Containing Madness

Containing Madness
Gender and ‘Psy’ in

Institutional Contexts
Edited by Jennifer M. Kilty and Erin Dej

Containing Madness
Jennifer M. Kilty • Erin Dej
Editors
Containing Madness
Gender and ‘Psy’ in Institutional Contexts
Editors
Jennifer M. Kilty Erin Dej
Department of Criminology Department of Criminology
University of Ottawa Wilfrid Laurier University
Ottawa, ON, Canada Brantford, ON, Canada
ISBN 978-3-319-89748-6 ISBN 978-3-319-89749-3 (eBook)

https://doi.org/10.1007/978-3-319-89749-3
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Madness Uncontained
Containing Madness is a collection about the power of various types of

carceral institutions, filtered through the lens of a critical account of the
‘psy’ complex. Understanding the containment of ‘mad’ and ‘bad’ bodies
in carceral spaces, and the meanings and material effects of incarceration,
has a long history. In his book Discipline and Punish, Michel Foucault
predicted that the body would be less the subject of physical institutional
controls over time, and that the mind would become the object of external
control and self-control (Foucault 1979). His ideas about subjectivity and
its formation and the impact of the discourses grouped together within
the ‘psy’ disciplines became the focus of a genealogy of subjectivity
advanced by social theorist Nikolas Rose in Governing the Soul: The Shaping
of the Private Self (Rose 1990).
Following these interventions, in this book, the editors and authors
examine the premise that ‘psy discourses and practices and different forms
of institutionalization form a complex web of gendered and racialized
oppression and social control’ (see Chap. 1). Separate authors take up the
ideas advanced by Foucault in The Birth of the Clinic (Foucault 1963),
with the ‘medical gaze’ an example of psychocentrism in the present. A
number of the chapters analyze institutional case studies using Foucauldian
perspectives, combined with feminist and post-structuralist methodolo-
gies, deepening the accounts of social control by advancing detailed read-
ings of forms of power in context. The ‘complex web’ of oppression, as
described by the editors, presents opportunities for intersectional analyses
of power and medical regimes. Disciplinary discourses, practices and tech-
nologies continued long after the rise and fall of eighteenth-century
v
vi MADNESS UNCONTAINED
risons and nineteenth-century asylums, as evidenced by both physical

p
and psychological practices, including techniques of punishment, used
inside contemporary institutions. Yet the accounts of discipline included
in this book also remind readers that madness is rarely contained. It spills
out and over, across and into the available spaces of a blurred and indis-
tinct set of power relations. Anything approximating ‘containment’ there-
fore becomes desperately impossible, for instance, in the case of
homelessness and mental illness.
In fact, this new account of institutional contexts zeros in on the core
tenets of the institution: its structures of power. Scholarship about institu-
tional power invites a careful unpicking of these structures, formed
through categories such as sexuality, gender, race/ethnicity and class. This
volume takes the case studies of people confined as mentally ill as well as
prisoners, including political detainees and immigrants in detention; it
examines the experiences of women and men, queer and transgender peo-
ples, the violent and those who have been subject to present and past
violence, including that produced by the after-effects of colonialism.
Further, this book extends our awareness of regimes of discursive power
inside institutions. These regimes demonstrate the hegemony of the ‘psy’
disciplines as they engage in various practices defined as violent, such as
mechanical and chemical restraints, and are imbued with the power to
define subjectivity, such as normative sexualities, through devices like
patient charts. The continuation of colonialist violence has found expres-
sion in the late twentieth century, and in the present, in immigration deten-
tion facilities. These are places where the demonstrable effects of the carceral
environment, such as detention centres, turn on the fear of Otherness, and
perpetuate the foreign element: that is, the proposition that illegal immi-
grants are dangerous and criminal, with the threat of immigrants tied to
much earlier claims about ‘race’ and eugenic ideas. The fact that postcolo-
nial nations also have a poor record of treatment of displaced Indigenous
peoples, often more vulnerable to policing and detention, underscores the
global problem of perceived racialized threats from mobile peoples.
The volume also examines the legibility of queer sexualities inside
patient case notes or medical charts, questioning the tendency towards the
occlusion of same-sex intimate partner violence. Larger samples of patient
charts also reveal patterns of diagnostic explanations of individual experi-
ences. In seeking the performance of patient ‘insight’, for example, medi-
cal personnel look for conformity and compliance with the expected
behaviours of inpatients, an institutional practice dating back to the earliest
MADNESS UNCONTAINED
vii
days of the asylum. Social identities are triggers for medical control and
also provide some potential for rehabilitation—although the meanings of
patients’ self-reflexivity are only explicable through institutional discourse
and categories. In these and other ways, psychocentrism promotes the
pathologies of individuals rather than exposing the structural inequalities
that shape social and cultural experiences. A number of the chapters take
up feminist approaches to interrogate this psychocentrism and to investi-
gate inside the ‘sickening institutions’ that were historically and are con-
tinually embedded within structures of power, with their own internal
power relations.
Carceral institutions historically did more than ‘contain’ individuals
and groups. They performed the intense work of segregation, classifica-
tion, monitoring and capturing subjects. From physical restraints, which
never really disappeared from view, to strategic forms of effecting differ-
ence within institutions through spatial arrangements, the expectation was
that to be confined was to be herded and controlled. Staff who worked in
institutions for the insane came to be part of these ‘total institutions’, in
Erving Goffman’s words (Goffman 1961), and the totalizing oppression
also bore down on them, making it difficult for any questioning or erup-
tions of dissonance, though these did occur. Tommy Dickinson, for exam-
ple, writes elsewhere about the nurses who disrupted the chemical and
social ‘cures’ of queer patients by subverting treatments (Dickson 2014,
181–188), and in the process offered chinks of light on the dominant
discourses of normative sexuality.
In this volume, we read an account of state-sanctioned violence inside
isolation wards in prisons, the most severe form of segregation. Acts of
violence against isolated women signify the objectification of confined
women; this form of visual record of violence against women in prisons is
akin to torture against racially othered, imprisoned terror suspects. Such
acts of spectatorship become evidence of injustice, but they are also stark
mechanisms of control. Strip-searching, too, is an invasive mode of coer-
cion, and a tool of the medical gaze. Despite the increased internalization
of modes of ‘self-control’, bodies are made vulnerable to gendered and
punitive techniques of the institution within which they are contained.
Current critical assumptions about the meanings of the modalities of
institutions are tested in this collection. Generations of historians of the
asylum and prison have been concerned with the institution’s capacity to
order space, to use and deploy clinical language, and more recently, to
understand social identities (Coleborne 2015). Taking questions about
viii MADNESS UNCONTAINED
gender and sexuality, feminist genealogical approaches, queer linguistic

interpretations and intersectional analyses of race, gender and sexuality,
these contributions posit new formulations of the web of oppression rep-
resented by various institutions. Some of the most interesting work in this
volume considers the spaces between institutional and home-worlds, such
as extra-institutional care and out-of-home care. This collection includes a
piece about homelessness and masculinity, which reminds us of the ines-
capable ways in which the ‘government of self’, as proposed by Rose, is
interpellated and practiced: men seeking to fashion masculinities under
duress who bring power relations into spaces where ‘normalized’ power,
such as economic, affective and cultural power, is unlikely to exist. In the
outdoor lives of those without homes, making meanings out of the forma-
tions of power on the street becomes its own objective. Likewise, com-
munity treatment in community-based settings sometimes reinscribes
institutional forms of gendered power: the repeated description of men
with mental illness as ‘violent’ rather than the recipients of social, political
and other forms of violence further marginalizes the unwell. In the ‘sick-
ening society’, psychocentrism underlines the politics of psychiatry, psy-
chiatric expertise and psy-praxis.
University of Newcastle Catharine Coleborne

Newcastle, NSW, Australia
References
Coleborne, C. 2015. Insanity, Identity and Empire: Immigrants and Institutional
Confinement in Australia and New Zealand, 1873–1910. Manchester:
Manchester University Press.
Dickinson, T. 2014. ‘Curing Queers’: Mental Nurses and Their Patients, 1935–74.
Manchester: Manchester University Press.
Foucault, M. 1963. The Birth of the Clinic. New York: Routledge.
———. 1979. Discipline & Punish: The Birth of the Prison. Translated by Alan
Sheridan. New York: Vintage.
Goffman, E. 1961. Asylums: Essays on the Social Situation of Mental Patients and
Other Inmates. New York: Doubleday Anchor.
Rose, N. 1990. Governing the Soul: The Shaping of the Private Self. London:
Routledge.
Contents
1 Introduction: Psy, Gender, and Containment 1

Jennifer M. Kilty and Erin Dej
Part I Historical ‘Psy’ Discourses Revisited 13
2 Sickening Institutions: A Feminist Sociological Analysis

and Critique of Religion, Medicine, and Psychiatry 15
Heidi Rimke
3 Traditions of Colonial and Eugenic Violence:

Immigration Detention in Canada 41
Ameil J. Joseph
4 Gender, Madness, and the Legacies of the Prisons

Information Group (GIP) 67
Michael Rembis
ix
x CONTENTS
Part II Containing Bodies 91
5 Patients’ Perspective on Mechanical Restraints in Acute

and Emergency Psychiatric Settings: A Poststructural
Feminist Analysis 93
Jean Daniel Jacob, Dave Holmes, Désiré Rioux, and
Pascale Corneau
6 Carceral Optics and the Crucible of Segregation:

Revisiting Scenes of State-Sanctioned Violence Against
Incarcerated Women 119
Jennifer M. Kilty
7 Gender Dysphoria and the Medical Gaze in Anglo-

American Carceral Regimes 145
Kyle Kirkup
Part III The Asylum and Beyond 167
8 Uncovering the Heteronormative Order of the Psychiatric

Institution: A Queer Reading of Chart Documentation
and Language Use 169
Andrea Daley and Lori E. Ross
9 Assessing ‘Insight’, Determining Agency and Autonomy:

Implicating Social Identities 191
Merrick D. Pilling, Andrea Daley, Margaret F. Gibson,
Lori E. Ross, and Juveria Zaheer
10 When a Man’s Home Isn’t a Castle: Hegemonic

Masculinity Among Men Experiencing Homelessness
and Mental Illness 215
Erin Dej
CONTENTS
xi
11 Dangerous Discourses: Masculinity, Coercion,

and Psychiatry 241
Christopher Van Veen, Mohamed Ibrahim, and
Marina Morrow
12 Conclusion: Expanding the Concept of ‘Containment’ 267

Erin Dej and Jennifer M. Kilty
Index 281
Notes on Contributors
Catharine Coleborne is Professor and Head of School of Humanities and

Social Science at the University of Newcastle in NSW, Australia. The author
of three books and co-editor of six collections, Coleborne has become
known for her scholarship about the social and cultural histories of madness
and institutions in the colonial societies of Australia and New Zealand. She
focuses on gender, families, immigrants, social identities and questions of
clinical language, categories of analysis and the work of institutions. In
2015, she published Insanity, Identity and Empire: Colonial Institutional
Confinement in Australia and New Zealand, 1870–1910 (Manchester
University Press). Coleborne’s current book projects include Why Talk
about Madness? and Narrating Madness in the Twentieth Century.
Pascale Corneau, RN, MSc, is a registered nurse at CISSS des Laurentides
with experience in pediatrics, obstetrics and substance abuse nursing. She
also has worked with the Research Chair in Forensic Nursing at the School
of Nursing, University of Ottawa, on projects related to psychiatric nursing
and violence in nursing practice.
Andrea Daley is Associate Professor at the School of Social Work, York
University, Toronto, Canada. She has published on social justice issues includ-
ing those impacting sexual and gender minority communities; lesbian/queer
women’s experiences of psychiatric services; and gender, sexuality, race and
class and the interpretative nature of psychiatric chart documentation.
Erin Dej is Assistant Professor in the Department of Criminology at Wilfrid
Laurier University, Brantford, Canada. Previously, she was a postdoctoral
xiii
xiv NOTES ON CONTRIBUTORS
fellow with the Canadian Observatory on Homelessness. She is currently

developing a book based on her research with UBC Press. Her areas of
research include homelessness, mental health, autonomy among marginal-
ized people and homelessness prevention.
Margaret F. Gibson is Visiting Assistant Professor in the School of Social
Work at York University, Toronto, Canada. Her research interests include
disability studies, LGBTQ communities, parenting and marginalization
and the history of ‘helping professions’. She is the editor of Queering
Motherhood: Narrative and Theoretical Perspectives (Demeter Press, 2014).
Dave Holmes, RN, PhD, is Professor and University Research Chair in
Forensic Nursing, School of Nursing, University of Ottawa. He is associ-
ate researcher at the Institut Philippe-Pinel de Montréal (Montréal,
Canada), a maximum security forensic psychiatric facility, and he is also
research affiliate at the Center for Positive Sexuality, Los Angeles,
California. Holmes has received funding, as principal investigator, from
Canadian federal granting agencies (CIHR and SSHRC) to conduct his
research program on risk management in the fields of public health and
forensic nursing. Most of his research, commentaries, essays and analyses
are based on the poststructuralist work of Gilles Deleuze and Feliz Guattari
and Michel Foucault.
Mohamed Ibrahim is Assistant Professor in the School of Social Work at
the University of British Columbia. He has worked as a mental health cli-
nician and educator in the United States, Canada and East Africa. His
areas of teaching, interests and research include transnational mental
health, mental health reforms, community mental health, addiction and
holistic approach to psychosocial distress.
Jean Daniel Jacob is Associate Professor at the School of Nursing,
Faculty of Health Sciences, University of Ottawa. His work draws on criti-
cal and sociopolitical approaches in the fields of psychiatric nursing and
also addresses questions related to power, ethics and violence risk manage-
ment. As a member of the University Chair in Forensic Nursing
(2009–2018), he is currently working on a number of projects that address
the use of control measures in psychiatry.
Ameil J. Joseph is Assistant Professor in the School of Social Work at
McMaster University, Hamilton, Canada. He draws on perspectives of criti-
cal forensic mental health, mad studies, postcolonial theory, critical race
theory and critical disability studies to analyze the historical production of
NOTES ON CONTRIBUTORS
xv
ideas about difference, normalcy, sexuality, eugenics, race, ability and men-
tal ‘illness’ as they cohere, diverge, interdepend and perform within policy,
law and practice.
Jennifer M. Kilty is Associate Professor in the Department of
Criminology, University of Ottawa. Author of numerous articles and book
chapters, in 2014 she edited Demarginalizing Voices: Commitment,
Emotion and Action in Qualitative Research (UBC Press) and Within the
Confines: Women and the Law in Canada (Women’s Press), and with
Sylvie Frigon authored The Enigma of a Violent Woman: A Critical
Examination of the Case of Karla Homolka (Routledge) in 2016.
Kyle Kirkup is Assistant Professor at the University of Ottawa Faculty of
Law (Common Law Section). His research explores the role of constitu-
tional law, criminal law and family law in regulating contemporary norms
of gender and sexuality. He is currently working on a book-length manu-
script titled Law and Order Queers: Respectability, Victimhood, and the
Carceral State.
Marina Morrow is Professor at the School of Health Policy and
Management at York University, Toronto, Canada. Marina’s research is in
critical health policy with a focus on understanding social, political and
institutional processes through which mental health policies and practices
are developed and how social and health inequities are sustained or atten-
uated for different populations.
Merrick D. Pilling is a research associate at the School of Social Work at
York University, Toronto, Canada. Research interests and areas of publica-
tion include access to community for queer and trans people who have
experienced psychosis, LGBTQ inclusion in Canadian mental health policy
and workplace discrimination against people with psychiatric disabilities.
Michael Rembis is an associate professor in the Department of History
and director of the Center for Disability Studies at the University at Buffalo
(SUNY). He has written or edited many books and articles, including:
Defining Deviance: Sex, Science, and Delinquent Girls, 1890–1960
(University of Illinois Press, 2011/2013); Disability Histories (University
of Illinois Press, 2014) co-edited with Susan Burch; The Oxford Handbook
of Disability History (Oxford University Press, 2018) co-edited with
Catherine Kudlick and Kim Nielsen; and Disabling Domesticity (Palgrave
Macmillan, 2016). He is currently working on a book entitled, “A Secret
Worth Knowing”: Living Mad Lives in the Shadow of the Asylum.
xvi NOTES ON CONTRIBUTORS
Heidi Rimke is Associate Professor in the Department of Sociology at

the University of Winnipeg where she teaches theory, critical ‘psy’ studies,
political sociology and the sociology of law and criminology. She has pub-
lished in The History of the Human Sciences, Cultural Studies, The
International Journal of Social Sciences, Studies in Social Justice, and in
numerous textbooks, collected volumes and encyclopedia sets. Her
research is broadly interested in questions of power, knowledge, suf-
fering, injustice and inequality in neoliberalism.
Désiré Rioux is a PhD candidate in Nursing at the University of Ottawa.
Lori E. Ross is Associate Professor in the Social and Behavioural Health
Sciences Division of the Dalla Lana School of Public Health, University of
Toronto. She uses a combination of quantitative and qualitative approaches
in her research work, with a strong focus on integrating the principles of
community-based research. Much of her research is conducted in partner-
ship with communities that face structural barriers to accessing health and
social services, including lesbian, gay, bisexual, trans and queer (LGBTQ)
communities and consumer/survivor communities, in order to address
these barriers and improve access to care.
Christopher Van Veen is a municipal urban health planner and doctoral
candidate in the Faculty of Health Sciences at Simon Fraser University.
Much of his career has been spent working in a variety of community-based
mental health, addictions and non-profit housing programs in Vancouver’s
Downtown Eastside. Drawing on practice experience, Chris is interested in
uncovering the taken-for-granted assumptions and political rationalities at
work in contemporary mental health and addictions policy and practice.
His doctoral research uses discourse analysis to examine the emergence of
Assertive Community Treatment (ACT) teams and their role in the gover-
nance of the ‘severely mentally ill’ and ‘hard-to-house’ in Vancouver.
Juveria Zaheer is a clinician investigator at the Centre for Addiction and
Mental Health and an assistant professor in the Department of Psychiatry
at the University of Toronto. Dr Zaheer’s research interests include
gender, culture and suicide, qualitative program evaluation and medical
education.
List of Figures
Fig. 6.1 IERT pushing naked woman to the wall with Plexiglas shields 127
Fig. 6.2 Smith blurring the CCTV camera in her segregation cell before
she died 127
Fig. 6.3 Smith receiving involuntary chemical injection 131
Fig. 6.4 Smith in the WRAP 131
Fig. 6.5 Male IERT cutting the clothes off of a segregated female
prisoner in P4W 136
Fig. 6.6 Smith bound while in air transport to a different institution 137
Fig. 6.7 Smith dying from self-tied ligature as guards watch from the hall 138
xvii
CHAPTER 1
Introduction: Psy, Gender, and Containment
Jennifer M. Kilty and Erin Dej
It is now well documented that mass incarceration has resulted in increas-

ing numbers of individuals with mental health diagnoses being housed in
carceral and forensic or psychiatric institutions across the globe. Often,
those identified as mentally ill are subject to exceptional forms of deten-
tion, including the frequent use of segregation or solitary confinement
and physical or mechanical restraint measures (e.g., the WRAP and the
Pinel Board1) as well as mandated forms of ‘treatment’ typically by way
of prescription psychotropic medications (and forced chemical injections
when the patient or prisoner refuses said prescribed medications) and
mandatory cognitive-behavioural programming (Arrigo and Bullock
2008; Etter et al. 2008; OCI 2013; Vogel et al. 2014). Relatedly, there
are increasing numbers of individuals receiving mental health services in
the community and living on the streets or in precarious forms of hous-
ing (Davis 2013). This particular phenomenon is due in part to the dein-
stitutionalization movement that occurred between the 1960s and
1990s, whereby in-patient psychiatric bed space was reduced in order to
J. M. Kilty (*)
Department of Criminology, University of Ottawa, Ottawa, ON, Canada
e-mail: jennifer.kilty@uottawa.ca
E. Dej
Department of Criminology, Wilfrid Laurier University, Brantford, ON, Canada
e-mail: edej@wlu.ca
© The Author(s) 2018 1

J. M. Kilty, E. Dej (eds.), Containing Madness,
https://doi.org/10.1007/978-3-319-89749-3_1
2 J. M. KILTY AND E. DEJ
provide more mental health support in the community rather than in

spaces of physical confinement (Rogers and Pilgrim 2010; Sealy and
Whitehead 2004; Wilson 1996). Unfortunately, those individuals who
are unable to find adequate care in the community are often taken up by
the criminal justice system, an unintended consequence that is commonly
referred to as ‘transcarceration’ (Kilty and DeVellis 2010; Lowman et al.
1987; Stroman 2003) and that the late Stan Cohen (1985) described as
a result of the incessant widening of the carceral net in the era of mass
incarceration.
Within historic spaces of confinement as well as in more contemporary
institutional and transcarceral sites, the medical model remains the domi-
nant explanatory approach for interpreting and understanding human
behaviour and the preeminent analytic tool and modality for ‘treatment
intervention’. Given the medical model’s propensity towards individual-
ized and essentialist understandings of emotional and psychological dis-
tress (Rimke and Brock 2012; Tew 2005), it is important to make sense of
the ways in which the different forms of social control that are born from
the medical gaze are gendered and the material experiences of those who
are caught up in and by its oppressive institutions, discourses, and prac-
tices. The chapters in this edited volume take up this call by examining the
psy discourses (by which we mean the language and diagnostic structures
inherent to psychiatry, psychology, and other biomedical explanatory
modalities), associated practices, and experiential accounts of varied forms
of institutional confinement (e.g., the prison and other forms of detention
and holding, the forensic or mental hospital, the homeless shelter, and
even by way of community-based interventions) as they are mediated by
gender and other markers of structural oppression—namely race, ethnic-
ity, Indigeneity, class, and sexuality.
Broadly speaking, this book investigates the intersection of ‘psy’ inter-
ventions, practices, discourses, gender, and institutionalization. Specifically,
the collection explores the discursive production and treatment of mental
illness, which, following Jane Ussher (2010, 2011), we conceptualize as
distress as it is mediated by gender in different institutional and transcarceral
contexts. A critically oriented and feminist-inspired collection of analyses,
contributors speak to different issues germane to the multiple interlocking
oppressions that result in the diagnosis and medical, psychological, and/
or psychiatric treatment of individuals constituted or constructed as ‘men-
tally ill’. Contributors draw from a variety of critical bodies of literature—
notably, critical and feminist criminology, critical psy and mad scholarship,
INTRODUCTION: PSY, GENDER, AND CONTAINMENT 3
critical disability studies, critical race studies, critical nursing studies,

feminist post-structuralism, and gender studies (i.e., gender performativ-
ity and the ‘doing gender’ literatures).
The scope of this book is intentionally broad in order to provide inno-
vative insight into the diverse ways that psy discourses and practices are
mediated by gender and institutional and transcarceral settings. Together,
the discussions offered herein accomplish two large goals. First, the chap-
ters in this book work to reformulate the traditional notion of institution-
alization so as to move beyond strict conceptualizations of what are
typically described as spaces of confinement or containment. As ‘total
institutions’ (Goffman 1961) the prison and the mental hospital (i.e., the
asylum and contemporary forensic and psychiatric hospital facilities) are
long-standing disciplinary sites (Foucault 1976, 1979, 1988) that warrant
continued investigation of the gendered, raced, and heteronormative ways
in which men and women experience psy-care. In addition to this effort,
in this book we take up Cohen’s (1985) call to examine the long shadow
of incarceration by casting a wider net vis-à-vis institutional containment
in order to consider other discursive and physical sites of social control
that are related to, but distinct from, the prison and the asylum. Chapters
in this collection also consider how the language and technologies of psy-
chiatric diagnosis and practice and spaces such as the homeless shelter and
actors in the wider community take up psy’s grammar in uniquely gen-
dered ways and thus provide new avenues for considering how psy-dis-
courses and practices act as dynamic forms of governance in a multiplicity
of institutional and transcarceral settings.
Second, this book approaches the notion of gender fluidly. Often,
books focus exclusively on a single gender. Historically, much of the litera-
ture on carceral settings addressed only male prisoners (Adelberg and
Currie 1987), while much of the critical psy and ‘madness’ scholarship
studies the material experiences and disproportionate number of mental
illness diagnoses amongst women (for an excellent example see Chan et al.
2009 edited book, Women, Madness and the Law: A Feminist Reader). At
times, however, this research inadvertently reinforces gendered notions of
madness and badness. Moreover, there is little scholarship that assesses
how individuals who exist outside of the gender binary experience distinct
forms of oppression. This collection aims to critically engage with the
broader parameters of gender by considering norms of masculinity and
femininity, the institutional experiences of transgender/gender non-con-
forming men and women, and the effects of heteronormativity in order to
examine the ways in which they mediate psy discourses, diagnoses and
intervention strategies, and disciplinary technologies.
While the book is international in scope it contains a great deal of
uniquely Canadian content that will be of great value to Canadian audi-
ences. We have enlisted the contributions of several internationally
renowned authors to explore the similarities and differences in how psy,
gender, and institutionalization manifest in various political, economic,
social, and geographic contexts. There are a number of similarly critical
edited book collections on the market, for example Mad Matters (edited
by LeFrançois et al. 2013) or Disability Incarcerated (edited by Ben-
Moshe et al. 2014), that consider how evolving political rationalities shape
the confinement and incarceration of marginalized peoples and that share
our interest in critically exploring forms of containment beyond the prison
and hospital. These texts are tremendously valuable in that they set the
stage for a number of the discussions raised in this book (notably, those
centred on the interlocking systems of social and psy control and confine-
ment), yet they do not specifically examine the impacts and effects of the
intersection of gender (diverse performatives thereof) and psy, although
these themes do emerge in some of their chapters. By contrast, the con-
tent of this edited collection centres analytic consideration at the intersec-
tion of gender, psy, and varying forms of institutional containment. In
what follows we provide an overview of the book’s contents.
Chapter Organization
In order to organize the varying discussions presented throughout this
collection, we divided this book into three overarching parts: (I) Historical
‘Psy’ Discourses Revisited; (II) Containing Bodies; and (III) The Asylum
and Beyond. The chapters contained in Part I are exceptionally useful in
setting up the broader approach and critical narrative taken up throughout
the contents of the rest of the book. In effect, these three chapters help to
set the stage for considering the historicity of psy’s power to identify and
define madness, to locate its roots and causes, and to determine the
common methods of intervention and treatment, as well as the dominant
technologies of discipline that are used to subordinate and control risky, at
risk, and otherwise resistant peoples. The three chapters do this by way of
intersectional analyses that consider how psychiatric discourses and prac-
tices are mediated by gender, race, class, and heteronormative sexuality.
Heidi Rimke’s feminist genealogy of psy hegemony in Chap. 2 ana-

lyzes how the notion of pathological individualism emerged in the nine-
teenth century and challenges the assumptions of psychiatric diagnoses,
discourses, and institutions. Her discussion situates women’s distress as
the result of socially structured problems rather than the consequence of
a flaw or defect of abnormal individuals. The chapter interrogates
Rimke’s own theory of psychocentrism to politicize and critique the cul-
ture of therapy that has proliferated within neoliberalism as producing a
kind of “sickening society” that capitalizes on individualism, stigmatiza-
tion, and pathologization. Rimke advocates for feminist intersectional
approaches to interpreting and treating women’s emotional distress and
suggests that these approaches should instead concentrate on creating a
non-psychocentric world whose objective is collective care, concern, and
cooperation.
Chapter 3 examines the parallel trajectories of eugenics and colonial
discourses and the ways they are bound up in the detention of racialized
immigrant bodies. Critical race scholar Ameil Joseph analyzes the histori-
cal continuity of immigration practices in Canada and how they are ratio-
nalized as necessary for the assessment and examination of immigrants
who might present a threat to the public. Against the contemporary back-
drop of deaths occurring inside immigration detention centres, Joseph
questions the purpose and conditions of these holding centres and the
human rights protections for the people being detained. The chapter dis-
cursively analyzes historic documents and positions contemporary immi-
gration detention as a continuation of colonial population regulation
practices that is fueled by the fashioning of a confluence of gendered
threats to the “Canadian public” and sustained by racial, sanest, and
eugenic thinking that constructs racialized people and those identified by
the biomedical psychiatric system (mostly young men) as inherently vio-
lent. Joseph argues that this outcome is achieved by advancing the patriar-
chal fantasy of the Canadian state as protector that is only made possible
by (re)forging historical ideas about a savage threat to an innocent and
largely white Canadian public.
In Chap. 4, critical disabilities studies scholar Michael Rembis trains his
analytical eye on the formation of the Groupe d’Information sur les
Prisons (GIP) in the early 1970s. The GIP was founded by preeminent
French philosopher Michel Foucault and other critical prison scholars and
practitioners as a way to investigate and make the public aware of the
intolerable nature of the French prison system. Taking up Foucault’s
methodological approach of ‘the investigation’ as a means of document-

