Trickle-down neopsychonomics: Neoliberal ideology in mental health systems

Abstract

This paper uses Foulkes’ theories of the social nature of the individual and Elias’ theories of symbols, power, and ideology to explore how neoliberal ideology manifests in contemporary mental health systems. Using clinical and organizational examples, this paper aims to understand how neoliberalism shapes the professional and patient identities that exist within mental health services in the National Health Service (NHS) in the United Kingdom (UK). With an emphasis on contemporary psychiatry and psychology, this paper will highlight the implications of neoliberal ideology in relation to how psychopathology and psychotherapy are perceived, constructed, and clinically implemented. Finally, this paper suggests how group analytic principles may be used to counter neoliberal violence.

Keywords

group analysis neoliberalism violence power ideology psychopathology psychotherapy

Introduction

The social nature of the individual is one of the cornerstones of group analysis, as a collectivist therapeutic practice theorised by S.H. Foulkes (Foulkes, 1973) and marks his most substantial departure from Freudian psychoanalysis, which adopts a more dyadic and individualistic position (Dalal, 1998).

This paper will unpack Foulkes’ ideas on the social construction of the individual within the social group matrix, and how his foundational ideas in group analysis have been enhanced by Norbert Elias’ and Farhad Dalal’s theories on figurations, power structures, and ideology (Elias, 1978, 1994; Elias and Scotson, 1994; Dalal, 1998). The social nature of the individual will be examined within a neoliberal context, which has been the predominant economic and psycho-socio-political ideology in the West for at least the last 40 years. Themes concerning neoliberalism’s preoccupation with hyper-individualism at the expense of collectivism, and hyper-rational scientific positivist absolutism, will be explored in relation to current practices in contemporary psychiatry, psychopathology, psychology and psychotherapy. This paper will also explore emergent professional identities within the National Health Service (NHS) shaped by neoliberal ideology.

With the use of organizational and clinical examples, it will be shown how neoliberal ideology trickles-down into health systems to counter-productively impact care provision, which may, in turn, hinder the long-term health that mental health services in the NHS seek to deliver. It will be argued that the application of group analytic thinking within health systems may help to counter the violence inflicted by neoliberal ideology.

Foulkes and the social nature of the individual

Throughout Foulkes’ writing, his position on the social nature of the individual tends to fluctuate; these two positions have been coined Orthodox and Radical Foulkes (Dalal, 1998). Orthodox Foulkes positions the social development of the individual as a growing child mastering their experience as they develop a stronger ego, who develops the capacity to make choices that align with their emerging ego-identity and is modulated and constrained by societal demands. Radical Foulkes contextualizes the individual in relation to the groups from which they emerge; in doing so, the individual becomes a nodal point in a social network, or matrix, consisting of an ego or self that is socially moulded (Foulkes, 1948). A phrase which is repeated several times throughout his work is how ‘what is inside is outside, the “social” is not external but very much internal to and penetrates the innermost being of the individual personality’ (Foulkes, 1973: 227). This shift renders the conventional psychoanalytic boundary between the intrapsychic and the environmental more permeable, giving way to a more radical group analytic understanding of the social construction of the individual. What is conceptualized is a psyche that is permeated by the social in both content and structure; a psyche that can only be understood within the social context that constructs it (Dalal, 2002).

To formulate these ideas, the influence of Kurt Golstein’s holism and Gestalt psychology is apparent in Foulkes’ thinking as he asserts that ‘this network is a psychic system as a whole network, and not a superimposed social interaction system in which individual minds interact’ (Foulkes, 1973: 226). For Foulkes, the individual cannot be separated from the group, the internal from the external, and objective reality from subjective experience. Both sides of the dialectic are inter-related, as is the boundary between each side. Either side is necessary for the construction of the other: both the individual and the group are ‘abstractions as far as the psychology of the total person is concerned’ (Foulkes, 1973: 230). Foulkes elaborates further on this metapsychology by stating that the contexts in which groups are held, and their relationships to other groups shape and define them: ‘we cannot isolate biological, social, cultural and economic factors, except by special abstraction’ (Foulkes, 1975: 252). In this way, ‘the group itself is the horizon’ (Foulkes, 1973: 230).

