From critical theory to critical therapy: Towards a permanent psycho-political revolution between subjective and objective disalienation

Introduction

Until recently, the left tended towards scepticism or downright hostility towards mental healthcare and deflationism about the ontology of mental illness, ¹ often romanticizing mad people as countercultural sages or martyrs. The British and Italian anti-psychiatry movements generally denied that mental illness existed apart from its social construction and control. ² Anti-psychiatrists argued that it was neither ‘objective’ scientific knowledge, nor ‘humanitarian’ medical care, but rather domination that enabled the emergence of psychiatric diagnoses, treatments and cures. They maintained that mental patients needed to recover not from madness, but from psychiatric domination – demanding total and immediate deinstitutionalization. ³ The anti-psychiatric notion that madness must be freed from all forms of psychologisation resonates across critical theory, both narrowly and broadly construed. In the wake of what is often called a ‘mental health crisis’, a care-ethical challenge to this genre of critical-theoretical psycho-social accelerationism is in order. As a descriptor not of an individual’s psychological breakdown but rather our present psycho-political conjuncture, ‘mental health crisis’ refers to the increasingly high incidence of reported mental illness together with the chronic strain under which our underfunded public mental health services operate. The scope of my contemporary social criticism is bounded by my own immediate psycho-political context in the UK, but there are strong parallels with the situation in the US that track shared neoliberal ideologies and policies. ⁴

The UK’s social-reproductive crisis in mental health/care has only deepened due to the recent perilous collision between a welfare state decimated by post-crash austerity and a deeply destabilizing global pandemic. ⁵ Yet the genealogy of this crisis extends back beyond David Cameron’s ‘age of austerity’ ⁶ to psychiatric decarceration. Whilst the coalition that coalesced around the asylum question in the long sixties ⁷ was singularly eclectic, its right wing proved triumphant. ⁸ The radical-left and even liberal-humanitarian hopes invested in deinstitutionalization were undermined by the deeply disempowering and dehumanizing effects of its neoliberal implementation from the top down. Enoch Powell ⁹ set out his deinstitutionalization programme in his famous 1961 Water Tower speech. He boasted of his ambition to halve the number of psychiatric hospital beds in 15 years, whilst remaining vague about what ‘provision in the community’ would entail beyond pushing responsibility for ‘the mentally ill and mentally subnormal’ onto local authorities. ¹⁰ The previous year, Powell had also tellingly underlined ‘the scope for voluntary effort’ contributing to essential functions in the National Health Service (NHS) in the same breath as stressing ‘value for money’ in mental healthcare. ¹¹ In 1962, the NHS Hospital Plan ‘set the torch to the funeral pyre’, as Powell had vowed the year before. The population of the UK’s mental hospitals reduced significantly through the sixties and seventies, culminating with the mass closure of asylums in the eighties under Margaret Thatcher. Towards the very end of her tenure, Thatcher consummated Powell’s vision by tasking the local authorities she had already incapacitated ¹² with delivering so-called ‘community care’ in the notorious 1990 National Health Service and Community Care Act.

The closure of NHS long-stay psychiatric hospitals was an austerity measure made ethically palatable by cynical communitarian rhetoric and medically plausible (albeit only in retrospect) by the promise of pharmacological technofixes. ¹³ Early left critic of deinstitutionalization Peter Sedgwick recognized that the ‘community care’ with which the asylum system was nominally replaced was little more than a euphemism for the ‘growing depletion of real services’. ¹⁴ Community care was not the communisation of mental healthcare, but rather its re-privatization within the family, where women predictably bore the greatest burden. ¹⁵ As is typical of neoliberal governmentality, ¹⁶ public irresponsibility for mental healthcare forced caring obligations onto the unsupported and isolated private patriarchal family, re-entrenching capitalist patriarchy’s social division of reproductive and productive labour. ¹⁷ Working in tandem with her attack on public housing, ¹⁸ Thatcher’s community care policy meant that severely mentally ill people who lacked even familial support faced addiction, highly precarious housing, outright homelessness or a different kind of incarceration within the criminal justice system. ¹⁹ Community care amounted to the state’s careless abandonment of mentally ill people, consigning them to slow death. ²⁰ This was especially true of people diagnosed with psychosis and schizophrenia ²¹ – a dark irony given their symbolic status in the same counterculture that had clamoured for their release. Former patients were now doubly free ²² from the asylum: free from both confinement and sanctuary, control and care.

