Incarcerating Bodies and Brains
If you’ve ever been to a prison or jail—and if you’re poor and brown in America the chances are better than they should be that you have—you know that they are loud places. Doors slam, people yell, guards bark, and bells ring. The absence of sound-absorbent building materials, like carpet and drywall, means that sounds echo against structures of concrete, steel, and riot-proof Plexiglas. The constant noise makes doing hard time even harder.
It may seem to many readers that the story of mass incarceration in the United States has already been told—this nation has the highest incarceration rate in the world and imprisons poor people, especially black and Latino men, disproportionately. More than 2 million people are held in prisons and jails across the United States, and millions more are on probation or parole. Currently some 400,000 foreign nationals are being held in privately run immigrant detention facilities, and 2.3 million other immigrants must check in with the government on a routine basis, many of them unsure if they will be deported. More than 10,000 immigrant children are being detained in massive tent cities. Hundreds if not thousands more individuals are incarcerated in war-zone prisons maintained by the U.S. military and other national security institutions. But what if we extend our conception of what it means to be confined to a much broader set of institutions that includes any that people are not exactly able to leave physically of their own volition? The state confines citizens in many places other than prisons. Take, for example, the roughly 400,000 young people who are in the custody of the foster care system. Or the millions of people serving in the armed forces, who cannot exactly go AWOL. What about the millions of elders living in government-regulated and -subsidized nursing homes? In American society today, a great many people exist, if not in actual prison cells, in spaces they are not exactly free to leave.
Let’s call this broader system of confinement captive America; it consists of a vast and interconnected network of total institutions that are subject to federal, state, and local governance. Sociologist Erving Goffman famously used Everett Hughes’s concept of the total institution to describe these highly rational and bureaucratic institutions, which are closed off in various ways from so-called free society. Total institutions have three principal organizational features: all aspects of life within them are highly regulated under one official authority, inmates are required to do the same activities together in public, and “the various enforced activities are brought together into a single rational plan purportedly designed to fulfill the official aims of the institution.” According to Goffman, there are five types of total institutions: (1) welfare institutions for the blind, the aged, the orphaned, and the indigent; (2) medical institutions for persons in need of inpatient physical or mental health care (e.g., tuberculosis sanitariums and mental hospitals); (3) penal institutions such as prisons, jails, concentration camps, and war camps; (4) institutions organized around specific kinds of work and labor (e.g., army barracks, ships, boarding schools, work campuses, colonial compounds, large mansions); and (5) religious training and practice institutions (e.g., abbeys, monasteries, convents, and cloisters). These institutions diminish the identities of the individuals within them, restructure their social roles and identities, and make them unfit for the outside world through a series of rituals enacted through admission, treatment, and social interactions with staff. Through these transformations, total institutions are “the forcing houses for changing persons,” each one a “natural experiment on what can be done to the self.”
Goffman believed that total institutions serve as “storage dumps” for society’s outcasts. The great contradiction of total institutions lies in the tension between their professed goals (e.g., caring for the mentally or physically ill, protecting the aged or vulnerable, guarding the dangerous) and their undeclared use as dumping grounds. As they conform to changing cultural ideas about what constitutes care, total institutions work on people in ways that tend to conflict with the need for the bureaucratic efficiencies and controlled costs associated with warehousing large numbers of people. In other words, the hypocrisy between what total institutions say they do to people and what they actually do is measured in changes in people’s bodies and in the institutions’ accounting for money spent or saved. In order for people to be warehoused in these storage dumps, they must be transformed into things that can be stored at a reasonable price.
What if the new plan for governing and controlling the millions of people forced to live in captive America is to move them from their institutional cells to new locations inside their own brain cells, into mental prisons that perform the same work as the old physical prisons or barracks or hospital rooms, but with new technologies of pacification? This would be a new kind of prison cell indeed. This is where an untold story about how we achieve mass incarceration begins.
Psychotropic drugs are widely distributed in so-called free society to help people cope with what are commonly understood to be mental or psychiatric illnesses. Reducing (and ultimately eliminating) racial and gender inequalities in access to mental health care has become a central priority of U.S. health care institutions, policies, and researchers. Enabling equitable access to mental health treatment has proven to be an especially pernicious problem given the individual, cultural, and economic factors that structure access to health care in general in the United States. Indeed, members of racial and ethnic minority groups are less likely than whites to report receiving any mental health treatment, counseling, or medication. Paradoxically, racial and ethnic minorities report lower rates of mental illness. Both of these findings may be attributed at least in part to differences in socioeconomic status. That is, lower-income minorities may have limited access to the health insurance and financial resources necessary to offset the cost of mental health care, and higher-income whites may be more aggressive in obtaining mental health care and treatment.
