Khameer Kidia says he wants “a supernova.” He wants “an explosion large and bright.” He has seen how his patients — and not just his patients, but how all the patients “flooding our emergency rooms” with “depression, anxiety, bipolar disorder, and schizophrenia,” how all the patients in the world, perhaps, are not suffering from any of the maladies found in the DSM. They’re “suffering from oppression.” He has seen how mental healthcare “purports to care while it inflicts harms that worsen mental health,” how “western psychiatry literally can’t keep up with the mental distress Western capitalism creates around the world.” So he “is calling for the end of psychiatry.”
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Or rather: He’s calling to make “mental health care … part of every health-care provider’s job.” He wants it to be “less specialized and part of everyone’s work, not just psychiatrists’.” Psychotherapy, which, as Kidia explains, “doesn’t tackle the causes” of “structural violence and” is therefore little different from the “discipline … used to justify the eugenic annihilation of millions of people with mental disabilities in Nazi Germany,” shouldn’t be so “expensive or hard to get.” After all, he has “seen antipsychotics help people.” Then again, he has also “seen antipsychotics harm people.” He has worked with doctors in Africa who are relieved to encounter the “therapy-speak” of Western medicine. But he has also seen them recoil at the “imposition” of narrow-minded Western therapy. It should be everywhere, but also nowhere. Mental illness is created by “racism,” “colonialism,” “status anxiety,” and “a colonization of the mind.” Psychiatry is “violent,” “extractive,” built on “sanist” assumptions; it’s a racket for punishing those who fail to conform and be “productive.” That’s why Kidia wants to use “a little psychiatry to help some individual patients cope.” In fact, he “has no real problem with psych meds or therapy” if “patients benefit from these interventions.” That’s why he wants to make the world “a place where psychiatry as we know it becomes obsolete.” Or not. “Ultimately,” Kidia says, “no single individual-level treatment — whether it’s Prozac or electroconvulsive therapy or the Friendship Bench — works for everyone in every context.” That’s why he wants mental healthcare for all. And then to end it all by supernova.
What else is new? Psychiatry has spent the better part of a century being undermined, overthrown, revolutionized, reimagined, reformed, reborn, and condemned. Like a malignancy, it is always growing and somehow, at the same time, is on the verge of being blasted away for good. Khameer Kidia isn’t the first doctor on the case. Despite the hype — the jacket copy promises that Kidia “asks the nuanced questions unaddressed by our current mental health model” — Empire of Madness is not the first book (nor the hundredth) to ask tough questions about our “mental health model.” It is not the thousandth to represent itself as a radical intervention against psychiatry. But it may be the first to be so uncertain about — to seem, at times, to actively forget from chapter to chapter, paragraph to paragraph, page to page — precisely what it wants to be, or wants to say. It may be the first to devote fewer than 50 of its over 300 pages to actual psychiatric conditions.
Here, roughly, are the case studies found in Empire of Madness: the desperately poor, the victims of colonial violence, people in Zimbabwe who “think too much,” Ivy League students with ADHD. HIV patients distressed over their conditions. Debtors. Hoarders. Burnt-out mental healthcare workers. Zimbabwean prisoners being tortured in rotting “mental hospitals” (prisons), emergency physicians during COVID-19, the general population during COVID-19, one woman with functional neurological disorder. An elderly woman with post-operative delirium, sedated with an antipsychotic. The malnourished. The homeless. Victims of hate crimes (all very stressed). Transgender people, queer people, “women or sexual and gender minorities” in general (“the white men who run academic institutions simply do not value this type of research”), a gender nonconforming rural African treated by a spirit healer who believes HIV can be cured with an herb (Kidia “disagreed” but he didn’t want to question “her entire way of knowing.”), debt-burdened farmers in India. His mother, whose diagnosis remains unresolved.
Over 100 pages into Empire of Madness, a single schizophrenic gets half a chapter as an anecdote about the well-known psychomotor side effects of antipsychotics. A little later, a man with schizoaffective disorder receives nearly a full chapter, but he is misdiagnosed and actually suffering from trauma. Kidia is skeptical of “trauma” — he is perhaps the only person to ever find Bessel van der Kolk’s The Body Keeps the Score lacking because it is insufficiently woke — but it is also taken to be the cause of nearly every psychic malady. Otherwise, psychiatry itself is confined to a recitation of true but well-worn critical tropes: There is no such thing as a “chemical imbalance” in the brain. Efficacy data for many psychiatric medications are slim. Poverty tends to exacerbate psychosis. We probably prescribe too many SSRIs and too much Adderall, and this has something to do with the profit motive. Sometimes people can hallucinate without much ill effect. He doesn’t have much to say about those who can’t.
