In October 1968, the American journal of Psychotherapy published the proceedings of the Sixth National Conference for The Advancement of Psychotherapy. That Conference, in Detroit, May 1967, took up the question of "psychiatry and its relationship to political behavior". This essay seeks to summarize and mirror what emerged from that conference and to present it as a bellwether signifying where the flock is now and where it seems to be heading. To this end, and after careful consideration of each of eleven contributions bearing both directly and indirectly on this subject, for positions were selected for present purposes. These four papers, and one of them an editorial, present both a broad political and medical spectrum of discord within the house of medicine.
In his editorial foreword, Stanley Lesse, M.D. expressed his hope that these conferences (1) would:

. . . serve as a milieu in which men from the biologic, social, and physical sciences may exchange viewpoints in the service of a more mature approach to the future. hopefully, this will hasten the maturation of the psychologic and social sciences which in our opinion will be signaled by their eventual disappearance. ideally, they will be replaced by a new science that might best be called 'psychosociology' or 'socio-psychology' in which the various elements of human functioning are seen as inseparable, mutually dependent factors. (2)

Aside from the vague reference to the disputed idea of 'maturation', this hope for the disappearance of compartmentalized professions and for the emergence of a new one to focus on all mutually dependent factors in humans is of course admirable - but only if such a new science would not e governed by the demands of narrowed political forces beyond, and within, itself, and only then if the factors of differential status among participants could be eliminated from the processes of scientific observation, analysis and interpretation of findings. But it is the fact of outside controls upon social sciences, and upon psychiatry, and the fact of considerable truckling to power on the parts of the professions, and it is the fact that status rather than science decides etiological issues which keeps Lesse's hope from being more than a pipedream. Lesse hardly touched on such facts, but they are clearly visible when comparing the diverse political postures taken by the several psychiatrists whose positions are reviewed here.

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(1). Lesse noted in his editorial, "Psychosocioloty - Reaching for a Future," american journal of Psychotherapy, Vol. 22, No. 4, that a second AAP conference on the same topic was held in Boston, May 12, 1968 and that a third was planned for Bal Harbour, Florida, May 4, 1969.

(2). Ibid., p. 559


Bureaucratic Hangups and External Controls

Before 1935 it was argued that psychiatry could not progress toward science because it had too little recognition and too little money. today, according to Lesse, such progress cannot be made because it has too much of both. But between these times, when psychiatry had neither too little nor too much, according to Wells, the only noteworthy progress made by psychiatry was what was forced upon it by experimental psychology and the cultural sciences (3). From 1935 on, because of this, many psychiatrists (falling away from orthodox Freudianism) fell back upon bio-chemical diagnostics and upon surgery, shock, and drugs as the principle modes of treatment. Others (falling forward toward culture and social processes) revised the Freudian mystique into ego-adaptation theory and developed a new technology of individual treatment to supplement the older forms of psychoanalysis while utilizing surgical, shock, and drug treatments. A third group (leaning heavily upon socio-cultural determination of mental disorders) developed theories of culture and personality which focussed upon interpersonal relations, values, and culture conflict as causal agents in mental disorders, and while retaining individual psychotherapy they sought for alterations in the environment of patients and for the creation of community mental health programs. this group, initially sparked by Karen Horney, Erich Fromm, and Harry Stack Sullivan has all but coopted the early theory of G.H. Mead which today, in sociology, is known as symbolic interactionism. Here the traditional medical approach stretches thinner and thinner as the door to societal reconstruction as therapy opens wider. But up to this point all three factions remain within the house of medicine and still operate from the mental hospital base (though admittedly short term confinement, and outpatient treatments are an increasing trend).
From this point, and definitely breaking with the houses of medicine and State, are other groups which, following David Cooper's lead, may be grouped under the term, 'anti-psychiatry' (4). The reference here is to the inroads which phenomenology and existentialism, as well as Marxism and symbolic interactionism have made into thoughts about problems of people in relation to structures of power and authority. While Cooper would not lump all such groups under his term 'anti-psychiatry' perhaps, I have done so here merely to indicate the variety of schools which, though greatly concerned with problems of alienation and identity, feel compelled, and for valid reasons, to take a stand outside the houses of medicine and the State.
When Lesse calls for his 'new science' of psychosociology, he is calling for it within the house of medicine - a house politically situated, as Foucault shrewdly observed, at the limits of the criminal law between the police and the courts and serving to isolate or hide from view all deviants from law which cannot be handled by penological methods. That is, traditional psychiatry, orthodox psychiatry, revised psychiatry, and a goodly proportion of 'reformed' psychiatry - all of which operate from the State's university/asylum complex - are forced by virtue of this political position to treat individuals when the causes of their troubles lie in the social structure and call for institutional - not individual - reconstruction. What then is the status of Lesse's hope? By what means did he believe his hope for his 'new science' would be achieved? Apparently his method was to get together a conference of psychiatrists - all but tow were M.D.s - to decide the matter. in view of all this, what did Lesse single out as psychiatry's number one problems?
Lesse deplores the bureaucratization of psychiatry, and the control which bureaucrats and medical diplomats exert over the goals and means of psychiatric research. He deplores the condition of 'grants-manship' among his colleagues - a condition which, in my opinion, implies an eagerness among them to toady to the goals of medical diplomats whose chief interests and those of the State are the same. He sees "compartmentalized, hierarchically ordered medical bureaucracy self-intoxicated by a crash-program philosophy" as the major stumbling block to the development of "original ideas". From researcher to department head, to hospital research committee, to superintendent, to research, proposals are screened, diluted and changed until at last they agree with what they Commissioner and his lawyer friends in legislature have decided are the needs and goals of 'society'. "Too many medical superintendents," Lesse writes, "have become pseudo-lawyers who appear to be more conscious of vote seeking legislative investigating committees than they are of possible medical pioneering." (5)
Medical diplomacy in a bureaucratic setting has been responsible for increasingly large sums of money being allocated by the State for psychiatric research - but only insofar as that research money is used for projects of which the State approves. Crash programs (and here Lesse cites all community mental health programs) have been "anachronistic" even before their implementation. Now psychiatry's community mental health programs have always presupposed the continued existence of the same institutional structure, the same system of distribution of power and authority. That is, they guarantee the continuity of the system which annually produces a goodly proportion of psychiatric clientele. But Lesse does not see the failure of such programs in that light. Instead of seeing the failure as owing to what does not change, he sees it only in terms of what does - viz., population flux, and all its related phenomena that one reads about in ecological literature. Accordingly, Lesse feels certain that sociologists, economists, anthropologists et al. would be able to help plan community mental health programs which would be of lasting effectiveness in reducing the traffic of functional disorders. Having misdefined the failure, he misdefines the remedy for the failure. It is apparently with this in mind that he calls for his 'new science'.
From the point of view of an outsider, Lesse's position is not simply ambiguous. It is absurd. His sincere indignation strikes an unsympathetic chord and has a hollow ring. Lesse takes the position that unless someting is done, psychiatry, psychology, and psychotherapy "are in real danger of a type of 'bureaucratic gold poisoning' inhibiting real progress by making psychiatrists and psychologists mere extensions or pseudopods of a mechanistic structure." (6) In danger of? Is this not already a fait accompli? Has not Lesse already described it as such? One wonders what the Mad Hatter or the Red queen would have to say about all this? After portraying the actual linkage sbetween psychiatry and the State, Lesse warns us that it may yet come to pass. After Humpty Dumpty has already fallen, is not the 'real danger' of his falling already over? With Malice already in blunderland, why pretend that it must not enter? Lesse's position is remindful of a man who could not sleep. After ten years of that, he figured he was in real danger of getting insomnia. Maybe it's the other way around. Maybe the man was actually in a coma, and after ten years he dreamed he was waking up.