Throughout his writings, Foulkes oscillates between the inter-connected, co-constructed, co-equal nature of inter-related beings on the one hand, and on the other, prioritises one aspect or position over another, such as the group over the individual, the whole over the part, and the external-social over the internal-biological (Dalal, 1998). While this is often perceived to be contradictory, he argues that the nature of psychological distress and its treatment must be de-constructed and redefined. This paper will pursue this line of inquiry to explore how contemporary neoliberal ideology, which foregrounds neuro-bio-genetic constructs of psychopathology, and which informs the way in which psychotherapy is carried out, may be challenged using group analytic principles.

Elias on Symbol Theory, power, and ideology

Like Foulkes, Elias also believed the individual to be fundamentally socially formed which is most explicit in his Symbol Theory. Although thinking is thought to be a private endeavour, Elias believed that this was intrinsically social because it involves an inner conversation, which implies the interaction of multiple entities. Furthermore, the symbols used in thought are first experienced socially and then internalized, such as in the way humans learn to use language (Elias, 1991). Symbol Theory also includes ways of understanding language and communication which is explicitly social. Like thought, language assumes a group context and the social integration and meaning-making of language; ‘in any given case a group of language speakers exist prior to the individual speaking act. A language, in other words, cannot be dissolved into individual actions, communicative or otherwise. It is as it were the prototype of a beginningless process’ (Elias, 1991: 21). Elias also emphasizes that language captures shared values and attitudes and orientates the individual to its social, emotional, and physical context. Thus, Symbol Theory is a helpful tool that bridges the gap between what we perceive to be psychically internal and socially external (Dalal, 1998).

Foulkes’ concept of the group matrix parallels Elias’ figurations, which he describes as ‘the structure of societies . . . the figuration or pattern of bonding of the individuals who form these societies’ and the inter-relatedness of each part of the social structure (Elias, 1978: 176). What is perhaps most helpful about Elias’ figurations is the significance he gives to power relations, which is less prominent in Foulkes’ writing. He writes: ‘people make up webs of interdependence or figurations of many kinds, characterized by power balances of many sorts, such as families, schools, towns, societal strata, or states . . . what we attempt to conceptualize as social forces are in fact forces exerted by people over one another and over themselves’ (Elias, 1978: 14). These social forces are not exerted by any one individual in isolation and are likely to be enacted from the social unconscious, which can make it difficult to detect and challenge (Dalal, 1998).

Elias elaborates on how power dynamics are maintained through the establishment of ideology of the ruling class as a way of splitting society into subgroups (Elias and Scotson, 1994). The assumption is that the current social order is the natural order (Rose et. al., 1984) because those in power are superior to those that are not. According to Elias, gossip is used to maintain the split between the superior, virtuous ruling class and the inferior, barbaric oppressed (Elias, 1994). This inevitably sets up a system of oppression which is inherently violent (Freire, 1972). Ideology directly contributes to the social formation of identity, as well as an emotional response to the constructed identity; one that is inferior and deserving of denigration (Dalal, 1998). Neoliberalism has become the dominant political ideology in the West over (at least) the last 40 years and serves the interests of the ruling class. It has shaped the development of mental health services in the NHS and has influenced the formation of professional identities of clinicians, as well as the lives of the patients we treat.