In amongst the human debris of the neoliberal restructuring of public services, it is unsurprising that the contemporary organized left has expended most of its energies defending the welfare state against cuts and privatization, seeking to rebuild the latter’s total institutions rather than demanding their abolition. ²³ Leftist common sense has shifted towards uncritical support for the NHS. Where its new left predecessors had generally regarded the psy-disciplines as gatekeepers of the bourgeois moral order, today’s grassroots left now bemoans the paucity of public mental healthcare provision and draws attention to the deleterious impact of austerity policies on mental health, including higher suicide rates. ²⁴ The counterculture’s exoticisation of the often-mundane suffering wrought by mental illness is seen by many on today’s radical left as naïve and self-indulgent. It would be inapt to people’s lived experiences of mental illness and careless abandonment to maintain anti-psychiatry’s blanket denial of the existence of mental illness and the specific care needs it generates – never mind to cheer on the increasing unavailability and inaccessibility of this much-needed care. It would be callous and instrumentalising to simply appropriate people’s mental distress as a fertile ground for, or even a form of, political resistance.

But what if mental healthcare could do more than just mitigate individual psychic pain? My contention is that a critical therapy aiming at not individual adjustment but collective emancipation could help us recover ourselves and each other as we struggle together for a better world – not only out of a care-ethical concern with harm-reduction, but also for the sake of the struggle itself. In this paper, I will argue that once-dominant critical theories of mental health/care are no longer adequate to our present psycho-political conjuncture. I will offer a necessarily brief sample of the recent history of anti-psychiatric critique from the left, surveying the radical psycho-political thought of Theodor Adorno, Herbert Marcuse, Michel Foucault and Carol Hanisch. I will argue that each of these thinkers pose an undialectical either/or between reformist therapy and revolutionary politics. I will then offer institutional psychotherapist Frantz Fanon’s dialectical conception of recovery as perpetual psycho-social disalienation as a way out of this false dilemma. I will suggest that Fanon’s critical therapeutic praxis can expand our psycho-political imagination and enrich our psycho-political struggles today. Fanon’s struggle in and against the asylum eluded the dichotomy between psy-apologism and psy-abolitionism. My Fanonian theorisation of recovery speaks to the recent care-ethical turn of the contemporary organized left, whilst pushing back against the latter’s welfarist melancholy and maintaining a structural critique of the aetiology and treatment of mental illness. Mental healthcare is not merely an opiate for the masses, but nor is it simply an unalloyed public good to be defended, restored and extended. Our recovery requires the radical transformation of both mental healthcare and the pathogenic social world to and within which it responds.

‘Messed over, not messed up’: Recovery in the recent history of radical psycho-political theory and praxis

To motivate my turn to Fanonian critical therapy, I will first reconstruct some recent historical examples of the radical leftist rejection of therapy as disciplinary and conformist. I will begin by considering Critical Theory in the narrow sense: the first generation of the Frankfurt School. Despite its influential social-theoretical appropriation of psychoanalysis, the Institute of Social Research generally saw the clinical application of psychoanalysis as politically irrelevant or even pernicious. Most notoriously, in the summer of 1955, Marcuse lambasted his former Frankfurt colleague Erich Fromm’s ‘neo-Freudian psychology’ in the pages of Dissent magazine, ²⁵ initiating a fierce exchange that has recently attracted renewed scholarly interest. ²⁶ Whilst some of the dispute turned on differing interpretations of Sigmund Freud, I understand Fromm and Marcuse’s exegetical disagreements as downstream from their divergent syntheses of psychoanalysis with Marxism. Their competing Freudo-Marxist programmes provided conflicting answers to the question: should we try to make life under capitalism more liveable?

Marcuse answered with a resounding ‘no’. He distinguished between psychoanalytic theory as a diagnostic tool for critiquing capitalism’s social pathologies, and psychoanalytic therapy, which, he claimed, ‘aims at curing the individual so that he can continue to function as part of this civilization’. According to Marcuse, there is necessarily a ‘discrepancy between theory and therapy’: theory seeks to understand the actually-existing social world in order to refuse it; therapy seeks to adjust the patient to that world. ‘Therapy’, Marcuse claimed, ‘is a course in resignation’. ²⁷ It is inherently politically quietist, because it attempts to subjectively reconcile the patient to her objective condition of alienation. Marcuse’s charge of ‘revisionism’ was thus, on my reading, primarily ethico-political rather than interpretive. For Marcuse, the problem was not that Fromm had desecrated Freud. The issue was that Fromm had politically defanged psychoanalysis, rendering it a banal, conformist and moralistic ‘philosophy of the soul’ ²⁸ : a ‘positive’ therapy rather than a negativist critical theory. ²⁹ ‘Feeling better’ in lieu of the overthrow of capitalism, Marcuse argued, requires grossly distorting our perception of social reality in order to render our lived experience of it tolerable. On his view, therapy by its very nature cannot be critical, because it necessarily aims at the (false) ‘happy consciousness’. ³⁰