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(3). Cf Harry K. Wells, The Failure of Psychoanalysis (New York: International Publishers, 1963), chapters 1,2 with Lesse.

(4). David Cooper, Psychiatry and Anti-Psychiatry (London: Paladin, 1970). Cf. all references cited by Cooper, pp. 139-140, espec. references to T. s. Szasz, Jean Paul Sartre, R. D. Laing, Cf. Michel Foucault, Madness and Civilization: A History of Insanity in the age of Reason (London: Tavvistock, 1967).

(5). Lesse, op. cit., pp. 557-559.

(6). loc. cit.


Psychiatry's Fusion with Political Power

High on the list of medical diplomats is John A.P. Millet, M.D., erstwhile Chairman, United States Committee, World Federation for Mental Health. Millet regards his own role (and that of so many colleagues) as a servant of governments in high esteem. In his paper "Psychiatrists as Servants of Government - Problems and prospects," Millet is careful to avoid defining psychiatry "merely as the specialty of medicine dedicated to the study and treatment of mental illnesses" and is quite reluctant to confine psychiatry "to the actual care of the individual patient." (7)

It doesn't seem to upset Millet that he changed the definition of psychiatry only after psychiatry changed its orientation from care of the patient to that of furthering the goals of powerful minorities (8). As if to justify his more inclusive definition, Millet notes that the marriage between neurophysiology and psychoanalysis "has spread far beyond the consulting room and the hospital". (9) Here the assumption is, I guess, that anything is good if it has spread far enough.

Nevertheless, Millet finds satisfaction in his new King size definition of psychiatry - one he calls "our dynamic psychiatry as the science of motivation, understanding, and control." Millet's emphasis, and the emphasis of many whom he cites as dynamic psychiatrists, is placed on control. If we accept this, he says, "we are forced to the conclusion that (psychiatry) has some pertinence to the study and interpretation of behavior at all levels of human existence - from the embryo to the community of man." (10) It is an indubitable mercy that Millet gives us the option not to accept.
In reading Millet's article, the question kept arising: are we dealing here with some simplistic version of Machiavelli's Prince, or, with a muscular version of Mother Goose? What brings this to mind is Millet's fairyland conception of political behavior in relation to the rest of his work:

What indeed is political behavior other than a special aspect of communication between individuals and between groupings of individuals of various sizes, from the local community to the family of nations? What else is there to ask about or to understand than the motives which bring people together, and the way in which these motives are manipulated or consolidated to a point where they become the mainspring of action? What is there to search for beyond the understanding of this interplay of motivational forces and the most effective means for placing them under control when their eruption threatens the harmony of even the continued existence of the group in question? (11)

Into this concept of 'politics' Millet fits his 'dynamic psychiatrist' who today, Millet opines, "should by all odds be one of the persons best equipped" to study these motivational forces with the view to controlling them, "since with his medical training and his daily study and treatment of disturbed individuals and groups he should have the clearest view of the possible causes at work in releasing disturbed behavior." (12)

Passing briefly over "the more activist type" of psychiatry (and here only Dr. Benjamin Spock's name is mentioned), Millet develops his concept of dynamic psychiatry - and here he excludes all psychiatry and clinical psychology which do not conform to a neurophysiological-psychoanalytic diagnostic and treatment model - which, he says slowly developed since the turn of the century in America but which did not really come of age until after World War II. One realizes in studying Millet's work that nearly all of 'reformed' psychiatry is excluded from this evolutionary model Millet sets forth. It was in the World War II era that such 'dynamic psychiatrists' as Millet, Ernest Kris, Robert Waelder, David Levy, and Leo Bartemeir embodied the American Psychoanalytic Association's newly appointed Committee on Morale. (13)
With Millet as Chairman of this Committee, we begin to see what dynamic psychiatry is all about. Millet sees this neuro-psychoanalytic group as the core of psychiatry - around which paramedical units or "consultive resources" turn. These, he says, constitute such "personnel" as "political scientists, economists, historians, social scientists, and possibly psychologists." Notwithstanding the naiveté of using these words in seriatim, Millet seems undecided whether to include psychologists as part of his paramedical group of intellectual errand boys. Nonetheless, the Committee on Morale was not intended to be simply a committee within the American psychoanalytic Association; it was to have been a liaison between that Association and the military wing of the United States Government.
But the military, at that time, was not in the market for psychiatric consultants on matters of 'morale' because it had already purchased a psychologist for that function. Millet's indignation attending this fact is apparent in his lamentation:

We waited on General Donovan and other officials who then headed the agencies concerned with such questions in their respective areas. We spent a full day conferring with officials assigned to us. We learned that a psychologist had already been appointed to be the chief consultant in the field. Although we had no encouragement to pursue our goals, we continued for a time to meet and discuss our ideas, and learned an immense amount about propaganda from Ernst Kris who had been an active researcher in the field in England. (14)

In the competitive scramble to serve the military Psychiatry lost out to Ph.D.s! This sibling rivalry between M.D.s and Ph.D.s in hospital diagnostic session is well known. But there, of course, the M.D.'s have more power to control the diagnostic labels which will be pinned to patients. in the public arena, however, that power was not initially present. One wonders also whether the committee on Morale was to have focussed equally on all facets of morale or whether it was merely to focus upon propaganda, and the manipulation of morale by means of propaganda. Millet claims the focus was on questions of morale on both the 'civilian front' and in the armed forces. The impression comes through clearly that dynamic psychiatry (among all the other professions interested in human behavior) would be the first and leading point of contact with power and that it would then subordinate as its paramedical units or 'consultive resources' all other such professions - disallowing them any independent contact with the State.
From this early point, integration between psychiatry and the State tightened. Before the end of World War II, Millet reports, a three day interdisciplinary conference was organized by Richard Brickner. The thrust of this conference was to come up with an analysis of "the conflicting cultural compulsions in the German character" and to indicate how "Nazi psychology" emerged out of that situation. The purpose was more than academic - in view of what this conference came up with as suggestions to the Government about what political decisions should be made by it with the termination of war. Among those present were Margaret Mead, David Levy, and Theodore Abel. (15)
By the end of World War II, psychiatry had established a number of consultative relations with various branches of the Government, these persons (spearheaded by Frank Fremont-Smith, Millet reports, "persuaded the Secretary of State to arrange a series of conferences with prominent psychiatrists for the foreign service officers and heads of regional bureaus" then on duty. The burden of the conferences was to enlighten such persons" on the importance of cultural differences and on the basic principles of establishing fruitful communications with leaders and officials of foreign countries." Millet reports that all this was "enthusiastically received" and that it led to the appointment Mottram Torre as consultant to the State Department, a psychiatrist whose first task involved a world tour to consult with state Department personnel on their work problems (16).
During the presidency of Trygve Lie, and at his direction, a number of U.N. functions were allocated to psychiatry. These functions included screening of U.N. appointees, and the tasks of briefing them on the problems of their appointments. Millet reports that Lie had taken this task away from highly prestigious, non psychiatric experts because of difficulties which were spelled out in a book by Margaret Mead and Lawrence Frank. (17) This group of screeners and briefers was disbanded by Dag Hammarskjold, but the task continued to be "nurtured," Millet writes, "by a group of us under the auspices of the World Federation for Mental health . . . . This group met with the personnel director and other leading members of the Secretariat at monthly intervals over a period of a year or so . . . . Since then Mottram Torre, who had served as Assistant Director of the WFMH, has been in continuing contact with the Secretariat as consultant to the Chief Medical Officer of the united Nations on such problems." (18)
These activities were subsequent to the earlier formation of the American Psychiatric Association's Committee on International Relations which followed the Brickner Conference on German national character. In appointing this Committee, George H. Stevenson, then President of APA, named C.S. Bluemel as Chairman, a man interested in the psychology of leaders. At this point 'dynamic psychiatry' was interested in the emergence of psychopathic leaders, but it confined itself to Hitler and Mussolini. The interest in this shifted but the Committee remained intact,, and from that point this Committee moved into many different fields acquiring as many new functions and liaisons with the U.N., with other governments, and with the U.S. Government. We will pick up on some of them later, but for now it is important to see other political liaisons which generated for psychiatry near the end of World War II and the period immediately following it.
The thinking behind the Committee on Morale (Brickner, Mead, Levy, Abel) was essentially the same as the thinking behind the Committee on International Relations with reverence to "Nazi psychology" and the emergence of psychopathy in national leaders - i.e., enemy national leaders. It was in this context that there emerged a mutual attraction between psychiatry and the State Department. it was the kind of thinking which was attracted to the theory that out of something called "German national character" (Siegfried's or Goethe's?) there had to emerge not merely psychopathy among leaders, but psychopathy among followers as well. The State Department and Defense Department, following the implications which 'unconditional surrender' carried in terms of 'denazification' of Germany, once the Nuremberg idea was adopted, were intensely interested in means for delineating between the 'real' Nazis and the good guys. Millet is eminently proud of the role which psychiatry played in the delineation process, despite the fact (which Millet neglects to mention) that the whole process was a farce from start to finish - accomplishing none of the stated objectives of the trials. The same David Levy who had taken part in the whirlwind three-day conference on the emergence of "Nazi psychology" was sent to Germany after the war, Millet reports, "for the express purpose of advising the U.S. High Commissioner on the selection of testing procedures which might be helpful in sorting out the sheep from the wolves." Millet continues:

Dr. Douglas kelly and Dr. Bertram Schaffner were attached as advisers to the U.S. Commissioner charged with the trial of the Nazi leaders. Dr. J. R. Rees of England, with Drs. Nolan Lewis and Ewen Cameron of the United States, were charged with the responsibility for a diagnostic evaluation of the mental condition of rudolph Hess, the Nazi chieftain who had such a peculiarly dangerous solo flight to England to wage peace in defiance of hitler's designs. (19)

The question arises here, if, as Millet implies, these dynamic psychiatrists were at all instrumental in the attempt "to separate the sheep from the wolves", then what was the result? If the whole thing ended in a fiasco, which it apparently did, and if it accomplished the reverse of its objectives, which it apparently did, then would Millet still take pride in this kind of servitude? The question of Millet's possible naiveté on this matter is open. Conceivably he should take a lesson from Otto Kirchheimer who studied this process much more carefully that Millet for all of his 'dynamism' has done. kirchheimer writes:

Mass prosecutions follow unavoidably from the failure to differentiate between leaders and followers in a politically hostile organization. It was this type of dilemma which the American occupation authorities conjure up in their quixotic insistence on making their German charges initiate denazification proceedings against a potential of 3,669,230 people. This vast multitude became theoretically liable to the proceedings - a sort of cross between a criminal court and an administrative agency . . . . this attempt to institute bona fide court proceedings on a conveyor belt's system . . . was from the outset destined to bog down under its own weight and become a meaningless paper shuffling. Far from isolating major National Socialist Leaders, it created a firm bond among the disparate crowd of potential victims of denazification, from the master brains who had directed the political and economic sectors of national life to the last village teacher and postal clerk. In due course, its originators had to smother their own brain child in a cascade of scarcely face-saving 'amnesties', and with it any serious attempt to expose the responsibility for the regime's culpability. (20)

The aim of the Nuremberg trials was to transmute the harms of the Nazi camp into the status of crime and those of the allies to the status of penal sanctions. This, as Kirchheimer implies, was consistent with the aim eventually to disorganize the enemy camp and "to convert the established fact of defeat into the image of its historical and moral necessity." (21) The political aim of the State and the aim of dynamic psychiatry were one and the same at Nuremberg. Psychiatry was asked to do an impossible job. It eagerly accepted. It failed. Millet takes no credit for its failure - wanting merely to promote this sort of enterprise as a servant of government.
But the question most important here is one of precedent. For the first time in history, psychiatry has aided the State not in its business of packing people off to the mental hospital but in packing them off to the executioner and to prison. What is established is the fact that internationally those very people who were believed by psychiatry to be mentally sick were nudged along by psychiatry not into psychotherapy but into the grave. Inadvertently or otherwise, the function is just that. For to give findings to political figures that this or that person is (or is not) a 'real' Nazi (a 'sheep' or a 'wolf') is to set in motion all the processes of incrimination with which the Nuremberg trials carried out its "conveyor belt system".

The early Committee on International Relations soon shifted its interest in the psychopathology of national leaders to the study of "patterns of psychiatric care in the newly developing countries of Asia, africa, and Latin America, with particular emphasis on the great variety of attitudes toward mental illness and the many difficulties involved in promoting and assisting the new programs of prevention and care." With this shift of focus, APA changed the name of the Committee on International Relations, to the Committee on Transcultural Psychiatry. The interest of this Committee appear to be two fold: (1) to further the transplantation and development of Western (i.e., American) systems of psychiatry in traditionally cultural settings, and (2) to reinterpret folk mental distresses (those remitted by folk practices) into concepts which define the rather standard categories of mental illness as they appear in the APA's system of nomenclature. The first item involves creating or furthering the position of a hospital/university complex between the prisons and the courts where all cases not possible to handle penologically will be handled for the State psychiatrically. The prison represents those who are said to be personally responsible and accountable for their conduct. The mental hospital represents those said by psychiatry not to be responsible. Both involve confinement of course. The second interest neatly dovetails with the traditional conceptions of mental distress, by systematic reinterpretation, are discredited. Folk preventatives and remissions are equally discredited in the same process, and this clears the way for transferring distressed persons either into prison or into an asylum, or else into the newer urban roles of citizenship.
Nowhere will one find this stated as the purpose of "transcultural psychiatry', but everywhere one sees this sort of thing happening. If not the purpose, then certainly the function of this activity is that of assisting the State in the disestablishment of traditionally institutions, and it is just here where psychiatry as a political weapon of social control is clearly seen. Both processes which transcultural psychiatry is engaging in are appealing to the State, and appealing to larger numbers of students, bureaucrats, and native psychiatrists - since all of this is passed off as scientific and is made credible in that manner. Few pause to ponder the fact that no science is in it. In Millet's fairyland of politics the whole matter is put as follows:

There is no more acceptable good-will ambassador to foreign countries who are afraid of American dominance that the purveyor of health services., It is, therefore, important to realize that work done by men like Dan Hertz in Liberia. Wittkower in Nigeria, Shaffner in the West indies, Rees in Siam, must be considered to be of the greatest political significance. It is only through the understanding of cultural differences and the individual motivation of leaders in these foreign countries that the much needed reforms could be made to succeed. In such work the psychiatrist becomes an ambassador without portfolio. (22)

Of course, as even a most cursory glance at the cross-cultural research conducted by these 'ambassadors without portfolio' will sow, they know very little about the cultures of the people whose distress they pretend to study. They do not relate the symptomatology of stress to the culture, to the status role systems, or even to pre-onset behavior for that matter. For Wittkower, culture is merely an antecedent, 'pathoplastic' condition. That is, as a static blueprint for action, culture is seen merely as a molding force, the force which 'explains' why 'precultural' psychopathologies show a wide range of variation syptomatologically from one society or period of history to another. Thus, when a transcultural psychiatrist gets his description of the syptomatology of a person under stress (and often from second hand sources) he only assumes that 'culture' had molded 'it' this way - not that culture created it in the first place! Once this assumption is made - and it is typical to do so - then transcultural psychiatry forgets all about the culture concept and gets down to psychiatry-as-usual - that is in the relabeling the behavior, fitting it under pre-fabricated, western categories of psychopathology - and then (now defined as a sickness) defining a 'need' for psychotherapy (and or 'mental health') in the culture in question. As fast as they invent a spurious 'need' for psychiatry and 'mental health', they encourage the development of State-hospital systems, and western trained psyciatrists, to meet this alleged need. As fast as these ambassadors are softening the ground by creating the illusion of mental illness in traditional society, they are creating and deepening their links with the State by providing hospitals where 'therapy' to cure the victims of traditional behavior can be scored as a victory for the theory or rational progress.
Giving plaudits to Brando Wedge of Princeton for his incipient programs for the development of these new ambassadors of good will, Millet calls for more of the same:

The time is ripe now for the organization of special postgraduate programs for the education of psychiatrists eager for participation as contributors to solving the problems of modern society and for active work in some participant capacity near the center of policy-making. (23)

The image of the participant psychiatrist, the ambassador with portfolio, near the center of power summarizes only one movement within the house of medicine, the movement called dynamic psychiatry which Millet has described, and which I have critically reviewed here is rapidly expanding locally, nationally, transnationally. but at the other end of the psychiatric political spectrum, and also within the house of medicine, a countervailing movement, seeing its role as political activism, has also emerged. The psychiatry which Millet called 'dynamic' is the child of political and medical orthodoxy which was born in the era of World War II. The psychiatry of political activism is the child of all the conditions which led to the 1964 "Triple Revolution" statement to President Johnson and the Congress which supported him.