Neoliberal ideology

The term neoliberalism was first coined in 1938 and started to gain popularity among the wealthy and powerful following the publication of Friedrich Hayek’s The Road to Serfdom and Ludwig von Mises’s Bureaucracy in 1944. For several decades, neoliberalism remained a relatively fringe ideology of corporate lobbyists (re-branded as ‘think tanks’) such as the Mont Pelerin Society and circles at the University of Chicago. However, this changed in the 1970s where it was first adopted through political and economic means by Augusto Pinochet in Chile, and subsequently by Margaret Thatcher in the UK and Ronald Reagan in the US (Monbiot and Hutchinson, 2025). Neoliberalism is an ideological position on society’s politics and economics that are strongly capitalistic and anti-regulatory, which aims to shift power away from the public sector and into private enterprise to protect trade and capital (Manning, 2024). This involves the assumptions that sustained economic growth is necessary to both achieve and measure human progress, that a deregulated free market is the most efficient mechanism of allocating resources, and that the best way to achieve this is by reducing public ownership, minimizing state regulation, intervention, and spending (Smith, 2014). This results in the restriction of unionization among workers, the privatization of public utilities and services, and austerity and cuts in government investment and spending. Consequently, neoliberal ideology threatens democracy, undermines workers’ and citizens’ rights, and significantly contributes to worsening wealth and health inequalities¹ (Manning, 2024). The contradiction of neoliberal ideology is best described by the phrase ‘socialism for the rich and capitalism for the rest’. The working class is demonized, unions are undermined, and punitive austerity is imposed on those in most need of support, while big business, corporations and banks are granted tax breaks or bailed out by government when things go wrong, perhaps best exemplified by the 2008 financial crash (Jones, 2012, 2014). Neoliberal pontifications about hard work, responsibility, and accountability magically vanish from plain sight, as big business turns to mother state to wash away its sins.

The violence of hyper-individualism

Underpinning neoliberal ideology is a belief system of hyper-individualism which over-emphasizes the responsibility of the individual in building the future rather than society, self-determination rather than determination through collective systems and structures of groups, and that groups and systems are less accountable for the manifestation of peoples’ lives (Bacha, 2025). Since the 1970s, relentless corporate lobbying of governments, crises on the Left, and the emergence of new social movements, have resulted in neoliberal ideology becoming the dominant, political and economic hegemonic ideology in the West (Colpani, 2021). This has involved treating citizens as consumers, and conflating business freedom with personal freedom. Neoliberal ideology claims that humans, like businesses, are innately greedy and that competition between people divides society into winners and losers. It ignores the impact of power dynamics in assuming that this division is both normal and natural, and that individuals are solely responsible for their merit or misfortune. In doing so, neoliberalism as economic and political ideology, deliberately conflates individual-biological and collective-social laws and realities, which will be discussed in relation to psychopathology and psychotherapy below. Moreover, neoliberalism assumes that increasing the wealth of the winners, increases the wealth for all through a process of trickle-down economics. However, not only has economic growth under neoliberalism slowed since pre-Thatcher and Reagan, but the growth that has been possible is largely hoarded by the wealthy and powerful (Monbiot and Hutchinson, 2024). Finally, neoliberalism as a neo-colonial project perpetuates poverty and instability in the Global South (Bush, 2007).

Foulkes, Elias, and Dalal offer helpful insights as to why hyper-individual neoliberal ideology may dominate the discourse of our time. Foulkes writes about the resistance he experienced against accepting psychological processes as being fundamentally multi-personal phenomena, which may be comparable to the resistance Freud experienced against recognising unconscious phenomena in the individual psyche (Foulkes, 1973). Similarly, in Symbol Theory, Elias discusses the fear of the unknown and the nameless, which gives rise to fantasy knowledge that is adopted by groups. He writes: ‘it can give to such an extent the impression of being reality-congruent that it blocks the search for more reality-congruent symbols’ (Elias 1991: 57–58). He suggests that subjectivity of what we perceive to be objective reality emerges because it is the reality reflected back to us via the social domain. He also demonstrates how groups can be split, polarized, and reduced to dichotomous positions, which are perceived to be in conflict with each other. In reality, both groups are interdependent on each other, which results in a process of politicization of the psyche (Dalal, 1998). Conversely, neoliberal ideology aims to de-politicise social problems by locating them in individuals, rather than groups, to protect those in power. Doing so involves a denial of complexity, intersectionality, and responsibility by the powerful: what results is a frenetic and fragmented attempt at reality-congruency. Such denial and conflation act as fantasy knowledge to obscure the tensions that exist between the interests of businesses, private corporations, wealthy individuals, and citizens in ways that maintain and concentrate hegemonic power and wealth in the hands of the superrich and powerful, as outlined by Antonio Gramsci, Stuart Hall, and others (Colpani, 2021). This paper argues that wealth and power do not trickle down under the neoliberal world-order. Instead, it is neoliberal ideology which trickles down, and informs how societies, social values and attitudes have been shaped in the 21st-century in the West, and therefore by extension, how the westernized social unconscious has developed, through which our social selves and identities are constructed, even within health systems.