Adorno, who had joined the Institute shortly after Fromm’s formal departure, maintained a similar line. ‘Revisionist’ psychoanalytic therapy of the kind propagated by Karen Horney (and, implicitly, Adorno’s predecessor Fromm ³¹ ) individualized social pathologies even as it claimed to ‘sociologise’ Freud by incorporating the influence of ‘environmental’ factors into the analysis of neurosis. ³² It facilitated the analysand’s adaptation to sick normality and thereby functioned as a form of social hygiene. ³³ Adorno’s most sustained critique of therapy can be found in his 1946 speech at the San Francisco Psychoanalytic Society. ³⁴ Beyond the revisionists’ quietist ‘endorsement of complacent optimism and conformism’, their attempt to therapeutically reconcile self and society, he thought, was destined to fail. Disalienation, Adorno claimed, ‘is an ideal which would be realized only in a non-traumatic society’; under capitalism, the ‘totality of the so-called “character”’ is at most ‘a system of scars, which are integrated only under suffering, and never completely.’ ³⁵ Much as ‘there is no right way of living the wrong life’, for Adorno, there was no disalienated way of living the alienated life – even if therapy deluded patients into believing otherwise, thereby foreclosing political dissent. ³⁶

Foucault was straightforwardly hostile to psychoanalysis, but his anti-psychiatric advocacy of ‘killing psychology’ ³⁷ and embracing the ungovernability of ‘madness itself’ ³⁸ resonated with Frankfurt School Freudo-Marxism all the same. Where Adorno and Marcuse denaturalised the psy-disciplines through ideology critique, Foucault opted for a Nietzschean ³⁹ historicisation of what he saw as the invention of mental illness. In History of Madness (1964), he offered a proto-genealogical ⁴⁰ history of this positivist capture of madness, challenging then dominant triumphalist histories of gradual scientific and humanitarian progress culminating in the inevitable victory of modern psychiatry. ⁴¹ Foucault argued that the modernization of madness actually involved a ‘double movement of liberation and enslavement’: celebrated nineteenth century reformers like William Tuke and Philippe Pinel ‘liberated’ mad people from old brutal forms of physical constraint only to ‘enslave’ them through new, more efficient and insidious techniques of control in the guise of medical care. ⁴² In short, by ‘confining madness in mental illness’, psychiatry ‘grasped madness as something both known and mastered at a stroke’, rendering its newfound ‘liberty’ empty. ⁴³ For Foucault, modern psychiatry was primarily a ‘moral tactic…covered over by the myths of positivism’. Foucault maintained that psychoanalysis, whilst constituting a departure from positivism, ⁴⁴ was just another normalizing ‘monologue of reason about madness’. ⁴⁵

At the 1969 Évolution Psychiatrique Toulouse congress dedicated to discussing History of Madness, a member of the floor, recorded as ‘H. Aubin’, claimed:

‘“Foucault is an anti-psychiatrist because the whole of his philosophy is inscribed within the revolutionary current, in the wake of Marcuse.”’ ⁴⁶

Foucault’s biographer David Macey describes this association with Marcuse as ‘wildly inaccurate’. ⁴⁷  Volume I of The History of Sexuality (1976) is, after all, widely thought to have been directed at Marcuse’s ‘repressive hypothesis’. ⁴⁸ But Foucault himself later acknowledged his affinity with Critical Theory in his understudied 1978 dialogue with Marxist journalist Duccio Trombadori. ⁴⁹ The militant Foucault of the seventies especially shared Marcuse’s countercultural romanticisation of the maladjusted and marginal as primordial forces of resistance against ‘civilization’. For example, as part of the Prison Information Group, Foucault co-authored a pamphlet series entitled Intolerable, which marked out ‘hospitals, asylums’ as sites of intolerable disciplinary power. ⁵⁰ Foucault theorized ‘struggle’ as springing from the experience of ‘intolerable’ ‘power’. ⁵¹ Insofar as the psy-disciplines make the experience of power tolerable, then, on Foucault’s view, they reduce the likelihood of struggle. Psychologisation, he thought, extinguishes mad people’s vitalistic spirit of transgression. In his Collége lectures on Psychiatric Power (1973-4), Foucault playfully ‘salute[d] the hysterics as the true militants of antipsychiatry’: treatment-resistant unhappy consciousnesses refusing to tolerate social reality. ⁵² Even if he positioned himself against the Freudo-Marxist ⁵³ framework of his Frankfurt School contemporaries, Foucault nonetheless echoed their grounding of political resistance in negativist subjectivity borne out of unbearable suffering, and their rejection of the psy-disciplines insofar as the latter sought to mitigate this distress-induced negativism.

