Reading Between the Diagnoses: A Social Worker’s Guide to Psychiatry’s Past and Present
The new client’s chart read paranoid schizophrenia. His offense? Refusing to sit during a police-led “wellness check.”
For clinical social work students, this is where the work gets complicated. These moments are not rare, and they are never just clinical. They are shaped by a long history in which psychiatry has been as much a tool of control as a source of care. The profession’s public image — science rescuing people from ignorance and suffering — obscures a parallel story: one in which coercion, systemic bias, and the policing of social norms have been central from the start (Burstow, 2015, p. 4).
This paper examines that parallel story. It moves from psychiatry’s early entanglement with racial, gender, and class hierarchies, through the institutional harms of “therapeutic” violence, to the political economy that still shapes diagnosis today. It then turns to what all of this means for social work practice: how to read the DSM critically, question institutional norms, and develop anti-oppressive approaches that center lived experience over professional authority.
Thesis StatementPsychiatry’s historical practices — rooted in coercion, medicalized oppression, and systemic bias — continue to influence present-day psychopathology frameworks. As such, social work professionals must engage critically with the field’s history and current practices, integrating an anti-oppressive lens to resist replicating past harms and to advocate for mental health approaches grounded in justice, dignity, and the lived experiences of those they serve.
Historical Roots of Psychiatric Oppression
To understand today’s diagnostic and treatment practices, you have to see where they come from. Psychiatry did not emerge in a vacuum — it grew within legal, political, and economic systems invested in defining, managing, and containing “difference.” The field’s early institutions combined the language of medicine with the powers of the state, authorizing confinement, forced treatment, and the removal of personal liberty under the banner of care. These roots matter because the logic that justified them has not disappeared; it has been revised, reframed, and in many cases, absorbed into the everyday workings of modern mental health systems.
Coercion as the Core
From its earliest institutions, psychiatry has operated not only as a medical discipline but as an arm of social control. Thomas Szasz (2009) argued that psychiatry’s defining characteristic is not its healing capacity but its reliance on coercion — “the theory and practice of coercion, rationalized as the diagnosis of mental illness and justified as medical treatment aimed at protecting the patient from himself and society from the patient” (p. xii). This is psychiatry’s central paradox: it claims the mantle of care while exercising the powers of confinement, forced treatment, and the removal of personal liberty.
Source: https://www.uphs.upenn.edu/paharc/features/brush.html
The asylum system of the nineteenth and early twentieth centuries made this plain. People — often from marginalized or simply “inconvenient” groups — could be institutionalized indefinitely on the say-so of a physician, family member, or state official, with little to no recourse. The medical rationale for detention blurred with social anxieties about deviance, poverty, and nonconformity. As Szasz notes, this “therapeutic imprisonment” erased the boundary between treatment and punishment, subordinating patient autonomy to the psychiatrist’s judgment and the state’s interest in public order.
The language of care masked the politics beneath. Coercion was not an occasional misstep but a structural feature, legitimized by medical discourse that framed psychiatric authority as neutral, objective, and benevolent. In practice, involuntary hospitalization, compulsory medication, and other forms of enforced “treatment” reflected deep cultural beliefs about who is “fit” to decide for themselves, whose narratives count as credible, and what kinds of human difference can be tolerated.
This history still reverberates. In contemporary systems, the tension between patient rights and psychiatric authority is unresolved. For social work students and practitioners, this is not just context — it’s a caution sign. Before accepting any practice as “therapeutic” because it carries medical endorsement, ask: Does this intervention support client autonomy, or does it replicate a coercive logic under new names? This question is especially urgent in settings that use involuntary treatment, mandated programs, or risk-assessment protocols that quietly limit freedom of choice.
Pause & ReflectThink of a time in fieldwork or classroom simulations when “risk” was cited as a reason for overriding a client’s preference. What assumptions were operating? Were they about safety — or about control?
Scientific Racism and Gender Oppression
Psychiatry’s coercive foundations were not only preserved but strengthened through pseudoscience that dressed racial and gender hierarchies in the language of medicine. Nineteenth-century American psychiatry offers some of the clearest — and most disturbing — examples. Physicians like Dr. Samuel Cartwright coined “diagnoses” such as drapetomania to explain the flight of enslaved Africans as a mental illness rather than as a rational act of resistance to violence and enslavement. In Cartwright’s schema, the “treatment” for this so-called disorder included whipping and forced labor — measures designed not to heal, but to enforce submission. Such diagnoses illustrate what Jonathan Foiles (2021) calls the pathologizing of protest: recasting resistance to oppression as evidence of a disordered mind (p. 17). By medicalizing defiance, psychiatry upheld the racial order while insulating itself from charges of overt political repression.