The violence of hyper-rational positivism

According to philosopher Slavoj Žižek, the way in which ‘the fate of whole strata of the population and sometimes of whole countries can be decided by the solipsistic speculative dance of capital, which pursues its goal of profitability in blessed indifference to how its movement will affect social reality’ in a neoliberal economy results in an system that is inherently, systemically, and objectively violent: ‘the fundamental systemic violence of capitalism . . . is no longer attributable to concrete individuals and their “evil” intentions, but is purely objective; systemic, anonymous’ (Žižek, 2008: 11). This violence is often experienced as psycho-socially traumatising for individuals and groups alike (Scanlon and Adlam, 2022).

Neoliberal ideology is intricately linked with hyper-rational positivism. Positivism is a philosophy emergent from the Enlightenment which valorises quantitative evidence to guide decision-making because it assumes that what can be quantified is objective and, therefore, real and true. It also assumes that more data, evidence, and scientific experiments translate to all things becoming knowable and is perhaps most evident with the current obsession of the wealthy and powerful with Big Data and Artificial Intelligence as over-simplistic answers to the multiple crises humanity faces, absolving us all of the need to interrogate power dynamics. This position is in stark contradiction to the notion of the unconscious and idealizes the use of reason and logic to make sense of the world around us, rather than intuition, introspection and creativity. Modern neoliberal ideology incorporates hyper-rational positivism, in what philosopher Byun-Chul Han describes as an ‘orgy of liberation, deregulation, dissolution of boundaries, and de-ritualization’ which has become pervasive in the neoliberal world as it drives an ‘excess of mobility, of consumption, of communication, of information, and of production’ (Han, 2018: 90). What results is an excess of hyper-consumptive positivity that blocks the system, leading to collapse and implosion: this is both external in the form of social and ecological collapse (e.g., rising wealth inequality and climate breakdown), but also internal in the form of inattention, depression, and burnout (Han, 2015).

Positivist violence represents an extension and distortion of the advances in thought brought about by the Enlightenment and has been weaponized to shut down thinking, reflection, and critique. It does this by adopting an atomized, decontextualized, and depoliticized position to complex problems, such as social inequality or mental illness (Dalal, 2018). This tends to involve a reductive approach to complexity by the denial of power relations, by oversimplification, and by attributing problems to a single cause, which tends to be the individual, rather than systems of power structuring society. In this way, hyper-rational positivism and hyper-individualism act to maintain neoliberal ideology.

Neopsychopathology

The oversimplification or erasure of socio-economic processes in neoliberal ideology is parallelled by a decrease in biopsychosocial formulation of psychiatric illness in mental health services. Neuro-biogenetic explanations of underlying aetiologies of mental illness are adopted instead (even though the evidence to support this is limited), and involves several inflations, conflations and assumptions based on the advances in neuroscience, giving the illusion of reality-congruency, thus functioning as fantasy knowledge. This becomes more apparent by the paradoxical shift in psychiatric diagnosis away from being based in aetiology², and towards symptom-based descriptions. In doing so there is the false assumption that there exist objective and well-understood medical pathologies that give rise to psychiatric symptoms. If this were the case, we would have robust objective biochemical, genetic, immunological, or radiological tests for psychiatric illnesses, which would inform specific treatments. If such tests and treatments were available, we would expect to see a decrease in psychiatric illness and morbidity as has been observed in the majority of other medical specialties, rather than stagnation or deterioration (Davies, 2021). Instead of clear and specific neuropathology, what we really have are descriptive constellations of symptoms organized as disorders which are treated using non-specific, broadly acting psychoactive drugs, or psychosocial interventions.