As noted in the Preface, psychotropics encompass several subclasses of prescription drugs (antipsychotics, antidepressants, mood stabilizers, stimulants, and antianxiety drugs) that change brain chemistry and affect the functioning of the brain and the central nervous system. In recent decades, psychotropic drug use has increased steadily among noninstitutionalized adolescents and adults. It is surprisingly hard to get recent data on this question, but researchers who analyzed a nationally representative sample of adults from the 2013 Medical Expenditure Panel Survey estimated that 16.7 percent of adult Americans were taking at least one psychotropic drug—about one out of six people. White people have been found to be twice as likely as people of color, and women twice as likely as men, to take psychotropics, and 80 percent of users report long-term use. General practitioners, who are not typically trained to recognize and diagnose mental illnesses, are more likely than psychiatrists to prescribe psychotropics to patients and to keep patients on psychotropics longer. Yet, even when they are prescribed and used in ways consistent with gold-standard psychiatric practice, psychotropic drugs are associated with suicide, homicide, and other forms of interpersonal violence.
Critics have questioned the effectiveness, overall safety, and clinical appropriateness of psychotropics for treating mental health problems in noninstitutional settings. Exactly how psychotropics affect the brain, how they actually transform the human body, is not known, but clearly they do “work” by interacting with brain and body. Scholars in the field of social studies of science, technology, and medicine frame pharmaceuticals as biotechnologies that actively mediate the relationship between human bodies and cultural systems, particularly along the axes of gender and race. The positioning of psychotropics as biotechnologies opens up the investigation of these drugs beyond questions about the intentions of patients as they consume direct-to-consumer advertising or health care professionals as they prescribe drugs under pressure from pharmaceutical companies. I take the view that psychotropics are not merely “tools” that social actors use to achieve particular effects; they are technologies that have agency in the world in large measure through the ways in which they transform the brains and bodies of those who ingest them.
In this book, I argue that psychotropics have become central not only to mass incarceration in prisons but also to other kinds of mass captivity within the U.S. carceral state. I address one big counterfactual question: Is it possible for the U.S. carceral state to exist without psychotropics? Answering this question requires thinking about the material effects that psychotropic drugs have on human brains and bodies and interrogating the systematic production of knowledge about how psychotropics are used in captive America. My central argument is that psychotropic drugs manufacture two kinds of silent cells: one at the level of the bodies and brains of captive people and the other at the level of knowledge about the material effects of those drugs on people. These two interlocking meanings of silent cells permeate this book.
Psychotropics and the Rise of the Carceral State
Alongside the explosion in prescription psychotropic use, since the 1980s, the United States has experienced unparalleled growth in prison structures, populations, and industries. At the end of 1980, there were 319,598 persons incarcerated in state and federal prisons. By 2014, the number had swelled to an alarming 1,574,700. Including those in jails and on probation, currently more than 2.3 million people are under penal control in the United States, which now incarcerates a greater percentage of its citizens than any other nation in recorded history. The exponential growth in prison construction and prison-related industries has created an entirely new sector of the U.S. economy. Further, the ubiquity of prisons in U.S. popular culture—in movies, television, and popular music—has contributed to the seeming permanence of mass incarceration. Simultaneously, prisons have become “the new asylums,” warehousing hundreds of thousands of men and women who experience mental illness; for some, mental illness preceded their detention, but for many others, it emerged as a result of their imprisonment. It is estimated that well over half of all people incarcerated in federal, state, and jail facilities in the United States suffer from some form of psychic distress. Today, there are more people with serious psychiatric illness in prisons than there are in America’s remaining psychiatric hospitals.
At the turn of the millennium, the administration of psychotropic drugs was the most prevalent and often the only form of mental health practice available in U.S. prisons. Currently, doctors routinely prescribe psychotropics to prisoners for a wide range of reasons, some of which are related to the treatment of psychosocial symptoms and psychiatric disorders and some of which are linked to the need to maintain order. According to a federal census of state prisons in 2000, 73 percent of state prisons were distributing psychotropic drugs to their prisoners—this was the most common form of mental health treatment, followed by initial mental health screening (70 percent), therapy/counseling (71 percent), referrals to mental health services upon reentry (66 percent), psychiatric assessments (65 percent), and twenty-four-hour mental health care (51 percent). The institutional use of psychotropics has been found to be positively related to increasing levels of confinement: in 2000, 95 percent of maximum/high-security state prisons distributed psychotropics, compared to 88 percent of medium-security prisons and 62 percent of minimum/low-security prisons.
Data from the 2004 Survey of Inmates in State and Federal Correctional Facilities show that among inmates with previously diagnosed mental conditions who had been treated with psychotropic drugs before their incarceration, 69.1 percent of federal and 68.8 percent of state inmates received psychotropics during their incarceration. In 2006, 46 percent of prisoners in Vermont’s Department of Corrections were taking at least one psychotropic drug. In 2009, more than 16,000 federal prisoners received psychotropics—7 percent of the total federal prison population. In 2009, the Corrections Center of Northeast Ohio spent half of its medical budget on psychotropics. In July 2002, Clark County Jail in Springfield, Ohio, spent more on psychotropics than it did on food.
Psychotropics are a major element of the policy approach called technocorrections, the strategic application of new technologies in the effort to reduce the costs of mass incarceration and minimize the risks that prisoners pose to society. Psychotropics, electronic tracking and location systems, and genetic and neurobiological risk assessments are all tools of technocorrections. Dr. Tony Fabelo, a prison policy strategist who now works for the Council of State Governments, coined the term in 2000. Here, he outlines the great potential of psychotropics as a tool of technocorrections:
Pharmacological breakthroughs—new “wonder” drugs being developed to control behavior in correctional and noncorrectional settings—will also affect technocorrections. Correctional officials are already familiar with some of these drugs, as many are currently used to treat mentally ill offenders. Yet these drugs could be easily used to control mental conditions affecting behaviors considered undesirable even when the offenders are not mentally ill. . . .