Frances Cress Welsing (1991) widens the frame by situating psychiatric racism within a global system of white supremacy. She argues that the construction of Blackness as inherently pathological functions as a defensive strategy to preserve white genetic dominance (p. 55). From this vantage point, the misdiagnosis and overdiagnosis of Black individuals — particularly with psychotic disorders — cannot be written off as clinical “error.” They are part of a long, deliberate pattern of racial control embedded in the profession’s diagnostic habits.
Parallel mechanisms shaped gendered diagnoses. In the nineteenth and early twentieth centuries, hysteria was disproportionately applied to women who resisted norms of passivity, domesticity, and sexual compliance. The label reframed acts of autonomy or dissent as proof of mental instability, justifying interventions ranging from institutionalization to invasive surgical procedures. Like racialized diagnoses, hysteria erased the social and political contexts of women’s lives, reducing systemic injustice to individual “pathology.”
Together, these histories show how psychiatric diagnostic systems have functioned not just to name illness, but to police the boundaries of race and gender. By embedding prejudice within the language of science, psychiatric authority could present itself as objective while enforcing oppressive social structures. And this pattern did not vanish when openly racist or sexist terms were removed from manuals; it was absorbed, rebranded, and often recoded in new diagnostic language.
For social work students, the takeaway is clear: interrogating the DSM means more than studying its categories — it means asking whose behavior, emotion, or identity is being marked as “abnormal” and why. If you notice a diagnosis applied disproportionately to certain racial, ethnic, or gender groups in your agency, you are not observing a harmless quirk. You are seeing the living echo of a system designed to maintain social hierarchies.
Pause & ReflectIn your current or past placements, have you noticed certain diagnoses clustering around specific racial or gender groups? What explanations were offered — and whose interests did those explanations serve?
Economic & Class Control
Alongside its racialized and gendered functions, psychiatry has long worked to manage class relations. Under industrial capitalism, the rise of the asylum was closely tied to the need to segregate and control those deemed “nonproductive” or disruptive to economic order. Bruce Cohen (2016) observes that the mental health system has been “impressively compliant to the wishes of the ruling classes,” often functioning less to address the social determinants of distress and more to warehouse the poor, unemployed, and otherwise marginalized (p. 29).
In this frame, institutionalization was less a therapeutic intervention than a strategy of social management. People whose poverty, homelessness, or inability to conform to wage-labor schedules made them economically “unviable” were labeled mentally unfit. That label, backed by psychiatric authority, legitimated their removal from public life and placement in facilities that reinforced their exclusion from civic and economic participation. At its core, this was an economic decision disguised as medical necessity.
The economic alignment extended well beyond asylum walls. Discharge policies frequently prioritized efficiency and cost-cutting over long-term stability, sending people back into precarious conditions that made re-institutionalization more likely. By framing systemic poverty as a personal pathology, psychiatry shifted the focus from structural inequality to individual defect — while reinforcing the ideology that economic marginalization results from personal failure rather than political economy.
This history complicates any claim of psychiatric neutrality. It reveals a long-standing interplay between psychiatric authority and state or corporate priorities, where medical language was used to justify containing those who challenged — or simply failed to meet — the demands of a capitalist economy. These dynamics are not relics. Today they surface in discharge-to-homelessness pipelines, insurance-driven treatment limits, and the medical framing of poverty-related distress. Each reproduces the same exclusionary logic, now under the banner of “efficiency” or “evidence-based care.”
For social work students, recognizing this through-line is essential to resisting its replication. It means advocating for structural responses — housing-first approaches, living-wage campaigns, robust income supports — rather than interventions that merely manage symptoms of economic injustice.
Pause & ReflectWhen you encounter a client whose “treatment plan” hinges on quick discharge despite unstable housing, ask yourself: whose needs are being prioritized — the client’s, or the institution’s?
Institutional Harms and “Treatments” as Violence
Lobotomy as Cultural Spectacle
Few interventions capture the collision of medical authority, institutional power, and public spectacle as starkly as the mid-twentieth-century rise of the lobotomy. Walter Freeman — its most visible U.S. advocate — was not only a promoter of the procedure but also its showman. As Jack El-Hai (2005) documents, Freeman refined and popularized the transorbital lobotomy, inserting an instrument through the eye socket to sever neural connections in the frontal lobes, despite the high risk of profound cognitive, emotional, and functional damage (p. 12).
Freeman marketed lobotomy as quick, inexpensive, and universally applicable. It required no neurosurgical suite, minimal anesthesia, and only minutes to perform — features that appealed to overcrowded institutions eager to move patients through the system. But the speed he championed came at staggering human cost: many patients were left with irreversible brain injury, flattened affect, incontinence, and loss of independent function.
His promotional tours — complete with live demonstrations — blurred medicine and entertainment. Freeman operated in front of audiences of clinicians and sometimes lay observers, reinforcing psychiatry’s image as boldly innovative while normalizing extreme, irreversible interventions on some of society’s most vulnerable people. This performative dimension, as El-Hai shows, embedded lobotomy in the cultural imagination as both a symbol of miraculous transformation and of psychiatry’s capacity for devastating harm.