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(7). Millet, american Journal of Psychotherapy, op. cit. p. 646.

(8). Cf. Simon Maddison's "Mindless Militants", this issue of Catalyst.

(9). Millet, loc. cit.

(10). loc. cit.

(11). Ibid., p. 646

(12). Ibid., p. 647.

(13). Ibid., pp. 647-648.

(14). Ibid., p. 648.

(15). Ibid., p. 647.

(16). Ibid., pp. 649-650.

(17). Cf. Cultural patterns and Technical Change, (Paris: UNESCO, 1953).

(18). Millet, op. cit., p. 650. Millet goes on to mention the increasing role of psychiatry in the psychometrics of international conference communication problems.

(19). Ibid., p. 652.

(20). Political Justice: The Use of Legal Procedure for Political Ends (Princeton: Princeton University Press, 1961), see pp. 8-9, and footnote 4, pp. 8-9.

(21). Ibid.

(22). Millet, op. cit., p. 649.

(23). Ibid., p. 653.




The Emergence of Psychiatric Activism

The proper role of psychiatry as defined by Millet would hardly include the kind of psychiatry as described by Paul Lowinger, M.D. of Detroit whose contribution to the Sixth National Conference was given the title, "The Doctor As A Political Activist". (24)
In Lowinger, the Never Never Land of politics as set forth by Millet vanishes. What we have here is a progress report of the new left in Medicine with special reference to the role of several organizations which have sprung up in the last decade: Physicians for Social Responsibility, Committee of Responsibility, Medical Committee for Human Rights, and the Student Health Organizations. The take off point for all this, Lowinger reports, were the conditions leading to the 'Triple Revolution' memorandum of 1964. Activism in medicine and psychiatry as it pertains to these organizations involves demonstrations, lobbying, marches, political campaigning, publishing, public speaking, soliciting, giving medical aid to demonstrators, refusals to practice medicine under certain conditions, taking part in the activities of those whose lives are being harmed in some way by the practices and policies of the powerful.
What brings such actions into play, Lowinger reports, are nuclear blasts, fallout, use of chemicals, tear gas, viruses, crop defoliants, nerve gas, and germs in warfare. In other areas these strategies come into play owning to air pollution, prolonged war, stricken women and children in war-torn hinterlands of American foreign policy, escalation, the draft, use of napalm, genocidal practices, segregation, discriminations of all sorts. it is clear that activism in medicine is part of the activism in general in the United States. The fact that M.D.s are doing it only testifies to the interclass, transprofessional character of activism.
Just as Millet neglected to mention all this in painting his picture of the dynamic psychiatrist, so did Lowinger omit reference to psychiatrists who have left the house of medicine entirely due to incompatibility between their views, their theory of mental distress, and the views and theories of individually oriented medical psychiatrists.
On the medical spectrum, Lowinger and Millet occupy opposite positions. For Millet the causes of mental disturbance are bio-chemical and must be treated that way, patient by patient and, were necessary, under conditions of confinement. For Lowinger, the causes are socio-cultural - having to do wit all the social conditions of powerlessness which lead to functional disorders - and must be treated by altering, sometimes radically, the institutional structure of an entire society. For Millet, the very demonstrations involving clashes with police and military in which Lowinger finds a role for psychiatry would no doubt be viewed as the evidence of mental illness and as objects of social control. For Lowinger, apparently, such demonstrations, signifying social movements and the reallocation of power, are the signs of mental health. What must be controlled is the State, the military, the police, and all other forms of human oppression. Obviously, a position on the medical spectrum determines largely one's position on the political spectrum.
Millet's hero gets close to the centers of power and services them all the way. Lowinger's hero identifies with the young, the masses, the oppressed. For Lowinger, therapy involves direct intervention in social happenings by participatory involvement with those who are oppressed. Therapy is social and is at once political for that reason. For Millet, therapy involves direct intervention into the nervous system of the organism. The medical and political issue here are one and the same - that of power versus pills for individuals.
Lowinger's reasoning that functional disorders are a function of socio-cultural factors, and especially those having to do wit the distribution of power and authority is quite correct and is demonstrable on empirical grounds. But the logical extreme of this argument is not demonstrable - i.e., that 'sanity' or 'mental health' is a function of holding absolute power. How power is viewed, the goals to which power is applied, the means by which power is asserted in achieving its ends, the distribution of this power, and the whole problem of the manner in which work is organized according to people's values and aspirations - all this, and minimally, must be taken into account. But especially important is the obsolete and fictional theory of individual responsibility and personal accountability upon which the whole legal structure of western societies still rests. Nowhere within the house of medicine, nowhere between the positions of Millet and Lowinger are these matters considered as crucial to personal integrity.
Lowinger is correct to assume that treating the causes of human distress is not to apply surgery, shock, drugs, and talk, but to bring more power to the powerless. But none of this can be a lasting accomplishment short of overhauling the present power structure (which is transnational) and the pivotal institutional structure upon which that power rests. If Lowinger really believes that the causes and the cures of mental illness lie in the socio-cultural system, and not in the organism as such, then he has no theoretical grounds, no scientific basis for remaining within the house of medicine. Yet, in his closing remarks is evidence that he wants to stay where he is.


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(24). The American Journal of Psychotherapy, op. cit. pp. 616-626.