ing and making known the deplorable material conditions of France’s pris-
ons, the GIP aimed to challenge the very notion of the prison as an
organizing concept in French society. Using recently translated archival
documents, Rembis recounts how the intellectual organizers of the GIP,
while intending to give prisoners and their families ‘the floor’ and empow-
ering them to ‘speak for themselves’, remained the key political figures in
the organization, interpretation, and public discussion of the conditions of
confinement in French prisons. Long criticized by feminist scholars
(Harding 1986; Hill-Collins 2000) Rembis intimates the irony of the
notion of ‘giving voice’ in the title of his chapter, in which he quotes
Foucault: ‘You’re going to tell me it is the intellectuals who are molding
this discourse … Big deal! The intellectual, in a given society, is precisely
the “discourse officer”’. Problematizing this construction of the intellec-
tual as discourse officer for marginalized prisoners, Rembis follows Spivak’s
call not simply to ask whether the subaltern can speak, but rather what
happens when they do speak. Rembis maintains that for all of their stated
goals about giving prisoners the floor, the GIP reinforced masculinist and
ableist ideas about protest, revolt, and agency in ways that have deeply
affected how activists and scholars work to critique, reform, and denounce
the prison and that the GIP were primarily concerned with organizing
able-bodied male political prisoners, despite their repeated nods toward a
more inclusive protest.
Part II, entitled ‘Containing Bodies’, includes three diverse yet topically
and or theoretically related chapters. All three of these chapters critically
examine some of the more punitive aspects of incarceration and methods
of restraint and control that occur across two different sites of physical
confinement, namely, the contemporary in-patient emergency psychiatric
hospital and prison. Chapter 5, authored by Jean-Daniel Jacob, Dave
Holmes, Désiré Rioux, and Pascale Corneau, documents women’s mate-
rial experiences of being mechanically restrained in acute and emergency
forensic psychiatric settings. The chapter offers a post-structural feminist
analysis of patient perspectives and privileges their p henomenological
experience(s) of mechanical restraint use. In this text, the authors examine
the patients’ positive and negative views of mechanical restraints, and both
the environmental and interpersonal dimensions that shape those interpre-
tative experiences. Considering the role of place, gender, and power, the
chapter exposes the ways in which power is embedded, produced, and
reproduced in practices of care and suggests that the visibility and uses of
mechanical restraints embody the authoritative (masculine) psychiatric cul-

ture that reminds us of the gendered nature of institutional practices that
officialize and operationalize the domination of one group (nurses) over
another (patients).
In Chap. 6, Jennifer M. Kilty provides a visual criminological analysis of
the historical continuity of state-sanctioned acts of violence against women
in prison segregation settings. Her chapter combines the visual criminol-
ogy literature with the nascent scholarship on ‘critical hauntology’
(Lincoln and Lincoln 2015) to examine two infamous cases of prisoner
mistreatment and carceral abuses of power in Canadian federal prisons for
women; namely, the 1994 illegal cell extraction and strip searches of eight
women by a male institutional emergency response team in the now closed
Kingston Prison for Women and the tragic 2007 death of Ashley Smith in
Grand Valley Institution for Women. Using image stills extracted from the
correctional videography of the events as they unfolded in real time, Kilty
identifies the haunting parallels between the two cases with respect to ille-
gal uses of force against women housed in maximum security segregation
cells that eventually led to legal attempts to prevent the public from view-
ing the videos in both cases. Despite the federal public inquiry into the
1994 incident and the subsequent restructuring of federal corrections for
women in the decade that followed, the Smith case demonstrates the
steadfastness and historical continuity of extra-punitive carceral control
discourses and associated practices as they are applied to women prisoners
deemed mentally ill, unruly, and dangerous. Kilty contends that the cine-
matic images of incarcerated women stripped naked, physically and chemi-
cally restrained, and permanently isolated act as a form of secondary
haunting that provided the public with visual and ‘haptic’ (Young 2010)
evidence that correctional officials broke the law through the use of mor-
ally depraved, yet bureaucratically sanctioned, carceral control and strate-
gic management tactics. As mainstream media outlets began showing
video clips and image stills on primetime news programs, public outrage
grew and helped to solidify the political will to call for public inquiries into
the illegality of the events that took place.
Chapter 7, by Kyle Kirkup, similarly considers regimes of power in the
Canadian federal prison system, this time focusing on the problematic
ways in which carceral spaces are segregated on the basis of sex. Kirkup
contends that the administrative state produces a series of identity docu-
ments that confirm the truth of the medical gaze’s initial sex designation
and inform decisions about where and how to admit, place, and classify
those ensnared in the apparatuses of the criminal legal system. Using the
stories of two transgender women, Katherine Johnson and Synthia
Kavanagh, both of whom were placed in men’s prisons, this chapter ana-
lyzes the ways in which non-normative genders are constituted using bio-
medical discourses in carceral spaces. By segregating individuals on the
basis of sex, using diagnostic categories such as ‘gender dysphoria’, and
imposing surgical requirements on those who refuse to be subjugated by
essentialist gender norms, Kirkup argues that carceral spaces participate in
a larger corporeal project. The chapter concludes by arguing that the
advent of carceral policies that move away from gender essentialism, along
with a broader project of decarceration, constitute important sites of
resistance to the imposition of biomedical medical discourses on trans-
gender people.
Part III, entitled ‘The Asylum and Beyond’, pushes traditional concep-
tualizations of institutional containment to consider spaces and institu-
tional management technologies and practices that occur within and
outside of the prison and mental hospital, effectively demonstrating psy’s
transcarceral nature. In Chap. 8, authors Andrea Daley and Lori E. Ross
conduct a case study of one patient’s psychiatric chart to examine how
psychocentric understandings of mental distress and heteronormativity
intersect to preclude mental health service providers’ recognition of and
response to same-sex intimate partner violence. The authors conduct a
critical discourse analysis informed by Queer linguistics to problematize
the psychiatric legacy of pathologizing and regulating Queer sexualities.
The case study of ‘Sheena’s’ psychiatric chart demonstrates how the bio-
psychiatric knowledge and practices operationalized within the heteronor-
mative space of the psychiatric institution by various actors (i.e., psychiatrists,
nurses, and social workers) discursively work to erase recognition of inti-
mate partner violence from their understandings of ‘Sheena’s’ distress, and
consequently, her queerness. Considering how documentation practices
are informed by and reproduce heteronormative gender relations within
the psychiatric setting, the authors uncover how documentation related to
Sheena’s telling of physical and emotional abuse perpetrated by her partner
accomplish heteronormativity. The authors conclude the chapter by con-
sidering how distress related to same-sex intimate partner violence is recon-
figured as ‘mental illness’ and the consequences this has for Sheena.
Part of the same large research project, Chap. 9, by Merrick Pilling,
Andrea Daley, Margaret Gibson, Lori E. Ross, and Juveria Zaheer, exam-
ines the psychiatric institution’s method of assessing patient insight and
judgment. Drawing on data from 120 inpatient charts from a psychiatric

institution in Toronto, Ontario the authors examine how ‘insight’ is
understood as the degree to which patients believe they have a mental ill-
ness and comply with psychiatric treatment, meaning that ‘insight’ is
linked to patient acceptance of the medical model interpretation of mental
illness. Likewise, the authors find that ‘judgment’ is assessed as the patient’s
ability to make logical decisions and appreciate consequences and it too is
evaluated in relation to patient compliance with physician directives about
hospitalization and treatment. The analysis shows that professional pro-
cesses of attributing insight and judgment in psychiatric charts may be
fundamental to the extent to which patients are granted control over their
own treatment. The authors conclude by way of drawing attention to the
fundamental role these constructs play in justifying coercive measures such
as involuntary detention and compulsory treatment.
Chapter 10, by Erin Dej, considers how men experiencing homeless-
ness and who identify as mentally ill perform (hyper)masculinity in vulner-
able spaces where exaggerated forms of physical strength, aggression, and
emotional detachment are not easily expressed. Dej found that the men
she interviewed were unable to use traditional ‘macho scripts’ (Zaitchik
and Mosher 1993) for a number of reasons, including the lack of financial
resources, diminished personal autonomy in homeless shelters, and the
lack of opportunity for heterosexual intimate relationships. She also con-
siders the role that mental health treatment programs play in creating a
level of emotional openness and vulnerability that is opposed to gendered
discourses that position emotionality as a feminine and thus inferior trait.
Despite these limitations, many of the men performed hypermasculinity
by situating their homeless status as a direct result of malignant women,
by objectifying and demeaning women mental health professionals, and
by minimizing the role of emotion work (Hochschild 1979) in their
efforts to manage their distress. This chapter also presents the counter-
narrative offered by men who rejected hypermasculine performatives in
favour of a more complex understanding of masculinity.
Chapter 11, the final analytic chapter, authored by Chris Van Veen,
Mohamed Ibrahim, and Marina Morrow, examines coercive practices that
are most often associated with institutional and inpatient forms of care as
they are routinely used in community-based mental health care efforts.
The authors examine data collected by the British Columbia Ministry of
Health that shows that the incidence of involuntary psychiatric commit-
tals and community treatment orders under the Mental Health Act have
significantly increased over the past ten years, a trend that coincides with
increased poverty and homelessness and the introduction of Assertive
Community Treatment (ACT) teams, which now include the police as
part of their professional complement. This chapter explores the intersec-
tions of masculinity, psychiatric diagnosis, and discourses of dangerous-
ness as they play out in coercive practices in community-based settings.
Their intent is to expose the ways in which these damaging practices crop
up in new and innovative ways in community-based mental health, giving
lie to the promise of recovery and person-centred models of mental health
care. The authors contextualize the discussion through an historical
examination of the role of psychiatric confinement and its links to colo-
nialism and intersecting forms of oppression and discuss the implications
of ‘new’ forms of psychiatric violence and coercion for the lives of men
diagnosed with mental illness.
The book’s concluding chapter (Chap. 12) aims to tie together some of
the main connective threads that run throughout the substantive discus-
sions offered by the stellar collection of contributors. We use the conclu-
sion to more concretely conceptualize the very notion of ‘containment’ in
its different capacities and forms—be it discursive in nature or physical
incarceration in a total institution, the use of segregation cells, mechanical
restraints, psychotropic medications, or force. Using the transcarceration
literature as a starting point, we reconsider what it means to live within an
institutional context and to experience institutionalization. We take care
to consider how gender intersects with other markers of systemic oppres-
sion, including race, Indigeneity, sexuality, and class to impact how we
think about and discursively constitute different groups of people as mad,
sick, or mentally ill and how these discursive characterizations and classifi-
cations contribute to institutional/ization efforts to contain, surveil, con-
trol, and otherwise re/transform marginalized bodies. Drawing from the
discussions offered throughout the chapters we consider how this plays
out differently for men, women, and transgender people, noting similari-
ties across different institutional sites. It is our hope that this collection
will inspire critical discussion about the role and power we continue to
afford psy discourses and practices to name, identify, classify, and intervene
upon the lives of disparate groups of people and how gender and other
identity and status markers come to affect the material experiences of men
and women caught up in different institutional forms of containment.
Note
1. The ‘WRAP’ consists of applying restraint belts beginning at the individual’s
feet, all the way up to her shoulders, ceasing all possibility of bodily move-
ment; a hockey helmet is placed on the head to prevent injury in the event
that they topple over and to prevent the subject from biting anyone. The
Pinel Board involves strapping an individual to a board in five-point restraints
(hands, feet, head, chest, hips, and legs) to cease bodily movement.
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PART I
Historical ‘Psy’ Discourses Revisited

CHAPTER 2
Sickening Institutions: A Feminist

Sociological Analysis and Critique
of Religion, Medicine, and Psychiatry
Heidi Rimke
Introduction
This chapter seeks to outline the ways in which psy-hegemony operates in
Western medicine by analyzing the emergence of pathological individual-
ism since the nineteenth century. Contextualized within, and directly
related to the way social relations of power, knowledge, and inequality
have historically been structured in contemporary society, the chapter pro-
vides a feminist sociological framework that theoretically analyzes, cri-
tiques, and challenges the assumptions and problems of patriarchal or
dominant ‘psy’ discourses and institutions. The discussion provides the
sociological groundwork for approaching women’s distress and struggles
as socially structured problems rather than the consequence of flaws or
defects of abnormal individuals as seen in the current and popular ‘broken
brain hypothesis’. To do so, the chapter outlines patriarchal forces and
discusses the theory of psychocentrism to politicize and critique the culture
H. Rimke (*)
Department of Sociology, University of Winnipeg, Winnipeg, MB, Canada
e-mail: h.rimke@uwinnipeg.ca

https://doi.org/10.1007/978-3-319-89749-3_2
16 H. RIMKE
of therapy in contemporary neoliberalism as a ‘sickening society’ invested

in individualism, stigmatization, and pathologization. The chapter implic-
itly questions the over-therapization and thus depoliticization of women’s
issues as the sole means to address the individual consequences of socially
based problems. Instead, feminist intersectional approaches to women’s
mental health should concentrate on creating a non-psychocentric world
whose objective is collective care, concern, and cooperation.
Following the pioneering feminist sociology of Dorothy Smith (1975,
1978, 1987, 1990) and Patricia Hill Collins (2000), the chapter is on guard
against Eurocentric, androcentric, masculinist, positivist, classist, and white
supremacist social thought that serves the interests of dominant social
groups at the expense of marginalized groups. To this list of epistemic
problems, we should add psychocentrism, the discriminatory idea that peo-
ple are abnormal in their very make-up or constitution, that is, in the body
and/or mind of the individual. The chapter also relies upon Kimberle
Crenshaw’s (1989, 1991) notion of intersectionality to examine the mul-
tiple social factors at play in psychocentricity. This chapter thus provides an
overview of the historical development of contemporary psychocentric cul-
tural practices, discourses, and institutions that focus on women’s distress
and suffering as the consequence of individual pathology rather than view-
ing women’s mental health issues as resulting from the pathologies of patri-
archal, white supremacist, capitalist society, for example.
There is now an established literature of intersectional scholarship focus-
ing on women’s mental health (de Leeuw and Greenwood 2011; Senga
et al. 2012; Viruell-Fuentes et al. 2012). A feminist history of psychocen-
tricity entails an analysis of the ways that psychiatric stigmatization, dis-
crimination, inferiorization, and dehumanization are explicitly tied to the
problem of intersectional inequalities and injustices. A critical framework
questions the ways in which society makes women sick and then ultimately
blames them for experiencing distress. The social and historical production
of women’s madness seeks to interrogate the ways in which preconceptions
of social class, race, nation, age, sexuality, and gender underscore ways of
identifying, inscribing, and pathologizing different bodies. This highlights
what Dorothy Smith (1990) refers to as ‘the relations of ruling’, in which
an assemblage of scientific narratives, discoveries, inventions, technologies,
and practices develop over time and contribute to the patriarchal produc-
tion of women’s oppression. Psy-hegemony is particularly evident in the
growing production and consumption of self-help material, therapization,
and prescription drugs for mental health issues.
SICKENING INSTITUTIONS: A FEMINIST SOCIOLOGICAL ANALYSIS… 17
Psychocentrism: Theoretical Overview

Psy-hegemony operates on different social levels and through multiple
social mechanisms that blame the individual and thus erases the social
context and social bases of women’s distress and suffering. In neoliberal-
ism, social problems have been reduced to individual pathologies, often
embraced by the pathologized themselves. In other words, the medicaliza-
tion of social issues is reconstituted as individualized problems where
patient-subjects are viewed as successful or failed consumers of health and
illness. The pro-corporate or market-based approach to illness generally
neglects the social determinants of health such as potable water, affordable
housing, waste management, and educational and employment opportu-
nities (Armstrong and Armstrong 1996). The commodification and priva-
tization of illness and distress in neoliberal societies aggressively promotes
‘psych meds’ or pharmaceutical treatment as the main part of a broader
delivery of healthcare services in North America. Such individualized
approaches to women’s mental health concerns is depoliticizing in that it
reduces distress to treatable diseases rather than a broader public health
problem determined by unhealthy social forces, institutions, and condi-
tions. The governmental rationalities of neoliberal approaches to mental
distress reify pathological individualism while social structural factors are
erased, ignored, or downplayed. Psychocentrism is thus a critical theoreti-
cal concept used to study, analyze, and problematize the workings of the
dominant biomedical paradigm that emphasizes and profits from the neo-
liberal human deficit model.
Psychocentrism refers to the dominant view that pathologies are intrin-
sic to the person, promoting a hyper-individualistic perspective at the
expense of understanding social, political, economic, historical, and cul-
tural forces that shape human experience. Psychocentrism is itself a form
of social injustice that promotes individual reformation rather than social
and economic justice. Mental and emotional distress are thus understood
here as inextricably intertwined with systemic social inequalities that pro-
duce problems while simultaneously providing a source of profit due to
those individualized problems. The profits of pathology can be seen in the
psy industry’s extensive promotion, marketing and sales from global and
diverse self-help agendas to the exponential growth of prescriptions for
psychiatric medication, discussed later in the chapter.
A problem of the biopsychiatric paradigm is that it remains strictly at
the individualistic level, whether the abnormality is conceptualized as the
18 H. RIMKE
result of impaired cognition, neurochemical failures, mutant genes, or

hormonal imbalance. The notion of psychocentrism provides a framework
to investigate the ways in which neoliberal populations are governed
according to psy knowledge that is rooted in the biopsychiatric paradigm.
It also draws our attention to expert discourses that minimize or negate
the deleterious effect of social inequalities on women’s health and illness.
Because psychocentrism is based on the human deficit model as an indi-
vidual pathology, societal deficits and social relations of power that often
underlie and contribute to women’s suffering, struggles, and difficulties
are negated, erased, obscured.
A key aim of applying the concept is to attend to and emphasize broader
structural factors at play in the relationship between women’s distress and
multiple, interrelated socio-structural inequalities. The consequences of
the interrelationship of systems/institutions/discourses/practices of
oppression, domination, exploitation, stigmatization, and marginalization
can be seen in problems of trans and homophobia, racism and racializa-
tion, cis/sexism and misogyny, classism, ageism, sanism, adultism, able-
ism, and so forth. The concept of psychocentrism encompasses several
related characteristics that may or may not operate simultaneously: reduc-
tionism, determinism, essentialism, naturalism, ethnocentrism, positivism,
individualism, presentism, victim-blaming, and double-binds. I briefly dis-
cuss each in turn.
Reductionism (The Problem of Oversimplification): The problem of
reductionism can be understood as reducing the complexity of women’s
experiences and problems to overly simplistic explanations or
classifications.
Determinism (Denying Agency and Negating Reflexivity): The claim
that women’s conduct, identity, desire, and experience are determined by
the physiological processes of the body (genes, hormones, neurochemis-
try, etc.) is deterministic. This is witnessed most strongly in contemporary
biopsychiatric discourses where women’s mental health is taken to be the
product of a ‘broken’ brain or failed neurochemical processes, for
example.
Essentialism (Static Rather than Dynamic): The idea that a woman can
be classified into essential categorical or personality types as inherent in the
person. This promotes the notion that groups of individuals possess an
innate characteristic or essence that is permanent, unalterable, stable,
static, and so on over time and across situations.
Presentism (The Problem of Ahistoricism or Historical Amnesia): Typical

of the human sciences is the lack of historical understanding. Presentism
can be defined as the analytical neglect of historical forces and their role in
shaping women’s experiences. Historical amnesia is a basic characteristic
of psychocentrism as it disregards forces external to the individual and
gives the appearance that humans are primarily the product of physiology
rather than history, culture, and society.
Naturalism (Nature over Nurture): This concept emphasizes the
increasing role biological knowledge systems have played in women’s reg-
ulation especially since the nineteenth century. It also helps contextualize
the historical emergence of the mad female subject. Naturalism is inherent
in modernist thought where humans are viewed as naturally rather than
socially produced. In other words, the problematic assumption is that we
are born knowing how to be human rather than understanding ourselves
as socially produced.
Ethnocentrism (Unexamined Cultural Biases): Ethnocentricity can be
defined as the (largely unexamined) assumption that one’s own cultural
practices and beliefs about life and living are normal and thus superior to
other cultural practices and ways of being in the world. The largely unex-
amined and indiscriminate acceptance of the pathological approach of
human life is ethnocentric given its historically and culturally specific char-
acter and is thus not found in other time periods or societies.
The Double-Bind of Gender: Double standards can be said to occur
when a set of principles or standards are unequally applied to two or more
groups. An example is the gendered double standard of sexuality where
women are cast negatively while men are represented positively for the
same promiscuous sexual conduct. The hegemony of the dominant gen-
der binary provides an example where those who subscribe to dominant
cultural prescriptions are generally more rewarded than those who chal-
lenge or reject this socially imposed dualism.
Victim-blaming (Toxic Masculinity, Violence, and Rape Culture):
Victim-blaming is a significant part of psychocentrism as it is used as a
justification of holding individuals and groups responsible for their own
fates or negative outcomes, including their experience of mental and emo-
tional distress or traumatic life experiences.
Individualism: Pathological individualism encourages us to close our-
selves to others and discourages compassion, empathy, and connectedness.
Individualism prevents a sense of social responsibility to those without
networks and resources.
20 H. RIMKE
Positivism (The Social Prestige of Science in Medicine): Psychocentrism

largely rests upon the epistemological prestige of positivism derived from
the prominence of the ‘natural’ sciences. Technical sounding labels cre-
ated by the powerful and trusted agents of the medical establishment,
previously unknown to the public, are uncritically accepted, as people
assume that their creators possess superior knowledge of the human body
and mind, and that non-scientists cannot understand such complexities, or
the terminology used to describe them. Positivism seeks to measure, com-
pare, and classify individual differences objectively but upon closer exami-
nation demonstrates a strong bias according to a white, educated, male,
Christianist, heterosexist, European standard of normality that is assumed
to be universal rather than historically and socially defined and produced
(Rimke 2003).
This chapter examines ways in which psy discourses are not neutral but
rather always-already mediated by the social world—especially social rela-
tions of gender, racialization, sexuality, age, and class. In order to under-
stand individually based theories of psy-pathology, it is necessary to
examine their history and social contexts of emergence.
Witches, Hysterics, and Disordered Personalities:

Historical Overview
Women have always represented the Other in psychiatric discourses
(Rimke 2003; Smith 1975, 1978; Ussher 1991). Historically, women who
transgressed the cultural prescriptions of femininity issued by traditional
institutions such as religion and medicine have been subject to an array of
psy regulation and corrections efforts, such as involuntary hospitalization,
surgical and chemical interventions, physical punishment, and even death.
Indeed, the social production of madness must be understood within the
broader historical legacy of violence against women dating back to the
Western European witch hunts during the fifteenth to seventeenth centu-
ries that resulted in the deaths of upwards of nine million women (Barstow
1988, 1994; Ehrenreich and English 2010; Larner 1981). The ‘witch-
craze’ (Barstow 1994), also referred to as the ‘women’s holocaust’ and
‘gynocide’ or female genocide (Daly 1978, 202), occurred during a time
when the Church and the State cooperated and colluded in the targeting,
torture, and execution of women accused of being witches (Ehrenreich
and English 2010). In attempts to eradicate women’s social power who
provided for their communities as midwives, wise-women and healers, the
Christianist1 Church along with local governments instigated a reign of

terror over those women who did not conform to the patriarchal dictates
of religion and the law. Women’s oppression continued through the social
power of medicine and were confined to psychiatric institutions on the
authority of husbands, fathers, priests, and other religious authorities.
Today, personality disorders in particular, as will be discussed in more
detail later in the chapter, may be seen as a particularly powerful expert
promotion of idealized or hegemonic femininity where women who over-
or under-conform to gendered norms are pathologized.
Psychiatric knowledges have played a significant historic role in orga-
nizing and regulating patriarchal social practices, institutions, and dis-
courses in the West that have constituted the ways in which womanhood
is perceived and experienced today. The path from witchcraft to hysteria or
moral insanity, and then to these ‘female’ personality disorders—border-
line, dependent, and histrionic—epitomizes the transfer of power and
authority from religion to science that has taken place over the past several
centuries. Each label from each respective era was granted ‘official’ status
by (consistently male) ‘experts’ representing the absolute knowledge of
the most prominent institution de jour and was subsequently treated as
fact and used to define the boundaries between acceptable and unaccept-
able conduct for women, with pathologization often involving treading
on the border between the masculine and the feminine (Rimke 2003;
Wirth-Cauchon 2001). The phenomenon of ‘witchcraft’ and the labelling
of women as witches, and the newer phenomenon of diagnosing women
as ‘mentally ill’, are two institutional discourses that have functioned to
define socially acceptable female conduct and to legitimate a wide array of
punishments and treatments that were often torturous, if not lethal.
The differential socialization of children into the dominant gender
binary from infancy reflects and perpetuates problematic stereotypes
where young boys are taught to be autonomous and aggressive, while girls
are trained to be dependent and passive. The traits assigned to girls and
women are ones that patriarchal society devalues, thus females can be
understood as inductively devalued, leading to their differential treatment
and negative experiences as the inferiorized social group. Part of this infe-
riorization rests in the fact that women, girls, and other marginalized
groups have a greater probability of being diagnosed with a psychiatric
disorder, especially when these devalued traits are expressed in exagger-
ated behavioural conduct or that which is seen to be ‘excessive’ (for exam-
ple, overt sexuality versus frigidity). Thus, it is not surprising that most of
22 H. RIMKE
the individuals whom psychiatrists judge to have ventured into the realm
of ‘pathological’ dependency are women. In the period preceding the
Enlightenment, a woman who lived alone, that is, without a male com-
panion with whom she could dutifully reproduce, or a woman who
attracted too many men—proving her to be ‘sexually crazed’—could be
quite certain that she would be accused of being a witch (Ussher 1991,
49). One may see the reflection that mirrors two social tenets that con-
tinue to permeate societal values and beliefs about women today: the link
between female sexuality and both ‘badness’ and ‘danger’, and the double-
bind women face as they are criticized for being either too sexual or too
‘frigid’. Women who fail to conform to the expected gender roles of wife
and mother were (and continue to be) stigmatized and demonized. The
Personality Disorders (PDs) rely upon particularly vague and highly inter-
pretive language demonstrating its broad-reaching effects as a tool in the
pathologization and stigmatization of women. Three of the eleven per-
sonality disorders in the DSM-5 are almost exclusively reserved for secur-
ing a psy diagnosis in women: Histrionic Personality Disorder (HPD),
Dependent Personality Disorder (DPD), and Borderline Personality
Disorder (BPD). The criteria for these ‘disorders’ describe gender stereo-
types and caricatures of female roles in late-modern society. The symptoms
included in these diagnoses might also be understood as reasonable
responses to the structural problems faced by women in patriarchal soci-
ety. According to one study, Narcissistic Personality Disorder (NPD),
characterized by a lack of empathy for other people and a highly exagger-
ated sense of self-importance, is not found equally amongst women; the
highest rates are found in Black and Hispanic women as well as in sepa-
rated, divorced, widowed, and never married women (Stinson et al. 2008).
Apparently, white privilege and traditional marriage are safeguards against
later psychiatric illness. Forced marriage and marital rape were just some
of the consequences of patriarchal institutions that did not consider
women as persons under the law.
The genderization of personality disorders can be witnessed in the three
DSM ‘Clusters’. Cluster A, which encompasses disorders diagnosed most
frequently in men (Paranoid Personality Disorder, Schizotypal Personality
Disorder, and Schizoid Personality Disorder), is defined under the head-
ing ‘odd or eccentric behaviour’. Meanwhile, Cluster B, which includes
Borderline Personality Disorder (BPD) and Histrionic Personality
Disorder (HPD), uses the heading of ‘dramatic, emotional, or erratic
behaviour’; and, Cluster C, into which Dependent Personality Disorder
(DPD) falls, is referred to as ‘anxious or fearful behaviour’ (APA 2013).