. . . These drugs could become correctional tools to manage violent offenders and perhaps even to prevent violence.
Psychotropics are used not only to manage mental illness but also to help people cope with exposure to stressful institutional environments, like prisons. We should expect prison health care policies to be organized with security and confinement in mind, even as these policies are also designed to provide minimum standards of care for the sick. In other words, even when a prisoner has serious mental health problems, the use of psychotropics always falls under the logic of control and submission that permeates the prison–prisoner relationship. Yet technocorrections is not new.
We know little about the use of psychotropics in U.S. prisons prior to the penal reform movement of the 1970s that emerged in the wake of the 1971 riot at Attica Prison. In the 1970s, the use of tranquilizers in state mental hospitals and prisons became visible through journalists’ investigations and high-profile legal cases. Several legal analysts also drew attention to the problematic use of psychotropics in prisons, a topic that has received only scant coverage in the years since. Prison officials are quick to point to a small number of cases that have been documented of prisoners abusing prescribed psychotropic medications, primarily the antipsychotic drug quetiapine (sold under the brand name Seroquel). Back in 1974, Ted Morgan of the New York Times visited a notorious New York City detention facility known as the Tombs (because it was said to resemble an Egyptian tomb). As Morgan described it, the main function of the psychiatrist in the Tombs was to “drug the inmate into submissiveness and prevent suicide attempts.” To the detainees who were awaiting trial, “the psychiatrist has become the successor of the brutal guard. Both men work toward the same goal: to produce a model prisoner, quiet and passive, who answers when he is spoken to and does what he is told. Where the brutal guard used rubber hoses, the psychiatrist relies on powerful tranquilizers like Thorazine.” This double function of psychotropics is also mirrored in Morgan’s observations about the cavalier practice of drugging: “A sure way to quiet down a man who is ‘acting out’ is to put him on 1,100 milligrams of Thorazine a day. It turns him into a zombie. Or, in clinical terms, it screens off the amount of input so the inmate can reorganize his psychic structure.” In 1980, a group of prisoners held in the U.S. penitentiary in Leavenworth, Kansas, wrote to Congress to protest unjust treatment by prison officials. They stated:
The Leavenworth prison authorities utilize widespread forced drugging for completely inappropriate reasons; it could be fairly viewed as a preventive detention measure utilizing chemical strait jackets. . . .
Some of us have tried to physically resist the injections—believing it inherently unjust to be given dangerous medication for certified psychotics when we’re not psychotic—only to be assaulted by their “goon squad,” beaten, held down, injected with Prolixin and confined in the neuropsychiatric ward. Some are resigned to our fate and regard it as futile to resist this mad technototalitarianism. We merely acquiesce to their demands and take our periodic injections quietly.
In mobilizing a policy of technocorrections, prisons press human beings through the mold of prison culture, reifying relations of institutionalized racism and sexism. The prison–industrial complex relies on and creates such relationships of power. The fact that American prisons are unjustly stratified by intersectional dynamics is beyond question. By intersectional dynamics, I mean the ways in which social structures of race, gender, and class operate simultaneously to shape people’s experiences, entire communities, and major social institutions. Scholars have carefully analyzed how the institutional practices and cultural meanings that structure prison life are shaped by intersectional dynamics that operate through race, gender, social class, sexuality, nationality, and disability. An intersectional approach provides an important framework for analysis because it rejects either/or thinking and embraces both/and thinking about the nature of relationships of power and resistance; this orientation asks us to interrogate the ways in which racism, sexism, and class inequality work together as complementary rather than competing explanations for mass captivity. As Angela Davis and Michelle Alexander have strenuously argued, the prison–industrial complex and the criminal injustice system that feeds it both rely on and inform these systems of power as they affect prisoners, their families and communities, and the entire nation.
If psychotropics function as “chemical straitjackets,” as the Leavenworth prisoners claimed, these drugs’ production and consumption are shaped by gendered and racial meanings. Prison psychiatrists are much more likely to prescribe psychotropics to female prisoners than to males, a fact related to higher rates of psychiatric diagnoses and symptomology among incarcerated women. The presumed criminality of women in prison is also understood within the context of gender ideology organized around femininity and through the female body. In 1976, a group of women imprisoned at the Bedford Hills Correctional Facility were strip-searched, shackled, and then transferred to the Matteawan State Hospital for the Criminally Insane in New York because they represented “disciplinary problems” for the prison. There, the women were drugged with antidepressants, antipsychotics, sedatives, and tranquilizers. None of the women were ever diagnosed with any mental disorders, and they subsequently filed and won a civil case against the prison and the hospital, settling out of court for $4,857.14 each. At the civil trial, hospital officials openly admitted that “medication often serves a dual purpose in the physical and mental rehabilitation of patients and inmates . . . toward both effective custody and effective rehabilitation.”