Finally, whilst Foucault and the Frankfurt School had very little to say about the contemporaneous women’s liberation movement, ⁵⁴ second-wave feminists adopted a similar attitude of suspicion towards the psy-disciplines – albeit partly in response to the masculinist dismissal of consciousness-raising groups by many of their more economistic socialist comrades. Radical feminist Hanisch’s influential 1970 essay, ‘The Personal Is Political’, is a case in point – despite the lifestylist, liberal-feminist work to which this now-colloquialised slogan is often put. In her self-published 2006 introduction to the essay, Hanisch positioned the piece against the androcentric Marxist dogma that ‘“the revolution” would take care of’ anything individual women could not ‘solve’ through ‘personal initiative’. ⁵⁵ Vulgar Marxism construed political organizing as primarily a matter of changing the working classes’ relationship to the means of production. Whilst a wage labourer’s relationship to herself and others might be affected by her (class’) relationship to the means of production, and was to that extent political, it was not seen as a domain for political action in its own right, but rather symptomatic or epiphenomenal. ⁵⁶ Second-wave feminism took the question of the relationship between ‘individual consciousness’ and ‘social movement’ to be central to politics, and made (inter)subjectivity itself into a site of resistance and transformation. ⁵⁷

In her attempt to refute the notion that feminist consciousness-raising amounted to ‘mere’ (implicitly feminized) ‘therapy’ – and thus a navel-gazing distraction from the ‘real’ work of (implicitly masculinized) revolutionary socialist politics – Hanisch argued that it was, in fact, an antidote to therapy. ⁵⁸ Therapy, she claimed, promoted acquiescence or resignation to patriarchy:

‘Therapy assumes that someone is sick and that there is a cure… We need to change the objective conditions, not adjust to them. Therapy is adjusting you to your bad personal alternative.’

Hanisch assumed that therapy was apolitical at best and ideological at worst, expressing offence at the suggestion ‘that I or any other woman is thought to need therapy in the first place’. ⁵⁹ Consciousness-raising, Hanisch argued, helped women realize they were ‘messed over, not messed up’, and thus incited them to ‘change the objective conditions’ that had messed them over, rather than simply seeking ‘a personal solution’. It sought to estrange women from a social reality they had hitherto taken for granted, rendering their existing lives intolerable with a view to radicalizing and recruiting them to the feminist cause. As Hanisch theorized it, consciousness-raising pursued subjective alienation in individual women that accurately reflected their objective alienation as a group, and was thus actively counter-therapeutic. Far from helping her ‘feel better’, Hanisch explained how consciousness-raising had ‘forced [me] to take off the rose colored glasses and face the awful truth about how grim my life really is as a woman’. In short, the consciousness raised by second-wave feminists was an unhappy one. There was no feminist way of living life under patriarchy, Hanisch argued: the feminist politicization of prima facie personal problems made it clear that ‘there are only bad alternatives’; to believe otherwise only perpetuated women’s oppression. ⁶⁰ Even though Hanisch had set out to contest the ‘after-the-revolution’ stance adopted by anti-feminists on the left, ‘The Personal Is Political’ tended towards a political millenarianism of its own. Hanisch portrayed the social world as fundamentally corrupt, with nothing short of total destruction and upheaval capable of securing more tolerable alternatives for women. Like many of her feminist contemporaries, ⁶¹ she left the dichotomy between therapy and struggle intact, even as she sought to dissolve the dichotomy between the personal and the political. Hanisch failed to recognize that both sickness and cure can be political as well as personal.

Each of these critical theorists assumed or posed an anti-psychiatric undialectical either/or between reformist therapy and revolutionary politics. One can either be mentally healthy and deluded, the story goes, or mentally ill and clear-eyed. Apparently, the only way for the therapist to make her patient ‘well’ is to encourage false consciousness and socially-rewarded conformity. Were she to raise her patient’s consciousness and prescribe socially-sanctioned transgression, the therapist would not be doing her job; she would be promoting ‘sickness’ instead of ‘health’. On this view of mental healthcare, the therapist can only offer opiates: she must dull the psychic pain wrought by sick normality, treating symptoms in lieu of addressing their social causes. For the psy-abolitionist, mental healthcare can at best ⁶² provide short-term individual harm-reduction at the expense of long-term radical social transformation that would render mental healthcare obsolete.

