that shapes social practices, which has become known as the culture of therapy. As modern subjects, we have at our disposal an immense medicalized vocabulary for speaking about our inner selves. Modern individuals speak with ease and condence about their thoughts, memories, beliefs, emotions, and the like through psy discourses. Convinced that we should understand our selves in psychological terms of adjustment, empowerment, fulllment, good relationships, personal growth, and so forth, we actively seek the wisdom of experts and cling to their promises to assist us in the quest for self-change that we freely undertake (Rose, 1998). The popularity of psy discourses reects a deeply held belief that psychology in one way or another can make one happy, and that at the root of our difculties are psy problems that can be treated with professional therapy, self-help, and/or prescription drug use. In this chapter, we will explore how the modern subject has been shaped through the cultural authority of the psy complexwhich itself is derived from the reigning culture of science, as you have just explored in Chapter 8. We will employ Foucaults conceptual and historical approach to present the social and historical construction of psy knowledge. We will then provide some important examples of how the development of the psy disciplines system of classication has had particular ramications for the production of gender, race, sexual orientation, and class. Later we will turn to an analysis of contemporary therapeutic culture, and an explanation of what Heidi Rimke (2000, 2010a, 2010b) refers to as psychocentrism: the outlook that all human problems are innate pathologies of the individual mind and/or body, with the individual held responsible for health and illness, success and failure. Through this analysis, we want to continue our task of interrogating the centre by demonstrating how powerknowledge relations permeate our every day, taken-for-granted world. We want you to think about how particular knowledges acquire the status of truth, and how people or subjects are made up (Hacking, 1986) or constituted through the expert knowledge of psy and medical professionals, including psychiatrists, teachers, social hygiene reformers, psychologists, health workers, sexologists, and social workers. The rise of these experts reects the development of professional knowledges relying upon a scientic rationality to understand, explain, and control human conduct.
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Our aim is to overthrow the naturalness of dominant ways of thinking about individual pathology by studying the historical relationship between forms of knowledge, the exercise of power, and the creation of subjects. For example, researchers have demonstrated the multiple and shifting ways subjects have been constituted or created by expert discourses seen in critical social studies on anxiety (Tone, 2008), multiple personality disorder (Hacking, 1995a), suicide (Marsh, 2010), antisocial personality disorders (Rimke, 2003), self-esteem (Ward, 1996), shyness (Lane, 2008), stuttering (Petrunik & Shearing, 2002), depression (Horwitz & Wakeeld, 2007), ADD/ADHD (Conrad & Schneider, 1980) and hysteria (Didi-Huberman, 2004). While this chapter draws primarily on the work of Foucault, we can also consider the signicance of the work of Karl Marx when studying the culture of therapy. In order to understand the economic conditions and nancial motivation which are signicant factors in the growth of the culture of therapy, we ask you to think back to your study of Karl Marx in Chapter 6. Marxs work is signicant for our study in many ways. Therapeutic culture has created an enormously protable economic sector, from the dozens of self-help books and videos released annually to the dramatic growth of pharmaceutical companies (now referred to as big pharma), to the proliferation of wellness retreats and wellness practices. Further, by asking who gains from the development and growth of a psy-oriented industry, we can question who has the ability to dene reality. While it is too simplistic to claim that the dominant class simply controls the oppressed class, it is fair to say that historically the medical explanations for mental illness shifted according to the patients class position. For example, while the mental illness of the poor was often attributed to factors as coming from bad stock or personal failures, the economically privileged were rarely blamed or held accountable for a psychiatric diagnosis. Instead, it was attributed to the climate, a fever, or a blow to the head. That said, the psy effect should not be identied with a particular cause or a singular powerful social group, but rather by its effects in everyday life and how it weaves throughout our lives, connecting and dividing as well as producing and constraining our movement. Thus while class is certainly signicant in the politics of mental health and illness, it is a Foucauldian analysis of the politics of truth and science that most guides this chapter. When we engage in this kind of analysis, it is not intended to deny that many people do have, either chronically or periodically, mental or emotional issues that signicantly affect their ability to get along in the world, to meet their own emotional needs, to develop good relationships with others, and so forth. Similarly, it is not our intent to pass a nal judgement on psy discourses by claiming that they are necessarily good or bad, or by declaring them merely ideological. Clearly they can be enormously benecial for many people, just as they can be destructive for others (for example, by imposing social stigma and discrimination). More often, our engagement with psy discourses and practices can be mixed, with positive, negative, or ambivalent implications. The point is that they do shape us in various ways. The issues and debates surrounding mental illness or psychological problems are complex, contradictory, and conicting as the growing literature in the sociology of medicine and psychiatry demonstrates. Just as we do not intend to evaluate the rightness or wrongness of
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psy discourses, we do not seek to provide answers and resolutions to this broad domain of contested expert claims and varied human experience. Our objective is a more modest one: to discuss the social and historical development of psy discourses, institutions, and practices, with particular attention to largely taken-for-granted popular and expert discourses about normalcy and abnormality.