The double-bind women experience in patriarchal psy discourses can be
seen in this instance where females are socialized to become dependent on
patriarchal systems (i.e., familial/father, marriage/husband, or State) and
then are pathologized for becoming dependent on male systems of domi-
nation. Significantly, the first cluster applied most commonly to men lacks
any reference to emotionality, while the other two accentuate emotional-
ity. While schemas of hegemonic masculinity discourage males from
expressing most emotions (see Chap. 10), women are encouraged to
adopt such expression and have historically been associated with emotion-
ality, yet are pathologized and even penalized for their so-called natural
state (see Chap. 6).
Genderization and the normalization of heterosexism are accomplished
by the criteria of the three female-oriented personality disorders that call
for socially ‘acceptable’ female behaviour—for example, one must not be
too dependent on a male companion, which is a symptom of DPD, but
she must also guard against involving herself in unserious relationships, a
listed criterion for both HPD and BPD. According to these psy discourses,
a normal woman should ‘settle down’ in a monogamous heterosexual
relationship, but should not overly rely on the man. The double-bind can
be said to operate when women are penalized for both conforming and
failing to conform to standards of ‘appropriate’ womanly behaviour. This
paradoxical situation constitutes a double-bind where women receive con-
tradictory messages. One harmful effect of patriarchy is the double-bind
that all women must confront—we may either conform to ‘proper’ femi-
nine conduct, which reinforces subordination and docility, or we can rebel
by rejecting hegemonic femininity and exhibiting so-called masculine
traits such as independence and face social chastisement and psychiatric
inquisition. Nonetheless, both possibilities may equally merit a ‘psy’
diagnosis and the more excessive one’s conduct veers in either direction,
the more likely a psy label will be affixed. The double-bind arises once
more when we consider that in an image-obsessed culture one criterion
for HPD is ‘preoccupation with physical attractiveness’. Such attention to
physical appearance is rarely found in physicians’ notes on male patients.
Patriarchal social forces insist on sending the message that women’s value
lies in their attractiveness, yet when women follow these culturally pre-
scribed dictates they are pathologized and stigmatized for it.
A serious problem with dominant psychocentric epistemologies is that
they tend to rely upon hegemonic categories: mental illness (abnormal vs.
24 H. RIMKE
normal), racialization (non-white vs. white), sex (female vs. male), gender
(woman vs. man) and sexuality (homo vs. hetero or asexual vs. sexual) as
ahistorical, universal, and fixed ideas and identities. As such it is no sur-
prise that gender identity disorder is treated as a mental illness in the
DSM-5. The pathologization and thus stigmatization of transgender
identities can be seen in the symptoms listed that include basic transgen-
der experiences: the rejection of one’s sex assignment at birth as well as
identification with the opposite sex (see Chap. 7). Increased pressure
from transgender communities and human rights activists argue that it is
not a medical disease or psychiatric illness in need of treatment and/or
cure. Homosexuality was removed in the third edition of the DSM (APA
1983). Women were essentialized into an inferior category as inherently
unstable compared to the normative rational man (Wirth-Cauchon 2001,
39). The binary logic of patriarchal culture that reinforces restrictive and
limiting dualisms also serves to naturalize and institutionalize hierarchies
and thus inequalities. ‘Female’ traits and qualities are not only devalued
and subordinated to masculinism but are actively pathologized. The
Cartesian subject embraced by patriarchal society values thinking over
feeling, the latter of which is associated with the feminine and is patholo-
gized in psychiatric discourse, seen especially in the categories of ‘moral
insanity’ and ‘hysteria’.
The cause of hysteria was thought to originate from the uterus, an idea
promoted by Hippocrates and later Plato that persisted into the Victorian
era and up to the 1950s. Hysteria was originally linked to innate female
weaknesses arising from physiological and intellectual inferiority, becom-
ing a catch-all of female pathology (Wirth-Cauchon 2001, 101). For
Freud and fellow psychoanalysts, the source of hysteria was women’s
‘penis envy’, which gave credence to the idea that hysteria is an illness
resulting from not being a man—thus pathologizing womanhood itself
(Didi-Huberman 2004). The DSM-I included ‘hysteria’ as a form of men-
tal illness, while the DSM-II adopted the term ‘hysterical personality’,
placing it into the category of personality-based ‘diseases’. In the DSM-III
the word hysterical was dropped and ‘histrionic’ adopted, which is derived
from the Latin ‘histrio’ meaning ‘performer’, to denote the same melodra-
matic or overdramatic theatricality ascribed to hysteria but without the
baggage of the older terminology. Biological determinism and essential-
ism within psychiatry effectively removes or denies the possibility of wom-
en’s feelings of control, autonomy, and agency.
Another form of women’s pathologization over the last fifty years is one
whose name has been changed from ‘Pre-Menstrual Syndrome’ in the
DSM-II, to ‘Pre-Menstrual Dysphoric Disorder’ in the DSM-III, to ‘Late
Luteal Dysphoric Disorder’ in the DSM-IV and finally back to ‘Pre-
Menstrual Dysphoric Disorder’ (PMDD) now listed under the depressive
disorders in the DSM-5 (APA 1968, 1980, 1994, 2013). Much scholar-
ship acknowledges the dismissal of women’s subjective reports of physical
and emotional suffering in relation to menstruation (Caplan 1995; Ussher
2003, 2006, 2011). According to Caplan (1995), the language of PMDD
is misleading in that it classifies as a psychiatric disorder women’s bona fide
pain and anguish. Furthermore, the category of PMDD gives the appear-
ance that emotional displays taken to be normative in men are viewed as
symptomatic of a psychiatric illness in women (Caplan 1995; Ussher
2011). This so-called disorder specific to women’s reproductive experi-
ence thus psychopathologizes what can be understood as a normative
aspect of some women’s lives. Insult is added to injury when complaints
of chronic physical and emotional pain are minimized, trivialized, and/or
pathologized as a ‘mental illness’ rather than a physical problem interfer-
ing with the quality of living for some women.
Feminist scholars have noted the gendered double standard of appear-
ance norms in patriarchy where women are judged first and foremost on
how they look (Bordo 2003). Women are caught in a double-bind when
on the one hand they are expected to focus on their appearance, yet on the
other hand when they do they are pathologized for it. Research on prob-
lematic eating patterns, for example, pathologized as anorexia nervosa and
bulimia nervosa, are historically and socially specific to Western societies.
These so-called mental illnesses should thus be understood as culture-
bound and resulting from a society that judges women’s worth based on
physical appearance, especially the display of youthful beauty, thinness and
sexuality. Patriarchal institutions and culture promote extremely thin
female body images that are largely unattainable; yet, in the psy literature
eating disorders are reduced to the individual failings of women and girls.
The pathologization unfairly ignores the powerful influence of mass-
mediated body imagery. Socio-structural factors affect the relationship
between feminization, embodiment, eating patterns, and body image in
patriarchal culture are thus ignored by psy expertise. As Schott et al.
(2016) argue, psychocentricity privileges the psy expert perspective that
negates the view of those pathologized while also negating the powerful
effects of women’s immersion in a fat-phobic culture.
26 H. RIMKE
The ‘DSM’ of the witch hunts, the Malleus Malificarum, a highly sexu-
alized text that identified and listed signs that a woman was likely a witch,
was not unlike the symptomatology found in the modern DSM. Official
religious diagnostics, for example, were handled by the expert ‘pricker’
who, like his modern counterpart, the psychiatrist, was granted the power
and privilege to enter any village and terrorize any woman by subjecting
her to a test—not just of her sanity, but of her spiritual health (Barstow
1994, 129–130; Ussher 1991, 53). The pricker could involuntarily com-
mit any woman who, in his eyes, failed the test—a tradition carried on
today by the psychiatrist, armed not with a needle but with a litany of
DSM diagnostic symptoms and characteristics to consider and a cornuco-
pia of psychopharmaceuticals to prescribe at the expert’s discretion.
Scientific Hetero/Sexism, Racism, and Classism

The racist and classist notion that humanity can and should be improved—
if not, perfected—by selective breeding and the elimination of ‘unfit’
groups through eugenics was common in the nineteenth century.
Eugenicists claimed they could scientifically identify inheritable traits so
that the human population could be improved by preventing inferior indi-
viduals from reproducing. The goal of eugenics was to improve the stock
of the white, Christianist human race and can be seen in governmental
policies applied in the Canadian Residential School system explicitly
designed to ‘kill the Indian in the child’ (Assembly of First Nations 2009,
n.p.). The colonialist genocidal practices of Canadian white supremacy
enshrined in the Indian Act (1857) institutionalized the reserve and the
residential school systems with the explicit purpose of eliminating
Indigenous cultures by the violent and State-sanctioned imposition of
white, patriarchal, Christianist, European values. The social and historical
trauma of these racist systems has had ongoing multi- and i ntergenerational
effects on the mental health crises of Indigenous communities (de Leeuw
and Greenwood 2011; Williams and Mumtaz 2008). As a consequence of
historical sexism, racism, classism, and Christianism, Indigenous women
are at a higher risk for being murdered, disappearing, losing a child to the
foster system, sexual exploitation, physical violence, incarceration, and sui-
cide than white women (Palmater 2017).
Another example of scientific racism is ‘drapetomania’, a nineteenth-
century psychiatric disorder created by US psychiatrist Dr. Samuel
Cartwright (1793–1863) who used theological and scientific essentialism,
determinism, naturalism, and positivism to psychiatrize a slave’s patholo-

gized desire to abscond from one’s owner. For Cartwright, slavery was the
natural order and thus ahistorical state according to both Christianism and
Western science (Rimke 2003). Western human scientific experts claimed
the innate biological inferiority naturally predisposed Blacks to a life of
servitude, providing another example of the problematic conflation of
social and political conditions with the psy paradigm. The invention of
drapetomania medicalized, and therefore legitimated, psychiatric dis-
course as a master narrative both literally and figuratively. This category
also demonstrates the institutionalization of a possessive logic of capitalist,
patriarchal, white supremacism as the intersection of social privilege.
Evolutionary theories were commonly used to propagate racist, het-
ero/sexist, and classist views and practices. The size of white women’s
skulls, for example, was marshalled as evidence of their superiority to Black
women who were routinely referred to as Bushwomen or Venus Hottentots
in nineteenth-century science. The Black woman was constructed as a sci-
entific oddity whose bodily traits supposedly reflected animalistic sexual
tendencies, and whose extruding genitalia and buttocks captured a primi-
tive form of female sexuality in human evolution. The father of Western
criminology, Cesare Lombroso, pathologized the buttocks of Black
women designating the so-called abnormality with the label of ‘steatopy-
gia’ (Rimke 2003).
Black, Indigenous, and Hispanic women were routinely pathologized
and inferiorized in nineteenth-century human scientific discourses. Psy
experts claimed these groups could not suffer from moral insanity as this
form of madness only existed amongst the civilized classes; the possession
of a moral faculty not a characteristic of racialized groups (Rimke 2003).
Racist, sexist, classist, and sanist discourses also dehumanized mad subjects
by comparing them to animals. This animalization of madness not only
deprives subject’s dignity, it also served two primary functions: first, it
legitimated evolutionary notions of a natural race, class, and sex hierarchy,
legitimating the belief that the mad had more in common with animals
than their fellow human beings; and second, it was used as evidence to
justify the reigning social inequalities and injustices found both within and
outside psychiatric institutions (Rimke 2003). The application of scientific
theories to the diagnoses of madness thus advanced the idea that socially
created inequalities were due to biological—natural, essential, determinist,
28 H. RIMKE
ahistorical—determinations rather than the organization of social rela-

tions. The co-constitution of racism and madness justified colonialist prac-
tices such as slavery and anti-immigration policies (Kanani 2011).
Experts claimed that since women on average possess physically smaller
brains than men women’s ‘natural inferiority’ proved they have more in
common with children and ‘savages’ or non-whites than middle class,
white men. Another example of a double standard can be seen in the clas-
sist interpretation of theft. When an impoverished woman was caught
stealing food, she was criminalized, but if a rich woman stole food she was
psychiatrized as a kleptomaniac or otherwise morally insane, as a way to
excuse her social transgression (Rimke 2003). Similar to contemporary
discourses that blame marginalized women for their problems via neolib-
eral discourses that emphasize ‘high-risk lifestyles’ or ‘poor choices’, eco-
nomically privileged white women receive less scrutiny for their
transgressions. This is an example of a classist double standard where poor
women were pathologized for coming from ‘bad stock’, whereas middle-
class women were exonerated for their deviance due to (uncontrollable)
madness rather than (willful) criminality (Rimke 2003). Likewise, accord-
ing to the gendered double standard of sexuality, if a woman is sexually
promiscuous, she might find herself labelled with a personality disorder,
while a man exhibiting the same behaviour might be celebrated as success-
fully masculine or seen as behaving ‘naturally’.
The nineteenth-century science of anthropological physiognomy or
‘system of sarcognomy’ inscribed the female genitals and reproductive
area as ‘the region of insanity’, the buttocks with ‘hate’, and the legs the
‘region of animality’ (Rimke 2005, 317–318) So-called science thus codi-
fied historical Western cultural dress codes where ‘chaste’ and ‘modest’
women were not to expose their legs in public, which was taken as an
immoral unveiling of the flesh, which sane women concealed. The histori-
cal solutions to madness were believed to be sterilization, confinement,
laws prohibiting marriage, or at the extreme, extermination. Clear
eugenicist logics of race survival impacted the scientific opinions of most
moral insanity experts.
Women who defied culturally prescribed codes of conduct, which also
served to constitute gender identities and social identifications of ‘the
good mother’ and ‘dutiful wife’, were treated as pathological subjects.
In this sense, socially constituted privilege was normalized as natural:
white, feminine, Christianist, middle class, heterosexist, and monoga-
mous subjectivity became the ideal type of womanhood and thus medically
institutionalized as the normal woman. The sane female sexual character
presented traits of sympathy, self-sacrifice, and devotion. Women’s mad-
ness was thus constructed in sexual terms of excess and lack, construct-
ing cultural boundaries of the permissible and the impermissible, leaving
little room for difference not only in terms of sexual practices but also
the acceptance of human diversity and multiplicity more generally.
Women’s resistance to patriarchal practices is deviantized, stigmatized,
regulated, and punished by three major social institutions: religion, law,
and science. While religion demonizes, and the law criminalizes, science
pathologizes or abnormalizes. In particular, the institutions of medicine
and psychiatry provide the discourses and practices that legitimate the
social processes of pathologization for those who do not conform to het-
erosexist culture. Thus, those women who resist, challenge, and reject
dominant or hegemonic gender prescriptions and heteronormative sexual-
ity face the indignities and injustices of scientific persecution in the form
of a ‘mental illness or disorder’. In order to maintain and reproduce patri-
archy, social institutions reward those who submit to its rules and dogma
and penalize resistors.
Pathologizing Resistance to Patriarchy

Trauma and derogation are experienced by many women in patriarchal
culture—taking a variety of forms, from the subtle but constant objectifi-
cation to harassment and intimidation, to the more violent acts of sexual
assault and rape. Living in a society where male-on-female abuse is excused
more often than it is punished thus normalizing and naturalizing male
violence against females—feminists have described this as a product of the
broader rape culture of patriarchal society (Buchwald et al. 1994).
Women’s mental health issues might thus be seen as a response to two
distinct forms of systemic sexism and abuse due to the toxic practices of
hegemonic masculinity: (1) The universal experience of abuse women
endure by living in a society that treats them as second-class citizens; or
(2) Individual cases of physical, sexual, emotional, economic, mental, or
spiritual abuse.
Traumatizing practices such as electroconvulsive therapy (ECT) and
other harmful psychiatric treatments have long targeted oppressed and
marginalized groups such as people of colour (Kanani 2011) and women.
30 H. RIMKE
Burstow shows how the interrelationship between ageism, sanism, and

sexism manifests in a disproportionate use of ECT in elderly (mainly

middle-class, white) women diagnosed as depressive and constitutes a form
of violence against women (Burstow 2006). Despite decades of clear evi-
dence demonstrating the long-term and permanent harms resulting from
ECT, it continues to be used in psy practice (Breggin 1979, 1991, 2007;
Burstow 2006, 2015). ECT is a violent act in a larger web of violence com-
mitted both by the total institution of psychiatry that is authorized by the
state and by patriarchal society more generally (Burstow 2006; Burstow
et al. 2014). Androcentric, masculinist psychocentrism views women’s
problems as internally produced pathologies rather than the effects of expe-
riencing and internalizing the misogyny of patriarchal culture.
Emotional gender rules in psy discourses can help highlight how wom-
en’s expressions and experiences have also been pathologized and stigma-
tized. Anger, for example, is emphasized in the definition of BPD yet is
curiously absent from the personality disorders that are almost exclusively
reserved for men. Whereas BPD is described in terms of it leading to insta-
bility with regard to relationships (notably sexual relations) and self-image,
it is claimed that Antisocial Personality Disorder (APD) results in the fail-
ure to honour work and financial obligations. The most important social
norms to adhere to on the basis of one’s gender are made very clear in the
DSM. The specific pathologizing and medicalizing of female ‘anger’, as
opposed to male ‘aggression’ is culturally and politically significant. Three
personality disorders focus on a certain type of pathological female ‘emo-
tionality’. HPD broadly pathologizes ‘exaggerated emotionality and the-
atricality’, DPD pathologizes ‘fearfulness and helplessness’, and BPD
specifically pathologizes female ‘anger’, whether it be ‘inappropriate’,
‘intense’, or ‘difficult to control’ and thus failing the neoliberal disciplin-
ary demands of self-governance.
Society encourages women to suppress anger—yelling is viewed as
unladylike and a woman’s screams are still seen as ‘hysterical’. Feminist
scholars have long examined the psy pathologization of women’s anger,
much of which stems from their subordinate position in patriarchal social
systems (Smith and David 1975; Ussher 1991, 2011). Terms such as
‘inappropriate’ and ‘intense’ irrationalize and depoliticize female anger,
making it ‘crazy’ rather than reasonable in a particular context (for discus-
sions of this in the carceral context, see Kilty 2012, 2014). Female rage
can be understood as a response to social inequalities such as the ways in
which women have been regulated and mistreated throughout patriarchal

history. First included in the concepts of hysteria and moral insanity, then
concretized in the diagnosis of BPD, psychiatry has consistently patholo-
gized women’s anger. The power of the institution of psychiatry, aided by
other traditional institutional treatment of women predating its existence,
has been a formidable regulatory mechanism in pathologizing women’s
emotions as unnatural and thus abnormal.
When looking at the experiences and conditions that are predominantly
suffered by women, it is important to take into account the effects of
misogyny, especially witnessed by way of derogating women.
Depression, anxiety, psychological distress, sexual violence, domestic vio-

lence and escalating rates of substance use affect women to a greater extent
than men across different countries and different settings. Pressures created
by their multiple roles, gender discrimination and associated factors of pov-
erty, hunger, malnutrition, overwork, domestic violence and sexual abuse,
combine to account for women’s poor mental health. There is a positive
relationship between the frequency and severity of such social factors and
the frequency and severity of mental health problems in women. Severe life
events that cause a sense of loss, inferiority, humiliation or entrapment can
predict depression. (World Health Organization n.d.)
The cumulative degradation and inferiorization rituals endemic to life and

living as a woman in patriarchal society should be seen as an important
social determinant of distress and suffering. Until women collectively
receive respect, dignity, and equality in all spheres of society, individual
women will continue to experience mental health problems in any number
of forms and at any point in their lives.
After more than 100 years of the hypothesis that abnormal function
and activity in specific brain circuits are the cause of mental illness, not one
single biological marker for any psychiatric disorder has been identified
(Rimke 2016). From Freudian psychoanalytic theory to the more recent
‘discovery’ of ‘False Memory Syndrome’, sexual abuse has a deep history
of denial, distortion, and blaming the victim, which continues to domi-
nate patriarchal attitudes towards its victims in contemporary society. The
lack of evidence, lack of etiology (cause), lack of cure, the subjectivism of
normal, the temporary and permanent harmful effects of psychiatric inter-
ventionism (e.g., ECT, lobotomy, leucotomy, drugging), all render the
32 H. RIMKE
psy industry socially and ethically problematic with some calling for the
abolition of the psychiatric profession as a whole (Burstow et al. 2014;
Burstow 2015).
Social determinants of illness, such as poverty, unemployment, hous-
ing, dietary needs, social exclusion, and discrimination, play key roles in
women’s mental health challenges; this is especially true for Indigenous,
elderly, and racialized immigrant women who remain amongst the poorest
and most socially disadvantaged groups in Canadian society.
Psychocentricity results in labelling mental illness as an individual pathol-
ogy and might help explain in part why there have not been adequate
social services for marginalized groups where mental health is seen as an
individual rather than social problem.
The many harmful effects of white supremacist, capitalist, patriarchy
inevitably results in violence, fear, anxiety, anger, depression, self-harm,
addiction, suicide, and homicide. Although individually experienced, such
human experiences must be placed within the context of social life and
systemic structural oppressions if we are to challenge and critique psycho-
centric methods of coping. Humans are not immune to the stress and
strains caused by growing economic deterioration and austerity, as well as
social conflicts based on axes of age, sexuality, class position, gender, able-
ism, physical appearance, familial ties, educational attainment, religious
status, racialization and ethnicity, politics, harassment, bullying, and other
socially created problems and insecurities.
Therapeutic culture has created an enormously profitable economic
sector, from self-help products to the dramatic growth of pharmaceutical
use marketed to improve all aspects of women’s lives. This is a massive and
growing industry, with estimates ranging in billions of dollars in profits
annually for the self-help and addictions fields alone, never mind Big
Pharma,2 the leading profiteer on the planet (Breggin 1991; Fallon 2011;
Frances 2013; Healy 2012; Rimke 2017). The wide-spread practice of
polypharmacy has increased substantially over the past two decades, creat-
ing its own set of problems not least of all the high risks associated with
psychopharmaceutical therapy whose toxic effects often go unreported to
patients and the public at large (Gøtzsche 2013; Moncrieff 2009;
Moncrieff et al. 2013). Temporary and permanent problems can be expe-
rienced in the form of hallucinations, gastrointestinal problems, neuro-
logical damage, or other problematic symptoms now referred to as
‘withdrawal’ or ‘discontinuation syndrome’ (Breggin 2008; Moncrieff
2013; Moncrieff et al. 2013). Even general practitioners of medicine—the

garden-variety physician—write the highest number of psychotropic pre-
scriptions of any doctors, despite their lack of systemic training in both
pharmacology and psychiatry. As much research has shown (Fallon 2011;
Gøtzsche 2013; Gabriel and Goldberg 2014), an increasingly incontro-
vertible body of evidence now points to growing pharmaceutical wrong-
doing seen in the fines, lawsuits, and convictions for gross misconduct,
fraud, price gauging, and concealment of data and evidence. Harmful and
often fatal medications are pushed in the name of biological psychiatry
while significantly ignoring side effects and difficulty withdrawing from
prescribed drug treatment. Growing problems of what some are calling
‘death by medicine’ (Null et al. 2010) seriously complicates dominant or
traditional approaches to women’s mental health regimes that almost
exclusively rely upon psychotropic medication. The failure to alleviate
women’s suffering or to increase it due to negative side effects of certain
medications has led to the high risk of unintended consequences such as
increased violence and self-harm, additional health problems, and suicide
(Breggin 2008).
Victims of institutionalized trauma are blamed as fragile, weak, and not
‘resilient’, to use the current neoliberal buzzword. The problem with
resilience discourses is that they promote a neoliberal model of mental
distress that frames struggle as a distinctly personal obstacle to overcome
by those with the fortitude and the moral strength of so-called resilience.
Moreover, the idea that people who ‘survive and thrive’ or succeed in
overcoming mental distress because they are ‘resilient’ by definition
renders those with persistent problems as morally weak or otherwise psy-
chologically inadequate. Contemporary mental health and wellness dis-
courses are deeply influenced by neoliberal therapeutic culture where the
healthy self is constructed as possessing a reservoir of inner strength and
an indomitable free will, which implies that good neoliberal subjects are
‘resilient’ subjects, who are, first and foremost, responsible and account-
able for their choices and thus their outcomes and experiences in the world
(Rimke 2000). Thus, to not exercise agency and develop personal strength
or ‘resilience’ is another way to be a failed subject in neoliberal society.3
Likewise, the failure of self-help media to produce feelings of peace, well-
ness, or happiness may just become another in an endless series of reasons
to blame the self as the source of one’s mental and emotional failure
(Rimke 2017).
34 H. RIMKE
Conclusion
Given its staggering commercial profits, the social influence and effects of
therapeutic culture and the psy industry cannot be overstated (Breggin
1979, 1983, 1991, 2008; Burstow 2015; Frances 2013; Rimke 2017).
The increasing neoliberal focus placed on individual responsibility has
occurred simultaneous to the dismantling of public health care and social
services, forcing individual women to absorb structural deterioration. The
culture of therapy is a massive industry creating an enormously profitable
enterprise based on human distress and suffering. However, women’s
health and illness involve social factors that are predominantly dismissed or
marginalized within contemporary biomedical approaches. Research indi-
cates that there is an indisputable social dimension to well-being that can-
not be reduced to or explained at the individual level alone. Quality of life
is the best indicator for health and wellness thus demonstrating the non-
negotiable needs for secure housing, stable income, social networks, com-
munity participation, healthy workplaces, and meaningful relationships.
The framework of psychocentrism highlights and problematizes the psy-
hegemony of neoliberal society by emphasizing the following: first, psy
experts exercise power in the construction of knowledge that psycholo-
gizes, medicalizes, and pathologizes what are ultimately social and cultural
values and practices; second, expert discourses encourage clients, patients,
consumers, users, or subjects to locate ‘pathologies’ inside themselves
rather than properties of social processes, structures, and experiences; third,
expert discourse denies, trivializes, or minimizes the importance of social
factors and social relations at play in mental health issues; and fourth, expert
psy discourses distract from wider structural issues of social injustice and
social inequality (Rimke 2016). Such questioning entails analyzing dis-
courses and practices that operate within and across intersecting systems of
domination that are simultaneously codified by psy discourses that blame
women rather than the wider social forces at work in patriarchal society.
This chapter outlined and discussed both historical and contemporary
psy discourses to highlight and analyze the integral role of the domina-
tion of psychocentrism in patriarchal societies. The analysis demonstrated
the pervasion of female stereotypes not to mention profitable propaga-
tion of these caricatures by the psy industry in its many forms—but espe-
cially via self-help, therapization, and the psychopharmaceuticalization of
women’s issues. Understanding the psychocentric regulation of women’s
lives can address and therefore work to eradicate the hegemonic practices
of patriarchy that historically targets and then blames the marginalized

and in which gender, sexuality, race and ethnicity, class, ability, religion,
and national identities are inextricably intertwined. The constitution of
women’s madness needs to be understood as a historically situated social
production that requires a shift away from coercive psychiatrization
towards an informed, rights-based approach that respects and empowers
women’s diverse needs, personal autonomy, and lived experiences.
Notes
1. I intentionally use the term Christianist over the dominant discourse
(Christian and Christianity) to problematize its hegemony as ‘natural’ and
‘normal’ while other religions are suffixed with ‘ist’.
2. Although there is no agreed-upon definition, ‘Big Pharma’ can generally be
defined as a term used by critical scholars to problematize the growing
power, control, and influence of the pharmaceutical industry in North
American society. It is often conceptualized as a social, political, and eco-
nomic empire with toxic effects on people and the planet due to disease-
mongering primarily for profitability rather than medicinal ethics. Other
critical terms in the literature that refer to the problematic and mutually
lucrative relationship between the psy and pharmaceutical industries include
‘pharmacracy’ (Szasz 2003) and ‘pharmageddon’ (Healy 2012).
3. For an excellent critique of ‘resilience’ as a political discourse that promotes
the neoliberal agenda, which is really about furthering the resilience of the
state and capital, see Mark Neocleous, ‘Resisting Resilience’ in Radical
Philosophy, 2013. He writes (n.p.): ‘We know by now just how much “resil-
ience” has become the new fetish of the liberal state. The word falls easily
from the mouths of politicians, state departments of all kinds fund research
into it, urban planners are now obliged to take it into consideration, disaster
recovery systems plan it in their preparations, and academics are falling over
each other to conduct research on it. The language of resilience now comes
to us “naturally”’.
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CHAPTER 3
Traditions of Colonial and Eugenic Violence:

Immigration Detention in Canada
Ameil J. Joseph
Introduction
In March 2016, two men died in Canadian immigration detention facili-
ties “in the care of Canada Border Services Agency in less than a week”
(Black 2016). Francisco Javier Romero Astorga (a Chilean national, unre-
ported reasons for detention) died in Maplehurst Correctional Centre in
the province of Ontario on Sunday, March 13 (Kassam 2016). Also in
Ontario, Melkioro Gahungu (a Burundian national who was convicted of
killing his wife in 2009) died in the Toronto East Detention Centre on
Monday, March 7 (Cain 2016). These events triggered an atypical public
reaction to the existence, purpose, and conditions of immigration holding
centres and questioned the human rights protections for people being
detained. This chapter explores these recent events by situating them in
two key historical parallel discourses that underscore the broader colonial
project, those pertaining to immigration and eugenics, to consider how we
understand and talk about the practice and implications of immigration
detention. Contemporary concerns about immigration detention practices
A. J. Joseph (*)
McMaster University, Hamilton, ON, Canada
e-mail: ameilj@mcmaster.ca

https://doi.org/10.1007/978-3-319-89749-3_3
42 A. J. JOSEPH
in Canada reflect a historical confluence of shifting, colliding, submerging,

and (re)emerging ideas about threat, dangerousness, foreignness, and
criminality (Chadha 2008; Menzies 1998). These ideas have been forged
over time, globally, through projects of nation building, population regu-
lation, surveillance, and control (Dowbiggin 1997; McLaren 1990).
These are also deeply gendered ideas that constitute contemporary
understandings of what is a threat and who is dangerous, as well as what is
framed as a solution to individual ‘threats’ and who is delineated as both
worthy of protection and positioned as in need of saving from danger.
These ideas also frame and form discourses about the immigrant, the
undesirable, the criminal, the feebleminded, ideas of racial hierarchy, and
genetic, social, and epistemic supremacy (Joseph 2015). Information
about the contemporary practice of immigration detention is often repre-
sented in limited ways within political agendas and media discussion. In
response, questions and concerns are repeatedly offered and analyzed by
advocacy groups such as the End Immigration Detention Network,
Amnesty International, the Canadian Council for Refugees, and No One
Is Illegal. This chapter adds to this discussion by drawing on analytical
contributions from mad studies, critical race theory, and postcolonial
studies, to discursively analyze public media debates on the contemporary
practice of immigration detention and the historical practices of immigra-
tion detention in Canada.1 I draw connections between contemporary
immigration detention centres and the historical use of gaols in the crimi-
nal justice system for the detention of undesirables by the Department of
Immigration and Colonization in 1919 and the Department of
Immigration’s designation of Ontario hospitals for the insane as immigra-
tion stations in 1927. The analysis positions contemporary immigration
detention as a continuation of colonial population regulation practices, a
form of systemic institutionalized hatred that is fueled from the fashioning
of a confluence of gendered threats to the ‘Canadian public’ sustained by
racial, sanest, and eugenic thinking that affects racialized people and those
identified by the biomedical psychiatric system (mostly young men) in
violent ways. This outcome is achieved while advancing the racial, gen-
dered, and cisheteropatriarchal fantasy of a Canadian state protector made
possible upon the (re)forging of historical ideas of threat and the produc-
tion of the innocent Canadian public in need of protection. This chapter
considers how historical ideas of race, (in)sanity, and eugenics contribute
to the rationalization of immigration detention through invocations of
gendered ideas of mental illness as a threat and burden.
TRADITIONS OF COLONIAL AND EUGENIC VIOLENCE: IMMIGRATION… 43
Histories of Immigration Detention in Canada

The federal government department responsible for issues pertaining to
immigration is Immigration, Refugees, and Citizenship Canada (IRCC).
This was renamed from Citizenship and Immigration Canada in 2015
with the election of Prime Minister Justin Trudeau. This was not the first
time the department changed its name or emphasis, often shifting its
priorities with the concerns of the national building and colonial proj-
ects. For example, when the Canadian Pacific Railway was completed in
1885, the movement of people, material resources, and labour changed
dramatically and immigration increased by more than three million peo-
ple by 1914 (Brown and Cook 1974; Creighton 1975). As immigration
increased, growing concerns about a threat of immigrants coming to
Canada escalated. These concerns were about ‘race suicide’ and preserv-
ing the British Empire (Dowbiggin 1997). In the Canadian context,
many public officials supported eugenic policies. As Richard Cairney
describes: ‘When Albertans bought into eugenics in the 1920s, eugenics
and sterilization of the mentally disabled were being heartily endorsed
and vigorously promoted by social and political crusaders such as Nellie
McClung, Louise McKinney and Emily Murphy, who promised better
living through science’ (1996, 790). Emily Murphy who was the first
female judge in the British Empire argued that ‘feeble-mindedness’ was
heredity and that ‘insane people are not entitled to progeny’ (Cairney
1996, 791). There were discussions across Canada that carried within
them a warning that immigrants were of ‘low quality’ (Dowbiggin
1997). This provoked responses that demanded programs and protocols
for the assimilation of newcomers by refusing admission and training
immigrants to be ‘law-abiding, productive, healthy, and self-reliant citi-
zens’ (Dowbiggin 1997, n.p.).
Canada prided itself on carrying on the British imperial colonial project
to remake England in Canada. Colonization involved assessing not only
who was coming into Canada but also upon the oppression of Indigenous
Peoples. Settler colonialism continues to carry out its project on Indigenous
Peoples in Canada with the reserve system maintaining its apartheid, dis-
crimination in healthcare, child welfare, the invisibility and disrespect for
missing and murdered Indigenous women, and general failures to provide
basic infrastructure and services (including clean water) to Indigenous
communities. In 1917, the War Measures Act consolidated in law the idea
of an ‘enemy alien’ permitting the arrest, detention, and deportation of
44 A. J. JOSEPH
prisoners of war as well as civilians who were positioned as the enemy

(Canadian Council for Refugees 2000). The kind of arrest and detention
was termed ‘internment’, which was used to imply that this particular
form of arrest and detention was protective and preventative.
Problematically, arrest, detainment, and internment did not require peo-
ple to have committed or been convicted of any crime. In 1917, the
Department of the Interior changed its name to the Department of
Immigration and Colonization, rendering transparent its intent to protect
and advance the British colonial project in Canada. Name changes ensued
to reflect the changing priorities of the federal government (Kary 2013).2
In 1910, the Department of Immigration and Colonization outlined a
list of prohibited classes of immigrants in An Act Respecting Immigration.
This built upon the categories added in 1906 that for the first time speci-
fied the ‘feeble-minded, idiot, epileptic, or [person] who is insane or has
had an attack of insanity within five years; [the] deaf and dumb, or dumb,
blind or infirm’ (Chadha 2008). These particular changes coincided with
the rise of eugenic ideas flourishing globally at the time. The implementa-
tion of eugenic policies and practices continued until eugenics lost popu-
larity due to its association with Nazism in the 1930s and the Final Solution
by the end of World War II. The 1910 Act has a list that can be appreci-
ated as providing a concrete example of the confluence of ideas of race,
criminality, threat, and biological inferiority that continues today. The list
includes: ‘persons mentally defective’ (named as ‘idiots, imbeciles, feeble-
minded persons, epileptics, insane persons’), ‘diseased persons’ (named as
‘person afflicted with any loathsome disease … which may become dan-
gerous’), ‘persons physically defective’ (named as ‘dumb, blind, or other-
wise physically defective’, ‘criminals’, ‘prostitutes or pimps’, ‘procurers’
(named as ‘persons who procure … prostitutes’), ‘beggars and vagrants’,
‘charity immigrants’3 and ‘persons not complying with regulations’ (An
Act Respecting Immigration 1910). In 1910, the House of Commons
debates revealed that early twentieth-century psychiatry propounded the
belief that persons with mental disabilities were undesirable immigrants
because they were by nature degenerates, dangerous and dishonest in dis-
position. This idea was based upon the premise that all forms of mental or
physical defectiveness was caused by non-British immigrants who carried
with them hereditary degeneracy (Dowbiggin 1997; McLaren 1990).
The idea of using immigration detention centres as prisons for people
who experience mental health issues has significant historical precedent. In
1919, the Ontario Department of the Attorney General authorized the use
of gaols4 for immigration detention for the Department of Immigration

and Colonization (Archives of Ontario 1919). Correspondence documents
between the Ontario Department of the Attorney General (Edward Bayly)
and the ‘inspector of prisons and public charities’ (W.W. Dunlop) reveal
that the approval of use of gaols was achieved by referencing selective
pieces of legislation and authority (Archives of Ontario 1919), such as
blending one piece of law that allowed for the rejection and deportation of
those identified as undesirable within the prohibited classes designations of
the 1910 Act Respecting Immigration alongside other separate permis-
sions for immigration officials to detain a person. The legislation did not
permit the detention of a person for simply being ‘undesirable’ or for being
identified as belonging within the groups identified on the prohibited
classes list. In order for a person to be detained under the authority of the
Department of Immigration and Colonization, they had to commit a crime
or be found to have come to Canada by way of a ‘non-continuous journey’;
be without adequate financial support or enough paid work potential; be
without family in Canada; or have been subject to detainment by in an
individual incidence written order from the minister (Joseph 2015).
Bayly’s response to Dunlop’s request recognizes that the selective ref-
erencing of legislation and authority does not allow for the detention of
prohibited classes in gaols of the criminal justice system. He clearly states
that, ‘there is no specific provision in any of these sections or in either of
the Orders in Council which covers the point’ (Archives of Ontario 1919,
n.p.). Bayly also describes Dunlop’s interpretation of the legislation as
covering detention for the prohibited classes of undesirables as ‘mistaken’
(Archives of Ontario 1919, n.p.). Bayly then writes that, ‘If there is room
in a prison and a request is made … and they pay reasonable expenses it
would be unusual and at times inconvenient if the accommodation would
be refused to them’ (Archives of Ontario 1919, n.p.). Bayly also offers
Dunlop a way around the legislation, suggesting that if a request is made
a letter of protest be issued ‘rather than a refusal to permit the gaol to be
used’ (Archives of Ontario 1919, n.p.). During these exchanges, a Privy
Council order was also referenced that permitted the refusal of entry into
Canada of ‘immigrants belonging to any Asiatic Race’ (Archives of Ontario
1919, n.p.). In the end, the illegal authorization of detention for those
identified as undesirables was carried out, the use of gaols of the criminal
justice system was permissioned, and ‘immigrants belonging to any Asiatic
Race’ was added to the list of exclusions.
46 A. J. JOSEPH
In the same archival file, documents from the Department of

Immigration and Colonization reveal that in 1919 this specific permission
was used to detain and deport a woman named Elise Saborowski, a
German national, for ‘her political views’ (Archives of Ontario 1919,
n.p.). Saborowski is described as believing in a ‘bloody revolution’ and
‘seeking to destroy organized government in Canada’ (Archives of Ontario
1919, n.p.). From the 1919 correspondence the examination evidence
states that ‘Elise Saborowski admitted under oath that she had been an
employee of the German Government for seven years and up to and within
two months before the outbreak of War’ (Archives of Ontario 1919, n.p.).
After being categorized as ‘enemy alien’ prohibited class of the 1910 Act
Respecting Immigration and after the recent authorization to use gaols for
immigration detention, in 1919 Saborowski was recommended for impris-
onment ‘in Gaol rather than in an internment camp’ (Archives of Ontario
1919, n.p.).
Archival correspondence from December 1919 from the Canadian
Department of Immigration and Colonization provides some unique
insight into Elise Saborowski’s case. As Immigration Officer J. Mitchell
reports, the preliminary examination that resulted in Elise’s detention in a
Toronto gaol for deportation noted that she was in possession of a fire arm
(a revolver) (Archives of Ontario 1919). Saborowski was ‘examined’ for
her political views and she and her partner Otto Ewart (whom she entered
Canada to marry, although this is represented as suspect) were drafting a
constitution to form a Communist Party in Canada (Archives of Ontario
1919). Elise described herself as a revolutionist according to the immigra-
tion official who ‘had two brothers who served in the German Army’
(Archives of Ontario 1919, n.p.). Elise is also named as part of the Political
Defense Committee and ‘was evidently seeking to destroy organized gov-
ernment in Canada, being prepared to go the length of a bloody revolu-
tion’ (Archives of Ontario 1919, n.p.). Elise was also said to have entered
Canada surreptitiously, using various aliases. Throughout the examination
report, Saborowki is described in relation to her connection with the
German government and communist revolutionaries (Archives of Ontario
1919). Throughout the report she is also often referred to as ‘the woman’,
‘this woman’, or ‘the woman in question’ and is introduced in reference
to Otto Ewart as ‘Ewart and the Saborowki woman have lived together in
adultery in Toronto’ (Archives of Ontario 1919, n.p.). The examination
crafts her as a threat to Canada, possessing a firearm, affiliating with revo-
lutionary groups, and having connections to German nationals and
c ommunists. She is represented within moral and gendered discourses that

presume to evaluate and judge her relationship to Otto Ewart as a form of
adultery. These discursive maneuvers establish a gendered question of
Elise’s moral integrity by emphasizing that she is living with Otto Ewart
while not yet married and by regularly emphasizing that she is a woman in
derogatory ways. In this early case, rationalizations for the use of gaols for
immigration detention constitute the Canadian government as national
protector of threatening enemy aliens by taking it upon themselves and
wielding their position of power to unlawfully imprison immigrants
deemed undesirable. What is unique in this case and considerably different
from contemporary public representations is the detention of a woman as
the threatening alien figure.
A similarly dubious authorization occurs in 1927 when Edward Bayly
was asked to verify if the Hospitals for the Insane Act (1914), and the
British North America Act (BNA) (1867) prevent the Department of
Immigration and Colonization from designating Ontario hospitals as
immigration stations (Archives of Ontario 1927). The BNA Act and the
Hospitals for the Insane Act give exclusive authority regarding the ‘estab-
lishment, maintenance and management of Hospitals, Asylums, charities,
and Eleemosynary5 Institutions’ to the province (Archives of Ontario
1927, n.p.). The 1910 Act Respecting Immigration defined an immigra-
tion station to include ‘any place at which immigrants or passengers are
examined, inspected, treated, or detained by an officer for any purpose
under this Act, and includes hospitals maintained for the purpose of this
Act’ (An Act Respecting Immigration 1910, 208). This provision was
intended to determine whether people met the criteria for inadmissibility,
not for the hospitals to become holding centres for immigration detainees
(Archives of Ontario 1927). Bayly recognized this in correspondence from
February of 1927, conveying that ‘the present provisions of the
Immigration Act, however, do not go that far’ (Archives of Ontario 1927,
n.p.). Many months later, the Ontario deputy provincial secretary
(H.M. Robbins) submitted letters (from October and November of the
same year) to inform Bayly that the Ontario Hospital at Brockville was
designated an immigration station under the provision of the 1910 Act
Respecting Immigration (Archives of Ontario 1927). The last correspon-
dence was dated December 1927, and the question of whether a hospital
for the insane should be designated an immigration station was left unan-
swered, thus permitting the ideas and practice of associating mental health
issues with immigrants based on persistent notions of undesirability and
48 A. J. JOSEPH
racial hereditary inferiority coming from eugenic science. This decision is

made without supportive provisions within the law and without official
debate or public scrutiny. The decision was not interrogated further and
perpetuates the conflation of ideas that discursively attached immigration
to mental illness, heredity, and the threat of the foreign and alien, as well
as rationalizing the need for inspection and confinement. Dating back to
the Elise Saborowski detention in 1919, we need to consider how the
historically established identities of the Canadian public, the state as pro-
tector, and the idea of ‘threat’ have been gendered; however, it is more
common that the representations and experiences of women are often
lifted out of view, thus limiting the public discourse on immigration deten-
tion and violence on those who are not men. Instead, women were pri-
marily targeted via eugenicist notions of heredity and reproductive value.
Anti-Feminism in Canada and Controlling

Women’s Bodies
Eugenics in Canada was specifically bound to the idea that regulating the
population and colonial nation building were not only achieved through
immigration controls but also controls over reproduction. Dr. Helen
MacMurchy was Ontario’s leading public health expert in 1914 and
‘inspector of the feeble minded’ from 1906 to 1916 (McLaren 1990, 30).
Her 1920 book, The Almosts: A Study of the Feeble-Minded, promoted
eugenic ideas that advocated for the segregation and sterilization of the
feeble-minded in order to eliminate their economic costs and their crimi-
nal threat to society (McLaren 1990, 39). MacMurchy declared at a con-
ference in 1914 that ‘the problem of defective children could only be
solved if special education and medical inspection were complemented by
restriction of immigration’ (McLaren 1990, 46). The eugenics program in
Canada was enforced by health professionals to control poverty, crime,
prostitution, and mental defectiveness. Social workers, mental hygienists,
psychiatrists, and geneticists were perpetuating ideas that being poor, hav-
ing committed a crime, experiencing madness, and so on were products of
‘defective genes and not a defective social system’ (McLaren 1990, cover).
Measures to improve racial quality recommended policies to control
women’s reproductive health so as to ensure the safety and reproductive
capacity of ‘the bearers of natural genius’ (read, white) women who could
produce ‘fit’ children (McLaren 1990, 14, 22). The policy recommenda-
tions also included changes to marriage laws that prevented ‘defectives’ from
being married, sterilization of those deemed to be ‘dangerous defectives’,

immigration controls, and sex segregation as well as public campaigns to
‘enlighten the public regarding the ideals of eugenics’ (McLaren 1990, 13).
The public campaigns also intended to promote ‘social conditions’ that
would prevent the marriage of those deemed genetically threatening
(McLaren 1990, 13).
The control of fertility, reproduction, and women’s bodies was a key
component of the larger eugenics project. Francis Galton actually dis-
couraged any use of birth control as there was a belief that ‘abler races’
would not be able to genetically compete for supremacy in the world
(McLaren 1990, 19). In these texts, women were constituted as without
agency and were discussed only in terms of their biological and reproduc-
tive function. For eugenicists, feminism came be seen as counter to the
biological subjugation that was said to produce ‘finer females’ (McLaren
1990, 21). As birth control was not available across the lines of social
mobility it was believed that ‘finer females, in restricting family size, were
snuffing out strains of hereditary intelligence’ (McLaren 1990, 21). Dr.
MacMurchy argued for both immigration restrictions and policy changes
for sterilization and marriage, shoring up ideas of both the threat and the
threatened.
Eugenic and colonial government policies were supported and enacted
in ways that were intended to protect certain kinds of women so that they
could reproduce ‘finer’, abler, affluent, and ‘fit’ Canadians. This occurred
alongside the project of immigration testing, and restrictions based on the
eugenic idea that immigrants were carriers of undesirable traits. This con-
fluence of identity formation both (re)produced the idea of racialized,
dangerous, biologically inferior immigrants and the finer, affluent, abler,
fit white women in need of protection by a patriarchal state and from the
threat of racialized, insane, criminal immigrant men. In his (2010) book,
In the Shadow of the Black Beast: African American Masculinity in the
Harlem and Southern Renaissances, Andrew Leiter historically traces the
idea of the aggressive African American male. Leiter identifies the begin-
nings of tropes of aggressive masculine Blackness from slavery through
literary works including Richard Wright’s novel, Native Son (1940). As
Leiter outlines, these stereotypes were foundational to establishing legal
segregation and were simultaneously wielded to reinforce ideas of white
protectionism and white solidarity (2010). These ideas contributed to the
rationalization of Black disenfranchisement and reinforced individual and
collective concerns tied to community, power, and sex, cultivated on a
50 A. J. JOSEPH
‘black beast’ as a threat to virginal white womanhood (Leiter 2010).

Dehumanizing Black masculinity in this way led to the rationalization of
the overt sexual victimization of Black women, lynching as spectacle, and
widespread concerns about interracial sex in the Southern United States
during the first 50 years of the twentieth century (Leiter 2010).
Eugenic and colonial discourses on what makes a nation existed in
colonial contexts outside of North America as well. For one example of
many, colonization in South Africa was carried out via a central process
that reordered labour and family to regulate Black bodies and work spe-
cifically. This was done through the legitimation of discourses on degen-
eration alongside notions of progress, where one discourse depends upon
the other—for example, the notion that the Canadian public needs pro-
tection from dangerous Others is fashioned alongside the historical fabri-
cation of the immigrant as a biologically inferior or insane threat to public
safety and social genetic progress. Anne McClintock demonstrates that
this central process of reordering Black labour and family was established
upon the ‘invented tradition of the white father at the head of the global
Family of Man’ (McClintock 2013, 234). Within McClintock’s analysis is
a review of the South African colonial administrator Henry Rider Haggard,
author of King Solomon’s Mines (1885). McClintock reveals that a reliance
on patriarchal discourses ‘reinvents the white patriarch—in the specific
class form of the English, upper-middle class gentleman—as the heir to
imperial “Progress” at the head of the “Family of Man”’ (McClintock
2013, 4). The production of a white, male, British protector subject was
central to colonial relations that rationalized the dehumanization and
exploitation of Black bodies.
Contemporary Practices of Immigration

Detention in Canada
Immigration detention in Canada is rationalized as necessary for the
assessment and examination of immigrants who might present a threat to
the Canadian public or be deemed inadmissible to Canada due to ‘seri-
ous criminality’ and therefore unable to attend hearings, procedures, or
examinations (Immigration and Refugee Protection Act S.C. 2001, c.
27). Specifically, according to the Immigration and Refugee Protection
Act (IRPA) provisions in section 36(1), a permanent resident or a for-
eign national is inadmissible on grounds of serious criminality for being
convicted of an offence inside or outside of Canada where the sentence

could be 10 years of imprisonment, but in Canada, if imprisonment is for
more than six months this also qualifies.
As I have outlined elsewhere (Joseph 2015), the IRPA provides permis-
sion to detain or remove a foreign national for assessment or examination
for serious criminality as well as to determine if a person is a threat to the
public or if they will be ‘unlikely’ to attend proceedings (2001, c. 27). The
law also includes medical guidelines that render a foreign national inad-
missible if they are deemed ‘likely’ to be a danger to public health, public
safety, or ‘might’ cause excessive demand on health and social services.
This includes specification in section 38 for physical and mental illness.
The minister is also provisioned with the authority to impose any restric-
tions or conditions they consider necessary (Citizenship and Immigration
Canada 2013a cited in Joseph 2015, 50). Section 38 reminds us that men-
tal illness is directly tied to notions of threat, danger, and burden. This
conceptual linkage is only temporally removed from a connection to the
eugenic idea of sanity (Scull 2005), reinforcing the notion that immi-
grants carry with them some kind of hereditary defectiveness that is a
threat to others by way of contamination.
The control of bodies and borders for historical notions of undesirabil-
ity through immigration systems is supported by the work of law enforce-
ment and security as well.
As 2013 Correspondence from Citizenship and Immigration Canada
clarifies:
Citizenship and Immigration Canada (CIC) works in conjunction with

many partners, including the Royal Canadian Mounted Police, the Canadian
Security and Intelligence Service, provincial and municipal police forces and
international law enforcement agencies. To protect the integrity of the
immigration program, we work in partnership with the Canada Border
Services Agency (CBSA). (Joseph 2015, 232–233)
The CBSA collects and uses information from a variety of sources to

identify people based on perceived notions of serious criminality or dan-
ger to public safety and or public health. Neither of these conceptualiza-
tions of ‘public’ includes foreign nationals who live in Canada. The
CBSA polices borders well beyond Canada’s physical borders, making
decisions on admissibility on an ongoing basis for foreign nationals who
live in Canada. The CBSA is not only responsible for removal orders
52 A. J. JOSEPH
(deportations) but also for detaining those who are considered a flight
risk while admissibility is adjudicated. The federal department responsi-
ble for immigration and citizenship provides policy directives for immi-
gration detention in Canada to the authorities or delegated officers
responsible for the enforcement of the IRPA. In a document entitled
ENF 20, the powers of officers in authority to detain people under IRPA
are detailed for operational purposes (Immigration, Refugees and
Citizenship Canada 2015). ENF 20 states in section 2 that the IRPA has
the following objectives:
• protect the health and safety of Canadians and to maintain the secu-
rity of Canadian society;
• promote international justice and security by fostering respect for
human rights and by denying access to Canadian territory to persons
who are criminals or security risks.
• The power to detain permanent residents and foreign nationals
meets these objectives by
• protecting Canadian society; and.
• supporting enforcement of IRPA. (Immigration, Refugees and
Citizenship Canada 2015, p. 6)
The document outlines, in section 3.2: Regulatory Factors and Condi

tions, permissions to arrest and detain people without a warrant for reasons
of ‘risk of flight’, ‘danger to the public’ and ‘identity not established’. It also
lists ‘Other factors’, ‘Special considerations for minor children’ and
‘Applications for travel documents’ in the same section. On page 9 of the
26-page document, in a section identified as ‘Principles’ (section 5.1), refer-
ences to dignity, respect, safety, rights, standards, and physical, emotional,
and spiritual needs are also listed. While these principles are listed in the
Departmental Policy section, the document itself already provisions for the
suspension of attention to these concerns in prior sections 2 and 3.2.
The ENF directives support the practice of immigration detention and
enlist those with the authority to arrest and detain people in a project that
authorizes and rationalizes violence carried out under the guise of protec-
tion. This ‘protective’ project is organized around an idea of security and
protection for a well-established and historically constituted idea of who is
represented within ‘the Canadian public’—presumably, those who have
citizenship, although this is not acknowledged in the document itself.
Within the broad categories of ‘risk of flight’, ‘danger to the public’,
‘identity not established’ and ‘other factors’, there exists a potential to

invoke historically, socially, and politically established ideas of risk, danger,
and identity. This breadth of scope allows for inherited practices based on
racial and xenophobic ideas to continue to be carried out. In contempo-
rary deportation cases (those given removal orders and apprehended by
the CBSA), people identified by biomedical psychiatric systems with men-
tal health concerns who are also racialized minorities are disproportion-
ately evaluated as dangerous, required to be detained and as undeserving
of Canadian support or care (Joseph 2015).
The contemporary immigration detention context that has led to racial-
ized men dying and being indeterminately detained under the IRPA was
reinvigorated by federal policy-making in Canada between 2006 and 2011
that has been described as ‘an institutional-punitive conception of social
policy’ (Prince 2015). As Michael J. Prince describes,
This stern approach to federal social policy-making involves the identifica-

tion of dangerous persons and threatening behaviours, the elaboration of
laws and creation of new offenses, and the intensification of legal penalties
and punishments. What emerges is the role of Prime Minister as moral cru-
sader in a politics of fear, judgment and regulation. (2015, 53)
This punitive climate escalated in Canada in 2006 with the advent of

the conservative Canadian federal government under Stephen Harper,
which implemented policies and restructuring approaches to criminal jus-
tice that involved the production of extensive crime legislation that were
eventually passed as large omnibus bills, revising previously established
policy and law, and creating super-sized prison/immigration detention
centres. The Safe Streets and Communities Act (S.C. 2012, c. 1):
Canada), the Faster Removal the Foreign Criminal Act (S.C. 2013, c.
16): Canada), the Not Criminally Responsible Reform Act (S.C. 2014, c.
6): Canada) and the Anti-Terrorism Act (S.C. 2015, c. 20): Canada),
respectively made: (1) drastic changes to sentencing; (2) removed the
right to appeal on any grounds for foreign nationals and permanent resi-
dents who are inadmissible on such grounds as serious criminality; (3)
added juridical powers to override decisions based on ‘serious criminal-
ity’; and (4) authorized sweeping powers to share security information
across national and international agencies. These systems rely on imagery
of racialized men as inherently criminal, untreatably mentally ill, and
undeserving of Canadian support or care. The agenda (re)produces the
54 A. J. JOSEPH
historical discursive confluences of mental health issues, immigrants,

criminality, dangerousness, and the need for coercive control for the
‘dangerous’, the ‘alien’, and the ‘insane’.
Prior to the decade of federal conservatism, the Ontario Provincial
Conservative Government attempted to privatize prisons in 2001. The
province constructed the Central North Detention Centre (which
replaced three other prisons and began as a privately run institution) in
Penetanguishene and the Central East Detention Centre (publicly run) in
Lindsay. The privatization experiment failed and the Central North facil-
ity was made a public institution after five years. The Toronto South
Detention Centre in Etobicoke (open in 2013) and the South West
Detention Centre in Windsor (open in 2014) were also built. These four
super-jails are used to detain prisoners and immigration detainees. The
construction of these super-jails added to a federal trend, a 17 percent
increase in the prison population in Canada from 2005 to 2015 (Latimer
2015). This increasingly carceral approach to immigration (re)invigorated
the public and political discourse that criminality and immigration deten-
tion were confined to the poor choices and reckless behaviour of specific
individuals that needed to be addressed with protective controls for the
wellbeing of the Canadian public at the expense of social, historical, and
political considerations. These ideas focus on the poor decision making of
isolated, ‘dangerous’ individuals that adheres with the neoliberal and
colonial trends of our contemporary socio-political climate that individu-
alizes issues and distances or completely denies social, political, and his-
torical systemic and structural factors. Disparities and inequities in income,
housing, education, employment, systemic and structural racism, sanism,
and ableism, and their respective dehumanizing discursive operations of
power are readily discounted while simultaneously advancing notions of
the self-interested, accountable, responsible, and thus worthy individual,
who is typically white.
As Michael Prince highlighted in 2014, the Assembly of First Nations
and the Canadian Human Rights Commission, along with a number of
different women’s and other grassroots advocacy groups, demanded a
national inquiry into missing and murdered Indigenous women in Canada
after the publicly reported death of a 15-year-old First Nations girl, Tina
Fontaine, whose body was found in Red River, Manitoba.6 Stephen Harper
responded to the demand by stating that ‘We should not view this as a
sociological phenomenon. We should view it as a crime’ (Carlson and
Mahoney 2014). This emphasis on the individual as a problem to be
identified and managed without recognition of the social, historical, and

political context is congruent with the arguments in support of the super-
prisons/immigration detention centres and drastic changes to legislation
authorizing criminalization, the restriction of freedom or the removal of
freedoms from racialized immigrant, and those identified with mental
health issues. Contemporary immigration detention practices allow for an
increasing number of people to fall within its mandate, thus increasing the
numbers of immigrants being detained (Silverman and Molnar 2016).
Media Representations of Immigration Detention