State-level research conducted by Renée Baillargeon and colleagues within the Texas prison system in the late 1990s showed that, in comparison with white prisoners, African American and Hispanic prisoners were more likely to receive older, more outdated antipsychotics and antidepressants or no pharmacotherapy at all. In 1988, officials at Stateville Prison and Menard Hospital in Illinois forced Albert Sullivan, a black prisoner, to take large doses of haloperidol (Haldol), an antipsychotic drug. In subsequent legal proceedings, Sullivan alleged that Dr. Parwatikar, a psychiatrist, and Mary Flannigan, the superintendent at Menard, forced him to take powerful drugs “because of [his] black race, male sex, poverty and because I am a prisoner and mental patient and sex-offender.” At trial, Dr. Parwatikar stated:
The need for Mr. Sullivan being on anti-psychotic medication is quite clear from the past history. During the period of 1972 thru 1982 [he] had 59 assaultive episodes. Thus, it is quite essential that Mr. Sullivan must be on some sort of anti-psychotic medication for the rest of his life.
Given the legal rules governing forced medication in Illinois, Sullivan was not able to stop taking the medication long enough to prove that he did not need it. As this case illustrates, the government’s power to force psychotropic medication, people’s rights of refusal, and the dynamics of psychiatric care are sometimes sorted out by the judicial system.
U.S. Law and the Use of Psychotropics
In this book I also explore the complex relationships among state power, human rights, and citizenship that accompany the use of psychotropics in captive America. Prisoners occupy a unique position within U.S. law and psychiatric practice. Not fully citizens with all of the rights and entitlements guaranteed thereto, they exist in a precarious social location at the bottom of the U.S. civic structure. In fact, the status of prisoners challenges our commonsense understanding of citizenship in the United States. While convicted felons lose their freedom, the right to vote, the right to work in certain occupations, and the right to public benefits such as housing, they also gain new rights to health care, including mental health treatment. By receiving health care, prisoners exercise their constitutional right not to die as the result of deliberate indifference in prison. These new rights bring with them significant costs, however. By exercising the right to receive health care, prisoners open themselves up to poor-quality care, ethical abuses, medical negligence, and forced treatments. Psychotropics serve as a kind of boundary object through which we can evaluate the substantive meanings of what anthropologist Adriana Petryna calls biological citizenship.
A number of laws and legal rulings provide some structure regarding the government’s authority to distribute psychotropics to confined people. The U.S. Supreme Court’s ruling in Estelle v. Gamble (1976) effectively established prisoners’ right to access health care, their right to receive care ordered for them by officials, and their right to seek professional medical judgment. Prisoners’ right of access to health care includes the constitutional obligation of the prison to provide a minimum standard of mental health care to inmates. Perhaps surprisingly, prisoners are the only group in the United States who have a federal constitutional right to health care; soldiers and veterans are also guaranteed access to health care, but that guarantee is not covered by the U.S. constitution.
Although federal regulations and state laws do not explicitly enshrine a right to health care for so-called free persons, they do shape psychotropic drug use in the broader U.S. carceral state. For example, the Code of Federal Regulations protects the right of nursing home residents “to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident’s medical symptoms.” State laws protect the right of children in foster care to receive adequate health care, including, as in the state of Texas, the right “not to be forced to take unnecessary or too much medication.”
One way in which the state asserts its custodial power over prisoners is by forcing them to take psychotropics, which it can do if a prisoner is classified as dangerous and if the forced drugging is deemed to be in the “best medical interest of the prisoner.” In the case of Washington v. Harper (1990), the U.S. Supreme Court examined two questions: Can the state administer antipsychotic drugs to prisoners involuntarily? And are there sufficient protections for prisoners in the policies that make such administration possible? The court ruled that the government can administer psychotropics involuntarily to an inmate if it is determined that “he is a danger to himself or others and the treatment is in his medical interest.” The court further found the Washington state policy under which inmate Walter Harper was forcibly medicated to be rational because “it applies exclusively to mentally ill inmates who are gravely disabled or represent a significant danger to themselves or others; the drugs may be administered only for treatment and under the direction of a licensed psychiatrist; and there is little dispute in the psychiatric profession that the proper use of the drugs is an effective means of treating and controlling a mental illness likely to cause violent behavior.” Prisoners can request review of the prison’s decision to forcibly drug them, but such reviews are essentially in-house, conducted by prison medical officials, and tend to favor the decisions of prison officials.
Legal analysts interpret Washington v. Harper as a case involving “biological alteration,” a process through which the “government transforms individuals into instruments of state policy.” Other biological alteration cases include Buck v. Bell (1927), which involved forced sterilization, and Jacobson v. Massachusetts (1905), which dealt with compulsory vaccination. These cases center on two key questions: What constitutes a biological alteration? And to what ends are the interventions deployed? In other words, what exactly is the government doing, and why is it doing it?