The Foundations of Psychiatric Ideology

Judd Marmor, M.d., Clinical Professor of Psychiatry, University of California at Los Angeles, and Director of Divisions of Psychiatry, Cedars-Sinai Medical Center, presented the lead article in the published proceedings of the Sixth National Conference. In "The Psychodynamics of Political Extremism." (25) Marmor quite typically assumes, but fails to maintain, a rigid distinction between the given reasons for political behavior as they exist in the ideology of the actor as part of his recollectable social experiences, and the "unconscious psychodynamic patterns that motivate an individual powerfully, and often blindly, to hew to an extremist political position regardless of the realities involved." This primary distinction, one so astutely examined by Laurie and Ian Taylor in this issue of CATALYST - between motives and motivations constructions is based upon inferred motivations, motivations operating beneath the level consciousness. The ghost of Arthur Schopenhauer still aunts psychiatry but in its ascetic un-Byronic mood.
In evaluating Marmor's position, the contention is not that his 'underlying' motivations do not exist, but that conscious motivations for political extremism also exist and are inherent in the particular culture which, as ideology, people internalize from others and in term of which they define and act toward the social world as they see it through this screen of meaning. ideology then is an internalized part of the personality character system, an unavoidable part of motivation itself. Anthropologists and historical sociologists have accumulated a staggering amount of ethnographic materials in support of this argument. But only a negligible, and dubious amount of such evidence supports the position of precultural and 'powerful' underlying motivations of the kind which Marmor seems to have in mind. For this reason not only Marmor's premises but also their derivative propositions must be regarded as specious.
What then are these propositions? First, Marmor states:

"A clear distinction should be made between the psychologic motivations underlying any particular point of view and the point of view itself." (26)

Fair enough, but in such a distinction one should lay down empirical criteria to allow us with validity to differentiate between A) those motivations which actually underlie a viewpoint or ideology form B) those which as attitudes are a part of the viewpoint or ideology itself. This kind of thing would allow us te singular advantage of not confusing levels. Moreover, it would then be necessary, under B, to set forth criteria by which to identify those culturally specific attitudes which may be present to the consciousness of the actor as opposed to those culturally specific attitudes which may have motivational import but which are not present to consciousness. But here we encounter difficulty - owing to the fact that culturally specific attitudes not present to consciousness may be cued into it while others present in consciousness may become momentarily 'dormant' - depending upon changes in the experiential situation of the actor and upon any redefinitions of it which the actor may achieve. For convenience I will refer to Type B motivations (as above) as historically and cross-culturally variable, and to Type A motivations (above) as inferred motivations of the kind which ostensibly Marmor had in mind when he used such phrases as "underlying", "unconscious psycho-dynamic patterns", "blindly", etc.
What is characteristic of Marmor's 'psychodynamics' is his failure to do what he set out saying should be done - viz., making a clear distinction between "psychologic motivations underlying any point of view and the point of view itself." Thus, throughout his paper one sees that Marmor treats as underlying and/or nonconscious motivations those motivations which are very probably motivations of type B, as stated above. It is owning to his failure to set forth empirical criteria that gets him into this sort of muddle. Of course, if we take ethnographic variability seriously, there may be no 'underlying motivations' of type A except those which are shared commonly by all sorts of 'extremists' and moderates alike. History is full of accounts of masses of moderates who turned extremist - owing to changes in motivations of the type B kind. It is equally full of revolutionaries who become moderates. Are we to presume here that unspecified and inferred motivations of a type A kind underwent a parallel transformation? No position would be less certain.
Marmor's first proposition (without specifying the necessary criteria) leads typically to confusing, and reconfusing, levels of motivation. This point was the focus of a good deal of informal discussion between myself and three psychiatrists who also participated in the Third International Congress of Social Psychiatry held at Zagreb, Yugoslavia in September, 1970. This group was an international mixture and each of us had independently arrived at remarkably similar conclusions in relation to this problem: Each was critical, on scientific grounds, of the unscientific diagnostic behavior of his psychiatric colleagues in pre-revolutionary, revolutionary, and post-revolutionary times. The interest and consensus may be paraphrased as follows: In times when social movements (including revolutions) are taking shape, leaders and followers verbalize and publish a great deal of literature setting forth the accepted, fully conscious (type B) reasons for revolutionary behavior as a logical beginning point in the further development of the ideology of the movement. In these same periods, psychiatrists generally discount these type B motivations (as is quite predictable given their own ideology) - saying that these reasons are 'superficial', 'ideological', and cannot be trusted at their face value. They then infer from this that there are deep-seated or 'underlying' motives operating 'behind' these verbalized motivations which are the 'real' causes of extremist' collective behavior. The stated motivations are then viewed as 'rationalizations' or mere covers for some deep-seated 'psychopathology' inaccessible to the consciousness of he actor. The stated reasons which call for institutional reconstruction, and especially for a redistribution of the authority power system, are then summarily written off as delusory - a 'symptom' of the 'sickness' itself! In this context, psychiatrically viewed, leaders become 'sick' and their followers become 'blind'. had psychiatrists been alive during the American and the French Revolutions they would no doubt have said the same things.
But what happens after revolutions have been successful? What usually happens is an attempt to make the necessary reforms as stated in the 'ideology', and this involves a process of translating the stated reasons for the movement into 'programs', changes in social structure, changes in land tenure, education, the distribution of wealth, power, and a good deal of this comes to re-writing the criminal and civil codes - making many behaviors legal which once were criminal and vice versa. it was an especially sore point in this informal discussion when the analysis turned toward psychiatric diagnostic behavior after revolutionary governments were clearly in power.
Here the same psychiatrists who had asserted that revolutionary leaders wee mentally ill and that their followers were 'blind' wholly abandoned that diagnosis. Now they proclaimed that the new regime was wholly rational, that their once-psychopathological motives (of type A) are now the acceptable motives of type B. The ideology of the movement together with the programs and laws which derived from it have, as if by magic, transformed into the epitome of sanity, justice, rationality, and the rest of it. Now psychiatry stands in full agreement with the new regime (as its new 'ambassadors without portfolio'). Now, only the enemies of the new State, its newly produced enemies, can become subject to the same diagnoses as once befell those who sought for power. It is possible that diagnoses based upon projections of type A motives are absurd? Or, if not absurd, it is possible that type A motives suddenly transform to those of type B in any major transformation of social institutions? This latter position implies that only the powerless can be insane? Or, is that all motives are of type B? Now we can appreciate what a real muddle psychiatry is in - simply because it has specified no empirical criteria for making the distinction which the good doctor Marmor insisted was necessary.