Returning to the cases mentioned at the start of this chapter, the public
attention to the deaths of Francisco Javier Romero Astorga and Melkioro
Gahungu generated interest from advocacy groups and revealed a wider
problem. It is important to problematize the contemporary practice of
immigration detention by considering it within the ongoing context of the
(re)production of historical colonial projects. In May 2016, a 24-year-old
unnamed man died in an Edmonton Remand Centre while being detained
under the IRPA (Parsons 2016). In July 2016, a Special Investigation
Unit found that a Peterborough, Ontario police officer and an Ontario
Provincial Police officer were not responsible for any wrongdoing with
respect to the death of 39-year-old Abdurahman Ibrahim Hassan who was
detained at the Central East Correctional Centre in Lindsay Ontario for
three years (Keung 2016). It was revealed in media reports that
Abdurahman ‘struggled for decades with mental illness and diabetes’
(Keung 2016). The psychiatric diagnoses disclosed during the investiga-
tion were ‘significant mental health issues, including schizophrenia and
bipolar disorder’ (Keung 2016). Abdurahman struggled for many years as
a youth refugee in a school system that could not support him or his men-
tal health issues. Abdurahman came to Canada more than 20 years prior
to his death as a refugee from Somalia, which was in a desperate humani-
tarian crisis after many years of civil war. Abdurahman was granted asylum
but was never able to become a permanent resident due to his mental
health issues (Keung 2016). Abdurahman was the youngest of eight chil-
dren and described as ‘a loving son who doted on his mother in Toronto
and adored his niece’ (Keung 2016). Abdurahman was granted asylum
but never given permanent residency due to ‘his mental illness’ (Keung
2016). As Nicholas Keung (2016, n.p.) notes from family reports, ‘he was
moved from school to school. No one knew how to deal with him.
56 A. J. JOSEPH
He finally dropped out and we kept him at home … Being bipolar, he had
his good days and bad days. On a bad day, he got agitated and people
would call police on him. He was just in and out of hospital a lot’.
Abdurahman was convicted of assault in 2012, served a four-month sen-
tence, and was held in immigration detention for deportation as a danger
to the public. Ultimately, he was deemed a danger, detained for deporta-
tion, and killed while being ‘restrained’ in prison. The two officers under
investigation (paid duty officers) were watching over Abdurahman when
he was taken to Peterborough Regional Health Centre for medical
treatment.
The problematic conditions and treatment of prisoners/detainees at
the Central East Correctional Centre in Lindsay Ontario were protested
by detainees inside the institution. Eleven days prior to the reporting of
the Special Investigations Unit on Abdurahman, 60 immigration detain-
ees in the Central East Correctional Centre in Lindsay and the Toronto
East Detention Centre in Scarborough began a hunger strike with
demands to meet with Minister of Public Safety Ralph Goodale (Keung
2016). Groups such as the End Immigration Network advocated for
reform during this time and raised awareness about the hunger strike and
the problems associated with immigration detention. Advocates revealed
that 15 people have died in immigration detention while in CBSA custody
under the IRPA since 2000 (CBC 2016).
During the media coverage of the hunger strike, details began to
emerge about who was being detained, why, and for how long. For exam-
ple, a 40-year-old man by the name of Alvin Brown, who was detained at
the Toronto East Detention Centre since September 2011, was inter-
viewed by The Star after joining the hunger strike (Keung 2016). Brown
was in Canada for 32 years and lost his permanent residency status after
being convicted of robbery and serving a prison sentence for it. He was
detained for five years while awaiting travel documents. It was also revealed
to the public that the CBSA ‘uses provincial jail facilities in the event of an
overflow, or if an inmate poses a danger to others, has medical needs or is
not likely to be deported anytime soon’ (Keung 2016). In a devastating
commitment to the expansion of carceral power, in August 2016, Ralph
Goodale announced that Canada’s immigration detention program would
be getting a $138 million dollar investment for upgrades and to develop
alternatives to detention (CBC 2016). As one article reported during the
announcement, some 450–500 people are being detained at any given
time under the IRPA (CBC 2016).
The December 2016 death of Soleiman Faqiri brought another aspect

of the immigration detention problem into the public eye. Soleiman, who
was imprisoned (not as an immigration detainee) at the Central East
Correctional Centre in Lindsay, was diagnosed with schizophrenia and
placed in solitary confinement. Soleiman died when guards entered his cell
and engaged in a physical altercation. After viewing his body, his family
reported that Soleiman ‘was covered in bruises. There was a deep cut on
his forehead’ (Solomon 2017). The family’s lawyer reported that Soleiman
‘was restrained and that pepper spray and a hood were used’. The hood
described is known as a ‘spit hood’, a sack to be draped over someone’s
head to prevent ‘biting or spitting at guards’ (Solomon 2017). Soleiman’s
case demonstrates that the violence and deaths experienced within the
context of immigration detention extend to those in prison, the same
exact facility in this case, the Central East Correctional Centre. These con-
nections are not without historical precedent and are contemporary exam-
ples of systemic institutionalized hatred and disrespect driven from the
fabrication of gendered threats to the ‘Canadian public’ sustained by
racial, sanest, eugenic thinking that effects racialized people and those
identified by the biomedical psychiatry as violent.
The violence carried out on those who are detained and who lost their
lives should not be eclipsed by political agendas of protectionism that rely
on white supremacist ideas of the ‘Canadian public’. From the limited
portrayals and representations provided in news media reports, it is racial-
ized men who are identified as being detained and dying in immigration
detention facilities. On the surface, it appeared not to matter how long
one lived in Canada (Abdurahman Ibrahim Hassan lived in Canada for
22 years and came as a teenager), or that mental health or physical health
concerns should be considered for compassionate and humanitarian rea-
sons rather than interpreted as risk factors or threats when deciding
whether a person should be detained indefinitely. Another issue that found
its way into the public attention was the interchangeable use of prisons
and immigration facilities based on medical needs and ideas of dangerous-
ness. Notably, people with mental health diagnoses are often housed in
solitary confinement in these facilities where they will have little access to
care or treatment beyond prescription psychotropic medications (Kilty
2012, this volume).
These media representations provide a glimpse into the complex pro-
cesses of immigration detention, determination of serious criminality, and
dangerousness alongside notions of biomedical and genetic inferiority.
58 A. J. JOSEPH
Few of the decision documents themselves are available to the public as

privacy legislation effectively conceals these operations under the provi-
sion to protect personal health information; however, appeal decisions
from the Immigration and Refugee Board for people given removal orders
are available through public documents. In analyzing these documents, I
have argued that people identified as suffering from mental health issues
who were detained for removal from Canada spend on average 20 years in
the country before being selected for detention and deportation (Joseph
2015). Of the people who were given removal/deportation orders and
who were detained, 57 percent were from Jamaica, Guyana, Sri Lanka,
Somalia, Trinidad and Tobago, and China (tied for 5th with the United
Kingdom) (Joseph 2015). Another 29 percent of people being detained
and who are appealing their removal orders were from Ecuador, El
Salvador, Ethiopia, Guinea, Haiti, Israel, India, Iran, Morocco, Pakistan,
Panama, Philippines, South Korea, St. Lucia, Sudan, Vietnam, and Yemen
(Joseph 2015). This means that 86 percent of deportation orders are for
individuals originating from racialized countries in South Asia, East Asia,
Africa, Southeast Asia, West Asia, Latin America, and the Caribbean. Their
average age was 37 years (meaning most were youth when they arrived)
and appeals were granted in only 12 percent of cases (Joseph 2015).
As with the media representations, in a 2015 study of appeals cases of
the Immigration and Refugee Board of Canada for people identified with
mental health issues being detained with removal orders, the overwhelm-
ing majority of the cases involved people identified as men (89.3 percent)
(Joseph 2015). This gendered theme does not present without historical
precedent. These representations participate in an ongoing historical pro-
cess that establishes threat and danger within representations of racialized
immigrant men. These processes are achieved through the use of dehu-
manizing discourses that reference eugenic ideas of illness, criminality, and
mental incapacity to rationalize the use of violence and detention of these
dangerous Others. While racialized immigrants are constituted as danger-
ous, ideas of the white, able Canadian public are also constituted on the
historical premise that established those most in need of protection (The
British-Canadian race and the ‘affluent’ ‘finer females’ that are to repro-
duce them), while simultaneously advancing ideas that the Canadian gov-
ernment and the public are charged with enabling protection. A patriarchal
fantasy is achieved while also (re)establishing the idea of the Canadian
public as white and its protector in the image of an idealized English gen-
tleman. Women and transgender individuals and their experiences of
detention, violence, and resistance are eclipsed from consideration.

Through reference to colonial notions of racialized immigrants as dehu-
manized criminals with biologically inferior masculinity, as well as the fab-
ricated idea of a woman/mother as the biological mechanism of procreation
and vessel for eugenic purity, attention to and analysis of the experiences
of women and transgendered people in immigration detention are typi-
cally silenced.
These ideas are not without historical precedent. The rationalization of
violence and pain to bodies of colour is inherently connected to the white
male protector and to the positioning of desire, sexuality, and women’s
role in the colonial project. As Anthony Paul Farley has described, the
Black body has been historically cultivated to be consumed as a fetish
object. Farley describes race as ‘the preeminent pleasure of our time’
(Farley 1997, 458) and ‘whiteness’ as a way one feels pleasure both in
their body and about it. Farley argues that ‘whiteness is a sadistic pleasure
and that the black body is a fetish object and that law participates in pro-
ducing these themes’ (sadistic in that it experiences pleasure from inflict-
ing pain) and ‘that blackness has become a masochistic form of pleasure’
(one that takes pleasure from experiencing pain) (Farley 1997, 461).
Farley’s analysis considers the possibilities for alternative identity forma-
tions when ideological incentives and the constraints of the colourline do
not dictate the terms of identity and pleasure. As bodies of colour seek the
pleasure of whiteness, submission and subordination continues. Franz
Fanon discusses a similar trajectory in Black Skin, White Masks (1967),
appreciating that the fear of Blackness, xenophobia, and anti-immigration
discourse is bound to the idea that the Black male and Black masculinity is
a threat to white women. These irrational fears produced violence and
punishment toward Black men as well a deeply entrenched legacy of
self-hatred.
Farley contends that these analyses have the potential for liberation
within them, suggesting that although ideas and motivation based on race
and pleasure reveal that we are ‘totally imprinted by history’, the arrange-
ment of identity through political, hierarchical, difference can be altered
once difference is realized as complicit with our own mutual destruction.
Harriet Washington’s Medical Apartheid: The Dark History of Medical
Experimentation on Black Americans from Colonial Times to the Present
(2006) covers a wide history of the use of medical experimentation on
people of colour beginning with slavery in the United States from the late
1700s to the present. As Washington highlights, slavery (and the colonial
60 A. J. JOSEPH
and eugenicist projects in Canada) could not have continued without

medical science and physicians were dependent upon slavery for both eco-
nomic security and for the ‘clinical material’ that supplied American medi-
cal research and training that supported the ‘professional advancement’ of
physicians (2006, 26). As an example, Washington discusses James Marion
Sims, who was elected president of the American Dental Association in
1875. As his career developed he became an authority on women’s health
and developed numerous procedures and tools in the field of gynecology.
Many of the tools and procedures he invented were tested on Black female
slaves in the 1840s (Washington 2006). Once perfected, the medical pro-
cesses developed through medical experimentation on slave women ben-
efitted whites in terms of recovered health.
Xenophobic ideas in Canada have a long association with eugenicist
immigration policies that carried with them prohibitions of people based
on fears of ‘race suicide’ that were constituted with beliefs that immi-
grants carried some sort of hereditary defectiveness that was the source
of disease, mental illness, disability, criminality, and poverty and that
blamed immigrants for being socially and financially costly to society
(McLaren 1990).
Conclusion
Considering these eugenicist and colonial ideas are a requisite for analyz-
ing the historical-contemporary confluences of violence enabled within
the practice of immigration detention in Canada and the arrangement of
discourses that constitute the Canadian public as in need of protection,
the threat posed by the insane and racialized Others, and the bodies of
human reproduction that are worthy of protection versus those in need of
biological control. These points identify how considerations of women
and gender in immigration detention discussions are limited not only at
the levels of cisheteropatriarchical colonialism and eugenics, but also in
terms of how these conditions affect trans- and gender non-conforming
individuals as well.
Penny Pether focused much of her research on those asylum seekers
who are ‘invisibilised’ within systems and discourses that rationalize indefi-
nite detention with a historical attention to colonial India, Ireland, US
slavery, Australian detention camps of Aboriginal people, and laws aimed
at gay men developed under the guise of an attention to sexually violent
predators. Pether’s attention to gender and sexuality is an important
requirement for this discussion about immigration detention in Canada.

As Nan Seuffert published from one of Pether’s unfinished projects,
‘indefinite detention is a national trope, sourced in the violence of colo-
nialism … Next, indefinite detention is a practice begun by Britain in its
colonizing of another inhospitable source of wealth where violence was
needed to maintain hegemony and profit’ (Seuffert 2015). The issue of
Australian detention camps raised the level of complexity of analysis for
immigration detention scholarship.7 Pether in particular raises concerns
regarding the erasure of the experiences of women and transgender people
within immigration detention. In Canada, the need to research women’s
experiences must be prioritized. It is important to learn from and under-
stand the experiences of those at the confluence of eugenic, colonial prac-
tices of nation building, which are incomplete without attention to how
discourses of dangerousness, the protected, the public, the immigrant, the
protector, and bodies to be controlled are inherently gendered and racial-
ized and situated within an historical socio-political agenda that continues
to fashion policy, law, and practice.
The current context of immigration detention in Canada can only be
appreciated for its contradictory projects of colonial eugenic violence and
protection of the ‘Canadian public’ when we interrogate them for their
reproduction of a racist gender binary within eugenic colonial nation
building. The confluence of gendered ideas of the dangerous, the racial-
ized, the immigrant, the biologically mad, and the threat of men, are co-
constituted alongside the gendered construction of an idealized state
leader that will protect the Canadian public, operates as a reimagined dis-
course of (British imperial) colonial citizenry as supreme. These identities
are co-constituted when speaking about women as reproductive biological
entities to be either controlled or protected based on racial, eugenic ideas
for the purposes of colonial nation building and for the (re)making of a
white, British colonial subject.
Notes
1. These archival pieces were included in an earlier analysis with respect to
deportations in Joseph (2015).
2. Labour and commodity concerns led to a change of name to the Department
of Mines and Resources in 1936. When independent Canadian citizenship
was available after 1947 the name was changed again after 1950 to the
Department of Citizenship and Immigration, in 1966 the name changed to
62 A. J. JOSEPH
the Department of Manpower and Immigration, then to the Department of

Employment and Immigration in 1977, the Department of Multiculturalism
and Citizenship in 1991, and Citizenship and Immigration Canada from
1994 to 2015.
3. A history term for immigrants who might now be referred to as refugees.
4. Gaol being an earlier word to describe a cage, prison cell, or jail cell.
5. Charity or charitable.
6. In February 2018, a jury found Raymond Cormier not guilty of second-
degree murder in the death of Tina Fontaine (Maclean 2018). Many leaders
and family members from Indigenous communities reacted with sadness
and disbelief and argued that the verdict reflects Canada’s historically estab-
lished systemic failure to do justice for Indigenous people (Maclean 2018).
As Federal Crown-Indigenous Relations Minister Carolyn Bennett said ‘We
need to examine all the factors that lead to these violent acts, including
policing, child welfare, healthcare, and the social and economic conditions’
(Dangerfield 2018).
7. There are 10 maximum security immigration ‘reception and processing cen-
ters’ in Australia. There have been violent protests and hunger strikes from
inmates at the Christmas Island facility that drew attention to the maltreat-
ment and poor conditions for people in immigration detention. In 2014,
mothers who were being detained met with immigration officials to protest
the detention and conditions for their children and babies also in detention.
The mothers, after being told they were never going to be permitted into
Australia, experienced great distress that resulted in multiple incidents of
self-harm. The incident produced a national inquiry into the situation and
resulted in a report that focused on ‘children in immigration detention’.
See, Australia Human Rights Commission, and President Triggs. 2014. The
Forgotten Children: National Inquiry into Children in Immigration
Detention.
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———. 1927. Series RG 4–32. H.M. Robbins, Dept. Prov. Sec.: Request for
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CHAPTER 4
Gender, Madness, and the Legacies

of the Prisons Information Group (GIP)
Michael Rembis
In the early 1970s, following the incarceration of a number of political

prisoners, French philosopher Michel Foucault and others formed the
Groupe d’Information sur les Prisons (GIP) to investigate and make
known the intolerable French prison system. Foucault and colleagues used
“the investigation” as a means of documenting and sharing with the pub-
lic the deplorable material conditions within the French prison system,
and the intolerability of “prison” as an organizing concept within French
society. From the outset, the intellectual-organizers of the GIP stated their
intention to give prisoners, their families and prison employees “the floor”
(donner la parole), so that they might speak for themselves. A number of
subsequent scholars, including most famously Gayatri Chakravorty Spivak,
have questioned whether and to what extent the leaders of the GIP gave
the floor to their incarcerated subjects, with Spivak asking: Can the subal-
tern speak? (Spivak 1988). When confronted with the accusation that GIP
leaders were indeed speaking for prisoners in a 1975 interview, Foucault
responded in his characteristically glib fashion:
M. Rembis (*)
Department of History, University at Buffalo, Buffalo, NY, USA
e-mail: marembis@buffalo.edu

https://doi.org/10.1007/978-3-319-89749-3_4
68 M. REMBIS
You’re going to tell me: it is the intellectuals who are moulding this dis-
course … Big deal! The intellectual, in a given society, is precisely the
“discourse officer.” Whatever happens in the order of discourse is inevitably
going to be his/her business. S/he might be for or against it, but no opera-
tion can take place within the order of discourse without the intellectual’s
intervention. (Brich 2008, 37)
While this single utterance cannot stand in for the entirety of Foucault’s
work, it nevertheless speaks directly to the issues addressed in this essay,
namely the dialectical relationship between the incarcerated subject and
the liberal intellectual investigator-organizer.
Drawing on insights from feminist mad and disability studies, as well as
a rich cache of newly translated primary documents, this chapter offers an
assessment of Foucault and the GIP that focuses in more detail on the sub-
jects of their organizing efforts. Gender and madness figure into this chap-
ter, and although psychiatry is not explicitly addressed, it provides important
context for this discussion. As is evident among the prisoners that the GIP
sought to organize, efforts to contain madness became increasingly psy-
chiatrized and more explicitly carceral in the last third of the twentieth
century. These trends show no signs of abating in the early twenty-first
century. The psychiatrization of incarcerated populations is reaching near
endemic proportions, especially in the United States where jails and prisons
have become some of the largest providers of mental health “care” (Rembis
2014). My hope is that this chapter will build upon mounting scholarship
(Zurn and Dilts 2015) that explores Foucault, the GIP, and prison aboli-
tion, by opening a critical discussion among mad and carceral studies schol-
ars and social justice organizers looking to think in new ways about working
with incarcerated subjects and interested in expanding the reach of ongo-
ing activist, social justice and liberation movements.
The idea that both prisoners and mad people are subalterns is a core
component of this chapter. Building upon Spivak, Rosalind C. Morris
argues that, “subalternity is less an identity than what we might call a pre-
dicament.” It is a “structured place from which the capacity to access
power is radically obstructed” (Morris 2010, 8). Subalternity in this sense
is not merely an embodied identity but a social location. It is dynamic and
relational, and always influenced by the interplay among sex, gender, race,
religion, age and class. In so much as their ability to access power is “radi-
cally obstructed,” mad people and prisoners are both subalterns.
Sometimes contained within the same complexly embodied subject, the
prisoner and the mad person are both dispossessed, disenfranchised and
GENDER, MADNESS, AND THE LEGACIES OF THE PRISONS INFORMATION… 69
marginalized, removed from society and from social discourse, erased and
made to disappear, even among the most well-intentioned political actors.
A central concern of this essay is the exclusion of the most deeply dispos-
sessed, the most widely marginalized subjects within social justice organiz-
ing and critically minded scholarship.
As this chapter will show, for all of their statements about giving prison-
ers the floor, Foucault and his associates—who were part of a broader
social and cultural shift in the late 1960s and early 1970s—enacted and
perpetuated masculinist and ableist ideas about protest and who consti-
tuted the “agentic thinking” (Grech 2015, 105, 143) subject. Available
evidence indicates that the GIP was primarily concerned with organizing
the most able, most politicized actors, despite their repeated nods toward
a more inclusive protest. As Perry Zurn has argued, one of the “failures”
of the GIP was the replication of its “academic whiteness and maleness
within nonacademic, nonwhite, and nonmale elements of [its] legacy”
(Zurn 2016, 43–44). Though radical in many ways, the limitations appar-
ent in the work of the GIP can still be seen in organizing and scholarship
in the twenty-first century.
This chapter is broken into four sections. In the first section, I intro-
duce the problems faced by organizers and academics when they begin to
think about prisoners, protest and power. I use the relationships among
Dr. Edith Rose, the newly formed GIP and the prisoners they sought to
organize as a way of materializing and historicizing the issues at stake
when prisoners, academics and other professionals come together to form
critiques of incarceration. The idea of focusing an assessment of prison on
the lives of convicts and on the importance of their meaning making was
beginning to emerge within sociology and criminology (Taylor et al.
1973) at about the same time that Foucault and his friends formed the
GIP. Although they did not affiliate themselves with this “new” criminol-
ogy, the GIP was part of the broader social and cultural changes of the late
1960s and early 1970s. The second part of this chapter focuses more
intensely on the history of the GIP and its leaders’ explanations of their
organizing and their goals. I argue that the leaders of the GIP never
intended simply to give prisoners the floor. They knowingly shaped a cri-
tique of the French prison system from the outset (Biebricher 2011; Brich
2006, 2008; Gandal 1986; Hoffman 2012; Toevs 2016; Welch 2010;
Wolin 2012). I conclude this section by noting that scholars must move
beyond debating whether and to what extent Foucault and the GIP
molded prisoner protests in early 1970s France to a more fine-grained
70 M. REMBIS
assessment of the gendered and ableist politics that influenced their organiz-
ing efforts. In the third section of the chapter, I further complicate the cri-
tique of Foucault and the GIP by drawing upon feminist mad and disability
studies to make explicit the moments where the GIP displayed limited
notions of prisoners and protest. In the fourth section of the chapter, I briefly
reflect on one of the unintended legacies of the GIP, as it manifested in one
strand of the new “convict criminology” (e.g. Ross and Richards 2003) in
the early twenty-first century. In the conclusion, I bring together the differ-
ent threads of the argument and provide suggestions for moving forward.
The Intolerable Dr. Rose

Throughout 1971 and 1972, the Groupe d’Information sur les Prisons
(GIP) exposed the maltreatment of French prisoners. A catalyst in the
formation of the GIP was a letter written by Dr. Edith Rose, a psychiatrist
working at the Ney prison in Toul. Wolin (2012) characterizes Rose’s
account as a “chilling indictment of the prison system.” Through Rose’s
testimony, French citizens, high-ranking government officials and the
world learned that French prison administrators denied the young male
prisoners at Toul simple amenities, such as a soccer ball or their daily ration
of cigarettes and that prisoners spent their days “occupied with meaning-
less work” (Thompson and Zurn n.d.). Some prisoners spent months or
even a year in a cell that measured roughly 10′ × 7′ and emerged from
isolation with serious “mental disorders.” Rose reported that certain pris-
oners who “attempted suicide or self-mutilation” were strapped down to
a “restraint bed” sometimes “for a week or more” (Thompson and Zurn
n.d.). Evidence of the already deep and growing psychiatric and carceral
complex, prisoners who attempted suicide or self-mutilation often did so
in an effort to be transferred out of Ney to one of the regional hospitals.
As a prison psychiatrist, Rose was surprised to learn that “it was by medical
orders these people were strapped down” and yet she “never signed a
script [prescription] for a restraint bed” (Thompson and Zurn n.d.). Rose,
who proved intolerable to government officials, was eventually dismissed
from her duties at Ney.1
Foucault defended Rose. In a speech given shortly after her report,
Foucault praised Rose for bearing witness to the atrocities she experienced
firsthand at Ney. He stated that Rose possessed “a singular voice and one
we have never heard on the outskirts of the prison” (Thompson and Zurn
n.d.). For Foucault, Rose’s testimony “shook things up and broke the big
taboo” against speaking publicly about the French prison system