Prisoners can refuse to take psychotropics under certain legal conditions that affirm their constitutional rights to free speech, bodily integrity, and due process. In Riggins v. Nevada (1992), the Supreme Court found that involuntary administration of psychotropics to a defendant violated that defendant’s due process rights, but it could still be done. In Sell v. United States (2003), the court affirmed the government’s power to administer psychotropics to mentally ill defendants to make them competent to stand trial for serious criminal charges “if the treatment is medically appropriate, is substantially unlikely to have side effects that may undermine the trial’s fairness, and, taking account of less intrusive alternatives, is necessary significantly to further important governmental trial-related interests.” Similarly, the court found in an earlier case that in certain circumstances the state can condition parole on the involuntary use of antipsychotic drugs, subject to appropriate procedural protections. And, perhaps most alarmingly, government authorities have worked out ways to forcibly administer psychotropics to defendants to make them competent to stand trial when they are facing the death penalty.
The case of Nelson v. Heyne (1974) involved several inmates of the Indiana Boys School who had brought a class action lawsuit against the institution for using the antipsychotics Sparine and Thorazine solely for the purpose of controlling inmates’ excited behavior. Boys weighing less than 116 pounds were given 25 milligrams of Sparine, and boys over that weight were given 50 milligrams of Sparine. The boys had not been examined by medically competent staff members and were not a part of a structured psychotherapeutic program. In its ruling, the Seventh Circuit Court of Appeals wrote:
Major tranquilizing drugs are occasionally administered by the Defendants for the purpose of controlling excited behavior rather than as part of an ongoing, psycho-therapeutic program. Standing orders by the doctor at the Boys School permits the registered nurse and licensed practical nurse on duty to prescribe dosages of specified tranquilizers upon the recommendation of the custodial staff at the Boys School. The drugs are administered inter-muscularly. The facts show that there is no procedure utilized whereby medically competent staff members evaluate individuals to whom the drugs are administered, either before or after injections.
The court found that the indiscriminate use of tranquilizers in this case violated the boys’ Eighth Amendment protection against cruel and unusual punishment and their Fourteenth Amendment right to due process, noting that “the [Indiana Boys School] policies are far afield of minimal medical and constitutional standards.”
These legal cases demonstrate the meaninglessness of the boundary between psychiatric therapy and custodial control in prisons. During the 1970s, scholars investigated, and scholarly journals published articles about, isolated cases of the misuse of psychotropics, what Edward Opton, now a lawyer at the National Center for Youth Law, called at the time “psychiatric violence.” In an article published in 1974, Opton identifies psychiatrists as central actors in the perpetration of psychiatric violence in prisons. He analyzes their actions and intentions in the context of three social roles: compliant accomplice, naive dupe, and pressured subordinate. As compliant accomplices, psychiatrists complacently permit prison administrators to use their clinical authority in service of punitive ends. As naive dupes, psychiatrists participate in psychiatric violence but “fail to see the plainly visible punitive use to which they are being put.” As pressured subordinates, psychiatrists enable the punitive misuse of their authority reluctantly, but they do not challenge that misuse.
For Opton, the distinction between treatment and punishment is specious, thus an ethical context is created in which a whole range of practices, from psychotropic drugging to psychosurgery, become morally permissible under the aegis of medical authority; the fundamental difference between treatment and punishment lies in the intent of the actor. He writes: “An examination of the record of psychiatric treatment in prisons will show that prison psychiatrists are, in general, first and foremost functionaries in the disciplinary power structure of prison bureaucracy. Their interests are as adverse to the welfare of the prisoners as are those of the prison keepers.” From a constitutional standpoint, Opton argues that psychiatric treatments ought to be subjected to the same legal and ethical review applied to punishments.
Opton is one among many commentators, including prisoners themselves, who have drawn an analogy between psychotropic drugs and shackles. “To immobilize a person against his will with drugs,” he argues, “is violence for the same reasons that chaining a person to the wall with shackles is violence.” Unlike shackling, however, drugging causes permanent damage to the body and can be carried out inconspicuously on a large scale. Opton concludes that, put plainly, “most drugging is for the purpose of control, for keeping prisoners docile and quiet.” He quotes a former prisoner, who told him in an interview, “If you speak out, say things they don’t like, if you’re a leader, you know—it’s an unspoken threat: they’ll put you on Prolixin.” In a 1977 review of the principle of informed consent inside prisons and mental hospitals as it pertains to psychotropic drugging, law professor Richard Singer concludes, “Even discounting for paranoia, the nagging feeling remains, often because of the intense secrecy imposed on activities behind the walls and bars, that there is more truth to these rumors than we would wish to know.”
Analyzing the Silences
Throughout this book, I employ historical and comparative analyses of archival, scientific, and policy documents to chronicle meaning making in the social, medical, and ethical dimensions of psychotropics. I argue that practices of knowledge production about psychotropic drugging make it exceedingly difficult to assess how drugging is used to uphold the U.S. carceral state. The coercive ways in which psychotropics serve to manufacture prisoners’ silence are hidden behind practices of state secrecy, medical complicity, and corporate profiteering that result from and protect policies of mass confinement. Judging only by what I present in this book, it might seem as if we know quite a lot about psychotropic drugs in the U.S. carceral state, but knowing some things is different from knowing the right things.