Marmor's second proposition reads as follows:

"Unconscious psychologic motivations are not confined to those holding unpopular or extreme points of view." (27)

Indeed not! Many motivations of type B, before cued into consciousness, are common to all culture-bearers, just as are those of type B which are present to all culture-bearers as conscious ends-in-view - i.e., as goals. I think it goes without saying that when goal-acheivement is continuously blocked, frustrated, punished on a massive enough scale, then other means, commensurate wit the emotional build-up this implies, are resorted to. But in this kind of accounting of 'extremism' the kinds of motivations Marmor infers are present (those of type A), if they exist, are inessential to explanation, inessential to understanding, inessential to prediction.

Marmor supplements his second proposition with:

Personality factors are just as relevant to an individual's taking a moderate moderate political position. Whether one regards such middle position motivations as invidious or praiseworthy usually depends on where one stands on the political spectrum itself. It is not uncommon for extremists at either end to save some of their choicest epithets for those who choose the relative 'safety' of the middle. (28)

One should carefully note here that in this context Marmor has literally equated 'personality factors' with 'unconscious psychologic motivations' but without specifying exactly what these motivations are or how they stand vis-à-vis other types of conscious and nonconscious motivations of Type B. Are not these other motivations 'personality factors' too? In the second sentence we have a clear case where Marmor confuses levels of motivation when he refers to 'middle position' motivations. A word of clarification is needed. 'Middle position' on 'the political spectrum' clearly (and from Marmor's usage) indicates an ideological position with respect to two other opposing poles (extremisms), and this may be also a position on the power spectrum. Now Marmor is clearly referring to type B motivations inasmuch as 'middle position' motivations are not unconscious ones, but are either fully conscious or else may be readily cued in to consciousness. After equating unconscious motivations with 'personality factors' Marmor then shifts levels to type B motives but without telling the reader about it. What Marmor has done here is to classify all motives of type B (conscious or otherwise) under a type A, inferred category oof unconscious motivation! This is a nice piece of semantic drift but it contributes only to a great deal of confusion.
A further note is necessary to this second proposition. That is, the ideological content (and hence motivations of type B) which make up the two extremes and the middle on Marmor's political spectrum are treated by Marmor as static categories. That is, Marmor totally ignores the historical and cultural dynamics of this ever changing spectrum. Herbert Spencer's liberal in the last century was a conservative during the 1940's. That sort of 'liberal', or is it 'conservative', take many shades of ideological coloring and all of them are activists. It is, today quite impossible to tell where the middle actually is in the United States. If the 'middle' can't be located, there where are the 'poles'? Or who can tell any longer just what (or where) the poles are? If this can't be identified, then where (or what) is the 'middle'?
Apparently Marmor sees himself in 'the middle', but if he is, his theory of motivation, as an accounting of 'extremism', functions as a rationale for an extremely authoritarian State. The third proposition Marmor sets forth registers another instance of confusion of levels, for here more than in his second proposition he jumbles together all sorts of motives conscious or otherwise. Moreover, if he is actually interested in nonconscious motivations here, then his third proposition suggests that he is actually talking about nonconscious motives which are culturally relative, highly variant in space and time. And yet, his topic is the psychodynamics of political extremism. By the time we get to the following proposition it becomes hard to be sure just what Marmor's topic really is:

No single psychodynamic formulation can apply universally to every person who takes an extreme position. Any careful and objective study of such individuals will always uncover a range of varying personalities and motivations. However, the percentage of deviants from the 'norm' (itself a relative concept derived from the patterns and values of the large center group) will obviously increase as one moves out from the center to either extreme. The psychodynamic patterns that I shall describe for political extremists, therefore, are applicable to many members of such groups but not necessarily for all of them. (29)