NORMALIZATION AND CLASSIFICATION Critical scholarship about historical and contemporary psy discourses, institutions, and practices owe much to the guidance of Michel Foucault, whose scholarship includes two books on the history of madness and on the emergence of treatment regimes: Madness and Civilization (1961) and The Birth of the Clinic (1963). Foucaults governmentality approach and his attention to practices of regulation and normalization have been particularly important for studying the culture of therapy. As you learned in Chapter 2, distinguishing between the normal and the abnormal is an expression of normalizing power (Foucault, 1979). Specically, normalizing power compares, differentiates mental states, establishes a hierarchy of value between them, homogenizes by presenting a particular notion of normal, and excludes those who are in some way considered abnormal. From this explanation, we can see that normalizing power is simultaneously a dividing practice. People, beliefs, and practices are distinguished and divided from one another. By encouraging certain ways of life over others, discourses of normalization offer implicit conceptions of whom and what constitutes a good self or normal person. For example, the hypothetical questionnaire at the beginning of this chapter is a starting point for not only diagnosing people, but for classifying them according to signs or symptoms. The psy disciplines, like other human sciences, have developed an everexpanding system of classifying people, making distinctions between and among them. These evaluations and distinctions are not neutral. As Turner and Edgley (1983) have demonstrated, the very core of psychiatric categories and diagnosis is based upon subjective social and moral values. They critique the assumption that chemical imbalances are at the root of deviance because it is not possible to distinguish, medically or chemically, behaviours that are socially dened as acceptable or unacceptable. The seemingly neutral language of psychiatry masks value judgements about good and bad, or right from wrong. In the previous chapter, you read that no scientic test can determine morals and morality; such determinations are always already cultural. Another example of how systems of classication work is found through an account of the ever-expanding Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM was rst published in 1952 by the American Psychiatric Association (APA). It was intended to be a comprehensive account of mental illness in American society, and today acts as the psychiatric bible by dening the criteria for an ever-increasing number of mental illnesses and disorders (Kutchins & Kirk, 1998). Once an ofcial DSM classication of mental illness is declared, the category begins a life of its own, which can result in unanticipated consequences. As Hacking (1995b, 1999) shows, what develops is an interaction or looping effect between a classication and those people who are classied.
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Humans inevitably respond to being classied or classifying others, which in turn alters their conduct, which then has an effect on the classication, and so on. As Hacking (1999) explains, All our acts are under descriptions, and the acts that are open to us depend on the descriptions available to us. Moreover, classications do not exist only in the empty space of language but in institutions, practices, material interactions with things and other people. Expert classications thus operate at the level of the everyday culture, shaping our views of ourselves and of others. While we are on the topic of the DSM, it is worth noting that the original DSM, the DSM-I (1952) was 130 pages long, listing 106 disorders. By its fourth edition, published in 1994, the DSM-IV was 886 pages long and listed 297 disorders, thus nearly triple the volume (Grob, 1991). The controversial DSM-V has an expected publication date of May 2012. It is expected that the new version will expand the basis for psychiatric diagnosis and classication by including new disorders such as personality and relational disorders, night eating syndrome, sensory processing disorder, cannabis withdrawal, obesity, anxious depression, childhood disintegrative disorder, parental alienation, compulsive buying, and Internet addiction (American Psychiatric Association, 2009; Block, 2008; Kaplan, 2009).1 A Foucauldian approach interrogates the assumptions and certainties embedded in our cultural attitudes, beliefs, desires, and practices concerning the normal and the pathological. We can thus attend to the powerknowledge relations that inform our everyday beliefs and practices about mental health and illness, including the dominant assumptions about whom or what forms of conduct are socially dened as normal or abnormal. Yet scholarly critiques of beliefs and practices about mental illness by no means began with, or are limited to, Foucault and those whom he has inuenced. For example, Rosenhans (1973) classic sociological study, On Being Sane in Insane Places, also demonstrates the subjective nature of psychiatric medicine. Rosenhan had eight pseudopatients relying on scripts present themselves as mentally ill patients in a psychiatric institution. The actors did not display any form of symptomatic behaviour yet were nevertheless diagnosed and treated as if they were indeed mentally ill. The study demonstrated that even psy professionals cannot always distinguish the sane from the insane because of the subjective nature of judging human conduct.