I position silence as a way of talking about the effects of psychotropics on the brains and bodies of people living in the U.S. carceral state. Psychotropics transform the silencing function of custodial institutions by manufacturing a new kind of interior silence within the spirits/souls/psyches of individuals. Using psychotropics to act on a person’s psychic spirit requires that state agents (i.e., administrators, guards, medical providers, officers) treat the spirit as if it is a material thing that can be forced into silence. People living within the carceral state are not literally dead (yet) or missing; rather, they are experiencing a kind of “spirit murder,” which legal scholar Patricia Williams defines as “disregard for others whose lives qualitatively depend on our regard.” This spirit murder takes places, at least in part, through the unquestioned and largely unregulated use of psychotropics. The experience of spirit murder fosters a violent separation of human material existence from the spirit/soul/psyche, thus creating a new form of material and psychic existence. It is tempting to circumscribe materiality in such a way as to exclude the spirit life in favor of an understanding of life that is anchored in a hard, fleshy, and thus material, body.
I also use silence as a way of tracing the production of knowledge about psychotropics as part of a form of statecraft that generates mass confinement. This book is concerned with what we know as well as what we don’t know about psychotropic use, and why we don’t know what we don’t know. In the chapters that follow, I raise questions about the government’s practices of secrecy when it comes to the state-sanctioned distribution of psychotropics to confined people. Questions of who produces knowledge and what they intend to do with that knowledge are central to the sociology of knowledge. When it comes to psychotropics, there are some things we can know and others we cannot know. Practices of knowledge production are dictated by the kinds of things that institutions of power want to know—governments possess unique means of producing social knowledge about the elements of society that interest them. Governments also possess the means to not produce knowledge about society and actively structure which kinds of knowledge become known to the public. Governments use social knowledge in strategic campaigns to shape public opinion, govern social behavior, and produce certain kinds of subjectivities and identities.
This book also excavates the troubling silence of scientific and official knowledge about institutional uses of psychotropic drugs. Do we know enough about what these drugs are doing to people to draw firm conclusions about their role in upholding mass confinement in the United States? The lack of knowledge about prisons’ practices of psychotropic distribution serves to suppress knowledge about the utter failure of prisons and other confinement institutions to provide large numbers of psychically traumatized people with the humane and medically sound mental health care to which they are constitutionally and humanely entitled. Because scientists and prison administrators do not systematically evaluate psychotropic distribution practices in prisons and publish their information publicly, we do not know whether these practices result in improved psychiatric outcomes for prisoners or create new harms. Critics’ claims that psychotropics are widely used to silence prisoners cannot readily be evaluated because no systematic knowledge exists regarding the extent and nature of the practice of administering psychotropics. Given these drugs’ centrality to mental health care in prisons, surprisingly little is known about how frequently they are distributed, their biological effects on prisoners’ brains and bodies, and what they might mean as biotechnologies that serve diverse social, medical, and political aims. Paradoxically, an extensive body of knowledge about psychotropics is available in the mainstream biomedical research literature produced in noninstitutionalized free society. So why is there silence about the use of psychotropics in prisons specifically?
The reason is that silence is central to the meaning and practices of subordination. The U.S. carceral state requires dehumanizing forms of political ideology that can justify the legalized disappearance of millions of people and the suppression of social movements that actively oppose it. Silencing groups is a direct mechanism for achieving oppression and also an indirect means of suppressing opposition to that oppression. People living under oppressive social conditions are actively silenced through violent acts of murder and genocide, imprisonment and internment. Additionally, groups’ oppositional voices are contained through marginalization and exclusion from media landscapes, communicative exchanges, and scholarly conversations. As Paulo Freire notes: “More and more, the oppressors are using science and technology as unquestionably powerful instruments for their purpose: the maintenance of the oppressive order through manipulation and repression. The oppressed, as objects, as ‘things,’ have no purposes except those their oppressors prescribe for them.” The transformation of people into “things” makes them vulnerable to horrible kinds of violence.
To interpret this vulnerability to violence, I draw on two frameworks for understanding the social power involved in the use of psychotropics within the U.S. carceral state: biopower and necropower. Philosopher Michel Foucault used the framework of biopower, or biopolitics, to analyze social practices that target the biological processes of living organisms and entire species of organisms in the name of improving their health. Biopower involves the production of biomedical knowledge about the health of organisms and the use of that knowledge to create social structures (e.g., public health agencies and health laws) that act on the health of the population of organisms as a whole. This new combination of science and social regulation began in the mid- to late 1800s, as European nation-states developed new strategies for increasing their national strength and political power. Foucault argued that the conduct of war, in which a nation exercised its right to kill its enemies, both foreign and domestic, was central to the power of government. During the transition to biopower, however, governments began to do something different to build national strength. European nation-states started producing their own scientific knowledge about the health of their populations through surveys, implementing new forms of social medicine designed to improve the health of their populations, and monitoring the labor force conditions of their populations, all in service of strengthening themselves through the mechanism of health.