This undialectical either/or continues to structure critical-theoretical common sense today. How might critical theorists challenge the contemporary popular left’s uncritical embrace of psychologisation (and welfarism more broadly) whilst reckoning with the ambivalent legacy of anti-psychiatry? How might the left learn from anti-psychiatric insights into the ideological and disciplinary functions of the psy-disciplines without denying mentally ill people sorely-needed care? Instead of relying solely on the counterculture’s organic intellectuals, I suggest that we look to revolutionary psychiatrist Frantz Fanon. Whilst Fanon is best known as a critical theorist of race, he was also a central figure within institutional psychotherapy: an under-theorized French school of Freudo-Marxism that, unlike the contemporaneous Frankfurt School, placed therapeutic imperatives front and centre of its psycho-political praxis. Fanon refused the false choice between care and critique. He saw mental healthcare as having the potential to contribute to the disalienation of mentally ill people, helping them to ‘rediscover the meaning of freedom’. ⁶³ Trained by Francesc ⁶⁴ Tosquelles at the revolutionary Saint-Alban asylum, Fanon remained committed to medicine’s ‘deliberate choice for optimism in the face of human reality’ throughout his life. ⁶⁵ Fanon’s clinical practice, from France to Algeria to Tunisia, evolved in constant dialogue with his critical theory and revolutionary politics. Eschewing political millenarianism, Fanon argued that subjective recovery does not simply fall out of objective structural change, nor need it work against the latter. An end in itself, psychic healing can also enable collective struggle. For Fanon, disalienation could not wait until after the ‘Great Refusal’, ⁶⁶ once ‘the new society’ ⁶⁷ – ‘a non-traumatic society’ ⁶⁸ – was fully formed. Like his mentor Tosquelles, Fanon saw disalienation as a perpetual double movement between the subjective and the objective. He saw this ‘syncopated dialogue’ between the psychic and the social as necessary before, during, and after discrete episodes of revolutionary upheaval. ⁶⁹

Mental illness as freedom-diminishing

Thanks to the recent collection of previously unpublished psychiatric writings in Alienation and Freedom, ⁷⁰ Fanon’s philosophy of race, racism, colonialism and violent anti-colonial revolution is increasingly understood as drawing upon his professional life at the vanguard of institutional psychotherapy. Yet the archive of Fanon’s revolutionary psychiatry ought not only to be historically valued for its explanatory power in illuminating his already well-studied critical theory of the psychic life of race. Fanon also ought to be recognized as a critical theorist of psychiatry and mental illness simpliciter. His dialectical model of critical therapy enables us to move beyond the anti-psychiatric paradigm in critical theory. Resisting both control and carelessness, Fanonian critical therapy is more adequate to our psycho-political conjuncture than anti-psychiatry’s either/or thinking.

Like the anti-psychiatrists, Fanon depathologised mentally ill people. He argued that both ontogenetic and phylogenetic approaches to mental illness neglect its ‘sociogeny’, partly because they ignore the lived experience of mental illness. Fanon combined his well-known phenomenological account of race as socially-constructed with his lesser-known understanding of the social determinants of mental illness in his intersectional ‘sociodiagnostic’ critiques of French colonial psychiatry and its racially-essentialist misdiagnoses. ⁷¹ Fanon argued that mental illness is not ‘a taint’ located ‘in the “soul” of the individual’ (à la ontogenetic colonial psychoanalysis), nor in their brain (à la phylogenetic colonial ethnopsychiatry), but should rather be sociodiagnosed as contextually intelligible responses to ‘taints’ in their ‘environment’ ⁷² – what the Frankfurt School called ‘social pathologies’. ⁷³ Fanon saw ‘psychic alienation’ as produced at least in part by socio-historical processes acting upon rather than inhering within mentally ill people.

In contrast to anti-psychiatry, however, Fanon maintained that mental illness was ‘real’. Mental illness existed independently of psychiatric invention, and could no more be reduced to its political than its neurological dimensions. What’s more, whilst Fanon advocated far-reaching structural changes to psychiatric care, he still thought mental illness could and should be treated. He explicitly distanced himself from the ‘unremitting defence of the nobility rights of madness’. ⁷⁴ Forced daily to confront the psychic fall-out of colonial domination and violent warfare in (post)colonial North Africa, Fanon was no stranger to the very real suffering mental illness wrought. Far from anti-psychiatric romanticisation, Fanon viewed mental illness as a ‘pathology of freedom’ rather than its source or expression. ⁷⁵ Indeed, towards the very end of his life, as Fanon dictated The Wretched of the Earth (1961) to his Tunis day clinic assistant, the social worker Marie-Jeanne Manuellan, he would often remind her that ‘the goal of psychiatry was to produce free men’. ⁷⁶