1 Critics argue that the addition of new disorders to the DSM-V is another ploy in an endless series of scientic rationalizations for prescribing protable drugs for one of the fastest-growing industries in North America. For example, in 2002, the combined prots of the ten largest pharmaceutical companies in the Fortune 500 totalled $35.9 billion amounting to more than the combined prots ($33.7 billion) of the remaining 490 companies together (Angell, 2004). Big pharma has become a prot-oriented industry to advertise and sell drugs of questionable benet. In 2007, the British Medical Journal published a study analyzing approximately 2,500 common medical treatments and found that 13 percent were found to be benecial, 23 percent were likely to be benecial, 8 percent were as likely to be harmful as benecial, 6 percent were unlikely to be benecial, 4 percent were likely to be harmful or ineffective, and 46 percent were unknown in terms of helpful or harmful effects (Clinical evidence, 2007). The economic power of the pharmaceutical industry has resulted in the co-optation of every institution that might get in its way, including government, health, and drug regulatory bodies, academic medical centres, and the medical profession itself (Levi, 2006).
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THE HISTORY OF THE PRESENT As Nikolas Rose comments, We can question our present certaintiesabout what we know, who we are, and how we should actby confronting them with their histories (Rose, 1999: x). As you learned in Chapter 2, Foucault referred to his historical approach as the history of the present. Rather than understanding historical developments as inevitable, or as determined by universal laws, he viewed history as contingent, because for any event, other directions and outcomes were also possible. So while the contemporary interpreter of historical events might assume that the development of psychiatry and institutions to house the insane were practical, humane, unavoidable, or even evolutionary, Foucault provides us with a way of thinking about how this outcome was the result of power knowledge relations. Foucaults methodology is a counter-history because it is written against the taken-for-granted or dominant histories, as our examples below will show. Foucault eventually began to refer to this critical approach as his genealogical method. Genealogy starts with the present, not to afrm or deny it, but to ask how the present has come to be constituted as it is. The aim is to overthrow the naturalness of dominant ways of thinking by studying the historical relationship between forms of knowledge and the exercise of power. Foucault explored the multiple, contradictory, and shifting discourses that were emerging from the Enlightenment onwards, particularly those with a profound effect on how people were understood. Before the human sciences began to develop in the 19th century, ideas about human nature and human conduct were derived from a religious framework determined by Church authorities. Humans were understood in religious terms of evil or virtue, rather than medically and scientically. With the Enlightenment, scientic theories began to claim that human nature was the result of biological, physiological, and/or psychological factors. Thus by the end of the 18th century, Western theories shifted toward scientic rather than theological explanations. Positivists insisted that through systematic observation, human behaviour could be explained in the same objective manner as the hard sciences explained the natural world. The discovery that madness was not the result of demonic possession or a punishment from God, but a disease entity that required medical attention, was a catalyst for the formation of a medical model of mental pathology. The scientic search for endogenous (internal) causes rooted in the person thus became a hallmark of modernity. By the mid-to-late-19th century, the human sciences developed numerous new branches of study, such as comparative psychology, phrenology, anthropology, neurology, criminology, experimental psychology, physiognomy, craniology, necrology, and psychological medicine. Psychiatry as a distinct specialization only expanded in the mid-20th century. These areas of study often competed with one another, so the human scientic project of studying the normal/abnormal divide did not develop as a single and unied discipline (Rimke, 2008; Rimke & Hunt, 2002). Modern society thus rested upon the new ideals of science and progress. Human differences or problems were increasingly viewed as scientic problems that could be studied, known, categorized, regulated, and treated or cured. The modern claim that deviance or madness was a scientic, rather than religious, matter drastically altered how we interpret
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and perceive the self and others in the everyday. Human scientists began insisting that the cause of deviance was rooted in the body itself and that religious ideas were outdated by modern, scientic ideals and standards. While the medical models view of the diseased individual has gradually replaced the religious models view of the evil sinner as a means of understanding and explaining human conduct, the historical effects of religious practices and discourses still exist and affect current ideas. Rather than explain the historical shift in linear terms, where religious authority was simply displaced by the scientic, Foucauldian research has demonstrated that a hybrid discourse of Christian theology and Western science together medicalized immorality as an objective fact (Rimke & Hunt, 2002). So, for example, while religious discourses held that the sodomite (today, the gay male) was a sinner who engaged in immoral sexual practices with other men, the invention of the category of the homosexual by the human sciences, as Foucault has shown, relied on a notion of perversion derived from this earlier notion of sin. The importance of this example is that it demonstrates the inuence wielded by two dominant discoursesreligion and sciencein the making of the idea of the homosexual. We will return to this example shortly. We will now present you with some brief historical accounts, or fragments, concerning the history of institutionalization, diagnosis, and treatment, which disrupt and trouble the grand narrative of medical and scientic progress. They illustrate that so-called progressive historical measures carried with them certain assumptions about class, race, gender, and sexuality. They compel us to think further about the myriad ways knowledge and power intersect, and the impact upon populations and the daily lives of people.

Connement: The Emergence of the Asylum

Seventeenth-century Europe witnessed an unprecedented programme of building institutions designed specically for disciplining and regulating certain populations of people, in asylums, prisons, workhouses, and so on. Foucault referred to this as the great connement. He was intrigued by the emergence of new strategies to administer to and discipline the population, which included both those who found themselves conned, and those who feared that they could one day be (the poor, and women of all classes). These spaces of exclusion were both a cause and an effect of the growth of the disciplinary society. People considered mad were initially conned in the same institutions as the poor, the criminal, the unemployed, and the idle. As the psy disciplines expanded, institutions specically designed for the diagnosis, retention, and treatment of the mad were created. A diagnosis of madness became a dividing practice, through which those labelled were separated from their communities, both conceptually, and often physically. The process of diagnosing and locking up the mad in houses of connement allowed for the observation of signicant numbers of people under controlled conditions, making them objects of scientic study and knowledge. Moreover, this administration and control of the mad within public institutions came to increasingly

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Chapter Nine | The Culture of Therapy: Psychocentrism in Everyday Life FIGURE 9.1 The tranquilizing chair. Benjamin Rush (17451813), considered the father of American psychiatry, wrote the rst American psychiatric textbook and invented the tranquilizing chair in 1811 to immobilize the patient using the treatment of restraint and sensory deprivation.