(Thompson and Zurn n.d.). In the same speech, Foucault stated that in
the “mere details” of her report, Rose exposed not simply someone’s “dis-
honesty” or someone else’s “mistakes” but something much more insidi-
ous—“the violence of power relations” (Thompson and Zurn n.d.).
Foucault declared that, “Society painstakingly requires everyone to avert
their eyes from events that betray true power relations” (Thompson and
Zurn n.d.). Yet Rose did not avert her eyes. Rather, she stepped into the
light and called attention to the treatment of prisoners at Toul. “More
than outrage,” Foucault continued, “the response [to Rose] was really a
widespread stupor. Around her voice, there collected a kind of silence. An
uneasy hesitation. Everything needed to be put back in its place”
(Thompson and Zurn n.d.). Numerous interlocutors, including the
“habitual news circuits” stepped in and “redistributed” Rose’s speech,
removing its immediacy and its intimacy. Foucault lamented that the “I”
in Rose’s testimonial had been “snuffed out.” The facts were reported, as
if they were “anonymous tips, or the result of an investigation” (Thompson
and Zurn n.d.). Nevertheless, he declared that Rose’s speech “may well be
a critical event in the history of the penitentiary and psychiatric institu-
tion” (Thompson and Zurn n.d.).
Rose’s testimony and the response it elicited from French media, gov-
ernment and intellectuals provides an important entry point into a discus-
sion of prisoners, power, protest and the gendered and ableist formation
of knowledge. Dr. Rose, the men with whom she worked (both prisoners
and the leaders of the GIP) and French media and government represent
competing elements in the complex power relations that permeate efforts
to organize oppressed subjects and to create new knowledges (Wolin
2012). Clearly, government authorities considered Rose intolerable, while
French media worked to depersonalize and ultimately dismiss Rose’s
account of life at the Ney prison in Toul. Foucault lauded her localized
knowledge, itself a certain type of insurrection or act of resistance. Yet
Rose was not a prisoner, the inclusion of whom was the stated goal of the
organizing efforts of the GIP. She was a psychiatrist working within the
French prison system. In many ways, Rose embodied everything that the
GIP considered intolerable—hospitals, asylums, prisons and psychiatric
intervention by the state—but that did not stop them from including her
in their protest. Quite to the contrary, they held her up as exemplary of a
“new” kind of power precisely because she highlighted specific cases of
abuse, cracking open a complex assemblage of power relations, laying bare
72 M. REMBIS
the inner workings of the prison system, which included the psychiatriza-
tion of systems of containment and the containment of mad prisoners. In
this specific moment, multiple vectors of power converged upon, refracted
through and emanated from Dr. Rose and the men with whom she
worked. It is these power relations, which always circulate in one way or
another among researchers, organizers and subjects that have become a
primary concern of scholars in a number of fields in the decades since the
uprisings of the 1960s and early 1970s (e.g. Balfour and Comack 2014;
Burstow 2004; Costa et al. 2012; Davar and Ravindran 2015; Davies
2001; Fabian et al. 2014; Fabris 2011; Kilty 2008; Klien 2015; Morris
2010; Rose 2007; Scott 1991; Spivak 1988; Voronka 2016; Waldman and
Levi 2016).
This episode in French history—one of many similar moments begin-
ning in the mid-twentieth century and continuing through to the present
day in which liberal elites seek to affect change by aligning themselves with
socially and structurally marginalized subjects—is both emblematic of and
helped to give rise to a shift within the academic study of prisons and pris-
oners. During the 1960s and 1970s, a “new” criminology developed that
sought to move away from older positivist and biologically and psycho-
logically determinist explanations of criminality (Taylor et al. 1973, 279).
The “new” criminologists worked to create a social theory of deviance
that attended to individual meaning making, lived experience and the
political economy of crime, as well as the social dynamics of reactions to
crime (Taylor et al. 1973, 276–277). The “new” criminologists advocated
a “politicization of crime in criminology” (Taylor et al. 1973, 282). For
them, the “abolition of crime [was] possible under certain social arrange-
ments” (Taylor et al. 1973, 281). Grounded in a Marxist understanding
of the dialectics of human relations under late capitalism, this approach
marked a radical shift in the study of prisons and prisoners.
Though they did not identify themselves with this new strand of schol-
arship, Foucault and the GIP were part of the sea change of the late 1960s
and early 1970s. Through their work with French prisoners, the GIP
simultaneously recognized and problematized the value of lived experi-
ence, not only in terms of the formation of new knowledges but also in
terms of affecting social change. Their work was not without its limits,
however. In the next section, we will take a closer look at the GIP’s own
understanding of its role in shaping prisoner discourse.
The GIP
The formation of the GIP marks a specific moment in French history in
which liberal elites, prisoners and prisoner families came together to affect
both ideological and material change in prisoners’ lives and in the prison
system. The aim of their organizing was not prison reform, but a transfor-
mation in the way people thought about and acted in relation to prisoners
and the prison system.2 Reflecting on the formation of the GIP, Foucault
later recalled that it was “an enterprise of ‘problematization’, an effort to
make problematic and to throw into question the practices, the rules, the
institutions, the habits and the self evidences that have piled up for decades
and decades. And that in relation to the prison itself, but also, across it, in
relation to penal justice, the law, and, still more generally, punishment”
(Gandal 1986, 127). For Foucault and his colleagues, the only conceiv-
able way to achieve transformation in thought and action was to use their
investigations and questionnaires to create a space from which prisoners,
their families and sympathetic prison employees like Dr. Rose could speak.
From its inception, the GIP was both coalitional and hierarchical in nature.
Its predominantly male leaders organized a loose network of physicians,
intellectuals, prison employees, prisoners and prisoner families in an effort
to expose a corrupt and abusive French prison system and call into question
the very notion of incarceration. While ideologically and rhetorically the
GIP committed itself to giving prisoners “the floor,” they understood the
impossibility of enabling prisoners to construct an unmediated protest.
Prisoners and their intellectual-organizer leaders, like every other political
actor, were embedded within elaborate networks of power that could be
altered but never avoided or undone.
To achieve their goal of giving prisoners the floor, the GIP sought to
minimize its own role in the inquiries and insurrections conducted during
the early 1970s. “What matters,” the GIP insisted, “is whatever prisoners
want to make known, by saying it themselves. The point is to transfer to
them the right and the possibility to speak about prisons. To say what only
they have the power to say” (Thompson and Zurn n.d.). When asked
“What are your personal opinions on the problem created by the existence
of prisons?” Foucault responded, “I have none. I am here to receive, to
disseminate, and, if need be, to elicit documents whenever necessary”
(Thompson and Zurn n.d.). One GIP document explained that, “These
inquiries are not made externally by a group of technical specialists: the
74 M. REMBIS
inquirers, here, are the inquirees themselves. … It is for them to take charge
of the struggle that will prevent the exercise of oppression” (emphasis in origi-
nal, Thompson and Zurn n.d.). Foucault and Vidal-Naquet noted in an
interview in March 1971 that, “it is not we who lead but already hundreds
of other people … they simply needed a catalyst [a hunger strike and the
formation of the GIP]. From now on, we are the relay station for groups
formed in and outside of Paris” (Thompson and Zurn n.d.). As Foucault
stated in an interview in July 1971, “we [the GIP] are going to try here-
after to publish this material [from prisoners] in its raw state” (Thompson
and Zurn n.d.).3
The GIP recognized that prisoners possessed localized knowledges and
a political consciousness born largely of both personal and collective expe-
riences of oppression. Prisoners and their families were not devoid of
thought, nor were they incapable of formulating critiques. According to
Foucault, “the masses know perfectly well what’s going on, it is perfectly
clear to them, they even know better than the intellectuals do, and they say
so convincingly enough” (Deleuze et al. 2004, 207). “When prisoners
speak, it poses such a problem [for power],” Foucault declared, “[b]
ecause, as soon as prisoners speak, we are at the heart of the debate”
(Thompson and Zurn n.d.). One GIP document stated that the group
launched its investigations “to let those who have an experience of prison
speak. Not that they need our help to ‘gain consciousness’: consciousness
of oppression is there, perfectly clear; they are well aware of the enemy”
(Thompson and Zurn n.d.). In another document, the GIP explained that
they did not “claim, among prisoners and their families, to raise awareness
of the conditions to which they are subjected. They have had this aware-
ness for a long time … Knowledge, reactions, indignations, reflections on
the penitentiary situation—that all exists on an individual level …”
(Thompson and Zurn n.d.). From the GIP perspective, prisoners pos-
sessed multiple local knowledges, but those knowledges existed in a “raw
state.” They required elite interlocutors to make them legible to a wider
French public.
While not unaware of the implications of their own social location, the
leaders of the GIP used their privileged position to mold the discourse
around French prisons. Through its coalitional politics the GIP shaped
what they viewed as disconnected and largely inarticulate acts of resistance
into a coherent critique of the French penal system. In an article dated 15
March 1971, the GIP stated its goal of transforming “isolated [prisoner]
rebellions” into a “shared body of knowledge, and into coordinated
action” (Brich 2008, 28), which was done by way of inquiries intended
“to heighten our intolerance and make it an active intolerance” (Thompson
and Zurn n.d.). The GIP sought to transform what Foucault would later
call “unqualified” or “disqualified” knowledges into “collective” or “polit-
ical” knowledge. As the GIP stated, “From here on out, information must
circulate … Individual experience must be transformed into collective
knowledge. That is to say, into political knowledge” (Thompson and Zurn
n.d.). Deleuze explained that, “This [prison protest] is a personalized cri-
tique, the example of which was given by Dr. Rose, whose report took up
the prisoners’ cause” (emphasis in original, Deleuze et al. 2004, 205).
Here Deleuze speaks of an ostensibly cooperative relationship in which
Dr. Rose transformed the isolated rebellions of the prisoners at Ney into
collective or political knowledge through her creation of a report.
In some cases, the GIP did more than reorient or redirect prisoner expe-
riences; they rewrote them. In yet another interview in March 1972,
Foucault admitted that La Cause du peuple “itself censored a prisoner’s
text. The piece didn’t correspond to their ideas, they preferred revolts on
roofs [referring to Toul]” (Thompson and Zurn n.d.). Yet, GIP leaders
maintained that their role in the inquiries remained minimal: “To every
person who wanted to do something, we said: Go do it. Sure, we discussed
what was most effective, but we did not give orders” (Thompson and Zurn
n.d.). In a November 1979 interview, Foucault defended GIP tactics:
I would be hard-pressed to identify the part each played. For example, in

these booklets we made, in a sense there wasn’t a single line not written in
the hand of a former prisoner. We added nothing, fabricated nothing.
Things were said to us and written to us. True, we had a grid, some ques-
tions we posed, and information we wanted to obtain. But there was never
a conflict between former prisoners, prisoners, and us in the drafting pro-
cess. (Thompson and Zurn n.d.)
In a letter published in January 1980, Foucault further explained that:
One of our principles was in some way to make it so that prisoners and,
around them, an entire fringe of the population could express themselves.
The GIP texts were not the elaborations of a noxious intellectual, but the
result of this attempt. That is why the GIP … (as anticipated from the begin-
ning) was dissolved once former detainees were able to organize their own
movement. All of that was the result of our cause and not the effect of con-
tradictions. (Thompson and Zurn n.d.)4
76 M. REMBIS
While he stopped short of saying that he gave the prisoners’ movement a

direction or a “theoretical apparatus,” Foucault admitted to setting up
“possible strategies” for protest and social and institutional change (Gandal
1986, 123). In an interview in 1975, Foucault clarified the GIP intent:
“What we tried to do with the prison issue was […] to weave together
discourses which were on an equal footing. We did not keep quiet if an
inmate was speaking, we did not acknowledge that he had the right to
shut us up, but nor did we assume the right to speak in his place” (Brich
2008, 36).
According to the GIP, speaking with—but not necessarily over, for or
against—prisoners was necessary because multiple circuits of power
worked to delegitimize, disqualify and silence those subalterns living at the
edges of society (Deleuze et al. 2004, 207). “The present system denies
them the means to express and organize themselves,” the GIP declared
(Thompson and Zurn n.d.). The leaders of the GIP worked to counter
this denial by organizing prisoners and their families with the ultimate goal
of enabling them to forge their own protests. Yet the GIP remained reluc-
tant to address in any systematic way their own power and privilege. Recall,
for example, Foucault’s response when questioned on the matter—“Big
deal!” (Brich 2008, 37). Though extant documentary evidence is limited,
enough exists that we can, with the help of insights from feminist mad and
disability studies and other relevant secondary literature (Brich 2008;
Bourg 2007; Gandal 1986; Halperin 1995; Macey 1993), make more
explicit some of the limitations of the GIP. In the next section, I give more
attention to questioning the idea that there was “never a conflict”
(Foucault quoted in Thompson and Zurn n.d.) between former prisoners,
prisoners and the GIP.
“… People Who Hardly Know How to Hold

a Pencil”
The GIP claimed to make “absolutely no distinction” (Thompson and

Zurn n.d.) among prisoners, because in their thinking all prisoners were
political prisoners. Yet the GIP might never have existed and French elites
may never have taken notice of prisoners’ lives if it were not for the social
and political turmoil of the 1960s. The GIP formed in response to a hun-
ger strike mounted by young male prisoners who had been part of the
Maoist organization Gauche proletarienne (founded in 1968) and were
incarcerated as a result of government backlash against the protests of May

1968.5 After the hunger strike and the revelations of Dr. Rose, the GIP
created “a front, an attack front” (emphasis in original, Thompson and
Zurn n.d.) against the French prison system. GIP leaders committed
themselves rhetorically to organizing all detainees. In the end, however,
they only reached a tiny fraction of politicized, articulate prisoners and
ex-convicts (Brich 2008).6 The GIP’s approach, which was based on
unquestioned gendered, classed, racialized and ableist assumptions about
appropriate and effective communication, limited its influence especially
among prisoners and former detainees. Although she does not specifically
address madness or disability, Foucault scholar, Cecile Brich (2008, 30,
31, 41–46) speaks to this point when she contends that the GIP’s meth-
odologies—primarily the questionnaire—and the way they used lan-
guage—what she refers to as a “communicative hegemony” and a “clash
of sociolects”—may well have alienated those prisoners who had trouble
reading and writing, or for whom French was not their first language.
Through the work of the GIP, the mostly male (there is little evidence that
they worked directly to organize women) prisoners got marked as either
“political detainees” or “common-law detainees” (Thompson and Zurn
n.d.) based largely on their ability to organize and communicate in ways
that were both familiar to and satisfied liberal elites.
Recently translated primary documents reveal the extent to which the
GIP made distinctions based on ability when categorizing prisoners.
Describing their writings as “raw” (Foucault quoted in Thompson and
Zurn n.d.) is revealing in and of itself, but the GIP went even further in
delimiting the testimonials and other responses they received from prison-
ers and their families. In a July 1971 interview Foucault stated that, “we
have received autobiographies, private journals, and narrative fragments
[in addition to the questionnaires]. Some pieces are written by people who
hardly know how to hold a pencil” (Thompson and Zurn n.d.). In a sepa-
rate interview, Foucault and Vidal-Naquet stated that, “Political prisoners
have means that common-law prisoners do not. They have the means to
express themselves” (Thompson and Zurn n.d.). Although they worked
to organize both common-law and political detainees, the leaders of the
GIP perceived common-law detainees as disabled or mad, but not in the
ways that one might expect.
It was not necessarily the literal inability to hold a pencil that became
disabling for certain prisoners. Though this may have been the case for
some prisoners, we can surmise from Foucault’s other utterances and
78 M. REMBIS
ritings that the pencil is a metaphor for a larger inability to express one-
w
self in socially valued ways. From the perspective of the GIP, common-law
prisoners, who it seems had a lot to say, were unable to speak. They were
disabled. While some prisoners may have been unable to write for any
number of unknown reasons, it is more likely that most common-law pris-
oners were silenced (disabled) by their own subalternity. Their experi-
ences, their revolts, their lives did not fit within the governing structures
established by the GIP and so the GIP worked to remold or omit them.
The lack of any documented discussions and considerations of madness
and its effects on prisoners’ communicative potential beyond the GIP’s
final published pamphlet Prison Suicides (discussed below, Thompson
2016) likewise demonstrates the near erasure of mad people’s voices from
history and from this body of carceral literature.
Political prisoners, it seems were held in a much different regard by the
GIP. According to GIP documents, political detainees, unlike their
common-law counterparts had,
… knowledge[s], social relations, outside contacts that permit them to make

known what they say, what they do, and above all they have the political
support to make their action reverberate. Several dozen common-law pris-
oners could not, like political prisoners, react together, write, and make their
demands known to the outside world. (Thompson and Zurn n.d.)
Given the historical context of the formation of the GIP, it is telling that
it organized at most 100 or 200 prisoners out of a prison population of
30,000. Through their own discourse and organizing methods—both of
which were shaped by limited conceptualizations of “normal” protest—
the leaders of the GIP disqualified, disabled and contained many common-
law prisoners, effectively silencing them.
This silencing can be seen in the pamphlet, Prison Suicides. Thompson
(2016) argues that the editors of the GIP’s final published pamphlet Prison
Suicides, Daniel Defert and Gilles Deleuze, used the everyday writings and
dramatic actions of prisoners—in this case suicide—to produce “new
statements” (2016, 2015) concerning the effects of expanding carceral
networks. According to Thompson, letters written by prisoners “say very
little” (2016, 201). It is the editing by Defert and Deleuze that “proves
decisive” (2016, 201) because it reframes prisoner writing and the more
dramatic act of suicide—and one might infer madness (2016, 200)—as
resistance, and perhaps more importantly as the product of incarceration.
Through what Thompson calls “structural juxtaposition” (2016, 205) or

editing, the letters and the suicide of one common-law inmate, a “thirty-
two-year-old petty criminal” (2016, 199), “a schizophrenic” (2016, 206)
whose case was also colored by “his homosexuality” (2016, 207) are
stripped of their (embodied) specificity, and become “emblematic of what
any prisoner caught up in the midst of the struggles and conflicts of the
French prison system in 1972 was thinking” (2016, 206).
As the actions of the GIP make clear, scholars and organizers working
with marginalized and oppressed peoples need expanded understandings of
“normal” citizenship and protest. Emerging scholarship in mad studies and
mad activists (Menzies et al. 2013; Spandler et al. 2015) are pointing to
new ways to think about what have generally been considered non-
normative ways of being, thinking, feeling and communicating—tools that
can be used in a critical assessment of the GIP. Part of the broader anti-
psychiatry and mad people’s liberation movements, the field of mad studies
gained purchase primarily in the United Kingdom and Canada in the early
twenty-first century. Drawing on a long tradition of critiquing the medical
model of “mental illness,” as well as their own interpretation of the “social
model” of disability,7 mad studies scholars have reclaimed a mad identity, as
well as mad ontologies and epistemologies that run counter to—and under-
mine—dominant ways of knowing and being, which have their roots in
hetero-patriarchal, capitalist and ableist social and economic structures (e.g.
Beresford 2009). While mostly focused on providing an intellectual appara-
tus for ongoing social movements, which historically have been dominated
by global North elite white academics and activists, mad studies is becom-
ing more diverse both in its composition and in its intellectual interests.
Work in mad studies relies on intersectional approaches that consider mad-
ness or distress within the material contexts that produce it and together
with gender, race, class, sexuality and religion (Menzies et al. 2013; Spandler
et al. 2015). The multiple overlapping interests among mad and carceral
studies scholars to reclaim bodies and stories in more complex and dialecti-
cal ways that account for other identity categories as well as social and struc-
tural inequities are critical to understanding GIP organizing, as well as the
general predicament within which many subalterns—like prisoners and mad
people—live and within which their protests form.
Feminist scholars working at the intersection of mad and carceral stud-
ies are expanding understandings of prison, incarceration and madness.
Jennifer Kilty’s work (in Balfour et al. 2014) in this area is especially
important. Through her studies of the psy-carceral complex, Kilty shows
80 M. REMBIS
how Canada’s medical and carceral networks have constructed women’s

criminality “only as a defect of their individual mind,” opening up means
to drug incarcerated women in an effort to make them compliant self-
governing subjects (2014, 240). Highlighting the importance of intersec-
tional approaches in the study of women prisoners, Kilty notes that drug
use is highest in Canada’s prairie prisons, where more Indigenous women
are incarcerated. “If we peel back the liberal veil that shrouds Canadian
correctional mandates and programs as primarily rehabilitative,” Kilty
concludes, “we uncover a system that appears to be incapable of providing
adequate mental health care” (2014, 247). Instead, psychiatric medica-
tions are used to discipline and control prisoners, especially women of
colour. Kilty (2008, n.p.) contends that prison regimes in Canada remain
“repressive institutions that sacrifice treatment (and prisoners’ rights as
psy-citizens) for social control.” In his provocative study of community
treatment orders, Canadian mad activist and academic, Erick Fabris (2011)
extends the reach of the prison when he argues that forced drugging of
people living in the community is a form of “chemical incarceration” that
creates “tranquil prisons” within mad people’s own minds, making them
unable to access valued parts of themselves and their communities. These
and other studies point not only to new lines of academic inquiry but also
to new areas of collaborative resistance against the tyranny of expanding
carceral and psy networks. By assessing the GIP and its legacies from this
perspective, it becomes possible to formulate a more comprehensive cri-
tique that attends to the gendered ableist structures that dominate mod-
ern society, including the liberal academy.
The point of this chapter is not to make simple parallels between the
containment of mad or disabled people and prisoners, but rather to think
about representation and “empowerment,” often configured as giving a
voice to the oppressed—or in the specific case of the GIP, giving the floor
to prisoners and their allies in early 1970s France. Though progressive in
many ways, the GIP and the new criminologists of the 1960s and 1970s did
not work to overthrow (in any fundamental or lasting way) the relative
power or the racial, gender and class privilege held by academics, profes-
sionals and other organizers working with marginalized populations. These
particular power relations went largely unmarked until feminist, anticolo-
nial, mad and racialized researchers, organizers and academics questioned
both the privileged position of primarily white, male, middle-class academ-
ics and movement organizers, and the hegemony of global North theories,
practices and policies (e.g. Balfour and Comack 2014; Fabian et al. 2014).
The result of this later development was scholarship and community

work that lays bare the gender, race, ableist and class-based biases of move-
ment organizers and researchers and scholars (Sweeny et al. 2009; Voronka
2016). In her now classic essay, French historian and theorist Joan Wallach
Scott was among the first feminists to highlight the complications involved
in relying on “experience” to create alternative discourses. Experience—
like that of mad people and prisoners—should not become “evidence for
the fact of difference” but rather “a way of exploring how difference is
established, how it operates, how and in what ways it constitutes subjects
who see and act in the world” (Quoted in Voronka 2016, 194). Foucault
and the other leaders of the GIP may have been thoughtful in their
approach to organizing prisoners and their allies, but they did not address,
nor did they work to dismantle, the privileged place from which they
engaged in their work.
Questions of power in academic work and in social justice organizing,
or in any other human relation for that matter, cannot be addressed with-
out accounting for the bodies and embodied experiences of those “on
whom social forces of inequality operate” (Swartz and Bantjes 2016, 23).
Madness and criminality are not inherent in individuals. They are called
into being through gendered overlapping systems of governmentality that
have their roots in material conditions. They are both historically contin-
gent and socially created, and as such they can be altered or even abol-
ished. Thinking of madness and criminality as gendered, social and
relational, and also embedded in the materiality of the body and the social
and economic structures that contain them enables a more nuanced read-
ing of various protest movements both past and present, and a more pow-
erful critique of how power operates within, circulates through and works
to contain bodies and the spaces they are able to inhabit. In the last section
of the chapter, we will briefly consider one of the unintended legacies of
the GIP as it has appeared in at least one strand of convict criminology.
Convict Criminology
New scholarship and activism done in the wake of the GIP has had innu-
merable positive effects on the study of prisons and prisoners. The advent
of convict criminology at the end of the twentieth century, for example,
was, without a doubt, a bold and radical move. It was (and remains) a ver-
sion of what the GIP hoped to accomplish—criminological investigations
and classroom instruction conducted by ex-convicts turned academics.
82 M. REMBIS
Yet the initial forays into this rich and exciting field remained limited by
what Zurn (2016) has called the “whiteness and maleness” of academia.
The original “felonius friends” or “con-sultants” (Ross and Richards
2003, 9–10) as they called themselves were predominantly white cisgen-
der men who took a rather narrow view of criminology. Women prisoners
and the “mentally ill offender” were “special populations” with “unique
needs” in early convict criminology (Ross and Richards 2003, 227, 267),
despite the emergence of new feminist mad and disability studies scholar-
ship and the explosive growth in both populations since the 1980s. The
convict criminologists’ patriarch was John Irwin—a white man who served
five years in Soledad Prison in the 1950s for armed robbery and went on
to become a professor of sociology and criminology at San Francisco State
University, dying at the age of 80 in 2010. The initial ex-con professors
referred to themselves as a “club” (Ross and Richards 2003, 7)—although
fraternity might have been closer to the truth8—and they came danger-
ously close to romanticizing incarceration and the ex-con experience.
They claimed to write not for vitae lines, promotion, or tenure, but “so
that one day the ghosts will sleep” (Ross and Richards 2003, 6). Only
subjects operating from positions of power—like the GIP during the early
1970s or the early convict criminologists—can be dismissive (“Big deal!”)
of dominant hierarchies or “relations of ruling” (Smith 1977, 1999, 2008,
2010, 2012, 2016).
Like the “new” criminologists of the 1960s and 1970s, the first convict
criminologists favoured approaches that focused on convict and ex-con
experiences, but they limited their studies to their own or other similar
experiences with incarceration. They engaged in a neo-positivist approach
that sought truth in certain insider perspectives. The convict criminolo-
gists had two main goals: to transform the way prison research was con-
ducted, focusing on ethnographic approaches, and to outline policy
reforms that would “make the criminal justice system humane” (Ross and
Richards 2003, 10). They were reformers. And while the reforms they
suggested were essential in the everyday lives of convicts, they did little to
promote the type of systemic or ideological changes articulated by
Foucault and the GIP.9 Although they knew and appreciated the full
weight of even the most seemingly minor reform in prison life, Foucault,
the GIP and the original voices of the “new” criminology sought to avoid
focusing on reform, because from their perspective, these types of changes
did little more than perpetuate carceral networks. Intersectional ethno-
methodological approaches focused on the phenomenology of convict life
needed to be positioned dialectically within the political economy of crim-

inality, giving rise to structural critiques grounded in the material relations
of late capitalism. This would, among other things, enable scholars and
activists working in a number of areas to merge their growing critiques of
expanding psy-carceral networks. The convict criminologists who emerged
as an academic force around the turn of the 21st century did not take this
approach to their work.
In 2016, convict criminologist Rod Earle published Convict
Criminology: Inside and Out, in which he addressed the shortcomings of
early work in convict criminology. In recounting the origins of convict
criminology, Earle moved beyond John Irwin and mentioned (2016,
40–42) black convict George Jackson and his publication of Soledad
Brother in 1971, as well as Angela Davis and the Black Panthers. He
asserted that both feminists and African American ex-prisoners had been
included in convict criminology, and that convict criminologists analyzed
the “astonishing racialised parameters of America’s penal nightmare”
(2016, 55). He admitted, however, (2016, 55) that “the voices of middle-
class white men prevail well beyond their representation in the general
[convict] population, as they frequently do in most aspects of higher edu-
cation” (2016, 55); and that a “predominantly white academy seems to
find it harder to identify consistently” (2016, 42) the connections among
race and US criminal justice and criminology. In a chapter dedicated to
race, class and gender—he made no mention of madness or disability—
Earle (2016) further stated that building the knowledge and creating the
“collaborative enterprise” (101) necessary for a sustained critique of the
whiteness and maleness of convict criminology was a “slow” and “pains-
taking” (101) process and a “work in progress for convict criminologists”
(101). In an effort to build a more inclusive academic field—what he
called a “stronger anti-racist pedagogy in the struggle over the future of
prison” (110)—Earle remained explicitly reflexive throughout his text. He
foregrounded a critical analysis of the power of heteronormativity, cis-
gendered masculinity and whiteness in shaping his own life and most work
in convict criminology. Earle’s recognition of the limitations of convict
criminology as it was organized and practiced during the first 15 years of
the twenty-first century is a powerful first step toward more inclusive
scholarship and social justice organizing, yet there are still those groups—
mad and disabled persons—who have yet to be identified among those in
need of “the floor.”
84 M. REMBIS
Conclusion
Too often intellectual-organizers forgo a sustained critique of the social
location of allied actors against oppression largely at the expense of those
subalterns who cannot speak. Intellectuals, organizers and researchers
must move beyond (but not abandon) reflexivity to an approach that takes
into account not only the social location of various political actors but also
embeds those individual or collective subjectivities within a historical
materialist analysis of the structures that contain them. Seeing the prison-
ers at Toul and mad or incarcerated subjects more generally as occupying
a structured place of subalternity—in addition to an embodied identity—
allows one to move away from individualized and atomized (postmodern
and neoliberal) understandings of their subjectivity, toward a more collec-
tive and materially based understanding of their predicament. Recognizing
the intersectional, dynamic, relational and dialectical nature of subalter-
nity, while also attending to the material conditions that contain subaltern
subjects, is critical for academics and activists.
Yet that is not enough, political actors—and I would argue that we are
all political actors—must move beyond what disability studies scholar
David Mitchell has called “inclusionism” (Mitchell 2015) to account for
the most marginalized among us. Writing in a different context, Mitchell
(2015) defines what he calls neoliberal practices of “inclusionism,” or
surface-level efforts to include only the most normative among us, only
the most able, sane, white and cis-gendered in mainstream society, con-
signing the rest of us to a slow and silent death outside the edges of
“meaningful” existence. I argue that a form of this inclusionism subtly
influenced the organizing of the GIP, and although it was not unrecog-
nized or uncontested, it continued to influence the rise of convict crimi-
nology around the turn of the twenty-first century. In an insightful analysis
of Foucault and the GIP, Janos Toevs, an inmate serving a life sentence in
Colorado and “an admitted autodidact” (2016, 136), argues that “we all
other” (emphasis in original, 2016, 136), but that we rarely discuss or even
think of the ways in which we create others ourselves (Toevs 2016).
It is my hope that this chapter has provided a critical place from which to
begin thinking about the relationship between movements for social justice
and the scholarship they generate. The dialectics of theory and practice are
not nearly as straightforward as we might assume. Giving a voice or giving
the floor to historically and often brutally oppressed and marginalized peo-
ple is never a simple task precisely because subalternity is much more than
an embodied identity. It is a socially created predicament, a social location.
And as Morris argues, and the GIP organizing demonstrates, “To the
extent that anyone escapes the muting of subalternity, she ceases being sub-
altern” (Morris 2010, 8). Disability rights activists developed the social
model of disability and the slogan nothing about us, without us, feminists
wrote the personal is political into popular discourse, and mad activists cre-
ated the user, survivor and anti-psychiatry movements and organizations
like MindFreedom and the Hearing Voices Network to escape their own
subalternity, but what of the rest of these populations? How do intellectu-
als, researchers and organizers account for, work with, represent and respect
those mad and incarcerated people—especially women, children, LGBTQA
and people of colour—whose capacity to access power remains radically
obstructed not only by their own embodiment but also by their social loca-
tion? Foucault and GIP have provided us with powerful tools to begin to
answer, and perhaps reformulate, these questions.
Notes
1. Thompson (2010) argues that Foucault used the notion of “intolerability to
denote a set of traits whereby one form of life could be distinguished from oth-
ers as undesirable,” and that Foucault “also clearly believed that the designa-
tion of these conditions as intolerable was sufficient to compel struggle against
this system.” Thompson concludes that, “Intolerability therefore served in this
[the GIP] movement against a contemporary form of the configuration of
knowledge and power as both the measure of and for political action.”
2. At times the GIP framed the prisoners struggle as a matter rights although
they were not engaged in prison reform. They were seeking a radical recon-
ceptualization of the dividing line between innocence and guilt, between
citizen and prisoner. They sought to speak truth to power, thereby opening
and exposing its variegated and continually shifting articulations. In a sepa-
rate GIP announcement, Foucault declared, “let what is intolerable—
imposed, as it is, by force and by silence—cease to be accepted. We do not
make our inquiry in order to accumulate knowledge, but to heighten our
intolerance and make it an active intolerance. Let us become people intoler-
ant of prisons, the legal system, the hospital system, psychiatric practice,
military service, etc.” (On prisons, in Thompson and Zurn n.d.).
3. Most scholars agree, as Wolin has argued, that Foucault and “the GIP
sought, in the spirit of Maoist populism, to empower [the prisoners] so that
they would be capable of organizing their own resistance to the penal sys-
tem” (2012, 308). Bourg (2007) describes the GIP’s organizing efforts as a
form of “radical democracy,” which Gandal (1986) describes as “radical
reformism.”
4. Prisoners created the Comite d’action des prisonniers (CAP) in 1972.
86 M. REMBIS
5. The French government passed the “anti-wreckers” law in June 1970, mak-
ing the organizers of demonstrations liable for any disturbances (Brich
2008, 28).
6. French prisons held 29,026 prisoners on 1 January 1970. The GIP sent out
approximately 1000 questionnaires. They received only 50 responses. About
20 inmates or ex-cons sent in diaries, letters and prison narratives.
7. The “social model” of disability, which emerged out of the disability rights
movement in the United Kingdom in the early 1970s, fundamentally altered
the way activists, scholars, governments and governing bodies define dis-
ability. Activists and subsequent disability studies theorists made an impor-
tant distinction between impairment and disability within the social model
of disability, viewing impairment as a different although not necessarily
devalued form of embodiment, and disability as socially created and orga-
nized impediments to the full integration of people living with impairments
into society through, for example, inaccessible built environments, negative
attitudes and a lack of access to important resources such as education and
employment. Some make the analogy between impairment and disability
and sex and gender, with impairment/sex marking certain bodies, and dis-
ability/gender being socially created. A growing group of activists and theo-
rists (including myself) have complicated understandings of impairment
within the social model, arguing that impairment itself is often socially con-
structed, especially in the case of madness. Significant differences also exist
between a “UK school” and a “US school” of disability studies that are
beyond the scope of this essay.
8. Robert Gaucher is a white male professor retired from the University of
Ottawa. Richard Jones is a white male professor at Marquette University,
Milwaukee. Stephen Richards is a white male sociology professor at the
University of Wisconsin, Oshkosh. Chuck Terry appears to be a white male
ex-heroin addict who spent 12 years in prison, got a PhD from UC Irvine,
and worked as a professor at St. Louis University. Edward Tromanhauser is
a white male retired professor. Canterbury University sociology professor
and criminologist Greg Newbold is a white man who in 2016 sparked con-
troversy by giving a lecture after which seven students complained in a letter
about his “‘apologetic attitude towards accused rapists.’” “I wasn’t there to
try and make women feel good about themselves; I wasn’t there to mollify
feminists,” Newbold said. He continued: “I was there to give a factual talk
about factual situations as I see it. I really don’t care whether people were
offended or not. It’s not my problem.” Donna Miles and Julia Evans,
“High-profile criminologist Greg Newbold’s rape lecture sparks student
complaints,” Stuff (Last updated 17:02, July 21, 2016: Viewed June
4, 2017). www.stuff.co.nz/national/education/82338738/High-profile-
criminologist-Greg-Newbolds-rape-lecture-sparks-student-complaints.
9. The reforms included: reducing the prison population through diversion,