These “patients” are interwoven through what is otherwise a kind of memoir-slash-light-history-of-colonial-Rhodesia. Before we meet any patients unrelated to Kidia himself, we meet King Lobengula of the Ndebele, who, despite being a king, did not understand “property ownership” and sold his country to Cecil Rhodes for a pittance. Then we discuss Dylann Roof. We learn how Robert Mugabe seemed good at first and then turned out to be not so good, and how IMF loans — ditto. We learn a great deal about Kidia’s family, Indian emigres who occupy a kind of middle tier in the colonial and postcolonial hierarchy, a position that allows him and his family to be either incredibly privileged (they are educated, they own a home in a white neighborhood, Khameer attended “the best white schools” before attending Princeton, receiving a Rhodes Scholarship, founding an NGO, and landing a job at Harvard Medical School) or incredibly precarious (his family barely scraping by, his father drinking himself to death, his mother’s “nervous breakdowns” inflicted by the pain of living in the Global South). Their position changes depending on the point Kidia is currently making.
Kidia’s mother is the thread binding the text. She is mentally ill, or perhaps just stressed. She should be made to take medication or given the autonomy to refuse. She is a textbook manic-depressive, or she is just another victim of an unjust world. Even when he was a child, she “told [Kidia] things she didn’t tell my dad” because “in me, my mother saw an intellectual and emotional counterpart: something lacking from her relationship with my father” (if we haven’t quite abolished psychiatry yet, let me say the thread is often Oedipal). With his mother’s encouragement, Kidia undertakes his journey to the top tier of the global health elite, documenting his own mistakes, inadequacies, and failures, but also reminding us, incessantly, of how uniquely capable he is, how his “superpower in medicine” is “connecting with a marginalized patient whom others find difficult to care for” because he “[relishes] the challenge of forgiving connections across hierarchical divides,” how, in short, my greatest flaw? I just care too much. Of course, he sees all that pressure to succeed as a symptom of the Empire of Madness now. But he did succeed. He’s very successful. He wants us to know that too.
In the end, after nearly 250 pages of radical intervention, Kidia finally offers a solution: he would like to see some solid social democratic reforms. Universal basic income. Medical and IMF debt forgiveness. Housing programs. We should also try adopting the spirit of ubuntu, which is a magical indigenous concept, “so ontologically opposed to Western experience that Western language cannot fully describe it,” but which also amounts to “we live in a society.” “Even the slightest turn toward something more collective,” Kidia explains, will provide “dramatic mental health benefits for many individuals at scale.” OK.
READING SELF-HELP AS THE SCIENCE FICTION THAT IT IS
The most damning thing that I could say about Empire of Madness is that it isn’t wrong or bad – it’s just obvious. It’s a parlor trick premised on using “mental illness” and “mental distress” interchangeably, and “mental health care” as the practice of responding to both. Sigmund Freud, the granddaddy of all the bad old Western doctors Kidia wants swallowed by that supernova, famously observed that the purpose of psychoanalysis was to transform “neurotic suffering into ordinary unhappiness.” Khameer Kidia spends 300 pages diagnosing the world with a great deal of ordinary unhappiness, and despite the relentlessly stigmatizing and pathologizing Western “knowledge system” Kidia is shadowboxing on every page, there is almost nobody in the entire world who would dispute the idea that the vast majority of human discontent is caused by our political, social, and personal circumstances rather than by some species of organic brain disease. You may not agree with Kidia’s particular left-wing, colonialism-and-racism variety of “you’re not crazy, the world is crazy,” but it is trivially easy to find precisely the same argument in a right-wing, centrist, or entirely apolitical flavor. Many people suffer from ordinary unhappiness. Redressing that unhappiness is beyond the remit of medical psychiatry. We ought to do something about it. Yes. And?
And: Empire of Madness is a common kind of book written by a common kind of doctor aspiring to public health celebrity. For all the fretting over wicked doctors looking at a malnourished, debt-burdened, chronically ill escapee from a colonial concentration camp and diagnosing them with it’s-just-your-bad-brain disease, nearly every psychiatrist is eager to be the cool youth pastor with subversive tattoos now. Kidia isn’t the first to adopt the cloak of radicalism while leveling critiques of psychiatry already in wide circulation by the 1950s. They’re well trained for the act: the phony confidence, the false humility, the endless bluster, the trumpeting of studies that confirm the case they’re trying to make (and the breezy dismissal of those that don’t), the promise of revolutionary change just around the corner, the failure to ever deliver, the waffling, the setbacks, the mistakes, the diagnoses, the prescriptions, the relentless messianic complex insisting that now, at long last, we have the hard-won truth that will make everybody feel better, if only the world will listen. What else have psychiatrists ever promised or ever done?
Emmett Rensin is the author of The Complications: On Going Insane in America.