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Source: Engraved by Benjamin Tanner after John James Barralet. Bettmann/CORBIS

depend on the classication and separation of different types of madness. Diagnostic classications, in turn, fostered their own forms of treatment. In addition to connement, the mad were subjected to practices that included the frontal or icepick lobotomy, the clitorectomy, physical restraints, involuntary drugging, and electroconvulsive shock therapy (Valentin, 1986). Some of these practices have been ended, while others continue, although not without controversy.

Drapetomania
The psy disciplines have also participated in processes of racialization where, as you read in Chapter 5, scientic method was used to construct distinct racial types, each with its own morphology and character. A stark historical example is the classication of Drapetomania, introduced by a Dr. Cartwright in 1851, which was dened as the

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pathological desire of African-American slaves to escape captivity from their natural and God-given masters (Szasz, 1971b). We nd here another example of how both religious and medical discourses have been simultaneously exercised to make claims that buttress social inequalities. Contemporary readers should have no difculty identifying the absurdity of this diagnosis. However, it should remind us to consider more closely how, in our own time, racialized people are pathologized as an explanation for the social problems of their communities. For example, the claim that there is an epidemic of single mothers and absent fathers among African-Americans not only identies the single-parent family as non-normative, but alleges that male irresponsibility and family instability are integral features of Black communities.

DRAPETOMANIA, OR THE DISEASE CAUSING NEGROES TO RUN AWAY

It is unknown to our medical authorities, although its diagnostic symptom, the absconding from service, is well known to our planters and overseers. In noticing a disease not heretofore classed among the long list of maladies that man is subject to, it was necessary to have a new term to express it. The cause in the most of cases, that induces the negro to run away from service, is as much a disease of the mind as any other species of mental alienation, and much more curable, as a general rule. With the advantages of proper medical advice, strictly followed, this troublesome practice that many negroes have of running away, can be almost entirely prevented, although the slaves be located on the borders of a free state, within a stones throw of the abolitionists. If the white man attempts to oppose the Deitys will, by trying to make the negro anything else than the submissive knee-bender, (which the Almighty declared he should be,) by trying to raise him to a level with himself, or by putting himself on an equality with the negro; or if he abuses the power which God has given him over his fellow-man, by being cruel to him, or punishing him in anger, or by neglecting to protect him from the wanton abuses of his fellow-servants and all others, or by denying him the usual comforts and necessaries of life, the negro will run away; but if he keeps him in the position that we learn from the Scriptures he was intended to occupy, that is, the position of submission; and if his master or overseer be kind and gracious in his hearing towards him, without condescension, and at the same time ministers to his physical wants, and protects him from abuses, the negro is spellbound, and cannot run away.
Source: Diseases and Peculiarities of the Negro Race, by Dr. Cartwright (in DeBows Review, 1851)

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Moral Insanity and Psychopathic Disorder

Dr. James Prichard created the diagnosis of moral insanity in 1833. The invention of this diagnosis reected the growing medical xation on immoral or disrespectable conduct, particularly in response to what was perceived as increasing vices arising from industrialization and the growth of cities. Social danger increasingly came to be seen in violations of the norms of respectable society. Moral insanity would later be codied by the psy disciplines as defects of character, and eventually as personality disorders and other mental and emotional disturbances. As psy expertise distinguished itself from the wider category of medicine, it simultaneously generated a knowledge base about what it meant to be a normal individual through the study of the abnormal individual. By the turn of the 20th century, the list of psychopathic disorders grew to include: kleptomania, erotomania, pyromania, and dipsomania, masturbation, obscene language, gender transgressions, nymphomania (in females) and satyriasis (in males), vagrancy, gambling, poor personal hygiene, laziness, prostitution, general lawlessness, and the destruction or squandering of property or money. Modern human sciences thus sought to target and regulate bad social subjects, those who in some way resisted the normative expectations of civility and propriety (Rimke, 2003; Rimke & Hunt, 2002).

Homosexuality
From its initial publication, it was accepted wisdom that homosexuality be included in the DSM as a recognized form of mental illness, and that every attempt should be made by psychiatric and medical professionals to cure the aficted of this sexual malady. Foucault describes how in the 19th century sexuality in the West became an object of scientic analysis and regulation through the pathologizing of sexual difference. Experimental methods for the cure of homosexuality included electroshock therapy and the frontal lobotomy, although no evidence of a successful cure was ever derived from these methods. By the early 1960s a homophile (soon to be known as lesbian and gay) liberation movement was beginning to emerge in North America and Western Europe. Together with sympathetic psychiatrists such as Dr. Evelyn Hooker, they produced counter-narratives and political protest to successfully challenge the methodology and facticity of such scientic claims (see Changing Our Minds, 1991). Homosexuality was removed from the DSM II in 1973. However, various other sexuality- and gender-related diagnoses remained in place, or were subsequently added, such as the designation sexual orientation disturbance.