Lobotomy’s rise and fall reveal how institutional incentives, charismatic leadership, and public appetite for dramatic cures can override ethical caution. That such an invasive, high-risk procedure was so readily embraced — and even celebrated — shows how psychiatric “innovation” has often been driven as much by spectacle and expedience as by patient welfare.
For social work students, the lesson is urgent: every “breakthrough” arrives with institutional, economic, and cultural pressures attached. Before endorsing a new intervention, ask whose problems it truly solves — and whose risks it multiplies. The same dynamics that propelled lobotomy forward have reappeared in other celebrated treatments, from electroconvulsive therapy to deep sleep therapy, and will almost certainly surface again.
Pause & ReflectThink about a treatment currently described in glowing terms — by your agency, the media, or a policymaker. How would you evaluate its risks, benefits, and power dynamics before recommending it to a client?
Watch the video on YouTube
A dramatized portrayal of transorbital lobotomy in the Netflix series Ratched, capturing both the theatrical spectacle and the invasive violence that characterized this procedure in mid-20th-century psychiatry.
Shock Therapies and Political Contexts
Electroconvulsive therapy (ECT) emerged in the late 1930s as one of psychiatry’s most celebrated innovations. Heralded by some as the “penicillin of psychiatry” for its perceived ability to rapidly relieve severe depression, catatonia, and other psychiatric conditions (Shorter & Healy, 2007, p. 3), ECT was promoted as fast, effective, and scientifically modern. In overcrowded, resource-strapped institutions, its capacity to produce visible change in short order made it especially appealing. This framing bolstered psychiatry’s professional legitimacy during a period of intense scrutiny.
Yet the optimistic narrative was never the whole story. Survivors described the procedure as deeply traumatic — recalling fear, physical injury, disorientation, and, for many, persistent memory loss and cognitive changes that permanently altered their lives. While proponents often downplayed these harms as temporary or rare, the consistency of such testimonies points to a wide gap between clinical rhetoric and lived experience.
Understanding ECT’s rise requires attention to its political context. Like lobotomy, ECT’s appeal rested partly on its ability to manage large patient populations efficiently. In the post–World War II era, it also served institutional needs to demonstrate quick, visible “successes” to policymakers, funders, and the public. Its spread was shaped not only by clinical judgment but by public relations pressures, budget constraints, and a cultural appetite for technological solutions to complex human problems.
The history of ECT is both testament and warning: psychiatry can innovate, but it can also let systemic priorities override patient welfare. Taken alongside the lobotomy story, ECT’s trajectory underscores a pattern worth tracking in contemporary practice — what institutions celebrate as a breakthrough may, beneath the surface, be driven more by efficiency, optics, and control than by genuine therapeutic benefit.
For social work students, the takeaway is not to reject ECT — or any intervention — outright, but to interrogate its history, power dynamics, and current application. Ask: Is this treatment being chosen because it serves the client’s needs, or because it serves the institution’s? What would informed consent look like if the client had full access to both the clinical data and the survivor accounts?
Pause & ReflectThink of a current or emerging treatment you’ve encountered in training or practice. How might its popularity be shaped by institutional pressures rather than solely by patient outcomes?
Deep Sleep Therapy & Other Abuses
While lobotomy and electroconvulsive therapy dominate psychiatry’s controversial history, they were far from the only interventions that inflicted harm under the banner of treatment. Throughout much of the twentieth century, institutions used methods such as sedative-induced comas, insulin shock therapy, and hydrotherapy — approaches that often functioned more as instruments of control than as genuine therapeutic care.
Deep Sleep Therapy (DST), for example, involved keeping patients in a drug-induced coma for days or even weeks, sometimes paired with electroconvulsive shocks. The stated rationale was to “rest” the brain and relieve symptoms of mental illness. In reality, as Robert Whitaker (2003) documents, DST frequently caused severe medical complications — including death — and offered little reliable evidence of long-term benefit (p. 100).
Insulin shock therapy followed a similar pattern. Massive doses of insulin induced seizures and comas, and though it was initially hailed as an innovative cure for schizophrenia, its risks were substantial and its therapeutic value dubious.
Hydrotherapy — subjecting patients to prolonged immersion in baths with alternating extreme temperatures — was sometimes justified as calming agitation. In practice, it was often punitive or coercive, reinforcing institutional authority rather than addressing underlying distress.
Like lobotomy and ECT, these treatments were embedded in systems where the imperatives of order, efficiency, and public image routinely outweighed patient safety or consent. That they persisted into the late twentieth century shows the extent to which psychiatric authority could legitimize invasive, high-risk procedures on vulnerable populations without strong evidence of efficacy.
Across all three cases — lobotomy, ECT, and DST/other “therapeutic” abuses — the through-line is clear: interventions were often embraced less because they worked than because they served institutional priorities, produced the appearance of progress, and offered quick fixes for complex social problems.
