Madness and Civilization, Revisited

“For the madness of men is a divine spectacle: In fact, could one make observations from the Moon, as did Menippus, considering the numberless agitations of the Earth, one would think one saw a swarm of flies or gnats fighting among themselves, struggling and laying traps, stealing from one another, playing, gambling, falling, and dying, and one would not believe the troubles, the tragedies that were produced by such a minute animalcule destined to perish so shortly.

Michel Foucault, Madness and Civilization: A History of Insanity in the Age of Reason. 1961.

Published December 9, 2017-Updated July 15, 2020

America struggles with mental health: we are in the grip of systemic failures of the mental health care system. It is not astonishing that the issue of mental health is now on the forefront of public attention: The country has knowingly elected a President who is a pathological liar and exhibits other signs of mental illness. The 2016 Presidential Election is just a symptom of a deeper madness in American culture: We have seen 307 mass shootings from January to November 2017 alone, which averages to almost 7 mass shootings a week. 1 We are legalizing marihuana everywhere, while the number of deaths from drug overdoses has reached the staggering number of 160 people per day, or 59,000 in 2016. 2 At the same time, Republicans try as hard as they can to roll back universal health care coverage. The political discussion about health care reform is itself a sign of severe irrationality in public discourse. Mental Health treatment is part of the debate, and the following entry will examine some of these issues further.

The debate about American Healthcare operates with an underlying assumption: everything should be organized around commercial interests. The chase for a perfectly managed healthcare system means that at the intersection of bureaucracy and actual care, “healthcare” loses, and the “system” wins. The work of psychotherapists, for instance, is centered on a truthful dialog and a human encounter, and it is fundamentally resistant towards a delineation into “treatment plans.” What happens in the real encounters between therapists and clients cannot be expressed in the categories of the “Diagnostic and Statistical Manual of Mental Disorders (DSM–5). The psychotherapist’s office is not a place where standard procedures get administered; it is something entirely different: an epistemological location, a place where the clients’ relationship to truth, discourse, and power, can be transformed. It should be the place where the bureaucratically eliminated individual subject can find her voice again.

Attempts to organize health care in the American political/economic environment have not been very successful. The World Health Organization ranks the US Healthcare system as number 37 on the list of countries, after Costa Rica, Chile, and Morocco. 3 According to the World Bank, we spent 17% of GDP on healthcare in 2015. By comparison, the country with the best system in the world, France, only spends 11% of GDP on health care. 4 We live in a country where healthcare is not a public good, it is a service that has to be purchased. Therefore, it can be very good for some, and non-existent for others. The United States still has 28 million people without health insurance in 2017, down from 44 million before Obamacare started. The international comparison makes it clear: Of course we need strong single-payer healthcare (“Medicare for All”), similar to the European models.

Why are psychotherapists and other health professionals on the frontlines of this fight? Because America is also very sick: We live with addiction and drug epidemics, and 35% of the US population is obese. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), almost 1 out of 5 (18.2% of the adult US population) has a mental health disorder (about 42.5 million Americans.) The use of prescription drugs has increased enormously, and today around 1 out of 6 Americans (or 17% of the adult population) fills at least one psychiatric prescription per year. Drug overdoses are the leading cause of death for Americans under 50, and deaths are rising faster than ever, primarily because of opioids. Overdoses killed more people in 2016 than guns or car accidents, and the numbers grow at a pace faster than the H.I.V. epidemic at its peak. In 2015, roughly 2 percent of deaths — one in 50 — in the United States were drug-related. Overdoses are merely the most visible and easily counted symptom of the problem. Over two million Americans are estimated to have a problem with opioids. Over 97 million people took prescription painkillers in 2015; of these, 12 million did so without being directed by a doctor.

These numbers demonstrate the strong need for psychotherapy as a profession, but they also show that we need to think much more holistically about mental health problems. It is not only the healthcare system that is broken. American culture as a whole is in crisis: we live in the midst of rampant consumerism without values. Huge wealth and income inequalities destroy the fabric of American life. People are overworked and underpaid, and the political consensus that forms the foundation of our country is dissolving in a modern version of Marxist class warfare from above. 5 Why are we still treating mental health issues like depression and anxiety as individual diseases? They are systemic, and the medical/bureaucratic discourse about them drowns in denial and exhibits a deep passion for ignorance in relation to social facts and their causes.

An effective response to the mental health crisis will require a more complex political program. Consider this: the largest health insurance companies in the United States reaped historically large profits in the first quarter of 2017, despite many complaints about Obama’s Affordable Care Act. Aetna, Anthem, Cigna, Humana and UnitedHealth Group — the big five for-profit health insurers — cumulatively collected $4.5 billion in net earnings in the first three months of 2017. Health Care Service Corp, the parent company of the Blue Cross and Blue Shield, recorded an $869 million profit in the first quarter of 2017. For health insurance companies, there is no crisis – they live through golden times.

How do you force a national health care system to focus on what it is supposed to do, providing comprehensive health care for all, and stop it from using systemic diseases as profit opportunities? 6

We don’t need to explain why corporations want to make more profit and therefore use the political process as a tool to further their interests. What needs to be explained much better is why so many Americans buy into a system of lies and deceptions and turn easily against politicians like Hillary Clinton who want to help them (see her Mental Health proposals in the footnotes). Althusser provided some answers by developing the concept of ideology, but the real condition of American culture may be even worse: The system is beginning to transcend its rationality through violence. Just watch American TV for an evening.

Michel Foucault provided a lucid analysis of the entanglement between madness and civilization in 1961: “Self-attachment is the first sign of madness, but it is because man is attached to himself that he accepts error as truth, lies as reality, violence and ugliness as beauty and justice.


  1. A mass shooting occurs when four or more people are killed. Source:



  4. Interestingly, in 2016 the GDP/Capita in the US was $57,000, and the GDP/Capita in France was only $37,000.

  5. “There’s class warfare all right. But it’s my class, the rich class, that’s making war, and we’re winning. Warren Buffett.”

  6. Hillary Clinton suggested political guidelines for Mental Health Care in 2016, Here are some of her goals:

    • Promote early diagnosis and intervention. The majority of Americans living with lifelong mental health illnesses show signs of distress at an early age, and yet few are treated.

    • Launch a national initiative for suicide prevention. America is facing the highest suicide rate in 30 years—and it’s becoming increasingly prevalent among adolescents, college students, veterans, and older adults.

    • Integrate our nation’s mental and physical health care systems so that health care delivery focuses on the “whole person” and expand community-based treatment.

    • Prioritize treatment over jail for low-level, nonviolent offenders and help train law enforcement officers in responding to conflicts involving persons with mental illness.

    • Enforce mental health parity to the full extent of the law. The Mental Health Parity and Addiction Equity Act of 2008 requires group health plans to provide the same level of benefits for mental health as other medical conditions. Despite the law, too many Americans seeking mental health treatment still get turned away.

    • Invest in brain-behavioral science research.