Female Depression
As you learned in Chapter 2, Foucault uses the concept of the gaze to highlight and explain the process of surveillance and the growing inuence of expert knowledges. The gaze of the expert attempts to dene who people are, without direct input from those under observation. It thus reects relations of power in which those at the centre can dene and categorize those on the margins. Feminist scholars have identied many of the ways in

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which this gaze has been deployed to inculcate proper standards of behaviour in women. For example, in the late 19th and early 20th centuries, women who displayed masculine traits such as independence, assertiveness, and sexual self-condence might nd themselves classied as morally insane, because such conduct contradicted cultural conceptions of females as essentially weak, chaste, and passive. More recently, women subject to the psychiatric gaze have unsurprisingly also been the target of pharmaceutical companies. For example, introduced in 1963, Valium quickly became a widely prescribed tranquilizer, which was intended to relieve symptoms of boredom, anxiety, and depression and to increase relaxationand it was targeted at housewives (Tone, 2008). Unfortunately, it was also highly addictive, especially with long-term use, and could produce numerous side-effects. Prescribing Valium and other sedatives to postWorld War II white middle-class women was such a widely recognized practice that it formed the subject matter of a well-known song by the Rolling Stones, Mothers Little Helper. The medicalization of white middle- and upper-class womens disaffection with their lives was soon challenged by the development of a feminist analysis. In 1963 Betty Friedan published the landmark book The Feminine Mystique, in which she presented the problem with no name: The problem lay buried, unspoken, for many years in the minds of American women. It was a strange stirring, a sense of dissatisfaction, a yearning that women suffered in the middle of the twentieth century in the United States. Each suburban wife struggled with it alone. As she made the beds, shopped for groceries, matched slipcover material, ate peanut butter sandwiches with her children, chauffeured Cub Scouts and Brownies, lay beside her husband at nightshe was afraid to ask even of herself the silent questionIs this all? (Friedan, 1963: 13). Feminists began to explicitly critique the role of psychiatry in pathologizing women, claiming that womens mental health issues would be better addressed by trying to change womens social, political, and economic conditions rather than attempting to change the women themselves by coercing them to conform to traditional roles and expectations. As Dorothy Smith and Sara David entitled their 1975 collection of papers challenging psychiatry, Im Not Mad, Im Angry (Smith & David, 1975). Anger in this context refers to the collective emotional response of women and girls to the socially created limitations they encounter throughout their lives. Womens collective frustration surrounding unequal wages, lack of access to birth control, abortion, and child care, lack of opportunities for advancement in the paid labour force and limited educational opportunities was seen as having nothing to do with womens mental health, and everything to do with a gendered organization of social relations that beneted males to the disadvantage of females. We will return to the growth of the anti-psychiatry movement toward the conclusion of this chapter.

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Lest you think this is now all history, with no bearing on the lives of contemporary Western women, we need look no further than advertisements used by pharmaceutical giant Eli Lilly to introduce and promote the antidepressant Prozac to physicians. One particular ad, placed in The British Journal of Psychiatry, displayed images of a dirty, disordered kitchen, inset with a picture of a clean, tidy kitchen. Such a visual representation links womens mental health to her attention to household chores. As we explored in Chapter 8, this is an example of how scientic and medical discourses can carry with them some highly gendered assumptions, which are grounded in presumptuous social practices rather than objective, scientic fact. The persecution of women alleged to be witches, and the invention of hysteria, moral insanity, and now female personality disordersborderline, dependent, and histrionicdemonstrate an ongoing pattern of gendered regulation. Each respective era has proclaimed an ofcial category for females who in one way or another deed socially prescribed behaviour according to gender rules (Rimke, 2003; Szasz, 1974; Wirth-Cauchon, 2001; Ussher, 1991). Szasz asserted in 1974 that the contemporary phenomenon of diagnosing women as mentally ill continues to dene acceptable female conduct and punish transgression, now often in the form of medical treatment (1974). We want you to think about how his assertion continues to have relevance, despite the successes of feminism.

Psychoanalysis
Finally, in the early 20th century the creation of psychoanalysis occurred through the work of Sigmund Freud and Carl Jung. Psychoanalytic theory claims that individuals are motivated by strong and dynamic unconscious drives and conicts arising in early childhood rather than biological functions of the brain and central nervous system. Psychoanalysis thus provided a non-biological theory of emotional and mental life alongside the dominating neurological, behaviourist, evolutionary, or hereditarian paradigms (Rimke, 2008). Talk therapy was introduced as an alternative form of diagnosis and treatment. While more humane than some of our earlier examples, talk therapy was also to become a means of expanding the scope of diagnosis and treatment to well beyond the connes of the asylum, as you will learn more about when we turn our attention to therapeutic culture. In summary, this section has challenged the ofcial histories of medicine and psychiatry. These histories typically glorify the great men of science as benevolent, humanitarian reformers who freed the mad from brutal and inhumane institutional treatment. However, our brief examples suggest an entirely different phenomenon: the Age of Reason produced new regimes of discipline. Rather, than a new respect for humanity, the success of the human sciences involved the establishment of more nely tuned mechanisms of surveillance that resulted in a more effective web of power inltrating everyday life and practices (Foucault, 1979). The psy experts thus established their expertise on the basis of the general argument that society required remedies for its mental ills and only certain human experts possessed the scientic knowledge to achieve such ends.