For social work students, the caution is direct: before endorsing an “innovative” intervention, investigate whose needs it actually serves, whose power it reinforces, and what histories it may be repeating.
Pause & ReflectPicture a current “gold-standard” intervention in your field placement. What would you find if you traced its history — not just the clinical trials, but the institutional and political forces that brought it into common use?
The Political Economy of Diagnosis
DSM as Boundary-Maker
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is more than a reference book — it is one of psychiatry’s most powerful tools for drawing the line between “normal” and “disordered.” Those lines determine who is eligible for treatment, what interventions are considered appropriate, which services insurance will cover, and even who may be excused from legal responsibility.
Allen Frances (2014), who chaired the DSM-IV Task Force, warns that the manual’s recent trajectory has been toward what he calls diagnostic inflation: steadily lowering the thresholds for mental disorder so that more and more ordinary human experiences fall under psychiatric jurisdiction (p. xiii).
The result is a double movement. Rare diagnoses become increasingly common, and new categories emerge that transform everyday variation in mood, behavior, or cognition into treatable pathologies. Grief becomes Major Depressive Disorder, childhood tantrums become Disruptive Mood Dysregulation Disorder, and ordinary forgetfulness in aging adults becomes Mild Neurocognitive Disorder. Supporters argue this enables earlier intervention and more precise identification. Critics counter that it blurs the line between genuine psychiatric illness and the natural spectrum of human distress.
This expansion is not a purely academic debate — it is tied to an enormous market for psychotropic medications. Pharmaceutical companies profit when newly medicalized conditions create new patient populations. Lower diagnostic thresholds risk turning millions of “worried well” into psychiatric patients, subjecting them to unnecessary treatments, stigmatizing labels, and diverting resources from those with the most severe needs.
By shaping the categories through which mental health is understood, the DSM operates as a boundary-maker that reflects — and reinforces — the political economy of psychiatry. This influence demands critical scrutiny, especially from social workers, to ensure that diagnostic tools advance care, justice, and autonomy rather than market growth or institutional convenience.
For social work students, the DSM is not a neutral reference — it is a gatekeeper. A single code can open or close access to housing supports, disability benefits, school accommodations, or legal protections. Reading it critically is not optional; it is a core act of advocacy on behalf of clients whose well-being depends on more than the language in a manual.
Pause & ReflectThink about a recent diagnosis you’ve seen or discussed in training. If you were the one assigning it, how would you ensure it expands, rather than restricts, your client’s options and rights?
Bias in Diagnostic Practice
Even as the DSM presents itself as an objective, scientific catalog of mental disorders, its application has often mirrored — and reinforced — structural biases. Jonathan Metzl’s (2011) historical analysis of schizophrenia during the civil rights era shows how psychiatric diagnosis can be shaped by racial and political anxieties as much as by clinical observation.
Before the 1960s, schizophrenia was often described in psychiatric literature as a largely white, middle-class condition associated with benign withdrawal and docility. By the height of the civil rights movement, however, it was redefined — both in professional and public discourse — as a disorder marked by hostility, aggression, and a propensity for violence. These traits were disproportionately attributed to Black men (p. 95).
This shift had nothing to do with new biological discoveries. It reflected a changing social context: as Black activism gained visibility and challenged white dominance, psychiatric descriptions increasingly coded political resistance as psychopathology. Hospital records from the era reveal disproportionate diagnoses of paranoid schizophrenia among Black men — often linked to expressions of anger about racism or to participation in protest movements. These diagnoses didn’t just mislabel dissent; they enabled coercive interventions such as involuntary hospitalization and forced medication.
Metzl’s findings make clear that diagnostic bias is not simply the result of individual prejudice — it is embedded in the institutional and cultural frameworks that shape psychiatric practice. By redefining schizophrenia to align with prevailing racial fears, the mental health system became a tool for reinforcing social control.
For social work students, the lesson is twofold: diagnostic categories are never politically neutral, and the act of assigning a diagnosis can have consequences far beyond the treatment plan. Vigilance is essential — tracking diagnostic patterns in your setting, raising them in team meetings, and considering their social and political implications is part of ethical practice. Without such scrutiny, the diagnostic process risks reproducing the very inequities mental health care should work to dismantle.
Pause & ReflectIn your current or past placements, have you seen certain racial or cultural groups receive the same diagnosis more frequently than others? How was this explained — and how might those explanations reflect broader social narratives rather than individual clinical facts?
Capitalism and Psychiatric Hegemony
Beyond its clinical role, psychiatry operates within a wider network of institutions that reproduce and legitimize existing social and economic arrangements. Drawing from a Marxist framework, Bruce Cohen (2016) describes psychiatry as an ideological state apparatus — a system that not only manages mental illness but shapes consciousness in ways that reinforce the capitalist order (p. 88). By defining the limits of “normal” thought and behavior, psychiatry helps set the standards for who is deemed functional — or dysfunctional — within the demands of a market-driven society.
