David Smail - psychiatry and power - antipsych

[avalokitesvara]

Reading David Smail's book How to Survive Without Psychotherapy. With incredibly deep compassion for and understanding of human nature, Smail hows how pyschiatry's fundamental flaw is its inability to account for the functioning of power over individuals and how this deeply impacts any individual's ability to "change" in the way that the logic of psychiatry expects in order to justify its own existence. He shows the way power functions in a family to shape a child's approach to his or herself and to life, and how the internalisation of power relationships as being somehow one's own fault leads to the intractability of deep guilt and shame which from the base of "mental illnesses". Not to mention psychiatry's not-so concealed aim of imposing societal standards of behaviour. He shows that the world we grow up in and then inhabit, the external forces, absolutely must be taken into account when considering individual distress.

For me this is very freeing. I've long carried a belief that I "have" "depression" and that it is somehow my fault that I don't find meaning and values in the things of life. But the world I live in is one in which meaning and values have been stripped away to benefit those in power. Human beings in the last 40 years have been subjected to absolutely ruthless forces undermining every aspect of meaning in our lives, from education to the idea of a career to the stability of having a home, from the notion that the information we receive has some kind of relationship to truth to the notion that those in power have the majority's best interests at heart, from real in person communities to local traditions, even the deep meaning of the cycle of seasons and the life of nature. I am a product of a plasticised, polluted, distorted world of extreme power imbalance. I am a product of a world where due to greed, those in power have made the water un drinkable and unswimmable-in, made the seasons turn on their head, made it impossible to imagine reproduction. Made the idea of a steady job and income and stability laughable. Even commodified human relationships. I refuse to accept it and my depression is a sign of my awareness of reality, in fact is healthy, rather than acquiescing to the consolation prize of blind consumerism and suckling on endless streams of entertainment. I just have to find meaning in very small very simple things, and love those I come across, and scrape my subsistence however can. Yeah it's fucking sad when society used to have an idea of the value of the individual and the human spirit. Yeah I have many gifts that are wasted because power has cut off my ability to actualise them. Yeah that's how it is. I refuse to place the blame on myself, find it somewhere inside me, anymore.

And I refuse to submit to psychiatric explanations anymore. I don't have an illness. I am a product of the world.

 

[CatLvr]

I have not read his book but am off to order it. Thank you for sharing your thoughts.

 

[ObsidianEnigma]

Interesting book. Thanks for sharing.

It closely aligns with my experience. Because of external factors and also the choices I made, I am in a bad situation. I can try to reframe the facts, try to find some joy in it, try to think positively, but the situation itself cannot be changed.

 

[avalokitesvara]

I've finished the book now. The final 1/4 is pretty disappointing. Smail obviously struggled to find a positive note to end on, so what he settles on is not far off from "bootstraps" style, just get on and try to change your life for the better (albeit with compassion for the extreme difficulty of this), which really undermines his entire thesis for me. He could have been realistic and said that for some people their lives are just fucked, and the best they can hope for is distraction/sedation. I also wish he'd
explored a bit more what the alternatives to current power systems might be, whether there is really any hope beyond any individual's small victory of wresting more scraps of power for themselves.

Smail was also writing at a very specific time of UK history, both relatively recent but also lightyears away in terms of social, economic and technological changes. I think his gentle pessimistic realism would dial up a notch to more Mark Fisher style full on pessimism if he was writing today.

 

[Forever Sleep]

I've finished the book now. The final 1/4 is pretty disappointing. Smail obviously struggled to find a positive note to end on, so what he settles on is not far off from "bootstraps" style, just get on and try to change your life for the better (albeit with compassion for the extreme difficulty of this), which really undermines his entire thesis for me. He could have been realistic and said that for some people their lives are just fucked, and the best they can hope for is distraction/sedation. I also wish he'd
explored a bit more what the alternatives to current power systems might be, whether there is really any hope beyond any individual's small victory of wresting more scraps of power for themselves.

Smail was also writing at a very specific time of UK history, both relatively recent but also lightyears away in terms of social, economic and technological changes. I think his gentle pessimistic realism would dial up a notch to more Mark Fisher style full on pessimism if he was writing today.

A very beloved member of this forum, @Praestat_Mori often points this out- that if we have little or no power to change the circumstances causing us to be depressed- when our depression is situational that is- there's only so much therapy can do. Makes sense really. I think there are limits to how much we can 'reframe' something in a positive light etc.