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By the mid-20th century, the psy disciplines had accomplished a level of respectability in the West that conferred upon them signicant authority in public and political affairs. In particular, the physician and the psychiatrist (who, unlike the psychologist, are required to hold a medical degree to legally prescribe drugs) experienced growing social recognition and authority. Psy experts increasingly were called upon to analyze and intervene in a growing array of social, scientic, and legal developments. This included activities from forensic psychology and legal psychiatry (linking certain criminal acts to psychiatric illness), to education and welfare reform, to shaping domestic and foreign policy to commenting on public TV watching habits. By the postwar period, psychiatric and medical discourses were therefore shaping state policies and practices on an increasing range of public matters. This is one example of how expert knowledges have come to exert their inuence on the contemporary state, expanding governmental power. But there is another facet to the rise of psy knowledge, and its increasingly detailed classication and specication of the human subject. This knowledge has now been popularized and packaged in particular forms, so that it pervades contemporary Western popular culture, to the point where it has indeed become what some have referred to as a culture of therapy. It is to this popularization that we now turn.

Self-Help and Therapeutic Culture

The therapists ofce, the self-help group, and the blog are all examples of what Foucault referred to as the modern confessional (Valverde, 1985). Foucault claims that the modern person has become a confessing animal. Rather than turning to the priest to confess and absolve our sins, modern individuals rely on psy analyses for guidance, comfort, and direction. Today people may go to their therapists ofces or their support group to confess but the important point for Foucault is that it is in the process of confessing that the self is created rather than revealed. One of the main tenets of therapeutic discourses is the assumption that there is an inner core or truth about ourselves, which therapeutic techniques can help us to reveal to ourselves. Foucauldians, however, invert the common or traditional assumption that expert discourses reveal a hidden truth, and instead argue that the expert discourses themselves shape the individuals interpretation and perception of self. The self-help genre forms an important part of the modern culture of therapy in neoliberal societies. A massive and growing industry, self-help culture provides a dizzying array of groups, books, experts, shows, podcasts, and so forth to guide us in our exploration of our inner selves and our relations with others. Self-help literature comes in numerous different forms of advice: spirituality, how-to manuals, personal change, dealing with loss, relationship advice, and more. We are incited to seek self-enlightenment by excavating and exposing our true selves to the therapeutic gaze in multiple forms, such as our MSN friends, online diagnostic questionnaires, Facebook applications, or fashion magazine quizzes. We may search for our inner child, reveal our codependency, insist on tough love, recover our true or real selves, or experiment with Eastern, aboriginal, or otherwise alternative healing practices. As such, we are part of a culture of recovery.

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The culture of recovery now clearly has a very public character. Far from the privacy of the psychiatrists ofce, self-revelation takes place through the gamut of public media. Self-help discourses circulate and proliferate on television, the internet (websites and webcasts), in autobiographical books, in celebrity interviews, in magazines and newspapers, radio shows, psy-related books and texts, movies, and documentaries. Often, now, self-help can also be considered a form of popular entertainment, seen especially on shows like Dr. Phil, The Dr. Oz Show, or The Oprah Winfrey Show. Increasingly, this psy network contributes more in terms of entertainment than enlightenment, and treatment programs rather than cures. Moreover, reality TV shows such as Intervention, Hoarders, or Celebrity Rehab centre on the pathologies of people in multiple guises, rarely examining the relations and cultural expectations in which the suffering individual is embedded. In our culture of therapy, most, if not all, of us engage in activities designed to keep ourselves emotionally healthy, regardless of whether we ever go to the therapists ofce. We commonly use what Foucault referred to as techniques of the self to diagnose and classify ourselves and others. When we employ these techniques of the self, we are being governed, we govern ourselves, and this also leads us to govern others. Lets focus now on a very popular technique of the self: reading self-help books. A trip to your local bookstore will make obvious the popularity of this genre. Shelves are now lled with books dedicated to self-improvement; to helping us to remake ourselves into better people living more successful lives. We can see evidence of how virtually every human experience is reframed in psychocentric terms. Do you have difculty with managing your weight? Do you drink too much? Do you choose partners who are bad for you? Do your kids rule your life? Are you a shopaholic? Could your soul benet from some chicken soup? Do you sweat the small stuff ? Why are self-help books so popular? First, they promise to improve us not only mentally, but also spiritually, physically, and even nancially, if this is what we seek. Second, they make normalcy or mental health accessible to everyone, regardless of income or access to a therapist, and in the privacy of our own homes, if that is our preference. Third, they really can help. They may actually provide some useful or practical advice on how to get along better with one another, or how to feel better about ourselves. Maybe we will learn to be more understanding and forgiving of other people, as we learn to do the same toward ourselves. Perhaps we will become better people, but according to whose denition and evaluation? Much self-help advice appears to be simply common sense, although certain phrases (such as the Dont Sweat the Small Stuff reminder that soon the world will be completely populated by new people) can have a lasting impression for many readers. Part of the commonsense quality derives from the homey character of advice one might get from a wise elder such as a grandparent. Another part also derives from the everyday popularity of psychocentrism. The notion of the self as knowable, and as a work in progress, is now as familiar to us, and as taken for granted, as brushing our teeth.