In this view, psychiatric intervention is not simply a response to distress; it is a mechanism for enforcing conformity to the rhythms and values of capitalist production. Those unable to meet expectations for productivity, punctuality, and emotional self-regulation are at risk of being labeled as disordered. This framing shifts attention away from structural conditions — precarious work, wage stagnation, unsafe housing — and onto individual “pathology.” The result is a form of social management that naturalizes inequality and obscures the political roots of suffering.
This ideological role is strengthened by psychiatry’s alignment with powerful economic interests. As diagnostic categories expand (see DSM as Boundary-Maker), so does the market for pharmaceutical treatments, creating a profitable feedback loop between psychiatric authority and corporate capital. Cohen (2016) emphasizes that this is not incidental but foundational: psychiatry gains legitimacy by promising to “fix” the very distress that a competitive, alienating economic system produces — without challenging the system itself (p. 88).
For social work students, understanding psychiatry as an ideological state apparatus means expanding critical practice beyond individual casework. It involves questioning not only the accuracy of diagnoses and the efficacy of treatments, but also the socio-economic functions they serve. It calls for engagement in policy advocacy — fighting for livable wages, housing equity, labor protections, and universal access to care.
Without that systemic orientation, even the most well-intentioned mental health practice risks becoming a complicit partner in sustaining the very conditions that produce the suffering it aims to relieve. These political and economic alignments are not abstract — they have left measurable scars on the people and communities mental health systems claim to serve, shaping patterns of harm that persist into the present.
Pause & ReflectIn your own training or practice, have you seen “treatment plans” that focus entirely on individual behavior change without addressing the structural causes of distress? What would it look like to integrate systemic advocacy into that plan?
Enduring Harms and Structural Violence
Watch the video on YouTube
An educational overview of the Tuskegee Syphilis Study, a decades-long government experiment that withheld treatment from Black men, fueling generations of justified mistrust in medical and mental health systems.
The record of psychiatric coercion, bias, and alignment with systems of oppression has left deep marks on today’s mental health landscape. For many marginalized communities, mistrust of psychiatric institutions is not a product of “stigma” or misunderstanding — it is grounded in history. As Robert Whitaker (2003) notes, decades of harmful and often non-consensual interventions — from lobotomy and shock therapy to discriminatory diagnoses — have created a legacy in which mental health services are often perceived less as care and more as surveillance or control (p. 281). This mistrust is continually reinforced by disparities in diagnosis, treatment, and outcomes that echo earlier patterns of racialized, gendered, and class-based harm.
These harms rarely operate along a single axis of identity. As Bonnie Burstow (2015) emphasizes, psychiatric oppression is deeply intersectional, with its effects compounded at the intersections of race, gender, class, and disability (p. 119). Consider a low-income Black woman experiencing distress: she may face racial bias in diagnostic practices, gendered assumptions about emotional stability, economic barriers to care, and a heightened risk of coercive interventions for those labeled “noncompliant.” These overlapping oppressions increase the likelihood of harm while narrowing the options for meaningful, patient-directed support.
The persistence of these patterns shows that psychiatry’s oppressive functions are not just relics — they remain active structural forces. They surface in the overrepresentation of racialized groups in involuntary treatment, the medicalization of poverty-related distress, the sidelining of user and survivor voices, and the privileging of biomedical over social or community-based responses. Treating these inequities as background context, rather than central concerns, only perpetuates the problem.
For social work students, reframing mistrust as historically justified changes the practice approach. The goal is not to persuade clients to accept care but to co-create care that earns trust — through transparency, shared decision-making, and cultural responsiveness. Situating present-day disparities within their historical lineage allows practitioners to see resistance to psychiatric intervention as a form of self-preservation, not pathology. This understanding can guide the design of anti-oppressive approaches that acknowledge and repair past harms, challenge ongoing inequities, and help build mental health systems worthy of genuine trust.
Pause & ReflectThink of a time you observed or participated in care planning for a client who seemed “resistant” to services. How might their refusal make sense in light of this history?
Implications for Social Work Practice in Psychopathology
Critical Historical Consciousness
For social workers in psychopathology, cultivating a critical historical consciousness is not optional — it is essential to ethical and effective care. This means moving beyond the idea that psychiatric diagnoses and treatments are purely scientific “facts” and recognizing them as social constructions, shaped by political, cultural, and economic forces. Thomas Szasz (2009) argued that psychiatric categories are not discovered in nature but created within specific historical contexts, often serving as mechanisms of control as much as care (p. 14). By tracing the genealogy of these categories, practitioners can see how they have been used to enforce conformity, manage “deviance,” and legitimize coercive interventions.
