Dismantling structural violence to enable structural transformation and consequently social inclusion

As Henderson et al1 compellingly argue, traditional approaches to social inclusion in mental health overwhelmingly emphasize individual-level, clinically-focused interventions. These are often aimed at reducing societal burden and increasing economic productivity2. Here I propose a fundamentally different vision – one that aims to address the structural violence sustaining disability-linked poverty and exclusion, rather than continuing to rework the individualized solutions that have become the staple of contemporary mental health policy. This alternative approach draws on the abolitionist-leaning principles of non-reformist reforms, that “aim to undermine the prevailing political, economic, [and] social order, construct an essentially different one, and build democratic power toward emancipatory horizons”3. Central to such reforms is a commitment to centering those directly impacted, and a deep skepticism toward solutions that ultimately reproduce exclusionary systems. At this historical juncture – the mid 2020s – prevailing paradigms for addressing “severe mental illness” remain rooted in biomedical (or at best biopsychological) models of disability, and individual-level interventions that are in turn delivered within ever more marketized health care delivery systems. Meanwhile, in the US and elsewhere, the increasingly visible failures of deinstitutionalization have inspired new regimes of surveillance, coercion, and behavioral control. These include the expansion of compulsory treatment, the proliferation of residential facilities that, while smaller in size, otherwise replicate the logics of the asylums they replaced, and even the development of new technologies of surveillance such as ingestible event marker sensors intended to track drug ingestion and thereby facilitate “compliance”. In societies where social worth is primarily equated with economic productivity, disability is not only feared, but persistently devalued. In virtually all high-income countries, those who cannot work can access disability benefits – however, benefits policies are routinely structured to ensure a standard of living well below that of even lower-middle-class workers. Indeed, in the US, disability-based welfare policies essentially function as a mechanism of enforced impoverishment: save or earn just slightly above the disability benefit threshold and you risk losing not only monetary entitlements, but also access to life-sustaining health care and housing. Capitalism does not merely devalue disability – it fundamentally shapes the mental health system. In the US, public sector providers, particularly in high-cost coastal cities, rarely earn a living wage. Peer support and community health workers – disproportionately people of color and, by definition, disabled or systems-involved – are generally paid even less. The system exploits the emotional labor of individuals occupying these roles while relegating “lived experience” to the bottom of the professional hierarchy, extracting relational investments without material reciprocity. Extractivism and managerialism also find a friend in the evidence-based practice movement. A still ascendent “knowledge regime”4, this movement has given rise to a suite of linear, manualized interventions – ranging from third-wave cognitive therapies to motivational strategies. Aligning with narrow clinical trial methodologies and the constraints they impose, evidence-based practices are most often time-limited, centering reproducible technologies of intervention while decentering intuition, the unique and unpredictable but essential dynamics of any relationship between two or more people, the adaptation of people and systems. Such interventions may produce modest short-term effects, but rarely move the needle on deeper social integration. And they contribute all too perfectly to the cost-cutting, access-limiting, standardizing goals of managed care. The above examples all arguably function as forms or manifestations of structural violence5 – violence enacted through unequal structures rather than overt physical assault or injury. Such violence is rendered invisible precisely because it is so deeply embedded in institutions and practices that has come to seem “normal” and inevitable. Whether we look to the mental health system’s reliance on coercion, the entrenchedness of disability poverty, or workings of extractive capitalism, we see illustrated the normalization of structures of oppression. Within academia, deep epistemic inequalities also powerfully contribute through the exclusion of those directly impacted within the very processes through which knowledge about psychiatric conditions and structures is produced. The fundamental problem with reformist approaches is that they center incremental “fixes” to what are more fundamentally unjust systems. Reformist logic in turn “insulates” policies such as psychiatric institutionalization, workfare and disability-related coercion from deeper scrutiny, casting them as “problems for regulation, rather than products of status quo power relations”3. The same logic pervades the evidence-based practice and implementation science movements, as noted above. And reformism tends to enable the same people, the same in-groups, to remain in power, promising this or that incremental change as a means of rationalizing disinvestment in deep change. Non-reformist reform, by contrast, seeks to dismantle these foundations. It insists that systems producing mass disability-linked poverty, coercion, and epistemic exclusion are neither natural nor inevitable. It also insists that real transformation cannot come from above – from elite institutions or expert clinicians – but be led from below, from those whose lives are directly impacted by these systems. A non-reformist stance recognizes that it is not inevitable for people with psychiatric disabilities to die 15-20 years earlier than their peers in the world’s wealthiest countries; that poverty and premature death should never be expected. That it is not de rigueur that cognitive decline from iatrogenic causes erodes decades of potential, or that shame accompanies madness and mental difference. These are not inevitable outcomes of “illness”, but of the structural violence that surrounds the experiences we have decided to label as such. As abolitionists say over and over again, a different world is possible – but only if we start from different premises. If schizophrenia is framed as a “curable” neurobiological illness, the resulting interventional logics will center pharmaceuticals and underlying pathology – in fact driving exclusion. If, instead, we recognize madness, distress and disability as phenomena irreducible to biology – as polyvalent, culturally generative and politically meaningful – entirely different possibilities of intervention and social belongingness (re)emerge. And if we begin to reframe the “problem” of psychiatric disability not as an issue of faulty biology, but of underlying structures of exclusion, the same is true: fundamentally different strategies, policies and practices start to make sense and take form. Research can help with this transformation – illuminating current conditions, exposing logics of oppression through careful scholarly analysis – but the status quo will only truly change when structures change. For those currently in positions of power, their biggest contribution may be a combination of humility (about the limits of individual but also collective academic or empirical knowledge, acknowledging where, in the contemporary health sciences, the status quo has generally taken policy and practice concerning severe mental illness) and a willingness to join others, most especially those directly impacted, in non-reformist, democratic movements working to name sources of injustice and build a new world.