In a similar way to the reduction of complex biopsychosocial problems to neurobiology, psychiatric identity has been reduced, denigrated, and dehumanized to that of diagnostician and prescriber; an identity that some psychiatrists have readily adopted and perform of their own accord. However, this overlooks the trust, understanding, containment, and safety of the therapeutic alliance, which is central to patient care, even in the context of prescribing (Mintz, 2022). Felicity de Zulueta says that ‘psychiatry’s need to remain wedded to biological medicine often makes its practitioners impervious to the social and traumatic causes of their patients’ problems. This can lead to a re-enactment of the trauma in treatment, or to the denial of the importance of social factors in the aetiology of psychiatric symptoms’ (de Zulueta, 2006: 319). This crisis in professional identity has been capitalized by the pharmaceutical industry as Joanna Moncrieff writes: ‘antidepressants have transformed a myriad of social and personal problems into a source of corporate profit and professional prestige’ (Moncrieff, 2011: 188). Despite the shift towards the biological, there is a wealth of evidence to support the significance of psychosocial aetiological factors in mental illness (Remes, Mendes and Templeton, 2021), such as the links between depression and income inequality (Patel et. al., 2018), socioeconomic inequality (Lorant et. al., 2003) and area deprivation (Remes et.al., 2019), as well as psychosis and trauma, social adversity, and discrimination (Varchmin et. al., 2021; Longden and Read, 2016).

Throughout my psychiatry training, I experienced the over-biologization of mental distress the most when working in Child and Adolescent Mental Health Services (CAMHS) where nearly every child referred was given a diagnosis of a neurodevelopmental disorder. The ideology underpinning neurodevelopmental disorders, as the name implies, attributes genetic and neurobiological causes to patterns in symptoms and behaviour exhibited in early childhood. This is the case despite limited genetic and neurobiological evidence to support this (Timimi, 2020, 2025). Indeed, there is no objective genetic or neurobiological test that can be done for neurodiversity, and diagnosis is made using observational assessments that involve a high degree of subjectivity and clinical interpretation. CAMHS was once well-reputed for in-depth systemic and psychosocial thinking, but compared to discourse of the ‘differently-wired brain’ of the neurodivergent, there was comparatively little consideration for psychosocial factors which may be contributing to clinical presentations. Instead of a robust biopsychosocial formulation, patients’ distress was routinely reduced to a diagnostic checklist, which parallels the way individuals are reduced to arbitrary social signifiers in the neoliberal world of identity politics.

In an attempt to escape the constraints of social discourse around mental illness, the neurodiversity solution conveniently allows ‘responsible’ adults, groups, and society to locate the disturbance in something seemingly concrete and irreversible: the child’s brain and genome. The idea that our genetics and neurology are static is an assumption and has been challenged in the context of the foundation matrix (Paris, 2024). However, this is tragically inconvenient for the child whose brain and genome have been scapegoated and denigrated without clear objective evidence. It was not uncommon in multidisciplinary team (MDT) meetings to witness a pass-the-parcel blame-game between CAMHS, school, social care, and the family—all sectors ravaged by the brutal austerity politics of the neoliberal Conservative government following the financial crash in 2008, as well as the aftermath of the Covid-19 pandemic and the subsequent cost-of-living crisis. It struck me how difficult it was for the adults in the room to take and share responsibility as a collective. Again, Foulkes offers us some insight as to what may be played out as ‘any change in any individual part of such a network upsets the whole balance inside it. As this is true for psychologists, doctors or psychoanalysts . . . ultimately it would mean that the whole community must take a far greater responsibility for outbreaks of disturbing psychopathology generally. There is therefore a very specific defensive interest at play in denying the fact of interdependence’ (Foulkes, 1973: 225). This may be Foulkes at his most radical, and quite possibly inspired by the then-contemporary revolutionary, democratizing, countercultural, anti-psychiatry movements which gave rise to the development of the democratic therapeutic community, and subsequently, to group analysis.