Engaging with this history equips social workers to approach present-day diagnostic and treatment practices with discernment and humility. For example, knowing that schizophrenia was reframed during the civil rights era to align with racialized fears challenges the belief that current uses of the term are entirely objective or apolitical. Similarly, understanding the coercive histories of interventions like lobotomy, deep sleep therapy, and electroconvulsive therapy shifts how we view contemporary debates about involuntary care and the expansion of medical authority.
Mini-scenario: A clinician reviews the chart of a young Latina student referred for oppositional defiant disorder after repeated clashes with teachers. She recalls the historical pattern of pathologizing protest and controlling marginalized youth. Rather than accepting the diagnosis at face value, she asks: Is this resistance to authority — or is it distress rooted in systemic bias and unsafe school conditions? This question redirects the treatment plan toward advocacy for a safer learning environment instead of defaulting to compliance training.
Critical historical consciousness is not meant to paralyze practitioners with skepticism; it is meant to sharpen their ability to tell the difference between care that genuinely serves the client’s needs and care that reproduces systemic harm. In practice, this might mean challenging a diagnostic label, advocating for alternative supports, or ensuring the client’s own narrative remains central in treatment planning.
Ultimately, this stance transforms social work from a profession that passively applies psychiatric tools to one that actively interrogates and reshapes them. It aligns with the discipline’s anti-oppressive commitments, recognizing that ethical mental health practice requires not just knowledge of symptoms and interventions, but also a deep grasp of the socio-political forces that have shaped — and continue to shape — the field.
Pause & ReflectThink of a diagnosis you’ve worked with recently. How might its meaning change if you traced its history and the social forces that shaped it?
Ethical Commitment to Anti-Oppression
An anti-oppressive approach to psychopathology requires more than knowing psychiatry’s troubled history — it requires a deliberate, active commitment to resisting those harms in the present. Jonathan Foiles (2021) notes that this commitment begins with three principles: centering informed consent, resisting coercion, and validating clients’ lived experience over the default authority of psychiatric expertise (p. 142).
Centering informed consent means ensuring clients have clear, accessible information about their diagnoses, treatment options, risks, and alternatives. It means treating consent as ongoing — not as a one-time form — while recognizing that power imbalances and systemic pressures can limit a person’s ability to freely choose.
Resisting coercion involves scrutinizing policies and clinical decisions that compel treatment, whether through formal legal orders or subtle pressures. It also means advocating for the client’s right to refuse interventions without facing punitive consequences.
Mini-scenario: A 45-year-old woman is admitted involuntarily after a suicide attempt. She’s told ECT is the “fastest way” to get discharged. She hesitates, uncertain about side effects. The social worker’s role is not to convince her in either direction, but to make sure she receives full, balanced information about the risks, alternatives, and potential benefits — and to affirm that refusal will not automatically prolong her stay. This reframes treatment as a choice, not an institutional mandate.
Validating lived experience is equally critical. Historically, psychiatric systems have discounted or pathologized the narratives of those in distress, privileging professional interpretation over personal meaning. An anti-oppressive stance reverses this hierarchy, placing the client’s account at the center of understanding their needs, values, and goals. This directly challenges the epistemic injustice baked into traditional psychiatric relationships, where the clinician’s voice is assumed to be authoritative by default.
In practice, this commitment might involve advocating for less restrictive alternatives to hospitalization, integrating peer support and community-based resources, or ensuring treatment goals match the client’s own definition of well-being. By prioritizing autonomy, relational respect, and social justice, social workers can help dismantle the structural patterns that have historically turned mental health systems into sites of control rather than spaces of support.
Pause & ReflectIn your current or future practice, how will you make sure consent is truly informed and ongoing — especially in settings where the institutional culture assumes compliance?
Advocacy & Systems Change
Anti-oppressive social work in psychopathology cannot stop at the client–practitioner relationship; it must also engage the systemic structures that perpetuate psychiatric harm. Jonathan Metzl (2011) argues that meaningful change requires confronting how mental health policy and practice have reinforced racial, gender, and economic inequities — including the criminalization of mental illness, the use of forced treatment, and the persistence of diagnostic racism (p. 197).
Decriminalizing mental illness means shifting crisis response away from law enforcement and toward adequately funded, community-based care. That includes advocating for alternatives to police-led interventions — mobile crisis teams, peer-run respite centers, supportive housing — that address distress without criminalizing it. These reforms recognize that police involvement often escalates harm, especially for racialized individuals and those with prior traumatic experiences of institutional control.
Mini-scenario: A mother calls a social worker about her adult son in crisis. She fears calling 911 will trigger a police response. Instead, the social worker activates a local peer-led crisis team — no uniforms, no weapons — that stays for hours to stabilize the situation and link the family to ongoing support. The result: no arrest, no hospitalization, and trust preserved between the family and the mental health system.