In the framework of biopower, I view psychotropics as legitimate medical therapies that are more or less effective in managing the symptoms associated with psychiatric and emotional disorders. Psychotropics extend the power of biomedical psychiatry over the neurochemical terrain of the brain. Psychotropics are supposed to control patients’ symptoms under the assumption that such symptoms are behavioral and cognitive expressions of underlying biochemical processes in the brain. With no discernible mental health infrastructure for the most impaired citizens and the impossibly high cost of talk therapy, U.S. citizens have had few options for mental health care beyond psychotropics. Psychotropics are prescribed for people in the name of improving their mental health. In this context, the distribution of psychotropics, however excessive or unregulated it might be in practice, is always theoretically legitimate and rational in the context of high levels of serious mental illness and trauma among captive populations. I take the position that one of the major limitations of the existing research on psychotropic use in institutions is that such use is always embedded within the context of attempts to improve mental health—that is, within the context of biopower.
While this interpretation of social power as biopolitical may justify the distribution of what may ultimately be billions of doses of psychotropics annually to persons living and dying within institutions, I question whether all that drugging is really done in the name of health. If we confine our view of the production of scientific knowledge about psychotropics and their distribution to what we can see through a biopolitical lens, we miss how psychotropics might be used to silence people, or worse. While the rhetoric of help, care, and mental health may reasonably justify the distribution of psychotropics to populations living in the U.S. carceral state, this meaning of psychotropics obscures their great potential as tools of social power that are all about destruction. What is the boundary between benevolent medicine and malevolent drugging? Psychiatric treatment involving psychotropics is always going to involve a measure of control, regardless of whether the intention is to heal or simply to pacify.
So, in this book I also turn to an alternative framework called necropower, or necropolitics, to explore these darker interpretations of psychotropic drugging. Social theorist Achille Mbembe has proposed necropower as a kind of philosophical corrective to Foucault’s framework of biopower and its failure to account for social power that was, in fact, really still focused on killing the enemies of European nation-states. Viewing power through the historical contexts of European transnational slavery and colonialism, Mbembe argues that necropower is “the generalized instrumentalization of human existence and the material destruction of human bodies and populations.” In contrast to biopower, which functions through laws and other social regulations, necropower operates within what political theorist Giorgio Agamben calls “a state of exception”—a space outside the law in which murder can be carried out without regard for legal prohibitions against execution or assertions about individual rights under law. In the context of necropower, governments target particular human social groups for death, define those groups as enemies, herd them into isolated territories with no viable social infrastructure, and use overwhelming technological force to kill them. Necropolitics creates what Mbembe calls death worlds, a “new and unique form of social existence in which vast populations are subjected to conditions of life conferring upon them the status of the living dead.”
Accordingly, through the framework of necropower, psychotropics are distributed to people in the name of producing mass psychic death. Here, the provision of psychotropics is potentially unethical, medically illegitimate, and unconstitutional. In other words, psychotropics are used to destroy psychic lives—the psychic lives of people who have already been socially sequestered for eventual disposal in places like prisons, people who have been socially abandoned. If the purpose of custody is to confine and ultimately eliminate unwanted social groups, psychotropics can be quite useful toward those evil ends.
These two frameworks also position the role of knowledge very differently. In stark contrast to the role that the production of scientific knowledge plays in shaping the biopolitics of a society, the production of epistemic silence, or willful ignorance, shapes the necropolitics of a society. These contrasting approaches to social power are also helpful in the evaluation of scientific, moral, and legal claims about the legitimacy or illegitimacy of medical practices. Determining whether a particular medical practice is understood as legitimate (because it promotes life and good health) or illegitimate (because it accelerates death and suffering) is contingent on the form of legal discourse that justifies the enactment of the practice itself. The conceptual boundary between legitimate and illegitimate practices is, like the theoretical contiguity of biopower and necropower, porous and indeterminate. The question should not be whether practices are legitimate or illegitimate, but rather how social power functions to obliterate any meaningful distinction between normal medicine and abnormal killing. As rates of psychotropic use have increased inside the U.S. carceral state, they have also steadily increased in so-called free society, making it more difficult to interpret what it means to be held captive in the first place.
In the first two chapters that follow, I explore the contrasting relationships between biomedical knowledge and bureaucratic information specifically within the prison system. In chapter 1, “Climbing the Walls,” I examine what government surveys can tell us about prison pharmacoepidemiology, a scientific practice and knowledge that does not exist in a meaningful way for the purposes of evaluating government malfeasance. This science does not exist because it lacks an enduring institutional apparatus for collecting data. By detailing all of the major administrative surveys and institutional censuses concerning prescription drug use in prisons, this chapter outlines the scope of what prison pharmacoepidemiology can tell us, and what it cannot tell us, about the use of psychotropics among captive populations. As we will see, these limits foreclose attempts to answer many pressing questions about the use of psychotropics in prison and jail settings—a foreclosure that creates psychotropic ignorance.
In light of the built-in scientific limitations circumscribed by prison surveys and censuses, it has become increasingly difficult, if not entirely impossible, to determine the precise extent to which prisons are using psychotropics for any reason whatsoever, to say nothing of whether or not they are using them to control or silence prisoners. If there is one institution that should be able to provide the data needed to evaluate the claim that American prisons are systematically misusing psychotropics, it would be the prison pharmacy. In chapter 2, “The Pharmacy Prison,” I analyze the key findings of government audits of prison pharmacies in order to understand both how these pharmacies operate as major conduits for drugs, especially psychotropics, and how they represent a fiscal and management crisis for prisons. The performance audits represent an innovative form of evidence, given the auditors’ full statutory access to the prison pharmacies, prison policies, prisoner health records, institutional memory, and prison officials themselves. In many jurisdictions, government officials have required that teams of auditors examine prison policies, processes, and expenditures in order to determine whether money can be saved. Prison pharmacies have been found to be plagued by management problems, including poor record keeping and inventory systems, inadequate drug formularies, lack of space and well-trained personnel, and insufficient oversight.