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The rst book of the popular self-help series Dont Sweat the Small Stuff And Its All Small Stuff was published in 1997. The author, Richard Carlson, was a psychotherapist who had already published a number of books on stress management, one of which lead to an appearance on Oprah, guaranteeing instant success. The rst volume begins with a quote from William James (18421910), an American pragmatist philosopher and psychologist, whose prolic writings contributed signicantly to the development of psy discourse. Relying on a psychocentric logic, he argued that the greatest discovery of my generation is that a human being can alter his life by altering his attitude (Carlson, 1997: 1). The rst Dont Sweat book remained on the New York Times bestseller list for over two years. Its success led to the publication of more Dont Sweat books, which taught how not to sweat the small stuff at work, in love (co-written with his wife, Kris Carlson), for women (authored by his wife), for men, with your family, for teens, for parents, for moms, and for graduates. The series was successful because of its simplicity; it provided short bits of practical, commonsense advice for achieving a better life, ones that a person could apply immediately: Focus on the things that go right, rather than the things that go wrong. Find time for yourself every day. Write things down that you feel good about. Be compassionate toward other people. Accept your imperfections. Pick up litter. Dont argue with your partner about inconsequential matters. When you die, your in-basket will not be empty. In one hundred years, all new people will be here.

By dening human normality, and thus by extension, abnormality, self-help experts profess to offer strategies and truths to achieve the good life, and indeed the good self. Consequently, popular self-help projects have attempted to affect all areas of social life: how to live, how to work, how to parent, how to love, and how to behave in various spatial and temporal settings. In self-help books, subjects are cast as damaged and injured commodities, as potential consumers of unique and presumably preferable selves, but also as redeemable from within. As a result our culture has witnessed the transformation of ordinary behaviours of ordinary persons into the extraordinary awe-inspiring symptoms of mental diseases (Szasz, 1978: 194). Some of the impetus for a focus on individual well-being emerged from the social movements of the 1960s and 1970s, as people sought personal and social liberation through collective social action and resistance. For example, throughout the 1970s and 1980s, a feminist therapy movement emerged to treat and heal women who had been victimized by physical, emotional, and sexual abuse in a patriarchal world. However, in the 1990s, feminist and Ms. Magazine founder Gloria Steinem began emphasizing womens need to focus on the revolution within after years of feminist activism aimed at challenging socially and historically structured gender inequality. Self-help technologies resonated in Steinems book. The once-popular slogan of the 1960s womens and civil rights movement that declared The personal is political was inverted by Steinems advice to focus on ones
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self to achieve an inner revolution. Over time, the focus on self-transformation, joined with competitive individualism, has increasingly undermined social movements emphasis on collective resistance to achieve social justice and equality. As a result, prescriptions for revolutionary action or social change are being replaced by psychocentricity, thus propping up neoliberal ideals and practices glorifying the individual at the expense of social and political change and analysis. Furthermore, the increasing focus on individual responsibility and accountability has been occurring simultaneously with the dismantling of public services, including health care, forcing individuals to absorb structural deteriorationone partial explanation for the rise of self-help. You have already learned that neoliberalism is predicated on the valorization of free markets (that is, the unfettered movement of capital), on limiting state powers for the regulation of capital, and on competitive individualism. From the 1970s onward, the rise of both neoliberalism and the culture of therapy had a common theme: a focus on the I over the we. Nikolas Rose commented while giving a public lecture in Toronto in the mid-1990s that he had recently seen at a political demonstration by the unemployed, a picket sign demanding Jobs, not Prozac. This slogan neatly encapsulates the sociological insistence that the personal is also social and public. For example, the unemployed person is often not without work because s/he lacks skills or initiative, but rather because local and national economic arrangements have increased joblessness. While some economists claim that a certain unemployment rate is healthy for the economy because it drives competition, what of that percentage of the population that suffer the harsh realities of unemployment? Are they to feel individually responsible or proud for contributing to the health of the economy? Should they feel personally inadequate or otherwise psychologically inferior to those who are in advantageous social and economic positions? The fact is there are more people than there are jobs. Prozac may chemically help some individuals cope with the negative personal impact of unemployment, but it is the creation of new jobs that will resolve personal crises resulting from depression, stress, and anxiety, resulting from job loss. From this example, you can see how Marxs analysis of capitalism and its class structure, as well as Foucaults approach to government, both contribute to our understanding of how people (neoliberal subjects) are constituted through a therapeutic culture that serves to secure relations of domination as much as it portends to liberate the self. The growth of neoliberalism has resulted in the increasing de-responsibilization of social authorities. Moreover, psychocentrism ensures that social and political authorities are exonerated while individuals are held responsible and accountable for situations they did not necessarily create.