Ending forced treatment requires challenging laws and institutional norms that prioritize compliance over autonomy. While emergency interventions may be necessary in rare, life-threatening cases, the default reliance on coercion erodes trust, reproduces historical trauma, and often reduces future engagement in care. Policy advocacy here means pushing for stronger rights to refuse medication, robust due process protections, and investment in voluntary, person-directed services that make collaboration possible.
Dismantling diagnostic racism involves confronting both biased diagnostic criteria and the inequitable ways they are applied. Metzl’s historical work shows how racialized interpretations of psychiatric symptoms have long been used to pathologize political dissent and justify harsher interventions for Black men. Combating this requires more than clinician training — it demands structural changes to accountability mechanisms, research priorities, and data systems that track and correct disparities.
Through policy reform, coalition-building with advocacy groups, and sustained institutional pressure, social workers can help transform mental health systems from sites of control into spaces of support and justice. This systemic orientation complements individual-level practice, ensuring that autonomy, equity, and respect are built into the structures that govern mental health care — not just into the therapy room.
Pause & ReflectIf your agency suddenly lost police backup for crisis calls, what resources and community relationships would you need in place to respond safely and effectively?
Putting It into Practice: Reading Between the Diagnoses
The history outlined here makes clear that diagnoses are never just clinical labels — they are social, political, and cultural artifacts with real consequences for people’s lives. The challenge for social workers is to use these tools without becoming enforcers of their biases. This checklist is designed to help you “read between the diagnoses” and make choices that uphold autonomy, justice, and dignity in daily practice:
- Ask the Power Question — Who benefits from this diagnosis? Who might be harmed?
- Look for Patterns — Are certain racial, gender, or class groups more likely to receive this label? Does it reflect known historical biases?
- Consider Alternatives — Could the distress be better explained by social determinants (housing, racism, trauma) rather than a psychiatric disorder?
- Challenge Coercion — Is the intervention truly voluntary, or is refusal met with threat, punishment, or prolonged detention?
- Center the Client’s Voice — Has the client described their own understanding of what’s happening? Is that narrative reflected in the treatment plan?
- Test for Structural Impact — How will this diagnosis affect access to housing, benefits, legal protections, or community supports?
- Pause Before Pathologizing Protest — Is the client resisting oppression, or showing signs of illness? Be cautious not to conflate the two.
Pause & Reflect: Take one client from your caseload or field placement. Walk through this checklist point by point. How does it shift your understanding of their diagnosis and treatment plan?
Conclusion
The history of psychiatry reveals a complex legacy in which the promise of care has often been bound up with coercion, systemic bias, and the maintenance of social hierarchies. From the overtly racialized diagnoses of the nineteenth century to the institutional violence of lobotomy, shock therapies, and deep sleep treatment, psychiatric authority has been shaped by political, economic, and cultural forces as much as by medical ones. These forces still operate today, producing disparities in diagnosis, treatment access, and outcomes — especially for marginalized communities.
For social work education in psychopathology, this history is not a side note; it is foundational. A critically informed, historically grounded approach equips practitioners to see that the tools they inherit — diagnoses, treatment modalities, institutional protocols — are socially constructed and politically embedded. With that awareness comes the discernment to know when those tools serve healing and when they risk perpetuating harm.
To avoid repeating past mistakes, social work must fully integrate anti-oppressive, trauma-informed, and culturally responsive frameworks into both pedagogy and practice. That means centering client autonomy and lived experience, challenging coercive interventions, dismantling diagnostic and treatment biases, and advocating for systemic reforms that prioritize community-based, non-carceral responses to mental distress.
In doing so, social work can position itself not as a passive implementer of psychiatric authority but as an active agent of change — holding mental health systems accountable, amplifying the voices of those most affected, and building a vision of care grounded in justice, dignity, and genuine partnership. Our responsibility is not only to remember psychiatry’s shadow but to ensure it does not fall on the next generation of clients.
RESOURCES FOR EDUCATORS {SCROLL DOWN}
- Appendix A — Timeline: Key Events in Psychiatric Oppression and Reform Movements
- Appendix B — Glossary of Key Terms
- Appendix C — Case Study Prompts: Ethical Dilemmas in Diagnosis and Treatment
References
Burstow, B. (2015). Psychiatry and the business of madness: An ethical and epistemological accounting. Palgrave Macmillan.
Cohen, B. M. Z. (2016). Psychiatric Hegemony: A Marxist Theory of Mental Illness. Palgrave Macmillan UK. https://doi.org/10.1057/978-1-137-46051-6
El-Hai, J. (2005). The lobotomist: A maverick medical genius and his tragic quest to rid the world of mental illness. J. Wiley.
Foiles, J. (2021). (Mis)diagnosed: How bias distorts our perception of mental health (First edition). Belt Publishing.
Frances, A. (2014). Saving Normal: An insider’s revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life. William Morrow, an imprint of HarperCollins Publishers.