If no single formulation can be made with reference to the psychodynamics of political extremism, owing to cultural (ideological) relativity or variability, then (1) obviously Marmor is dealing with type B motivations which require an anthropological or a symbolic interactionist explanation and not a psychiatric explanation at all, and (2) there is no justification for presenting his ideas as the psychodynamics of political extremism. Moreover, if this third proposition is true (up to the last sentence), and I suspect it is, then there is no reason for Marmor to distinguish between a person's psychological motives and his ideology or point of view - which of course he does advocate in his very first proposition! That is to say, it is not possible to make a clear distinction between underlying psychological motivations and a point of view since both are culturally relative, in great historical flux and because they are dynamically intermixed all the way. it is also impossible, moreover, to pint to or identify any unconscious motivations which are not an integral part of the attitudes of which every point of view is composed. Thus, when Marmor admits of the fact of the cultural relativity of motivations, he has at once defeated his own objectives - that of explaining political extremism on psychiatric ground. When today's moderates can be removed from their middle position of 'safety' by transformations of the political power distribution, those attitudes -dormant once because of safety - will make extremists of them all. And is not that very thing happening? Where is the safety of the middle?
Since the remainder of Marmor's article is characterized by the patterns of logic, illogic, and confusions of levels of motivations as are demonstrated in the foregoing materials, it is unnecessary to continue this critique through to the end of his work. Paying a great deal more attention to methods for the validation of type B motives by good use of ethnographic data would doubtless go a long way to cure Marmor of his fetish for inferred (and untestable) motivational variables. It would, in short cure him of psychiatry. I said at first that Marmor's argument was specious. More correctly, it is quasi-specious. a specious argument is both plausible and deceptive. His argument is not plausible.
The aim of this paper was to use any varying conceptions of the political role of psychiatry, as held by psychiatrists themselves, as a possible bellwether to indicate where psychiatry stands politically and to give some general information where it seems to be going. From the various positions presented here, it is impossible to discern any uniform consensus among psychiatrists with reference to how each one defines the role of psychiatry in political life and in relation to the State. What we do see is a wide spectrum of varying conceptions and attendant actions among psychiatrists themselves - all of which indicates that today, in view of prolonged domestic and international problems and tensions, that within the house of psychiatry these conceptions are rapidly polarizing and thus political factions with regard to the political role of psychiatry are becoming much sharper than they appeared to be even 20 years ago.
This splitting into camps (between the position of Millet on the one hand and that of Lowinger on the other) is not simply a household quarrel because it implicates the future of psychiatry with reference to theory, methodology, diagnosis, and treatment of mental disturbances. Millet's generation began in the World War II era when the world outlook was quite different and when among professionals generally the idea that America represented a democracy was for them credible. Lowinger's generation lives in a different sort of world (and here I don't mean necessarily to imply merely chronological age). It contains none of the illusions about politics which are present in Millet's paper.
This political schism within psychiatry rests upon (1) the outward changes in the national culture since World War II (as indexed by the Triple Revolution statement), (2) the inertial forces of World War II ideology among Millet's generation, and (3) the cumulative buildup of the influence of anthropological and sociological knowledge regarding human conduct (with regard to 'dehumanization', 'alienation', 'anomie') which increasingly fed into the experience of younger psychiatric novitiates from the World War II period onward. Actually this influence upon psychiatric theory of the findings of psychiatry and sociology has been growing since about 1935, but it became acute in its influence in the post World War II era.
The point is that this political schism tears along the same points as the schism regarding etiology, diagnosis, and treatment of those who fall under one or another form of functional mental disorder. That is, psychiatric activists associating mental disorders with socio-cultural conditions of the social structure ('dehumanization', alienation, deprivation) turn to the social stratification of authority and power and to the conditions of relative powerlessness in their etiological schematics. Treatment is not to be seen as individualized but as social - involving the altering of institutionalized conditions of powerlessness either by direct or indirect action. In this conception, it follows that spontaneous social movements which aim to establish a new order of life are not to be regarded as 'symptomatic' of mental illness but rather as therapeutic. The emphasis is on changing or adjusting the societal systems to meet the needs (material and symbolic) of the persons who are expected to serve in such systems. here, therapy and institutional transformation, roughly, become the same things. Now this poses quite a dilemma for psychiatrists who want to get into the profiteering markets in their buildup of private practice. Activism in psychiatry rather precludes the fee-for-service approach and the individual treatment system such profiteering rests on. Psychiatrists who got into the game for reasons of guaranteed sinecure can be expected to find all sorts of 'scientific' reasons to continue with what they are presently doing.
At the other end of the political spectrum within psychiatry, we find lip service given to socio-cultural conditions, but the bias is toward bio-chemical causation of mental disorders, and bio-chemical, individualized treatment. This is the so-called 'dynamic psychiatry' group of which Millet is so fond - those who want to be closer to the centers of policy-making and to use individualized therapy as a positive measure of social control. Here the problem is not defined as one of powerlessness on the part of the distressed but rather how to treat individuals in such a way as to get them to adjust to the standing norms of the community. this group generally, and this is notable in Marmor's treatment of 'extremists', want to emphasize that all motives which figure into deviant behavior are 'underlying' ones, ones generally not present to the consciousness of the individual. The fundamental, though nondemonstrable, premise of 'dynamic psychiatry' lies just here - in the theory that all motivation is of the type A (or 'transcultural') kind. The meaning of 'transcultural psychiatry' lies just here, and this phrase, wherever it appears in psychiatric literature should not be confused with 'cross-cultural' psychiatry. The latter carries the opposite premiss that all motivation (of a researchable kind) is type B (i.e. culturally variable) motivation.
What all this means is that if the articles of medical faith of a given psychiatrist are known, then one has a fairly reliable index into his political role as he defines and acts upon it. It is fair to say that when these polar extremes and the middle positions between them are examined, the role of psychiatry in political affairs is less than uniform. If forced to specify psychiatry's political role with reference to how it is defined within psychiatry, one could say only that psychiatry is a clear cut case of role confusion. Or if 'true' psychiatry has but a single role to play in politics, would the real psychiatrist please stand up and tell us about it?
Given the general role confusion within the house of psychiatry, where is psychiatry moving? Which factions within psychiatry will lead psychiatry where? There are several things that have to be considered in answer to such questions. First, transcultural psychiatry and social psychiatry are supported monetarily and politically by local, national and international economic and political institutions. That is, the constraints upon conservative psychiatry are far less, and the economic and political supports are far greater than is so for activist psychiatry. Second, conservative psychiatry is existing within the framework that the State and traditional medicine expects it to exist within - that is, the mental hospital and medical school complex and the increasing dependence of conservative psychiatry upon surgical, shock, and drug treatment (i.e. direct alteration of the nervous systems of deviants from the laws which the State creates in furthering its own interests. fundamentally traditional psychiatry in the State Hospital setting is by design and function an instrument of social control. 'Dynamic psychiatry' is merely extending its operations outwardly from this political foundation. It does so in a multiform way. While national penology cannot extend outward past the borders of the nation in any direct way, psychiatry can, and it does. The processes involved in this should be the focal point of many serious studies of the shifting character of social control. Third, activist psychiatry on the other hand, fails to have these supports, and the constraints upon it are many and durable. Fourth, in theory and in its direct involvement in social movements, it is acting outside its medical and framework. Its action runs counter to concepts long endeared to the house of medicine (and the pharmaceutical firms), and in no way is treatment associated with the mental hospital or with social control in the usual sense of the term. Fifth, the positive inducements given to activists (in terms of status, prestige, splendid bank accounts, life-style) all stand liable to forfeiture. Each involvement with activism in the community among activist psychiatrists would seem to increase the 'mortgage' further and hasten the day to institutional foreclosure. sixth, there is a positive desire on the parts of activist psychiatrists to remain within the house of medicine.
In view of this it is indeed most difficult to see just where activism in psychiatry can have continuity as a part of the house of medicine. The medical models of human behavior are everywhere functionally obsolete, and yet owing to their political and prestige supports they are everywhere expanding. This very faction within psychiatry which recognizes this cannot be consistent with its knowledge of human behavior, and its knowledge of social conditions as related to it, and at the same time be consistent with these obsolete models of human conducts. That is, nowhere are the demands of science and the demands of the psychiatric profession in greater contradiction. If activist psychiatry can continue, it is apparent, in view of these forces, that it must leave both the house of medicine and the service of the State, and at once forfeit the hope of fee for service. it would find itself lined up as much on the side of the politically oppressed as conservative psychiatry has aligned itself with the sources of physical and mental domination.

The American University in Cairo.

_____

(25). Ibid., op. pp. 561-569.

(26) Ibid., p. 561.

(27) Ibid.

(28) Ibid.