In the same year that he published Black Skin, White Masks (1952), Fanon began his psychiatric career in the radical Saint-Alban milieu under the tutelage of Tosquelles. The following year, in a co-authored psychiatric paper, the two argued that ‘the psychiatric hospital must be an institution of disalienation’. ⁷⁷ This was the fundamental premise of the French mid-century institutional psychotherapy movement, of which Tosquelles was the progenitor. It emerged during the Second World War in opposition to the Vichy Regime’s starvation of asylum inmates. ⁷⁸ Where anti-psychiatry aimed to abolish psychiatry and thereby doubly free mentally ill people from medical control and care, institutional psychotherapy saw both the asylum and its inmates as ill and needing treatment. ⁷⁹ For Tosquelles, the authoritarian psychiatric institution was a microcosm of the Spanish fascism from which he had fled and comparable to the brutal Septfonds concentration camp in which he had been interned with fellow Republican political refugees upon arriving in southern France. ⁸⁰ Yet so too was mental illness itself a psychic analogue to these ‘concentrationist’ regimes. Institutional psychotherapists thought that the deep democratization of psychiatry was a political and therapeutic imperative; disalienating the hospital by fostering patients’ collective self-determination would disalienate them in the process.

Fanon was profoundly influenced by Tosquelles’ conception of mental illness as a kind of psychic occupation from which psychiatric care should aim to free those afflicted by it. Fascist or colonial occupation was not only conducive to, but also resembled mental illness; both necessitated resistance. Whilst anti-psychiatric critical theorists like Foucault conceived of normalizing psy-discourses as contributing to ‘the fascism…in our heads’, and depsychologisation (‘killing psychology’) as necessary for leading an anti-fascist life, ⁸¹ institutional psychotherapy sought to resist mental illness’ fascistic occupation of the subject – to ‘disoccupy’ patients’ minds. ⁸² Fanon saw mental illness as a freedom-diminishing psychic occupation because it ‘situates the patient in a world in which his or her freedom, will and desires are constantly broken by obsessions, inhibitions, countermands, anxieties’. ⁸³ She is petrified, ‘immobilize[d]’. ⁸⁴ In ‘Yesterday, today and tomorrow’, a 1953 editorial he penned for the Saint-Alban hospital newspaper, Trait d’Union, Fanon argued that mental illness prevents one from ‘keep[ing] all three constituents of time in view: past, present and future’ – and that ‘it is impossible to see and achieve anything positive, valid and lasting without taking all three elements into account’. ⁸⁵ The mentally ill person struggles to move beyond a longed-for but irretrievably lost or, conversely, feared and despised but inevitably recurring past – or loses sight of the past altogether. She struggles to exceed the limits of a seemingly unbearable, eternal present. She forgets that ‘she is here with other humans’, who, like her, ‘always exist in the process of…’. ⁸⁶ She turns (or rather, is turned) away from others, from time, and in on herself. ⁸⁷ When ‘the present is….turned inward’ by mental illness, ⁸⁸ Fanon argued, it becomes harder for the mentally ill person to interact with her social milieu in order to ‘invent’, or even imagine inventing, ‘a new mode of living’. ⁸⁹ Alienating the mentally ill person not just from sociality, but from temporality itself, mental illness’ occupation of her psyche inhibits her ability to act spontaneously with others, within history, to create a future in which she and they can breathe. ⁹⁰ The mentally ill person severed from time ‘acts as if he were dead’. ⁹¹ Mental illness threatens to estrange us from ‘natality’ – what Hannah Arendt famously theorized as the human capacity ‘to start something new’ – and thus from political action. ⁹² In contrast to the anti-psychiatric portrayal of madness as a radical refusal of the social pathologies of modern civilisation, Fanon appreciated how mental illness can obscure the very possibility of liberation and limit one’s capacity for participating in collective political action, even whilst he also critiqued colonial psychiatry’s pathologisation of anti-colonial resistance in order to depoliticize and undermine it. ⁹³ Fanon saw a place for a deeply democratized, communised mental healthcare that helped mentally ill people to break out of the solipsism and impotence of delusion, fear and self-loathing, and ‘educate man to be actional’ ⁹⁴ – as individuals (or, if you like, singularities ⁹⁵ ) constituting and in turn constituted by a collective.