Metzl, J. M. (2011). The protest psychosis: How schizophrenia became a Black disease. Beacon.
Shorter, E., & Healy, D. (2007). Shock therapy: A history of electroconvulsive treatment in mental illness. Rutgers University Press.
Szasz, T. S. (2009). Coercion as cure: A critical history of psychiatry. Transaction Publ.
Welsing, F. C. (1995). The Isis (Yssis) papers: The key to the colors. Third World Press.
Whitaker, R. (2003). Mad in America: Bad science, bad medicine, and the enduring mistreatment of the mentally ill. Perseus Publ.
Appendix A — Timeline: Key Events in Psychiatric Oppression and Reform Movements
Appendix B — Glossary of Key Terms
Therapeutic Imprisonment
A term used by Thomas Szasz (2009) to describe the coercive confinement of individuals under psychiatric authority, framed as treatment rather than punishment. This concept emphasizes how psychiatric hospitalization can operate as a form of social control, often without genuine therapeutic benefit.
Diagnostic Inflation
Coined and critiqued by Allen Frances (2014), this refers to the steady expansion of psychiatric diagnostic categories and the lowering of diagnostic thresholds, leading to the medicalization of normal variations in mood, behavior, and life experience. Diagnostic inflation increases the number of people labeled as mentally ill, often benefiting pharmaceutical and institutional interests.
Psychiatric Hegemony
Drawn from Bruce Cohen’s (2016) Marxist analysis, this concept describes psychiatry’s role as an “ideological state apparatus” that maintains social order under capitalism. Psychiatric hegemony refers to the dominance of psychiatric knowledge and practice in defining normality, shaping public policy, and legitimizing interventions that align with economic and political priorities.
Pathologizing Protest
A practice identified by Jonathan Foiles (2021), where political dissent or resistance to oppression is reframed as evidence of mental illness. Historical examples include the diagnosis of drapetomania for enslaved Africans and the labeling of civil rights activists as paranoid schizophrenics.
Intersectional Oppression in Psychiatry
A term reflecting Bonnie Burstow’s (2015) emphasis on how psychiatric oppression operates simultaneously across multiple axes of identity — such as race, gender, class, and disability — magnifying harm for individuals who experience overlapping forms of marginalization.
Coercive Treatment
Interventions administered without informed consent, including involuntary hospitalization, forced medication, and mandated therapy. While often justified as necessary for safety, these practices have been widely criticized for violating autonomy and perpetuating historical patterns of abuse.
Appendix C — Case Study Prompts: Ethical Dilemmas in Diagnosis and Treatment
Case Study 1 — The Protester and the Diagnosis
A 26-year-old Black man is brought to a psychiatric emergency unit following an arrest at a political demonstration. Police report that he was “paranoid” and “agitated” when taken into custody. The attending psychiatrist diagnoses paranoid schizophrenia within an hour, based largely on his distrust of authority figures and vocal criticism of systemic racism.
- From a critical social work perspective, how might historical patterns of racialized diagnosis (Metzl, 2011) inform your interpretation of this case?
- What steps would you take to ensure the assessment process is not reproducing diagnostic racism?
- How would you advocate for the client’s rights in the context of a potentially coercive hospitalization?
Case Study 2 — Consent Under Duress
45-year-old woman, living in poverty and recently evicted, is admitted involuntarily after an attempted suicide. She is offered electroconvulsive therapy (ECT) as a “fast and effective” treatment for depression but expresses uncertainty about side effects. The psychiatrist suggests that refusing ECT could prolong her hospital stay.
- How does the history of ECT as both a celebrated intervention and a source of trauma (Shorter & Healy, 2007; Whitaker, 2003) inform your approach?
- In what ways might the power imbalance and threat of extended hospitalization compromise informed consent?
- What advocacy strategies could you use to ensure her autonomy is respected?
Case Study 3 — The “Noncompliant” Teen
A 17-year-old Latina is referred for psychiatric evaluation after skipping school and openly challenging her teachers. She reports that school feels unsafe due to bullying and discrimination. A psychologist suggests she may have oppositional defiant disorder and recommends a residential treatment program.
- How might Foiles’ (2021) concept of pathologizing protest apply to this situation?
- How could intersectional factors (Burstow, 2015) influence the interpretation of her behavior?
- What alternatives to residential placement could you propose that address the root causes of her distress?
Case Study 4 — Institutional Pressure to Discharge
In an underfunded public hospital, administrators pressure clinicians to discharge long-term patients quickly to free up beds. A low-income elderly man with schizophrenia is stable on medication but has no housing plan. Staff suggest placing him in a for-profit nursing home known for poor conditions.
- How might Cohen’s (2016) analysis of psychiatry as an ideological state apparatus help explain this situation?
- What ethical conflicts arise between institutional priorities and client well-being?
- How could you advocate for systemic change while addressing the client’s immediate needs?
This essay was first published on Medium on August 18, 2025.