Of course, if our efforts can likely yield decent results then- maybe therapy does have a shot to motivate us to try. I tend to agree though. Realism can make us doubt that our efforts will be rewarded- enough anyway. I've come to the conclusion that 'recovery' doesn't seem worth the effort. Plus, like you say- it's not really recovery. It's compliance. People likely don't even care if you're still miserable- they probably are too. Just as long as you're contributing.

 

[Celerity]

Thank you for the recommendation. There is so little humility in the field of psychiatry, and I think the lack of it has hurt far more people than it has helped. There is in fact very little evidence for the diagnostic scheme used by the DSM. If I understand Smail's position correctly from your summary, the data instead very clearly supports his assertion of a common cause (guilt & shame) with many different responses (the symptoms and "disorders" we observe). This is why comorbidity among the mental illnesses is the rule, not the exception. Depression and anxiety co-occur far more often than they exist in isolation, and features of both are present in basically all other mental disorders aside from maybe a few personality disorders (and that is stretching it).

Psychiatrists and psychologists have had this data for decades. Reform has been an uphill battle because there is no good solution in sight. They don't have much else to offer that would be better.

Therapy works best when you have a skilled therapist with whom you have good rapport. Their method does not matter. Even psychoanalysts following Freud's approach can be successful. DBT is unique, but it is also not just another talk therapy. The protocol is standardized and involves group therapy and mindfulness components.

Psychiatric medication is not nearly as effective as advertised. 75% of the effect of antidepressants can be achieved with a sugar pill, and the sugar pill doesn't give you headaches, dry mouth, weight gain, or sexual dysfunction (mostly - nocebo is just as real as placebo). The medications that can be very effective are either addictive (benzos), restricted (stimulants), or have very nasty side effects and require careful monitoring (antipsychotics, mood stabilizers).

What people need is emotional support, helpful guidance for life's challenges, community, stable employment, a safe place to live, enough time to exercise, regular sleep, and a nutritious diet. Therapy can only help with the first two and in a very limited fashion.

 

[avalokitesvara]

@Celerity Yep, exactly. Smail also says discretely that it's in psychotherapists best interests to mask the fact there is no evidence supporting the efficacy of their work, and mounting evidence to the contrary.

He does talk about some of his own experience working in the 60s and 70s when there were more experimental therapeutic treatments with a focus on group therapy and looking at people's lives as a whole. It is absolutely fucking depressing to see what has happened in the intervening 50 years.

As well as the concrete elements of a livable life you mentioned, Smail really emphasises power, which means the ability to make choices. He shows how deeply we internalise the power that is impinged on us from without, from close proximity (parents) to far reaching forces (economy, policy).

The more I look at the world the more I see how choice has been stripped back and back. No wonder so many of us see no way out other than suicide. We simply are not ABLE to actualise our lives, to make choices, to live. The means to do so have been quite literally taken away.

 

[Celerity]

@Celerity Yep, exactly. Smail also says discretely that it's in psychotherapists best interests to mask the fact there is no evidence supporting the efficacy of their work, and mounting evidence to the contrary.

He does talk about some of his own experience working in the 60s and 70s when there were more experimental therapeutic treatments with a focus on group therapy and looking at people's lives as a whole. It is absolutely fucking depressing to see what has happened in the intervening 50 years.

As well as the concrete elements of a livable life you mentioned, Smail really emphasises power, which means the ability to make choices. He shows how deeply we internalise the power that is impinged on us from without, from close proximity (parents) to far reaching forces (economy, policy).

The more I look at the world the more I see how choice has been stripped back and back. No wonder so many of us see no way out other than suicide. We simply are not ABLE to actualise our lives, to make choices, to live. The means to do so have been quite literally taken away.

That's a really good way to put it. We lack freedom and power.

Brings to mind an observational study I heard about as a student years ago. The researchers measured the hormone levels and lifespan of monkeys IIRC and evaluated whether this was connected to their standing in the troupe's social hierarchy. Sure enough, the monkeys at the lowest rungs of their jungle society had much higher levels of cortisol, they died at younger ages, and post-mortem examination of their brains revealed pathological shrinking of different brain areas relative to the more powerful monkeys.

These findings make perfect sense when examined through the lens of attachment theory. Feelings of shame and alienation are among the most powerful in our repertoire as social animals. They are so distressing and painful because our ancestors would die without support from the group.

So, for people like us, an internal alarm rings day by day, and we will never be deaf to it. We can rationalize and ignore it all we want, but the body keeps the score.