July 20, 2024

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We Need To Decommodify Mental Health Care

We Need To Decommodify Mental Health Care


Catherine Liu is a professor of film and media studies at UC Irvine and the author of “Virtue Hoarders: the Case Against the Professional Managerial Class” (2021). She is at work on her next book, tentatively titled “Exploiting Trauma: Standardized Suffering in the Age of Surveillance Capitalism.”

As a species, human beings have always been vulnerable to the shock of an unforeseen violation of body, mind and spirit. But the way in which that injury is understood — not as a vagary of fate that must be endured, but as a subject of legal and medical intervention — emerged with industrial modernity. 

There is scholarly consensus that contemporary ideas about trauma originated in the 1800s, in legal and medical language about the railway accident, said to produce a nervous condition called “railway spine.” The railroad accident brought traveling businessmen — members of the mercantile capitalist or upper middle classes in the United Kingdom — into legal conflict with railroad companies, as it exposed them to what literature professor Roger Luckhurst calls “technological violence previously restricted to factories.” 

Work injuries suffered on the factory line are rarely mentioned in academic accounts of trauma, whether from a literary or a historical point of view. In fact, industrial forms of working-class injury are largely ignored by the literature on the railway accident. “Because the fevered expansion of railroads from the 1840s was driven by free market companies,” Luckhurst writes, “the medical question of injury was always also a legal question of liability.” When, in 1862, a certain Mr. Shepherd was awarded damages by a court for his inability to conduct business after being involved in a railway accident, the medico-legal notion of the “railway-spine” was cited as a specific form of damage to a person’s entire nervous system. In the absence of physical wounds, railway spine affected its victims with nervous ailments that had never been seen before.

Trauma, as we understand it today, is inseparable from the emergence of industrial and then finance capitalism. And since the days of the railway-spine, it has been good for business: Modern technologies created modern afflictions that were treatable not by priests and shamans but by legal, medical or psychological experts. This history of trauma’s emergence as a legal and financial category critical to the development of industrial and then finance capitalism’s class configuration is generally ignored by trauma experts, who range from psychologists to self-help gurus.

Today, the way that psychological trauma is performed and privileged in public discourse — which I will refer to as trauma culture — promotes an ideology of individual suffering that is remarkably well adapted to the spectacle-induced amnesia of late capitalism. Trauma culture destroys the political and historical ground on which to form a critique of capitalism. Since the end of the Cold War, it has worked tirelessly under the guise of progressive politics to depoliticize the public sphere.

The professional managerial class (PMC) has helped promote this culture, along with the fantasy that financial anxiety and stress are temporary states of being that can be overcome through hard work, competition and education. This class emerged in the late 19th and early 20th century as an intermediary between the bourgeoisie, who could live on trust funds and interest, and the working class that labored to produce the profits enjoyed by its exploiters. The PMC consisted of white-collar salaried employees with educational credentials, whose expertise was honed in institutions of higher education. Its expansion and empowerment happened in two waves in the United States: The first, emerging out of the Progressive Era, produced social scientists, engineers, economists and policy experts who could fill roles created by the New Deal. The second wave of PMC empowerment occurred during the Cold War, with the rapid expansion of the military industrial complex.

Trauma culture takes suffering at the individual level as a privileged site of political struggle, inheriting its mandate from the 1960s cliche: The personal is the political. In doing so, however, it standardizes and mass markets individual suffering, through what sociologist Eva Illouz defined as a tightly scripted “trauma narrative” — an innocent protagonist, fractured and destroyed, then redeemed and remade whole as a survivor — that endows individual stories with immediately recognizable meanings.

“Trauma culture takes suffering at the individual level as a privileged site of political struggle. In doing so, however, it standardizes and mass markets individual suffering.”

The goal of psychotherapy should be to work through an unconscious fixation on traumatic material, and it can only happen on an individual level. Psychoanalysis, as I have understood and lived it, helps the suffering individual let go of her attachment to a traumatizing past. This therapy is not political, it is personal.

By confusing the personal with the political, trauma culture actively prevents us from seeing the material conditions of wage labor as the proper site of political struggle. Ever since the dawn of industrial capitalism, the working class finds itself pitted against the capitalist, who seeks to surveil, exploit and extract every bit of labor power from her workers. The greater the suffering of the working class, the greater the profits for the capitalist. By focusing on all forms of trauma except exploitation, trauma culture has helped to disguise the economic violence at the heart of neoliberal macroeconomic policies.