CONCLUSION: CHALLENGING PSYCHOCENTRISM To summarize our recent analysis, struggling with the self has become a key cultural theme in modern life. There seems to be a persistent impulse among North Americans to worry about whether they are what they should be, and whether they have the sort of personal traits, skills, social manners, or inner strengths they should have. Experts translate all aspects of human life into myriad dysfunctions, addictions, disorders, pathologies, or destructive
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behaviours that require expert attention and self-treatment. Indeed, the diversity of the psy complex is what makes it so effective: no one is ever really good enough. We are incited, directed, and instructed to be self- and other-critical. In the early 21st century, the psy complex has become the most inuential eld in determining the best or proper way of being human, thus wielding tremendous social inuence. Consistent with the political rationalities of neoliberalism, psychocentrism dominates a cultural landscape, masking how broad and unequal political and social structures, discourses, and practices impact individual lives physically, emotionally, and mentally. The psy sciences provide a corpus of knowledge that categorizes social problems as individual deciencies or pathologies without seriously examining the social contexts and conditions that dene or produce those experiences and differences. While human differences certainly exist, the psy complex classies and hierarchalizes those differences into binary categories of good/bad, healthy/sick, normal/abnormal, moral/immoral, and so forth. Wellness has become conated or synonymous with culturally prescribed notions and practices of normalcy. Productive subjects have to be healthy, upstanding, obedient, and efcientin one word, self-governingin order to sustain neoliberalism in the face of a weakening and quickly shifting global economy, as you will read more about in Chapter 11. We live in a society in which our search for meaning has shifted away from the public sphere toward the privatized self. Yet, whatever self the self is pursuing, we must remember that we are always within the boundaries of cultural meanings. We learn how to appraise and judge ourselves, and how to behave in different contexts: one must not look, act, or talk like the marginalized or abnormal, and if one does, one is socially expected to fulll the obligations of the sick role (Parsons, 1951), which includes following doctors orders and prescriptions. The growing mental, physical, and emotional tensions, strains, and struggles of contemporary culture are indeed expressed in multiple forms. Loneliness, isolation, violence, anxiety, anger, apathy, repulsion, depression, suicide, and so forth, while individually experienced, must be placed within the context of social patterns and inequalities outlined in other chapters of this textbook. These include increasing economic deterioration, social conicts based on axes of age, sexual orientation, class, gender, physical appearance, familial ties, educational attainment, religious status, ethnicity, and so forth. Consider also how cultural prescriptions are contradictory, unrealistic, and nave in the face of many peoples daily lives and social insecurities, such as the lack of affordable housing, growing unemployment, the erosion of pensions, rising food and energy prices, increasing environmental disasters, and the credit crisis. Yet the resounding messages provided by the psy complex imply that peoples struggles are personal and internally produced, as though our experiences in the world were somehow separate and distinct from the social conditions that shape, produce, and order those experiences. Psychiatric discourses have beenand continue to becontentious and problematic for many reasons: classications can be ambiguous, they often lack sufcient evidence or are based upon conicting data, and they are premised on highly subjective notions such as normal and abnormal. The long, political, and controversial use of psy discourse renders the moral and intellectual status of the psy complex scientically and socially problematic.
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As we have already seen in our examples from the early womens and lesbian and gay liberation movements, the rise of psychiatry has not gone unchallenged. The antipsychiatry movement emerged in the 1960s as part of the larger anti-establishment movement, which included the collective struggles aimed at achieving womens liberation and civil rights. Leading anti-psychiatrists include Michel Foucault, R. D. Laing and David Cooper, Felix Guatarri, and Thomas Szasz, all of whom received formal training in medicine and psychiatry. Hostile to the fundamental assumptions and practices of the discipline, anti-psychiatry arguments inuenced the Western deinstitutionalization movement of the 1970s, which resulted in the dismantling of many state-run psychiatric institutions in favour of community-based treatment. Anti-psychiatry advocates have challenged the modern assumption that connement in a hospital or other institutional setting for the majority of those diagnosed as mentally ill was necessary. Today anti-psychiatry advocates also challenge the growth of chemical restraints (drugs) for those targeted as at risk, dangerous, disorderly, disruptive, and so forth, which has become commonplace in the West. Patients and ex-patients have challenged and resisted traditional assumptions and labels by embracing and celebrating their differences as strengths rather than weaknessesas witness, the growing psychiatric survivor and mad pride social movements (Crossley & Crossley, 2001; Curtis et al., 2000; Shaughnessy, 2001). We can also contribute to resistance strategies through our engagement with history and theory. The Foucauldian approach critically interrogates the psychocentricity of the human sciences. This perspective allows something new to be thought, and as Foucault announced, to learn to what extent the effort to think ones own history can free thought from what it silently thinks, and so enable it to think differently (1986: 9). After all, the purpose and promise of the sociological imagination is to produce theories and research methods, as well as new forms of knowledge, useful for understanding the link between private troubles and public issues. Understanding the practices and discourses of therapeutic culture thus necessarily entails critiquing the psychiatrization of everyday life that produces and masks the social and historical bases of human struggles.

STUDY QUESTIONS 1. What does it mean to say morality has been medicalized? What is a current example of this that was not addressed in this chapter?
2. In what ways has the treatment of those classied as mentally ill changed over the past 100 years? How does a Foucauldian approach explain these shifts? 3. How does the distinction between normality and abnormality contribute to social regulation? Provide examples. 4. How have counter-discourses challenged psychocentrism? What alternatives to psychocentrism have been proposed? Try also to think of some examples that are not discussed in this chapter.
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EXERCISES 1. Go to a bookstore to investigate the titles in the self-help genre. Check sections such as health and wellness, business, travel, biography, spirituality, new age, women, lesbian and gay, and sociology. What themes emerge from your investigation?
2. Research a criminal legal case in which a psychiatric diagnosis has been an important component of the evidence and sentencing. How have psy discourses been deployed in the construction of legal evidence? 3. Take note of how many times in a given day you encounter or make use of psy discourse. How does this exercise contribute to your comprehension of Foucaults notion of government?

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