One might object that, in suggesting that mental illness incapacitates the mentally ill person in such a way that bars her from politics, my use of Fanon here is ableist. One might argue that it plays into what Stacy Clifford Simplican calls the ‘capacity contract’, premising political participation on ‘a threshold level of capacity, and exclud[ing] anyone who falls below’. ⁹⁶ Simplican herself proposes an Arendtian model of political agency, based on acting in concert with others to create something new. Whilst I accept her conclusions with regard to intellectual disabilities, I maintain that, insofar as one is mentally ill, ⁹⁷ one is alienated from temporality and sociality, and one’s capacity for natality and thus political action is to that extent curbed. ⁹⁸ Mental illness is partly caused and exacerbated by objectively alienating socio-historical processes, but its internal logic is itself subjectively alienating. Mental illnesses can take on lives of their own, generating self-perpetuating vicious cycles that can outlast their sociogeny. Alienation begets alienation. Even if one did think that mental illness is best theorized via a strongly social model of disability and that any admission that mental illness is disabling in ways that are not reducible to the mentally ill person’s external environment amounts to ableism, one must still confront an even more troubling tension between mental illness and political action. If mental illness is social all the way down, and recovery requires the removal or alteration of the social conditions by which it is not just caused, but constituted, who are the political agents driving this social transformation? The social model (on this strong interpretation ⁹⁹ ) seems to leave us with two unappealing possible answers here. We are left either with the politically defeatist conclusion that we cannot change the social conditions that constitute mental illness because these same conditions diminish our capacity for political action, or the paternalistic conclusion that mentally healthy people must do this on our behalf (which violates one of the central principles of disability activism: ‘nothing about us without us’ ¹⁰⁰ ).

The anti-psychiatric critic might, of course, deny that there is anything at all inhibiting about mental illness. She might claim that mental illness is just an alternative, nonconformist and perhaps more perspicacious or even disalienated yet unjustly stigmatized mode of experience. Recovery would just require the destigmatization of the experiences we now categorize as ‘mental illness’. Whilst the stigmatization and resultant social isolation of mentally ill people certainly still accounts for a substantial portion of the alienation with which we contend, it does not exhaust it. Beyond my rejection of the romanticisation of mental illness as excitingly transgressive or enlightening, I am also ambivalent about even the so-called ‘normalization’ of mental illness, which is today usually recommended in the same breath as its ‘destigmatization’, but which I think is importantly different. If, as I have argued with Fanon, mental illness is a freedom-diminishing psychic occupation, why would we wish for it to become ‘normalized’ either descriptively or evaluatively? Why would we want this form of alienation to become a very common and widely accepted feature of human life? As Fanon argued, there is nothing wrong with the people living with mental illness, but there is something wrong with a social order that systematically causes and exacerbates mental illness and thereby diminishes our freedom and political agency. There is surely something doubly wrong with a social order that demands we accept this state of affairs as ‘normal’.

Recovery as psycho-social disalienation: Waging war on the ‘subjective’ and ‘objective’ fronts

Psycho-social recovery as permanent psycho-political revolution

I have used Fanonian institutional psychotherapy to problematise anti-psychiatric critical theory’s undialectical either/or between reformist therapy and revolutionary politics. Fanon understood that recovery was not a one-time event, but a perpetual process that could be non-linear, uneven and unpredictable. As his mentor Tosquelles always stressed, one was never disalienated once and for all; the ‘work’ of recovery was ‘never finished’. ¹³⁴ Recovery as disalienation is a vector of or a ‘movement towards’ change rather than its determinate endpoint. ¹³⁵ Fanon was never under any vulgar Marxist illusion that everything would be alright ‘after the revolution’, nor that ‘the revolution’ was guaranteed. Influenced by Tosquelles’ idiosyncratic conception of ‘permanent revolution’, Fanon understood that the revolution would never be over – that, on both the ‘subjective’ and ‘objective’ levels, we have to fight a permanent psycho-political revolution, constantly reconstructing ourselves and our world, and always remaining vigilant ¹³⁶ against the rise of new ‘concentrationisms’, even as old ones dissolve.

Whilst Tosquelles will have first encountered the notion of ‘permanent revolution’ as a founding member of the Catalan dissident communist group, Workers Party of Marxist Unification, ¹³⁷ the way he uses the term in the context of institutional psychotherapy differs from its standard Marxist-Trotskyist meaning. Marx and Engels, in a March 1850 address to the Communist League, warned members against being satiated by petty bourgeois reformist ‘bribes’ of welfare and state employment policies:

‘While the democratic petty bourgeois want to bring the revolution to an end as quickly as possible…, it is our interest and our task to make the revolution permanent’. ¹³⁸

