I want to say one thing first. The worst possible reading of my work would be to think that I am saying that psychological distress and psychiatric illness are not “real,” or that we should just run the deinstitutionalization experiment again, into the same kind of debacle. The Left should concern itself with the question of human suffering, which includes psychiatric suffering. However, when we talk about what kind of a thing is going to work to address population-level rises in suffering (which are being apprehended as psychiatric suffering), we have to think pretty seriously about what kind of a thing it is that we’re dealing with, and therefore what causes it, and what could fix it.
Let’s take, for instance, Los Angeles County. There’s been some noise here about reinstituting different types of legal mechanisms that let you involuntarily institutionalize people for long periods of time. These kinds of questions about the state, incarceration, and care are back on the table, and we need to be ready for them. I was reading a report from a Massachusetts state commission in 1984, which was set up to track the effects of deinstitutionalization, and what the report basically says is, “This has been a debacle.” First, a surprisingly high percentage of the patients had just straight up died in accidents like house fires, because they couldn’t take care of themselves. But what’s interesting is that a lot of the former patients they were able to find were either in and out of jail or the prison system, which is not equipped to provide psychiatric service, or bouncing around from shelter to flophouse to group home to the street. And many of the former long-term patients thought their situation was better in long-term institutions. What I’m saying here, as the first part of an answer to your question, is that we can’t ignore the fact that in a capitalist, alienated society, there are many people who simply will need long-term institutional care. I think that we should think about what that might look like, and what historical lessons we can take to make sure that that care is not, ah, fucked up.
However, when it comes to your question whether mental health care belongs in the clinic, let’s look at the way the clinic frames things. The clinic functions because you appear with a symptom, and the clinic then apprehends you as a body that has a medical problem. That’s what it was built to do, as an institution. And so the clinic looks at the symptoms, and as far as clinicians are concerned, the history of that symptom is more or less the history of one person’s body. What the clinic means by “history” is “there’s something wrong with your body, let’s take a quick history, and then let’s address this disease condition that is in your body.” That is quite clearly an insufficient imaginary to grasp population-level increases in things like suicide, depression, and despair.
The point is that you cannot disaggregate the question of mental health and try to turn it into something that’s only addressed in a clinic and have that work at all. But I don’t think the answers are so mysterious, really: changes in infrastructure at the level of transportation, at the level of food security, at the level of the types of food that are available, at the level of education and housing, basic social policy stuff.