In a similar vein to Foulkes when writing about the tendency of abuses of power in psychiatry, Sidney Bloch and Peter Reddaway point towards the vague definitions and boundaries of mental illness, and the scapegoating of the mentally ill as a way for society to avoid facing its fears, which leaves psychiatrists trying to balance the interests of patients and institutions that are often opposed to each other (Bloch and Reddaway, 1977). Just as neoliberalism locates disturbance in individuals, neopsychopathology locates the disturbance (that patients present to us with) rigidly within the genes and brains of the individual and assumes this to be the unquestionable natural order of things. This shuts down holistic biopsychosocial formulations of mental distress and oversimplifies the multifaceted nature of patient care needs, many of which are a direct result of political, economic, and social negligence.

Neopsychotherapy

The shift in psychiatry parallels that within the NHS’ psychological services which, due to budget cuts and service closures, have moved away from providing holistic, long-term psychotherapy and towards cognitive-behavioural therapies (CBT) which tend to be atomized, symptom-focused, and time-limited. Despite this, waiting times, patient numbers and case complexity are on the increase, as are the pressures psychotherapists face (British Psychoanalytic Council, 2015). Like psychiatry, there is a tendency in modern psychology to value individual, quantitative, and ‘objective’ evidence over the social, qualitative, and subjective (Nelson, 2015) and may be interpreted as an attempt to cement psychiatry and psychology as being objective and scientific, and therefore credible and real according to neoliberal values. The shift in psychiatry and psychology towards the neurobiological acts as neoliberal ideological fantasy knowledge in locating behavioural disturbance in our brains, rather than in the social or interpersonal domain. This ultimately serves those in power who can continue to violently cut public funding with impunity while minimizing the scrutiny of psychosocial ramifications.

In the CAMHS team this shift was evident in the availability of CBT and Dialectical Behavioural Therapy (DBT), compared with systemic therapy (minimal) and psychoanalytic psychotherapy (non-existent). It was common practice for young people to be offered brief (usually six sessions), manualized, symptom-focused, psychologically informed interventions, often several in quick succession for different symptoms by different clinicians and by different teams (also fragmented according to diagnostic category). The disregard for holistic, consistent care, and secure attachment formation was striking, as was the dehumanization of clinicians (and the therapeutic relationship) who took second place compared to the kind of intervention offered. It was consequently common practice for patients to be offered a replacement DBT therapist if their therapist could not make the session—the implicit message being that DBT helps the patient more than the clinician does. In the DBT group which I was a member of, there was little time for group dynamics to be worked with (despite significant acting out) because the material had to be delivered in accordance to a rigid schedule, specific skills needed to be taught, and the manual used as a dogmatic tome to be adhered to—much like a new product that must be clearly labelled, sold and shipped on time, in true capitalist fashion. The neoliberal approach to psychological interventions is mirrored in the history, processes and structures of how Improving Access to Psychological Therapist (IAPT) came into being under the New Labour government and has been written about extensively by Farhad Dalal and James Davies (Dalal, 2018; Davies, 2021).