In the next three chapters, I analyze legal and civic controversies involving psychotropics that bring psychiatry, prisoners’ rights, and the police powers of the state into political contestation. Between 1941 and 1976, American prisoners made up the vast majority of research subjects for phase 1 and 2 clinical drug trials conducted in the United States (the four-phase clinical trial system began in 1962). Drug testing in prisons also became linked to citizenship in ways that validated white prisoners’ sense of patriotism. In chapter 3, “Experimental Patriots,” I analyze how pharmaceutical companies positioned prisoners’ participation in drug tests as an altruistic act of patriotism and exercise of citizenship in order to justify ongoing drug testing regimes. In volunteering to be subjects in drug studies, white male prisoners were capable of becoming moral actors and better citizens. These “experimental patriots” also embodied a discourse of ethics, justice, and citizenship that aimed to justify the ongoing use of prisoners as drug test subjects. Through their participation, white prisoners were able to enact their citizenships in ways that were denied to black prisoners. Black prisoners’ lesser participation was linked to their lesser status as citizens; they could not be real patriots who were willing to sacrifice their brains and bodies for the sake of the nation. Perhaps the whiteness of the prisoners used as subjects enabled the effort to construct the testing regimes as patriotic, as medical trials that, if carried out without further government regulation, would strengthen the nation by speeding up technoscientific progress and shoring up U.S. hegemony.
In chapter 4, I relate a series of stories within what I call “psychic states of emergency”—institutional crises that justify custodial power to hold bodies and, within those bodies, use psychotropics to transform brains for the purpose of managing vulnerable populations. States of emergency work by positioning brains and bodies on a thin boundary between therapeutic medical practice, in which people can choose to participate freely, and coercive state violence, which people cannot legally refuse. This chapter addresses populations other than prisoners who are also relegated to confinement—for wildly different kinds of reasons but with tragically similar outcomes. Psychotropics are increasingly distributed to active-duty soldiers, elders living in nursing homes and assisted care facilities, and children living under the aegis of the foster care system. Here, I extend the discussion beyond the confines of the carceral within state and federal prisons. While psychotropics may have helped to solve one institutional problem by enabling the closure of state mental hospitals and stabilizing the mental health of communities, today they are creating new problems of institutional abuse, neglect, and psychiatric harm.
While custodial institutions like prisons and state mental hospitals and asylums have long histories of experimental behavioral modification programs, psychotropics are used to enact violence on populations that are otherwise defined as dangerous. In chapter 5, “There Are Dark Days Ahead,” I interpret psychotropics as neurochemical weapons that are deployed in extraordinary legal circumstances. In privately run federal detention centers, Immigration and Customs Enforcement (ICE) has been accused of forcibly administering psychotropics to civil detainees awaiting trial and deportation for immigration violations. In war-zone prisons in Iraq and Afghanistan, and at the Guantánamo Bay detention camp, the U.S. Department of Defense has, by its own admission, forcibly administered psychotropics to detainees prior to deportation and during marathon interrogation sessions; it has also used “chemical restraints” to manage threatening detainees. Elsewhere, high-dose antidepressants are being used to suppress the sexual desires of convicted sex offenders. By linking the use of psychotropics across these populations—undocumented immigrants, enemy combatants, and convicted sex offenders—I make the case that psychotropics have become indispensable to broader national security practices like border enforcement, international militarized conflict, and the prevention of sexual violence. Also in this chapter, I discuss the case of George Zimmerman, who, on the night he killed Trayvon Martin, had several psychotropics in his body—Restoril, Librax, and Adderall. Media reports suggested that Zimmerman had a history of violent behavior and that Zimmerman’s father intervened on his behalf with the Sanford, Florida, police because of his son’s history of psychiatric disturbances. Surprisingly, the prosecution and the news media downplayed Zimmerman’s history of mental health problems and psychotropic use, which was potentially important to his state of mind. I situate Zimmerman’s story within the context of biomedical research to examine the relationships among psychotropics, mental health, and gun violence.
In my Conclusion, “Overdose,” I respond to the major counterfactual question in this book: Is it possible for the U.S. carceral state to exist in its current form without psychotropics? Like any good counterfactual, this question cannot be answered directly. But I think the answer is no. To make sense of this brutal counterfactual, I discuss the significance of psychotropics for existing institutionalized power arrangements that converge around the mental health of vulnerable groups and the theoretical ideas that draw attention to the problematic relationships between global pharmaceutical firms and the institutions of state and pharmaceutical capitalism that govern captive America. The current legal, scientific, and cultural classification of psychotropic drugs as therapeutic medicines requires revision in light of the ways that psychotropics are used to create new forms of social, psychic, and sexual death.