They argued that the proletariat should become an independent political force so that they were poised to seize power in a proletarian revolution. ¹³⁹ Leon Trotsky’s famous theory of permanent revolution developed these ideas to address the situation in Russia, where he believed that the bourgeoisie would not institute political democracy, and that it would thus fall to the proletariat to carry out both the bourgeois-democratic and proletarian revolutions, adding that the Russian proletariat would not be in a position to hold onto power in a fiercely hostile international context unless it was quickly followed by proletarian revolutions in other countries. Trotsky’s conception of permanent revolution thus challenged Menshevik stagism and undermined ‘socialism in one country’ (a strategy later pursued by Joseph Stalin). More abstractly, following Michael Löwy’s interpretation, Trotsky counterposed permanent revolution to the ‘impotent fatalism that pervaded Menshevik thinking, where the dead ruled the living and the past determined the future’. ¹⁴⁰ Trotsky’s ‘open historicism’ understood ‘the process of permanent revolution towards socialist transformation…not as an inevitable necessity’, but a possibility the realization of which would depend on a host of unforeseeable contingencies that would present new opportunities and obstacles at every turn, which would have to be navigated by political agents. ¹⁴¹

Closer to Marx and Engels’ original usage and Trotsky’s ‘open historicism’ than to the latter’s specific theory of uneven and combined development, Tosquelles deployed the term ‘permanent revolution’ loosely and intuitively to describe a kind of endless and open-ended everyday psycho-political orientation and practice: that is to say, a psycho-political praxis. ¹⁴² Tosquelles advocated permanent revolution in mental healthcare to guard against reformist complacency, fatalism, stagnation and petrification. As the latter’s fellow institutional psychotherapist Jean Oury explained,

‘The entire project set forth by Tosquelles…at the clinic of Saint-Alban was to challenge all areas of suppression. It is not simply a question of suppressing this or that, but of slowly infiltrating suppressive models, of softly subverting.’ ¹⁴³

The struggle in and against mental healthcare was, for Tosquelles, ‘never finished’. Asked in 1985 if institutional psychotherapy was still relevant or if had been overtaken by new movements, Tosquelles emphasized that it was constantly changing through time and space:

‘There is always enough to initiate the process of going back and forth between practice and theory. With Aristotle and with Marx I had taken up here the term praxis which indicates these comings and goings. This is also why I would rather speak of a certain movement towards institutional psychotherapy than of a very definite type of model or explanation.’ ¹⁴⁴

This dialectic between critical theory and critical therapy never resolved; institutional-psychotherapeutic theories evolved as soon as mental healthcare-givers and -receivers attempted to put them into practice.

Where Marxist-Trotskyists theorized the bourgeois and proletarian revolutions not as two distinct historical stages, but two moments of the same uninterrupted revolutionary process, Tosquelles understood permanent psycho-political revolution as an uninterrupted double movement between subjective and objective disalienation, as well as between theory and practice. This was expressed most vividly during the years of Resistance, which put the patients into contact with the outside world – they left the psychiatric institution to buy and sell on the black market, to pick mushrooms, to work for local peasants in exchange for butter and turnips – and brought the outside world in: Saint-Alban became an asylum for fugitive fighters as well as mentally ill people. ¹⁴⁵ The question of survival proved didactic. ¹⁴⁶ Patients at Saint-Alban not only avoided the death by starvation faced by patients at almost every other psychiatric institution in France. They also became part of a movement which disturbed the rigid distinction between care-givers and -receivers, transforming their own subjectivities in the process.

Nevertheless, Tosquelles’ desire to bring the ‘outside’ into the asylum conflicted with his attempt to provide patients and militants refuge from social pathologies. As I argued in the previous section, Fanon was sceptical of the possibility of permanent revolution within the confines of even the reformed hospital’s ‘pseudo-society’. He advanced the revolution by turning his back on internment for even severe psychosis patients, breaking down the boundary between ‘inside’ and ‘outside’ and confronting ‘the toxicity of reality’ together with his patients and comrades. Note, however, that opening the doors of the hospital and abandoning psychiatric confinement did not mean carelessly abandoning mentally ill people. Fanon’s departure from the total psychiatric institution did not entail full deinstitutionalization of the sort pursued by the anti-psychiatry movement that gained prominence only after his untimely death. Fanon’s aim remained the disalienation rather than the abolition of psychiatry. After all, as Sedgwick put it in his critique of anti-psychiatric individualism, ‘Politics can be resisted only by politics, institutions by institutions’. ¹⁴⁷ Instead of merely nominal, cost-cutting ‘care in the community’, Fanon advocated deeply democratizing existing institutions and appropriating their resources to communise mental healthcare. His perpetual struggle in, against, and beyond metropolitan and (post)colonial psychiatry can provide inspiration for our response to the mental health/care crisis today. Recovering Fanon’s sociodiagnostic critique and his critical yet institutional psychotherapy offers us resources for demanding care that does not cost us freedom, and freedom that does not cost us care.