Another factor which may have contributed to the need for psychiatry and psychology to assert their neurobiological scientific professional identities might be the conflation of wellness with healthcare, which has become exceedingly prevalent on social media platforms like TikTok, YouTube and Instagram. The boundaries between psychologist and psychotherapist, and coach or therapist, have become increasingly permeable. Indeed, it is often difficult to establish who is saying what online, what product or service is being promoted or sold, and from what position and context. This plays out in the NHS in clear positivist fashion, with never-ending job title creation, such as assistant psychologist, psychological practitioner, associate psychologist, team therapist and wellbeing practitioner, to name a few; titles that are significantly more underqualified and underpaid than psychologist, psychotherapist or psychiatrist, and yet sound more senior than they actually are in an ingenious way of cutting costs, as well as the quality of clinical care available to patients. What results from the countless titles and types of 3-letter-acronym therapies is confusion and disorientation, both on the part of clinicians, as well as the patients we treat. The neoliberal method of providing endless consumer choice is clearly at play here. However, it is easy to get lost when trying to discern CBT, from DBT, from MBCT (Mindfulness-Based Cognitive Therapy), from CFT (Compassion Focused Therapy) from ACT (Acceptance and Commitment Therapy), from MCT (Meta Cognitive Therapy) et cetera. What becomes apparent is that the endless consumer choice is an illusion, more fantasy knowledge; neopsychotherapy plunges us all into the ‘inferno of the same’ (Han, 2017: 3). In doing so, patients are reduced to machines with cognitions that must be processed, rather than complex inter-related beings that need to be understood. In adopting a hyper-individualistic, decontextualized and depoliticized position, neopsychotherapy maintains sameness and neutralizes curiosity, vulnerability and Eros which arise when we discover, through being with Others, something new about ourselves, the people we are in connection with and the world around us. This, in turn, perpetuates and reinforces the formation of a personality that is anti-social, narcissistic and devoid of Eros, fuelling depression and burnout (Han, 2017).

Confronting neoliberalism through the analytic group

I ran an analytic group for people with a diagnosis of treatment-resistant depression: an intricately neoliberal term that locates resistance in the depressed individual, rather than in the failure of the (often pharmacological) treatment. Group member A spoke about how overwhelmed they felt due to the demands of others in various areas of their life. This resulted in other group members suggesting various practical solutions such as exercising, having a routine, using mindfulness apps, taking a holiday on their own, and even finding another group to join. It is common for groups to feel overwhelming and unbearable, and for members to want to assuage suffering and move away from difficult feelings. Unfortunately, in trying to find a quick solution, there is less space for curiosity, sympathy, and connection. What the group enacts parallels the positivist violence of neoliberal capitalism: a demand for consumption, to buy X to fix Y. All responsibility is placed on the individual whose needs are decontextualized. In this case the decontextualized narrative might be: ‘we want to help; we know that structure and relaxation are good for depression so do more of that’. However, what gets overlooked are A’s responsibilities to their job, family, and child (which they value dearly), and the group’s responsibility to look after them as they navigate these difficult circumstances, within the group they currently attend, in the here-and-now. This vignette occurred in the context of group member B’s last session in the group after two years of membership. The group was able to notice the multiple overwhelming feelings associated with this leaving that A might have been voicing on the group’s behalf. Unlike A’s circumstances, the group was able to stay with the feelings in the group around B’s leaving.

In another session, a group member said that it was important for us all to do positive things in our lives for medication to work optimally. This generated interesting conversations about who was the agent of change, and who was in charge—us, or the drug? Were we using medication to disrupt something pathological, or were we seeking brief respite only to return to familiar patterns of repetition and compulsion? The conversation moved on to the contexts in which medication is taken, and the use of the drug as a coping mechanism which, like other ways of coping, may have different risks and benefits in the short and long term. Interestingly, another group member spoke about feeling racially stereotyped in the group which served as a bridge of bringing their experience ‘out there’ into the group ‘in here’, which although had come up before, is something the group had been particularly avoidant of. The conversation included reflections about being depressed in the social context of trauma and abuse, and led to questions about diagnostic labels, scapegoating, and what disturbance was located in them, rather than where the disturbance was located in society. What also emerged was the idea of suicide as an individual ‘solution’ to a social problem in which the individual colludes with powerful social projections in acting out its own execution. It was fascinating to observe the conversations that were made possible once a challenge to the position of the individual in their neoliberal context was made, which could represent the unblocking of communication in an overloaded social system which Foulkes, Elias, and Han all allude to.