probation or other community programs; closing large-scale penitentiaries
and reformatories that had become human warehouses (some convict crimi-
nologists favoured smaller institutions, rather than the abolition of the
prison or the broader penal system); better food and clothing within the
prison; “paid institutional employment” for prisoners inside prison; better
vocational training, higher education and family skills programs; giving con-
victs more say in what they needed to “live law abiding lives”; voting rights;
voluntary drug education; “gate money” (a small sum given upon release);
and finally, eliminating the “snitch system” in prison (Ross and Richards
2003, 351–352).
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PART II
Containing Bodies
CHAPTER 5
Patients’ Perspective on Mechanical

Restraints in Acute and Emergency
Psychiatric Settings: A Poststructural
Feminist Analysis
Jean Daniel Jacob, Dave Holmes, Désiré Rioux,

and Pascale Corneau
Introduction and Background
According to the Canadian Institute for Health Information (2011),
roughly one in four patients admitted to a mental health bed in Ontario,
Canada will experience at least one type of control intervention during
their stay—either seclusion, or mechanical, or chemical restraints. More
importantly, the likelihood of experiencing mechanical restraints increases
more than twofold when looking at admissions to general versus psychiat-
ric hospitals in Ontario. These numbers are not to be taken lightly consid-
ering that mechanical restraints are often, if not always, used in conjunction
with chemical restraints and that evidently, their use is commonplace in
current psychiatric practice.
J. D. Jacob (*) • D. Holmes • D. Rioux • P. Corneau

University of Ottawa, Ottawa, ON, Canada
e-mail: jeandaniel.jacob@uottawa.ca; dholmes@uottawa.ca; driou034@uottawa.ca

https://doi.org/10.1007/978-3-319-89749-3_5
94 J. D. JACOB ET AL.
Mechanical restraints are most often used in circumstances where

behaviours are believed to be a threat to the welfare and safety of others
or the individual him or herself. However, the degree to which health care
professionals justify the uses of mechanical restraints in relation to the
perceived beneficial effects expressed by those who must experience them
may very well prove to be quite different. When looking at the existing
(albeit limited) literature that specifically addresses patient experiences in
relation to restraint use, only a few reports of positive experiences can be
found, while most articles point to a generalized negative portrayal of
restraint use (Stuart et al. 2009; Strout 2010). In effect, following a
review of the literature on the experience of being restrained, Strout
(2010) reports that the “division between beliefs about the therapeutic
benefit of physical restraint and the actual perceptions and experiences of
our patients points to a serious gap in our understanding about the poten-
tially harmful effects of this common intervention” (425). As with Strout
(2010), we problematize the fact that current practices with regards to
mechanical restraint remain relatively uniformed by patients’ lived experi-
ence. That is, justification for the use of mechanical restraints makes
abstraction of how patients may feel when they are applied while the need
to control immediate danger to oneself or others supersedes possible neg-
ative repercussions (psychological, physical, and interpersonal) for all
involved in the procedure.
Despite this evident gap in the literature as well as the ongoing humani-
tarian, legal, and ethical issues associated with the application of mechani-
cal restraints in psychiatry (Goethals et al. 2012; Paterson and Duxbury
2007; Strout 2010), there remains a paucity of research focusing on the
lived and embodied experience of mechanical restraints from the patient’s
perspective (Strout 2010). In response to this gap, we conducted a quali-
tative study to look at the phenomenological impact of mechanical
restraints on patients, both men and women (Holmes et al. 2016). The
stated objectives were (1) to gain access to the bodily phenomenon of
being placed in mechanical restraints; (2) to “give voice to” the intimate
experiential understanding and elaboration of this experience through
words and bodily gestures; and (3) through phenomenological interpreta-
tion, to understand the subjective processes and meaning-making of this
experience, a feature that is underdeveloped in the literature (Brocki and
Wearden 2006; Larkin et al. 2006). We turned to phenomenology, and
more precisely Interpretive Phenomenological Analysis (IPA), to foster
PATIENTS’ PERSPECTIVE ON MECHANICAL RESTRAINTS IN ACUTE… 95
the development of health care practices that are informed by those who
experience firsthand the effects of mechanical restraints. More precisely for
this chapter, we focused on the experiences of women and the research’s
emergent gendered discourses of authority in the application of mechani-
cal restraints in psychiatry. By paying attention to and engaging with gen-
dered discourses in the application of mechanical restraints, we touch on a
subject that has only been addressed sporadically in the literature both in
terms of gendered patient experiences, but also in terms of how we come
to understand the use of mechanical restraints as a gendered practice. If no
clear differences can be drawn in terms of restraint use by gender in the
literature, there is nonetheless evidence of gendered differences when
looking at experiences with regards to being restrained (Stuart et al.
2009). That is, while mechanical restraints are generally portrayed as neg-
ative by patients in the literature, regardless of gender, there also seems to
be a distinct theme of re-traumatization (Stuart et al. 2009; Strout 2010),
one that may have different meaning for men and women. Even if re-
traumatization is not gender specific per se, what is being re-experienced
may very well be (e.g., reawakening of distressing and/or abusive events,
flashback to sexual assaults, etc.) (Stuart et al. 2009). In the following
pages, we revisit the results of our qualitative study and turn to poststruc-
tural feminist scholarship to account for the specific gendered experience
of female patients placed under mechanical restraints in psychiatry.
Theoretical Framework
It is well understood that the phenomenological tradition is diverse. For
our study, we focused on the ways that the lived-body and place are con-
ceptualized. Merleau-Ponty (1962) discusses the manner in which the
lived-body (corps vecu) is “geared into” the world through perception;
Heidegger develops a relational understanding of care (1962) and place in
terms of “dwelling” (1971); and more recent work includes distinctly
embodied analyses of medicine (Leder 1998; Nancy 2009), ethics, and
ethical “know-how” (Varela 1999), as well as cognition (Varela et al.
1991). While the literature is transdisciplinary, what remains consistent is
the refusal of Cartesian mind/body dualism. We take up the insights of
this tradition and apply them as an ethics of the body (Shildrick and
Mykitiuk 2005) in the domain of health. Rather than seeking recourse in
the principle of rational autonomy, phenomenology allows us to locate
ethical agency and comportment as relational, incumbent upon the ways

that bodies and places interact and inform one another, to provide “the
structure of subjectivity” (Malpas 1998).
Poststructural Feminist Analysis

A poststructural feminist analysis requires the merging of two different,
yet commensurable, theoretical perspectives (Weedon 1997; Francis
2000): poststructuralism and feminism. On the one hand, poststructural-
ism brings researchers to pay close attention to power relations associated
to discursive constructions. Discursive constructions here must be under-
stood as bodies of knowledge that are reinforced by associated practices
and effects. It is precisely the effects of specific discourses that are of inter-
est when conducting a poststructural analysis so as to move away from
intentions to unearth the power dynamics at play within any given situa-
tion. Poststructural analysis is, therefore, inadvertently political. For our
analysis, engaging with discourses at play in the use of mechanical restraints
enables us to think critically about psychiatric practices and their effects by
focusing on relationships between discourse, social institutions, and indi-
vidual consciousness while concurrently exploring possibilities for change.
As with Francis (2000), we believe that:
Poststructuralist discourse analysis can provide a useful tool in description or

critical research in nursing and other progressive research, and can be
extremely productive in deconstructing formally taken-for-granted narra-
tives and constructions. (26)
On the other hand, feminist theory also brings researchers to pay close
attention to power, but focuses on its capacity to perpetuate unequal rela-
tions between genders. It operates under the assumptions that the multi-
ple dimensions that make up one’s identity (age, racial and ethnic origins,
sexual orientation, gender and sex, class, etc.) cannot be understood inde-
pendently from one another and must take into consideration the socio-
political, historical and cultural contexts within which the individual is
located (McCormick 1997). A feminist perspective, then, takes advantage
of the political vision proposed by poststructuralism insofar as gender
dynamics are explored within relationships between discourses, social
institutions, and individual consciousness while taking into consideration
the workings of power for special interests as well as exploring possibilities
for change (Francis 2000; Weedon 1997). For our analysis, the combina-
tion of poststructuralism and feminism gives us a particular lens through
which we can analyze the experience of women under mechanical restraints
by forcing us to be attentive to the exercise of power and the lived experi-
ence of women.
Gender and Violence Management in Psychiatry: A Question

of Culture?
Part of our poststructural feminist framework necessitates that we look at
the context in which patients are restrained and the inherent power rela-
tions that it fosters in order to grasp the ways in which body, place, and
gender interact. In psychiatry, the management of dangerous behaviours
is very much a question of culture, a culture that is located at the nexus
between therapy and control (Duxbury 2002; Duxbury and Whittington
2005; Morrison 1998). As with Goffman (1990) and Foucault (1995), we
understand this culture to be highly dependent on a series of normative
assumptions, to the extent that health care professionals function accord-
ing to a set of shared values and beliefs that are enacted through specific
procedures and practices (Johnson and Morrison 1993) that are then
taught to new health care providers as the proper way to conduct them-
selves with regards to various situations (Schein 2004). As such, the man-
agement of dangerous behaviours is, to some extent, the product of social
construction where responses (practices) are constituted through cultural
scripts that instruct people on how to determine what is considered dan-
gerous and how to respond to it. Here, the use of mechanical restraints
may be understood as a practice of professional morality that operates
within a disciplinary structure—the psychiatric institution—where we are
reminded of the power ascribed to health care professionals in the man-
agement of patients and their behaviour (Foucault 1995; Goffman 1990).
On the question of culture in psychiatry and the power relations it fos-
ters between nurses and patients, it is imperative that we consider the work
of Foucault (1994, 1995) and Goffman (1990). Foucault has contributed
substantially to our understanding of this “micro-physics” of power rela-
tions and disciplinary structure that operates within psychiatric institu-
tions. Goffman (1990) describes the existing tensions and contradictions
between the therapeutic demands of care and the imperatives of social
control and order that are at the heart of “total institutions,” in our case
the psychiatric institution. In this sense, “health care ‘places’ encompass

[...] normative considerations that reveal, materialize and extend significant
aspects of professional cultures and dynamics” (Lehoux et al. 2007, 1537).
These places of care are inextricably linked to surveillance and c ontrol of
the self and the other, relying on particular models and spaces of care that
organize the work of social agents and the deployment of various practices
(including mechanical restraints) to manage their internal lifeworld.
In psychiatric nursing specifically, the work of Morrison (1990) proves
to be particularly insightful regarding the enactment of a gendered culture
when working with potentially violent psychiatric patients. According to
Morrison, expertise in violence management, or at least, the valued ability
to physically manage behaviours, is a skill that operates within a culture of
toughness. That is, when value is placed on one’s ability to physically han-
dle situations that get out of hand, nurses come to operate within, and
enact a culture of toughness—a culture that incites certain individuals to
align their role with ensuring the safety and security of the unit (authority)
and, as Jacob (2012) argues, serve to reinforce divisive and stereotypical
gendered dynamics in the provision of nursing care.
As Jacob (2012) suggests, having to manage violent behaviour in psy-
chiatry (regardless of the setting) encourages the enactment of stereotypi-
cal masculine traits of physical strength, control, and authority—also
theorized by Holmes (2005) as a process of “virilisation” where “femi-
nine” attributes espoused by the nursing profession (e.g., attempting to
relate, expressing emotions, being flexible, etc.) are suppressed in favour
of adopting an authoritative persona. If not always evident in the face of a
potentially violent situation, nurses fulfil a number of scripted roles pre-
sented in the form of “taken for granted” assumptions associated to gen-
dered attributes—often positioning men at the forefront of physical
interventions (Lawoko et al. 2004). This type of “virilisation” or “mascu-
linization” of care fits well with Bourdieu’s (1998) description of paternal-
istic institutional ways of doing that officialize the domination of one
group (nurses) over another (patients)—where the masculine figure of
authority is deployed to ensure safety and security on the unit. The deploy-
ment of mechanical restraints within such a system of power relations
bring us to rethink gendered vulnerability in psychiatric care—a vulnera-
bility that may very well be lived similarly by all patients (male or female)
given the overarching authoritative culture engrained in psychiatric care,
and more precisely, the management of populations characterized simulta-
neously as risky and at risk. Looking at our results from a poststructuralist
feminist lens forces us to explore the gendered relations inherent in the

use of mechanical restraints and more specifically what it means for those
who must experience their application.
Methodological Considerations
Interpretive Phenomenological Analysis (IPA) is a qualitative method
originally developed for studies in health psychology (Colaizzi 1978; Reid
et al. 2005; Smith 1996, 2004). While it is a relatively new methodologi-
cal approach, in recent years it has become increasingly popular in the
human, social, and health sciences (Larkin et al. 2006; Smith et al. 2009).
The goal of using IPA in the current study is to understand the ways in
which individuals (female patients) perceive the world around them (the
psychiatric unit and more precisely, the use of mechanical restraints) and
make sense of their lived experiences. The study took place at a large
Canadian university-affiliated general hospital, and patients were recruited
from two psychiatric units: a locked acute inpatient unit as well as a locked
emergency psychiatric unit.
Data collection included: (1) 19 in-depth (10 women, 9 men), semi-
structured interviews conducted by the lead researchers and research assis-
tants (graduate students); and (2) gathering and analysis of institutional
documents related to the policies and procedures surrounding seclusion
and restraint. All participants have direct experience with mechanical
restraints, remembered that experience (current or past hospitalization),
and were able and willing to share their experiences. The goal of the data
collection was to consider the ethics of the lived-body and place, and,
through an interpretive phenomenological analysis, to better understand
the daily reality of participants—particularly their understanding of agency,
institutional power, and how they have experienced their relation to place
vis-à-vis their own bodies and others’ bodies with whom they come into
contact during the mechanical restraints episode.
Results: Experiencing Mechanical Restraints

The critical analysis of the data (experiences of women only) highlighted
various dimensions of patient experience with regards to mechanical
restraints, gender, and power; highlighting both (1) negative and (2) posi-
tive reactions to mechanical restraints, as well as (3) environmental dimen-
sions and (4) interpersonal factors/elements (including power dynamics)
of the intervention. The analysis further revealed (5) the expressed needs
of participants placed under mechanical restraints as well as an exploration
of alternatives to this practice. Each of these dimensions will be presented
in the next sections, followed by a discussion.
1. Negative Reactions to Mechanical Restraints

The majority of participants expressed a negative emotional reaction to
mechanical restraints. Although these reactions varied from one person to
the other, feelings of abuse and violation were prominent elements in the
recollection of these experiences. Despite the fact that mechanical restraints
directly target the body and may cause the advent of negative health out-
comes (e.g., bruising, physical pain, etc.), it was clear that the psychologi-
cal dimension with regards to the intervention is equally (if not more)
important to consider.
It was horrible because I felt abused. I felt as if just because I didn’t want to
do something they would grab you and throw you down into this bed and
put you in restraints right away. (P20)
I felt violated … Like we were supposed to be in the healthcare system.
They’re supposed to take care of you right? Because you’re having emo-
tional problems or mental health issues or whatever. Then you see all these
bruises and you call that help? I didn’t call that help. (P21)
Absolutely the worst thing ever in my life … the other thing is at the begin-
ning I wouldn’t actually want to remember that I went through it. So, I’m
blocking that form of memory so that’s why I can’t come up with the right
number [of times mechanical restraints were applied]. (P22)
As with the next participant, the emotions expressed in the last quote
bring us to question the beneficial effects of mechanical restraints on the
mental health of the individual, as very little is done to address the internal
psychological conflict that is experienced by the patient.
It pisses you off, it makes you worse. Restraints don’t make you better, it
controls you, controls behaviour but it doesn’t stop what’s inside you know.
Like it controls behaviours, to fix you, you know, so I don’t think they do
anything to help me you know, maybe the nurses are worried that I’m going
to hurt myself or hurt someone else or whatever, but I don’t think there’s
any productive thing with restraints, nobody wants to be in restraints. (P1)
The violation of the body in the application of mechanical restraints is

further problematized by these next participants who allude to questions
of ethical conduct, personal rights, and the inhumanity in the application
of restraints while concurrently exposing their humiliating effects.
Makes me feel exposed. You know I might be upset or angry or say things
that aren’t appropriate but I don’t know, it’s just like, it doesn’t mean that
I’m not a person, you know? (P1)
Just horrible … I have to keep going by the rules but also then they would
put me in restraints and they said I asked to use the washroom and they said
no, they made it feel like abuse … (P20)
It’s not ethical. No one deserves to be to be struck down … I felt like I
didn’t have that many rights I think the communication was … they may
not have listened to me as per what I would like to have happen. (P6)
People would walk by and look in … Well it made me feel out of place …
Embarrassed, it was embarrassing. (P21)
Emphasizing the impact restraints have on the lived-body and the person’s
emotional state, and as this next participant suggests, understanding the
powerlessness and fright associated with the experience of being mechanically
restrained is exceptionally difficult, unless it is actually experienced firsthand.
I’ve never been physically violated before but if I ever had to imagine what
a nightmare that must be … That’s what it felt like. So, you know, I don’t
know how to relate it if nobody has ever experienced that before. But if you
ever been scared about being so totally beat up or extremely badly violated,
for me, for my personality type, that was the experience. (P22)
As such, the lived experiences of participants placed under mechanical

restraints speak to a deeply personal understanding of the intervention—
one that is relatable only through living the experience itself.
2. Positive Reactions to Mechanical Restraints

The positive nature of the intervention was questioned by most participants,
but was also paradoxically positioned by some as a necessary intervention.
I don’t think it’s a therapeutic way to calm down, do I still think it’s some-
times necessary, yeah. I kind of see it if someone harming themselves or
someone I see where it’s needed I think. (P15)
While negative feelings largely overpowered indications that mechanical

restraints have positive dimensions, some participants did speak of the inter-
vention somewhat positively, even as therapeutic. As with the preceding
quote, the positive experiences conveyed by participants are in terms of safety
and global health trajectory (beyond the actual unpleasant intervention).
I think they kept me safe, I wasn’t safe when I was going off, and, and then
they, I mean in the end it was for my own good but at the same time, like it
can be done in a humane way you know. (P1)
I believe it was last resort and in hindsight I’m glad that it was done because
there was very little physical damage to my person and I needed to be here
… if it were between medical restraints again physical and chemical versus
being on the streets or in a shelter having a manic break, psychotic break, I
would choose the physical restraints and medical restraints any day so, I
mean I see the most supports, I see restraints as support for the staff. (P15)
In cases yes where it’s done for the person’s own safety and other people[’s]
safety yes I’d say it’s very therapeutic as long at times like I mean for me
anyway I know times where I would need it to be a restrained and the times
I’m not thinking clearly at all…. I think it is totally therapeutic I’ve got
nothing against it it’s going to help in the long run it’s not like you’re tied
up for days … I don’t see it as a bad thing, I think for me I think I needed
it at that time. (P2)
The following participant further positions the use of restraints as neces-

sary for health care professionals. In looking at her own experiences and
past behaviour, she comes to express how she would act in similar fashion
if she was confronted with the situation.
I do remember, like 30 years ago, for me to be going around fighting doc-

tors and biting nurses. If it was me at the other end I’d be kicking my ass.
So I do believe in restraints. Like I’ve had them and I know with the way I
get when I’m drinking … I just don’t care whether I live or die but I’ll do
anything to … people are going to have to try to stop me. Then, yeah, I’m
going to have to be restrained so there’s no two ways about that so I believe
in it for medical reasons yes. (P2)
As such, the expressed necessity of mechanical restraints inherently creates

a tension between the felt violations of one’s autonomy while concur-
rently acknowledging its usefulness in clinical situations—a tension that
remains difficult to reconcile.
3. Environmental Dimensions
The physical environment in which participants received care was particu-
larly important when discussing mechanical restraints—addressing issues
of cleanliness, lighting, accessibility, and so on. However, above and
beyond the need for these physical elements to ensure some form of com-
fort, it was the meaning attributed to mechanical restraints as an active
element of the environment that was most striking—bringing about the
experiential dimensions of visibility and punishment. As this next partici-
pant explains, temporarily placed restraints on the bedframe were a con-
stant reminder of their possible use by staff. The negative meaning ascribed
to the visibility of restraints and the possibility of being restrained is sug-
gestive of a certain vulnerability and fear expressed by the patient.
I had mine [mechanical restraints] on my bed for probably a week. Like they
were hanging down from the bed. Well I hated it because like, because I
knew that at any second I could be put in restraints again … (P1)
This vulnerability was further materialized when patients spoke about the
places where restraints were used as having an effect on the experience.
This next participant was particularly vocal about the room where people
are restrained, comparing it to a cell meant for punishment, susceptible of
triggering past memories of assault.
Oh I’ve got plenty to say about the room, the room is a cell … it feels like a
room that has been meant for punishment. If you want to trigger someone
who has a past history of you know … even like ADHD and be put in a
room at school you know … or punished and sexually abused in the church
in the school you know where restraints were used … (P15)
She goes on to elaborate on the meaning ascribed to the room itself, one
that is evidently threatening to patients.
I expect to be treated like shit if I’m introduced to a room that looks … it’s
a room that’s hated by everyone who goes in it, staff and patients alike it
feels like a room that nobody wants to be in. (P15)
This last quote makes the connection between how patients experience
the environmental and interpersonal dimensions, as the participant sug-
gests that it is not only the patients but also the staff that dislike certain
rooms and what is done to and expected of them in those spaces.
4. Interpersonal Dimensions
If the physical environment in and of itself gave way to a specific dimen-
sion of experience, so did the interpersonal dimensions of care associated
to the process of applying restraints. Despite resenting the actual proce-
dure, some participants did report positive experiences with regard to the
care received during the time spent in mechanical restraints. For some,
having a staff member present with the patient during the intervention
was conducive to fostering a therapeutic rapport.
He (orderly) was there and he was helpful I believe I don’t know if he was
lying or not that’s still to be determined but he did sit with me throughout
the experience and having someone there as a friend he did mention that
we’re friends, did help the experience to be more serene. (P6)
The interpersonal dimension associated with mechanical restraints was

most resounding when looking at references to the therapeutic relation-
ship between nurses and patients. For some, the tension is ongoing and
the use of restraints is perceived as a break in the therapeutic relationship.
For others, this tension was temporary. As the next participant explains,
there seems to be a difference between mechanical restraints as a p rocedure
(process and negative experience) and those who must apply them. Here,
the participant expresses trust in nurses, who also engage in care-oriented
work, but fears the restraints.
Researcher: Did you feel like you trusted the nurses after you were being
restrained? Were you afraid of being restrained again?
Participant: Both of those reasons actually. I was afraid of being
restrained again and … I also trusted the nurses. That was a
couple of years ago when I had psychosis … I always felt like
it was going to happen again. And even now as it goes on I
feel now that I can trust the nurses … (P20)
In general, the interviews revealed a certain apprehensiveness on behalf of

the patient when contemplating their relationship with the healthcare staff
after regaining freedom from restraints. Reconciling this relationship proved
to be an important component in providing quality mental health care. In
effect, not only is there a possible need to address the negative emotions
directed at the nursing staff, there also seems to be a need to address other
internal tensions (e.g., feelings of shame) experienced by patients.
Well after that it was obviously awkward, I didn’t want to talk, I was nervous
to talk to that nurse … I felt like oh she probably despises me at this point
like I didn’t want her to be my nurse ever again because … I caused this
huge scene while I didn’t feel like I caused it like maybe both of us caused it
right she wasn’t listening to me at the time to help me and then that’s how
I blew up. (P19)
In hindsight, these next participants spoke to the guilt and related feelings
that patients often experience after the intervention.
I’m able to step back from the experience of being restrained and see it from
you know not so much I don’t see it as a personal affront to my person … I also
would like to apologize to the nurses who were on staff that night … (P15)
I felt ridiculous because I know that they’re only here to help me but I
thought everybody was against me … (P14)
That’s just it I don’t remember much before and really not much after like
I said I felt so guilty about hurting someone when I finally came to and that
I’m glad that’s the only way to control me that they had to control me was
by that restraint I mean it did me no physical harm afterwards I know but if
it kept me from doing harm to others or even to myself at that time it had
to be done, it, there would’ve been no other way you know because I don’t
even know if they could have [...] to put the sedative, right, like in me with-
out restraint somehow. (P2)
Similarly, this next quote identifies how participants appreciated when

these feelings of guilt and embarrassment were taken into consideration by
the nurses in their future interactions with them.
Of course I was embarrassed. And I was, you know, like … that’s not normal
behaviour to have to wake up to something like that and she was very kind
she was very very kind you know she, she didn’t condemn or say anything
against it you know it’s just oh let me get you these and I’ll get you cleaned
up and we’ll get you to bed. (P2)
That said, one element that was particularly evident in the interpersonal
dimension of mechanical restraints was the overt feeling of power imbal-
ance between patients and nurses. Many examples given by participants
revolved around interpersonal conflict where mechanical restraints were
perceived as a form of punishment that, in some cases, affected the thera-
peutic relationship.
In other words it’s like you don’t want to, we’re not having a conversation
you are not following what I’m telling you, you’re not listening to what I’m
telling you and you’re not following my orders therefore I will restrain you,
that’s hardly a way to heal hardly … And trust … Is completely out of the
window. (P22)
She was treating me like I was five, you know I might have a mental illness
but I’m not five. Ok don’t talk to me like I’m a four-year-old you know, and
she does that and, and it’s rude, it’s more personalities that were going to
work together, no. And if she knew that her power was the restraint, “don’t
do what I say … I’ll put you in restraint.” (P1)
As these participants explained, restraints are, in part, a struggle of power

between the patient and the nurses. While some participants spoke of the
need to use restraints for safety reasons, many expressed their lack of under-
standing with regards to why mechanical restraints were applied and associ-
ated the intervention with their non-compliance to an imposed treatment.
I’m not a violent person. I am assertive yes. And I get scared, I assert myself
and people really don’t appreciate that, especially bossy nurses women … I
don’t understand why I was ever shackled. I don’t understand it. There was
no benefit to it, ever … because I refuse to take medication, right. (P23)
They had the ankles too, the wrists and ankles and then you were tied to the
bed and all because I wasn’t complying with the medication, I didn’t want
to take the medication so they called security put a needle inside of me,
restrained me. (P21)
When looking at the effects of the intervention on the patient, there were
a variety of experiences. For some, the aftermath of mechanical restraints
is one of induced docility, reinforcing the need to cooperate with staff.
I felt, well I was mad because I was in restraints, but I felt ok. It could be a
lot worse; I’ve seen a lot worse, yeah, yeah … You know and the nurses get
frustrated and they call a code and throw you in restraint, it mostly happens
to the men but, but you know I’ve seen women put in restraints, I learned
my lesson, you know … (P1)
On the topic of mechanical restraints as being used to ensure collabora-

tion, these next participants go as far as explaining how they are used as a
warning mechanism and even payback for noncompliance with medica-
tion orders or institutional rules.
I think there’s times where it’s needed but I think its overused you know, I
think the nurses are human beings who get frustrated and they pull out their
card their yellow card is the restraint … but for the most part like I think you
could get away without using it I think there’s other ways … I think it’s bet-
ter than it was, but I think it could be better. (P1)
It’s my way. And it’s not just the highway, it’s my way and it almost felt to
me “I’m gonna make you pay” because he didn’t listen to me the first time
around. That is not a conversation. (P22)
When examining the restraining process, there are many ways in which to
acknowledge the power deployed by nurses. However, our data suggest
that while nurses exercise power in the application of restraints, so do the
patients on whom they are being applied in the form of acts or strategies
of resistance. For some, this is best exemplified in the discussion of a
“fight” (i.e., kicking, screaming, etc.) with staff, while for others, it was
the capacity to take control in a “choiceless” situation.
They were rough, they were rough when they put them on me yeah they
were rough. Yeah well they rough you up like they leave bruises all over you
because like I’m kicking away. (P21)
I was trying to fight them off but eight nurses in the room against one per-
son then you know you’re not going to fight them off. They stick a needle
in your right leg right away and it’s like, it’s like you don’t even have a
choice you’re just put to sleep like that. (P20)
If you fight them, see that’s the whole thing (…) you never get your way. So
whatever the nurses want, you know and you never ever, it’s really hard to
get what you want you know, and then your heads butt and then people get
mad at each other. (P1)
In their efforts to make sense of how nurses simultaneously provided care

while also exercising the power to restrain them, patients described the
need to search for alternative methods of care and control that would
move nurses away from using mechanical restraints.
5. Patients’ Needs and the Search for Alternatives