Trauma culture does play an important role in helping to orient dislocated subjects of late capitalism on an itinerary of social mobility — those torn from families where parents were no longer figures of moral authority, myself included, crave a different form of ethical grounding. But while a therapeutic language of suffering may have helped us find ways to articulate abuse, the demand for emotional authenticity has delivered us into the arms of the market. Trauma culture provides us with psychological tools to free us from the raw domination of feudal, patriarchal culture while it softens us up for the soft discipline of the commodity.

In 2020, Routledge — which claims to be the most important humanities and social sciences press in the world and regularly publishes field-defining anthologies — released a nearly 500-page volume called “The Routledge Companion to Literature and Trauma.” Quick phrase searches reveal that there is little discussion of economic hardship throughout, and “economic crisis” is not mentioned once.

The editors of the anthology, Colin Davis and Hanna Meretoja, define trauma as “psychological injury, lasting damage done to individuals or communities by tragic events or severe distress.” “Tragic events” seem to be outside human control — note the passive voice in the editorial formulation. The editors, in emphasizing “psychological” as opposed to physical injury, promote a very white-collar notion of harm.

From Sigmund Freud, pioneers in trauma studies derived a very specific idea about psychic injury and its disembodied, textual and linguistic nature. When treating soldiers returning from World War I, Freud found that psychic damage could be as profound and long-lasting as physical injury.

“While a therapeutic language of suffering may have helped us find ways to articulate abuse, the demand for emotional authenticity has delivered us into the arms of the market.”

While some veterans he treated emerged from their grueling war experiences physically intact, they later experienced severe psychological symptoms, their meaning and impact buried in the unconscious and retrievable through the talking cure.

Davis and Meretoja argue that trauma is a critical concept for understanding literature and human experience in modernity. But their modernity barely takes into account industry and economy. The focus on genocide and horrific acts of violence is unrelenting and makes it almost impossible to criticize the composition of such a text without appearing evil oneself. The privileged activities promoted by the anthology are described in spiritual and transcendental terms: theorizing, witnessing, remembering and reflecting are the purview of an ethics of reading atrocity that cloaks itself in the highest order of political good.

The New Left anti-war and women’s movement proposed that private suffering should be turned into public action. The mantra that the “personal is the political” was brewed in the ferment of anti-war protests and feminist political agitation. A class of liberal experts reframed suffering as trauma in two ways, divided along gender lines: war trauma and sexual violence.

Anti-war psychologist Robert Jay Lifton’s advocacy for Vietnam veterans led to the introduction of post-traumatic stress disorder (PTSD) in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM III) in 1980. Disorders in the DSM are recognized by insurance companies and psychiatrists alike. In Lifton’s analysis of discussion groups held at the New York office of Vietnam Veterans Against War, he postulated that the collective discovery of one’s guilt and suffering would lead to healing and anti-war activism.

While Lifton focused mostly on male veterans of the Vietnam War, psychiatrist Judith Herman’s “Trauma and Recovery” became the feminist textbook for sexual trauma on the other side of this gendered divide in treating trauma. Not only did Herman give new meaning to the experiences of women who had been sexually assaulted and were mistreated by psychologists and the legal system alike, she made a point of politicizing such violence and healing processes as issues of gender and domination.

Ibrahim Rayintakath for Noema Magazine

Since the early 1970s, progressives promoted an early form of the trauma script: Publicizing the language of trauma would lead to political expression and action, transforming the very idea of the public sphere without transforming capitalism. All the religions of the world offer succor and comfort to those who suffer; suffering joined us to community and to the suffering, in Christianity at least, of the deity himself. With the decline of religious belief, psychologists and experts would henceforth reveal to the public the meaning of trauma and the ways to overcome it.

Unfortunately, it was also a moment when capitalism’s declining rate of profit allowed punishing economic policies to gain power, policies that would harm the poor and working classes in the Anglophone world while rewarding those at the very top. Neoliberals like Milton Friedman, who had been marginalized by postwar Keynesians, were the mouthpieces of a form of economic stimulation based on reversing the post-World War II distribution of wealth to the laboring classes. Capitalists chasing falling rates of profit understood that working-class people had to be financially punished for organized labor discontent, while credentialed elites could be copiously rewarded for reshaping a world order based on free market ideology.

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Neoliberal economists described the freezing of working-class wages and social benefits as a necessary tonic to stimulate stagnating national and global economies. Corporate and wealth taxes were reduced for the rich, while cutting labor costs by outsourcing manufacturing jobs saved capitalists enough money in working-class wages to endow white-collar elites with a larger share of surplus value.

“The identity of the ‘survivor’ has become a privileged political subject, more significant than the old-fashioned notion of the worker.”

The PMC are the top earners of salaried employees: They have college degrees and professional credentials, and they manage others for the bosses. At the beginning of the 20th century, white-collar professionals made up a tiny but growing fraction of the American workforce: In political economist Harry Braverman’s analysis, in 1870, clerks — the precursors to white-collar workers — made up less of the workforce than wage laborers and a little more than family servants.