Personal reflections

Writing this paper has led to much reflection on the privilege and power I hold. I am privileged that I have never been given a label, nor have I ever needed a label to access healthcare or social services. As a psychiatrist, I am mindful of the power I hold in being able to give patients labels that can change their lives, for better or for worse. I am conscious that, as a medical psychotherapist, I am privileged not to need to diagnose and prescribe to feel like a potent and effective clinician. These privileges make me feel less reliant on and identified with the use of diagnosis and prescribing, which facilitates a critique of such practices. It feels important to direct critique at the institutions and systems that uphold and perpetuate neoliberal ideology, rather than the individuals who are limited, constrained, and disempowered by it; be they patients in need of care or clinicians doing their best to provide care in a profoundly uncaring, hostile, and violent neoliberal world.

The processes have been explored in which our personalities and selves are constructed in the context of neoliberal ideology: the dominant political and economic position in the West. By the time I was born in the 1990s, neoliberal ideology had already infiltrated the social unconscious, firmly establishing itself as the contemporary world order. Indeed, I do not have any lived experience of a world or reality before or outside neoliberalism; it is likely that it will take a long time for us to confront and work through its various ramifications. Like other individuals of a similar age, my personality, sense of self and perceptions of normality have been shaped and co-constructed through and by neoliberalism. Despite the profound sense of pessimism and despair about the NHS that I have inherited, I am also mindful of the collective power of my generation of clinicians to co-construct a better future for the NHS.

Conclusions and implications for group analysis

In group analysis we have begun to have conversations about decolonization by adopting a pro-active anti-racist and anti-colonial stance, and by examining how the legacies of capitalism, colonialism, and slavery play out in the analytic group. Neoliberalism is one manifestation of such processes of globalized oppression, extraction, and exploitation, emergent in contemporary life. As has been demonstrated, these positions and processes should not be fragmented, decontextualized, and depoliticized as neoliberal ideology would dictate. In my view, taking a holistic and intersectional approach as group analysts includes being pro-actively anti-neoliberal, as well as being politically engaged, in our clinical, organizational, and personal circles.

This paper has demonstrated how neoliberal ideology has infiltrated and co-opted the way psychiatry conflates descriptive psychopathology with biological pseudo-realities, and how manualized, decontextualized, hyper-individualistic psychological approaches predominate in the NHS. This has shaped the professional identities of clinicians working in mental health services and the patients that they treat. Group analysis, and other forms of relational collectivist therapeutic practices such as family therapy and democratic therapeutic communities, are unique in their ability to address neoliberal power dynamics at play, which is less possible in individual psychotherapy or in cognitive and behavioural groups. If practised carefully, group analysis has the potential to challenge the idea that patients can be reduced to descriptive data out of context and to turn the contemporary pop-culture phrase ‘am I the drama?’ on its head. Instead, group analysis prompts us to consider where the drama is located, how the drama might be shared, and how the drama might be acting through and between us.

Unlike the hoarded wealth that stagnates by those in power, neoliberal ideology does trickle-down. Like rainwater permeating a leaky roof, it penetrates every corner of society rendering our social home damp and mouldy, and our social foundations, precarious and unstable. Mental health services are no exception and believing otherwise risks colluding with hyper-rational positivism and hyper-individualism, stripping individuals of the bio-psycho-socio-political contexts which have shaped them, and in which they find themselves. This is denial, and this is violence—a violence that has no place in clinical care.

Footnotes

ORCID iD

Timothy Paris

Notes

Dr Timothy Paris is a psychiatrist training in medical psychotherapy. He is based in Bristol and works in the NHS. He is also training to be a group analyst at the Institute of Group Analysis in London.

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