When authors John and Barbara Ehrenreich analyzed the PMC’s growing power in 1977, they focused on the ways in which it dominated the liberal professions, from academia to media to progressive political organizations. In my book, “Virtue Hoarders: the Case Against the Professional Managerial Class,” I emphasized the contempt this class has for the working class. The economic policies put into place by PMC President Bill Clinton demonstrated that this disdain was not purely cultural: Free trade and globalization were overseen by economic experts and managers in his administration and led to the economic devastation of American industry and agriculture in favor of corporate profits. The PMC has been the servant of capitalism, just as the family clerk was a servant to the family firm in 1870.

In return for its share of profits extracted from labor, the PMC undertook the endless work of ideological reproduction, sidelining economic issues in favor of endless culture wars. On corporate platforms, PMC content production has cemented its hold on depoliticized concepts of trauma, suffering and healing in order to consolidate its victory over classical liberalism and its embrace of anti-democratic politics. The liberal PMC has successfully reframed the American media public sphere as one in which the identity of the “survivor” has become a privileged political subject, more significant than the old-fashioned notion of the worker. In this way, the trauma script conveniently sidelines the division of labor and exploitation.

This dynamic can be seen in the way the field of trauma studies emerged in academia in the 1990s, formulated in a way that attacks history and historical understanding and contributes to the obfuscation of the workings of capitalism. I believe the field had its origins in the trauma of its two leading thinkers, Shoshana Felman and Cathy Caruth, both devoted students of Yale literature professor Paul de Man. After de Man died in 1983, researcher Ortwin de Graef discovered that de Man wrote columns filled with antisemitic propaganda for a newspaper that had been co-opted by Nazis in occupied Belgium.

His former students were ready, however, to promote a new approach to history and suffering that would exonerate literary theory and deconstruction in the wake of these revelations: They would transform it into trauma studies. Caruth focused on the Holocaust as an event that created a rupture in the fabric of human experience itself. From de Man, they adopted the term “aporia” — a logical or linguistic impasse that indicates difficulty or rupture — as critical to understanding the obscure temporal logic of psychic damage. From Jacques Derrida, Caruth and Felman adopted the ethical importance of close textual readings and a Heideggerian respect for the unknowability, unapproachability or intractability of “the Other.”

Caruth’s “Unclaimed Experience: Trauma, Narrative and History,” a trauma studies urtext — written with the de Man scandal still fresh in everyone’s minds — seems to remove history from the grasp of anyone outside of the elite class:

Through the notion of trauma, I will argue, we can understand that a rethinking of reference is aimed not at eliminating history but at resituating it in our understanding, that is, in precisely permitting history to arise where immediate understanding may not.

In other words, average people who are not initiated in trauma theory — people who believe in immediate understanding — simply do not understand what happened in the past. As I demonstrated in “Virtue Hoarders,” PMC elites have become adept at this kind of obfuscating move: making things the uninitiated thought we could grasp or have access to, like historical understanding, incomprehensible and full of impossible contradictions.

Trauma studies, despite its own claims, was never truly psychoanalytic. The academics and theorists neglected a crucial aspect of Freud’s theories of shell shock and repetition compulsion: Every trauma evokes a narcissistic disorder, one that needs to be worked through. For Freud, it was in the talking cure specifically that one could discover the ego’s complicity in creating a secondary narcissism, where the war neurosis or the PTSD — which is a search for anesthetization or mastery of the trauma — takes place.

The exposure of de Man’s Nazi sympathies was likely traumatizing for his former students. The creation of trauma studies allowed them to intellectualize the narcissistic disruption as a professionalized witnessing, a simplified listening where the narcissistic particularity of each traumatized subject is standardized according to a reassuring script that follows a familiar narrative of fracture and recovery.

Now, in the 21st century, the trauma narrative has been instrumentalized to commodify mental health as a realm of experience that can be shared and processed collectively online. As Shoshana Zuboff documents in her book “The Age of Surveillance Capitalism,” Sergey Brin and Mark Zuckerberg made it part of their business strategies to gather information about users’ behavior online and sell it to advertisers. As private suffering and distress shape our activity online, we’re providing valuable information to social media platforms, allowing them to serve us ads that exploit our vulnerabilities, economic and psychic.

Today, trauma content has become an easy way for celebrities and politicians to brand themselves. Examining how they deploy ideologically framed social media trauma to create pseudo-intimacy in the name of digitally mediated mental health discourse can allow us to understand the transformation of the public sphere that has taken place in our post-industrial age.

As Caruth was writing about trauma and founding a new field of literary study, Oprah Winfrey was transforming the “personal is the political” sensibility of the New Left into media-friendly content. Although she never participated in any form of political radicalism, she used a language of redemption and emancipation to build a unique media brand.

Winfrey was a master of televised intimacy: She understood the medium, her audience and TV’s role in defining a market by inserting itself in the fabric of female-dominated domestic consumption practices. In 1986, she confessed to having been a victim of childhood sexual assault “so that maybe the closet where so many sexual abuse victims and their abusers hide might swing open just a crack today and let some light in.” In using the image of the closet, Winfrey carefully deployed the terms of gay liberation without frightening her mostly suburban, white, female audience by actually talking about gay people.

Winfrey’s success can be understood in the trajectory of another segment of 1960s political unrest and political transformation: the civil rights movement. On her show, in her pleas for healing and recognition, Winfrey echoes the cadences of African American preachers and political leaders, stripped of political content. Her appeal transcends race, and her success and power can be understood as one singular individual’s fulfillment of Martin Luther King Jr.’s expansive dream for racial justice.

In 2021, Winfrey co-launched a series with Prince Harry, “The Me You Can’t See” on Apple TV+, featuring her own elaboration of her suffering as a child, while offering a media space for celebrities like Glenn Close and Lady Gaga to talk about their own experiences of violence and trauma. Celebrities and political figures are invited to make public their most private experiences of suffering. With Winfrey’s help, celebrities can come out of the closet as “survivors.”

“Nothing less than the decommodification of mental health is needed to provide a socially responsible form of public and collective reckoning with trauma and human suffering.”

In the same vein, liberal and progressive political actors soften the boundaries between the personal and the political in order to persuade their audiences of their suffering and authenticity. In Alexandria Ocasio-Cortez’s Instagram Live broadcast of her account of her experience of Jan. 6, 2020, the congresswoman described hiding in her office that day, sure that she was going to be physically attacked. In the midst of the broadcast, Ocasio-Cortez confessed before millions of followers that the terrifying experience triggered her memories of having been sexually assaulted, adding that many people in her life did not even know that she was a survivor of sexual assault. An adept user of social media, Ocasio-Cortez performed two simultaneous acts of self-revealing that could give her supporters and viewers a sense of being directly in touch with her experience of violence.

By 2021, trauma — its scripts, plots and theories — had finally taken up permanent residency in the Anglophone culture industry, from content production to the managerial ethos. From Disney’s “Encanto” to Jason Mott’s National Book Award-winning novel, “Hell of a Book,” trauma took center stage in the narratives the liberal PMC produces and consumes. The ubiquity of trauma as cultural content has been a huge, uncelebrated victory for progressive psychologists and literature professors. Their ideas about trauma have eclipsed all other ideas of psychological suffering and have been used to promote “resilience” as a very specific form of recovery and healing.

In the closing months of 2021, the ubiquity of the trauma narrative finally led to a small media backlash, spearheaded by literary and cultural critics: Parul Sehgal in The New Yorker and Will Self in Harper’s. While Sehgal and Self gave voice to exhaustion with trauma culture, criticism of what Sehgal disdainfully calls “the trauma plot” leaves the depoliticizing power of trauma culture intact. While Self’s critique is more theoretically and historically grounded than Sehgal’s disdain for trauma culture’s degradation of aesthetic forms, his display of sharp erudition and Selfian wit hardly gets to the heart of what trauma does for the present moment. The fragmented public sphere continues to be dominated by the values of the American PMC, which is committed to the monetization of private experience. We are no warier of trauma culture’s deep investment in selling us neoliberal dogma about history, politics and human suffering. Accepting the trauma script has left us, as a society, remarkably unprepared to focus on actual policy solutions that could alleviate suffering on a mass scale.

Trauma culture emerges to fill a gap in accessible mental health care: Traditional psychoanalysts on the coasts often charge over a hundred dollars an hour, making the individualized mental health treatment pioneered by Freud and his followers unaffordable for many. Managed care offers limited sessions with a network of psychologists who are finding themselves increasingly under pressure to produce quick results for their patients. The psychologists who can afford to leave insurance networks do. It is not surprising that people might look to celebrities, social media or trauma studies to find meaning for their pain and suffering.

Nothing less than the decommodification of mental health is needed to provide a socially responsible form of public and collective reckoning with trauma and human suffering. I like to imagine that socialized medicine will take the profit motive out of the health care system and, in so doing, will make psychoanalysis, psychodynamic psychology and other forms of high quality therapy available to all Americans. Popular culture, social media and academic theories can do nothing to heal us. We must wage a political struggle to protect private experiences of suffering and trauma from the promises of the market and the algorithms of surveillance capitalism.