Mechanical restraints fully restrict a person’s physical autonomy—making
patients unable to attend to their physical and emotional needs. One of
those needs is the need for comfort. On the subject, participants spoke of
the (dis)comfort associated with materials involved in restraining patients

(i.e., the beds, the restraints themselves, etc.), their application (tightness)
as well as the environment in which they are applied (e.g., lighting, cleanli-
ness, etc.). On the other hand, they also spoke of (dis)comfort related to
being restrained; that is, the restriction of movement when placed in
mechanical restraints. In the following excerpt, the participant illustrates
her experience when asking staff to increase her comfort.
And I begged them to loosen it, no way, all I asked for was to loosen them,
you know. And I was pissed off enough that I was tied up but the throbbing,
my fingertips were throbbing that means like my blood flow is being cut off
so I begged them … Nothing. (P19)
As expressed in the following quote, the loss of one’s capacity to “make

oneself comfortable,” for example, by going to the bathroom, is particu-
larly distressing and even humiliating.
I couldn’t straighten my leg out, I couldn’t reposition my leg for it to not

be bent and have the plastic digging in so I don’t know if they’re meant to
be physically uncomfortable like a form of punishment but that’s, that’s
what it felt like. (P15)
If you got to go to the bathroom you’re screwed. You know, they give you
a bed pan, you know so you hold it. Literally I just wet the bed, you know I
was like I’m not going in a bed pan for no one, you know. (P1)
As these quotes demonstrate, forcing patients to use a bed pan was a

humiliating experience that some resisted by wetting the bed instead.
While the inability to attend to one’s physical needs due to the restraints
might seem fairly evident, attending to the varied psychological needs in
response to being mechanically restrained is not as easy. During the inter-
vention, patients frequently experience fear, anger, confusion, apprehen-
sion, frustration, irritability, sadness, abandonment, powerlessness, anxiety,
guilt, humiliation, and psychological pain. However, a recurring notion
was that patients desire for staff to act pre-emptively—to help them dees-
calate from their agitated state in order to avoid mechanical restraints. As
one participant states, staff members’ verbal and non-verbal communica-
tion embodied and expressed their frustration with patients, which aggra-
vated the emergency situation.
Yeah try communicating first, see if you can calm them down that way and
then if things escalate and it doesn’t work then you can use the restraints
because you don’t want to be getting hurt and of them hurting themselves
so they are used for a purpose. For my case I don’t know why they were used
… Just speak to me logically, calmly, rationally. (P21)
This quote identifies how participants felt their lack of voice in their rela-
tionships with nursing staff. As this next participant explains, the experience
of being put into restraints is situated in the broader context of negotiating
the ongoing interpersonal relations between healthcare personnel, staff,
and patients. Here, the participant speaks of acceptance and the need to
understand where the patient is at emotionally and psychologically at any
point in time—an individualized, holistic approach that is the foundation
for mutual respect. If the person feels disrespected, then the use of mechan-
ical restraints is experienced as confrontational and punitive. Also, in look-
ing at the quote, we can appreciate the participant’s acknowledgement of
“proper” etiquette in social interaction—positioning her actions as a form
of resistance to a perceived disrespectful authoritative figure.
Because it can be life-saving when used, when coming from a place of accep-
tance for where a person is … and an understanding of how to use a restraint
in a holistic manner, and when it’s used nonjudgmentally and I think it’s
impossible to tease out judgment, one’s personal judgment especially when
you’re wearing a uniform so that can’t always be expected and also from the
patient’s point of view and my own, I’m not going to have respect for some-
one in a position of authority if I have been fucking disrespected before,
screw that, I’m going to use my fucking potty mouth and I’m going to tell
you what you can do with your fucking restraints. Is it okay if I express
myself like that? (P15)
In talking about their experiences, participants highlighted power dynam-

ics that inadvertently exercise some form of limitation on their person, at
times accompanied by paradoxical feelings of necessity and antipathy. In
the search for alternatives, participants highlighted those interventions
that are less restrictive on their personal freedom and autonomy—advo-
cating for better methods of de-escalation, various forms of seclusion, and
physical activity. In brief, by and large, the participants contended that
mechanical restraints ought to be used as a last resort intervention and
never as punishment.
I think they need to talk to you. I think they need to give you your meds and
give you your options and if it’s like a time out in your room, go take some
time, go read a book, go listen to your music, go do whatever, do whatever
you want, just go sit in your room for a while, and if they don’t want to stay
in their room, they can put an orderly at the door … (P1)
Yeah, I think both patients and staff would be, find it’s easier with the seclu-
sion room just because it requires less staff to monitor … it’s less painful for
the patient … and they have a nice comfortable room they can stay in and then
leave them time to calm down where they can move around in a room. (P7)
A key message conveyed by participants was the clear need for flexibility
in approaches to care. Although experiences varied greatly, the physical
grasp on the body seemed to be at the center of expressed discontent with
the use of mechanical restraints, positioning it as the most extreme inter-
vention on a continuum of control measures used in psychiatry. This can
be especially traumatizing for women with histories of abuse and trauma,
as one participant highlights in her discussion of having her clothes cut
off of her.
I didn’t want them to touch me. I don’t I don’t like it when, you know,
personal space … I need my personal space. I think that the situation
could’ve been dealt with in a better manner to decrease the amount of viola-
tion that I felt. I don’t think anybody wants to be chained to a bed and then
have their dress cut. (P6)
Although we may think of “alternatives” to mechanical restraints in the

form of specific interventions, participants spoke primarily of the interper-
sonal dimension to alternatives and the need to increase de-escalation
techniques, which emphasizes nurses’ expertise and capacity to persuade
patients to calm themselves and to adopt certain behaviours.
I didn’t feel that was right, they could have taken other measures. They
[could have] calmed me down first and then convinced me to take it … (P21)
As expressed above, the notion of time (explicit or implied) is an interesting

finding in participant discourses; that is, if less constraining interventions
were proposed as preferred modes of intervention, they were nonetheless
repositioned in a context that accounted for the time required for their
application. As expressed by this next participant, the notion of time was

most commonly presented as a perceived lack of time on the part of nurses
to actually engage with patients.
I think you know, I think if the nurses had a little more time to talk to people
… Like you can’t, and you can give them medication and it’s their job to like
figure out how to get the medication in them, and I know they’re going to
say well we can’t make them take it, ok but it’s true you can’t make them
take it, but if you’re a generally good nurse, you can make anybody take
anything, you know … (P1)
Participants emphasized their desire for nurses to mobilize their power in

ways that stress their caring role rather than their coercive or oppressive
one, noting in particular that nurses be able to spend more time with
patients as a way to build trust rather than relying on more overt exercises
of power by way of mechanical restraints. This narrative points to the
dynamic interplay between power, gender, and the use of mechanical
restraints.
Discussion: Power, Gender, and Mechanical

Restraints
The use of mechanical restraints in psychiatry should be a last-resort inter-
vention (Muir-Cochrane and Gerace 2014; Riahi et al. 2016) and is equiv-
alent to an intensive care situation. Associated with such an intervention
are the multiple contextual elements (i.e., the physical environment, the
patient-staff relationship, and the attendance to patients’ needs) that can
potentially alter, for better or worse, a patient’s experience and health out-
comes. As with current literature on the subject (Riahi et al. 2016; Strout
2010), we found that participant experiences of mechanical restraints were
mostly negative. However, the negative experience did not completely
negate the necessity of the intervention. In effect, some participants did
express some utility to the use of mechanical restraints in psychiatry,
namely for safety reasons. What is particularly interesting for this discus-
sion are the gendered power dynamics at play in the mechanical restraint
process.
Place and Power
In psychiatry, we must consider the fact that patients interact in an envi-
ronment that is rife with significance. As with the results of our study,
place (in terms of the environment associated with the use of mechanical
restraints) proves to be particularly meaningful for participants. That is,
the location where restraints were situated, their visibility, and the mean-
ing ascribed to their presence inevitably shaped the way mechanical
restraints were experienced. As with McGrath and Reavey (2013), we
understand the place of mechanical restraints as an active element in the
production of experience. The fear induced by the presence of restraints
on bedframes or the room where the intervention took place was a con-
stant reminder of the possibility of their use that operated to modulate
individual behaviour. By exploring the links between place and the effects
it has on individuals, we can expose the ways in which power is embedded,
produced, and reproduced in practices of care (Holmes and Gastaldo
2002). In this study, we found that above and beyond the safety and secu-
rity discourse, the visibility and uses of mechanical restraints embody the
authoritative (masculine) psychiatric culture and remind us of gendered
institutional practices that officialize and operationalize the domination of
one group (nurses) over another (patients) (Bourdieu 1998).
In effect, our data allow us to speak of gendered institutional practices
and to move away from considering the practices enacted by specific male
actors in which overt oppression of women may be identified; instead, we
considered the interplay of structural elements in producing gendered
forms of oppression. We turn to gendered institutional practices as a way
to highlight how gendered authority goes beyond face-to-face interac-
tions between men and women and has infiltrated the very structure of the
psychiatric environment to the point that it has become commonplace and
unquestioned. Gendered institutional practices must therefore be under-
stood as part of those structures (interventions, policies, etc.) that embody
an authority that (re)produces imbalances of power and, in the process,
oppresses certain individuals and groups. In other words, the experiences
conveyed by participants and the meaning they ascribed to these experi-
ences help us rethink the assumed neutrality of institutional practices and
question their underlying logic: it exposes a dispositif. In this case, looking
at the experiences of women with respect to mechanical restraints from a
postructuralist feminist lens enabled us to give a voice to those who expe-
rience restraints and, in the process, offer an alternative narrative. It also
helped us uncover an underlying gendered dynamic in the provision of

psychiatric care. Turning our attention to gendered institutional practices
rather than the immediate dynamics between men and women help us
rethink gendered vulnerability in psychiatric care to the extent that this
vulnerability may very well be lived similarly by all patients, both men and
women.
Power, Gender, and Environment

In the context of our study, the way place and power intersect is perhaps
most evident in the hierarchical structure that shapes nurse-patient dynam-
ics. A distinct aspect of the results addressed the perceived imbalance of
power between nurses and patients in the mechanical restraint experience.
If mechanical restraints prove to be necessary for safety reasons, it was
equally perceived as a punitive intervention for not complying with treat-
ment. Coupled with the visibility of the intervention and its perceived
disciplinary function, such an experience proves to be extremely insightful
in terms of nursing care. As with other forms of restrictive (control) mea-
sures, when mechanical restraints are perceived as a form of punishment to
ensure compliance, psychiatric nurses are equally perceived as exercising a
form of sovereign power (Jacob et al. 2009)—an arbitrary application of
power deployed to reinforce authority. As with Morrall and Muir-Cochrane
(2002), we come to realize that coercion is an “indelible part of nursing
practice” (8) in psychiatric care, one that is legitimized by a safety and
security discourse. What is problematic and necessitates further reflection
are the perceived uses of mechanical restraints as interventions to facilitate
adherence to a “therapeutic” agenda (compliance) and reinforce author-
ity. In effect, it is exactly when such practices are elevated to the level of
therapy and form a specific type of nursing expertise in the management
of behaviour that gendered power relations becomes evident, not so much
to highlight the specific experiences of women, but rather to expose
dynamics that affect a whole group of patients.
As Jacob (2012), Holmes (2005), and Morrison (1990) suggest, the
management of violence encourages the enactment of stereotypical mas-
culine traits of control and authority where feminine attributes espoused
by the nursing profession (attempting to relate, expressing emotions,
being flexible, etc.) are suppressed in favour of adopting an authoritative
persona. In looking at the results, it is precisely these “feminine” attributes
(flexibility, empathy, communication, and comfort) that were expressed as
necessary by participants. In effect, participants’ perceptions of the thera-

peutic relationship and need for communication with their nurse prior,
during, and after being placed under mechanical restraints cannot be
ignored. As the results suggest, patients may very well feel conflicting
emotions directed at both the staff who participated in the restraining
process, but also themselves in reflecting on what transpired during the
intervention. If not evident, the results of this study suggest a need to
think about the approach to care during these interventions—a call to “re-
feminise” the care to vulnerable patients in an environment that often
promotes divisions. This call is in keeping with the emerging literature on
trauma-informed care where one must consider both the trauma the
patient has experienced and the possible traumatic effects of interventions
(Hall et al. 2016). As expressed by participants, the need to make time and
address patients in a holistic manner is of great importance and if restraints
must be applied, constant attention must be provided to ensure that both
the patient’s physical and psychological needs are met.
Emergency situations requiring the use of mechanical restraints is often
a spontaneous event occurring in an agitated climate. Hence, as the results
of this study suggest, it is likely that other patients on a psychiatric ward
bear witness to the use of mechanical restraints. In such a case, if no effort
is made to consider the traumatic experience for the patient(s) involved in
the mechanical restraint experience, it is likely that it will continue to be
experienced as a distressing show of force, rather than an exceptional
intervention to ensure the safety and security of all.
Conclusion
In psychiatric settings, nurses are continuously navigating between care
and control. The use of mechanical restraints continues to exist despite
little evidence of its safety and effectiveness. The overarching purpose of
this chapter was to shed light on the lived experience of mechanically
restrained (women) patients hospitalized in psychiatric settings (acute psy-
chiatric care unit and psychiatric emergency unit) in order to explore gen-
dered power relations in psychiatric care. While this chapter focuses
specifically on the experience of women who have been restrained, it
would seem that mechanical restraints operate in a system where authority
is embedded in psychiatric practices and likely to affect all who are in con-
tact with this setting, men included.
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Blackwell.
CHAPTER 6
Carceral Optics and the Crucible

of Segregation: Revisiting Scenes of State-
Sanctioned Violence Against Incarcerated
Women
Jennifer M. Kilty
Introduction
The cultural turn in criminology is intimately tied to examining the role
the visual plays in the (re)production of normative discourses about crime
and (in)justice (Hayward 2009); it is of no surprise, then, that visual
criminology has emerged as a critical analytic field in the broader disci-
pline. Over the last decade, key scholars (Brown 2014; Brown and Rafter
2013; Carrabine 2012, 2014) have noted the importance of visual analy-
ses in social research and have attempted to generate a methodological
orientation toward the visual that enables a socio-political analysis of the
construction, representation and framing of images, what Young (2005,
2010, 2014) describes as “criminological aesthetics” and a kind of “aes-
thetic politics” and Carrabine (2012) considers in terms of “aesthetic
J. M. Kilty (*)

https://doi.org/10.1007/978-3-319-89749-3_6
120 J. M. KILTY
e thics”. The goal of this work moves beyond constructivist analyses that
examine image content and what crime images “mean” by way of studying
what is and is not depicted, toward trying to understand the mechanics of
how images work upon us so that we can begin to consider “how we
watch” (Bennett 2005 in Young 2010, 2). This position demands that we
consider our role as spectators in the (re)production of images and thus
our individual and cultural affective investment in certain images, espe-
cially when considering scenes of violence.
In this chapter, I draw heavily from Alison Young’s work on haptic
spectatorship developed in her book The Scene of Violence. Young contends
that crime images make us feel something—they elicit “sensation in our
bodies and memories as we watch” (2010, 2) by stimulating affect and
accompanying emotions (i.e., fear, disgust, anger, sadness, pleasure, ela-
tion, etc.) and gestural cues (i.e., sighing, wincing, turning away, lip purs-
ing, jaw dropping, covering one’s mouth or eyes, etc.). In this way, we
examine how “mediated processes of visual production and cultural
exchange now ‘constitute’ the experience of crime, self and society”
(Hayward 2009, 5). This work entails questioning “how we identify with,
in and as the illicit and the legitimate” as represented in the crime-image
(Young 2010, 2–3).
To emphasize affect, then, (and to do so in a way which does not see affect
as simply “emotion”) is to start from a position which acknowledges that
crime connects bodies known and unknown through the proliferation of
images. The connection might be a minor or substantial interruption to
one’s sense of the proper, or a reinforcement of one’s view of “the state of
society today”, or an experience of the exhilaration of illicit behaviour.
Whatever the case, crime as image connects bodies through affect. (Young
2010, 10)
To experience the cinematic image in this way creates a kind of relation-

ship between the image and the spectator that is felt in and through the
body via sight, sound, tactility, affect and memory. Specifically, Young asks
how “the body of the spectator register[s] sensations relating to what she
is seeing without undergoing or having undergone what is depicted?”
(2010, 9). This corporeal and affective relationality with the visual is the
basis of Young’s notion of haptic spectatorship, which commands that we
engage not only in a thematic analysis but also in a “scenographic analysis”
in order to “ask how the scene of violence works to establish how a
moment of desire [for revenge, justice, accountability etc.], with all its
CARCERAL OPTICS AND THE CRUCIBLE OF SEGREGATION… 121
affective and ethical implications, is experienced by the spectator within

the scene” (Young 2010, 24). In this approach, viewing violence is not
simply a matter of looking or of watching passively, but rather of actively
seeing and feeling in order to critically consider and offer judgement
regarding how we as spectators are implicated in the affects and aesthetics
of violent cinematic images (24).
To develop her approach for examining haptic spectatorship, Young
uses the medium of film to focus her analytic work, which she suggests is
unique as a cultural form in that it deploys an image that “is always more
than visual: a medium which is always image, sound, affect, memory, plot,
episode, character, story and event” (2010, 5). In this chapter, I too exam-
ine film—however, I examine nonfictional correctional videos of scenes of
violence that were committed by state agents against incarcerated women
in Canada. There is a long history of prison/asylum-genre television and
film productions that portray different forms of violence in these institu-
tional sites (i.e., prisoner-on-prisoner; guard-on-prisoner; and even medi-
cal professional-on-prisoner as iconized by the Nurse Ratchet character in
One Flew Over the Cuckoo’s Nest). Yet, we rarely get the opportunity to see
film shot inside operating prison sites; even prison documentary television
shows like MSNBC’s Lockup series are produced like reality shows in that
only certain areas of the prison are shown, certain prisoners are selected by
staff for participation, and certain events are prohibited from being filmed
(Brown 2009). Instead, in this chapter I engage with ‘real reels’ of carceral
violence—those not filmed for public consumption and spectatorship—
but rather for legally required documentation purposes and internal insti-
tutional review and oversight. While fictional and nonfictional films are
created with the haptic spectator in mind and aim to produce certain emo-
tions and feelings through different scenes, camera angles and narratives,
I suggest that the authenticity of the images elicits affects that linger and
lead to political calls for action in ways that Hollywood film productions
may not.
By analyzing correctional videography that captures scenes of violence
in Canadian prisons in real time, I suggest that we are better positioned to
consider the aesthetic politics of visual representations. How do these real
scenes of violence foster affective reactions in the spectator? What does the
spectator register in their body when watching women being shackled,
stripped and isolated—in one case, by male officers? What is the specta-
tor’s corporeal affective relationality with the video imagery of a woman
tying a ligature around her neck that is filmed by a correctional officer just
122 J. M. KILTY
outside her cell door (as well as by the 24-hour closed-circuit television
camera (CCTV) that is in her segregation cell), when realizing that she is,
in fact, dying before their eyes? Young spends considerable effort examin-
ing the ways in which the affective encounter invites the spectator to see
the illegitimate as legitimate (for example, by way of the rape-revenge
scene), in order to show how we take pleasure in violence that we might
on a moral, ethical or political level oppose and abhor. Instead, I consider
how the affective encounter invites the spectator to see the legitimate as
illegitimate, which inevitably calls us to political action. Young contends
that it is in these moments—when watching scenes of violence that are
distant to us and outside of our material experiences that the affective
encounter with violence becomes proximate for the haptic spectator. I
build on this thesis and argue that as these scenes of carceral violence
become proximate, they also become spectral, and that it is the experience
of feeling haunted by the images and scenes of violence that becomes the
foundation and motivation for political action (aesthetic politics).
In what follows, I situate myself as a haptic spectator to study the cor-
rectional videography of two high-profile cases of state-sanctioned acts of
violence committed against federally incarcerated women in Canada—
namely the 1994 “events” at the now closed Kingston Prison for Women
(P4W) and the 2007 carceral death of 18-year-old Ashley Smith. These
cinematic scenes of violence were never meant to be seen by the public; in
fact, the Correctional Service of Canada (CSC) was unsuccessful in secur-
ing a court order to prevent the media from airing clips from the correc-
tional video footage in both cases. Following Young (2010, 5), I review
the footage as aired on three episodes of The Fifth Estate1 to consider the
affective relationality engendered by the images, sounds, affects, memo-
ries, plots, episodes, characters, stories and events in the two cases. To set
the stage for the visual analysis, I begin by reviewing the state of federal
corrections for women in Canada today, emphasizing segregation prac-
tices, and I outline the general facts of each case. Then I move on to dis-
cuss the impact of simultaneously being seen and “disappeared” by
correctional surveillance technologies as this pertains to both segregated
prisoners and the correctional staff who guard them. In the third section,
I consider the ways in which women’s methods of resistance while iso-
lated evoke violent correctional efforts to try to curb that resistance and
reclaim control of the prisoner. In the final section, I argue that aesthetic
politics involves more than the distant images becoming proximate for
the haptic spectator—they must become spectral—and that it is their
haunting a /effect that mobilizes calls for political action, prison reform
and justice for the incarcerated women that were victimized in these
scenes of violence.
Madness Contained: Self-Injury, Segregation

Practices and Correctional Videography
Despite the fact that the proportion of women serving long sentences for
more serious violent crimes has remained consistent over the years, feder-
ally sentenced women in Canada are increasingly designated as high risk
on the custody rating scale and are therefore housed in medium and maxi-
mum security cells. Between 2003 and 2013, the number of women
housed in minimum security decreased from 56% to 44%, while there was
a 47% increase in the number of women housed in medium security, and
a 53% increase in the number of women in maximum security (CSC 2013).
Women in medium security are three times more likely than men to be
convicted of an institutional offence (Harris et al. 2014), which corre-
sponds to significantly more time spent in administrative segregation for
periods of 15 and 30 days (Motiuk and Hayden 2016). As Hannah-Moffat
(2001) has long argued, criminalized women’s needs are largely inter-
preted as risks; it is unsurprising, then, that 83% of women are identified
at admission to custody as having a moderate or high need in the per-
sonal/emotional domain yet they are simultaneously housed in higher
security levels where access to programming is limited (CSC 2013).
From 2005 to 2015, the number of women in federal prisons increased
by more than 50% (compared to less than 10% for men over the same
period), which led to a 10.7% increase in the use of double bunking.
Similarly, over the past five years, women’s admission to segregation
increased by 15.8%, uses of force increased by 53.5% and self-injurious
incidents increased by 4.6% (OCI 2015). All of this is exacerbated for
Indigenous women, who now make up 35.5% of women in federal cus-
tody, are more likely to be classified as maximum security and who made
up almost half of all admissions to segregation in 2014–2015. Over the
last ten years, use of force incidents against Indigenous women more than
tripled and their rates of self-injury are 17 times higher than for non-
Indigenous women (OCI 2015; Sapers 2015).
Until a December 2017 judicial decision in BCCLA and JHSC v. AG of
Canada, the standard correctional policy response to self-injurious behav-
iour was to strip-search the prisoner (to ensure she does not have any
124 J. M. KILTY
items on her person with which she may harm herself) and to admit her to
administrative segregation where she can be more closely monitored via
24-hour-a-day CCTV surveillance. Despite the fact that the conditions of
confinement are exactly the same in administrative and disciplinary segre-
gation (it is a difference only in status), the CSC claims that administrative
segregation is non-punitive; it is well documented that incarcerated
women interpret admission to administration segregation as a form of
punishment (Kilty 2012; OCI 2013). Women in administrative segrega-
tion are locked in their cells for 23 hours a day, with only one hour per day
to shower and walk around a tiny individual caged yard; they also have no
access to programming. Contact with staff only occurs when guards slide
meals through a slot in their cell door and when a nurse or the warden
check on them once a day via a conversation through the meal slot/
cuffport.
1994 Events at the Kingston Prison for Women (P4W)

On April 22, 1994, a very brief but violent confrontation took place
between six women at the P4W and correctional staff. The women were
placed in segregation cells, where they would remain for nine months, and
criminal charges were laid against them (five pleaded guilty). Two days
later, three women who were already in segregation when the six women
were brought in, variously engaged in self-injury, took a hostage and
attempted suicide. On April 26, correctional staff demonstrated outside
the prison, demanding the women involved in the April 22 incident be
transferred to another institution.2 The women could hear and see the
demonstration from their cells. That evening, Warden Thérèse Leblanc
called in a male Institutional Emergency Response Team (IERT) from
Kingston Penitentiary to conduct cell extractions and strip searches of
eight women in segregation, the six who were involved in the April 22
incident and two others, to search for weapons. Following policy require-
ments for when the IERT is deployed, the cell extractions and strip
searches were videotaped. These events lasted upwards of six hours; after
it was over, the eight women were left in empty segregation cells wearing
nothing but paper gowns, waist-hand restraints and leg irons. The next
night, seven of the eight women were subjected to body cavity searches on
the concrete floors of their cells (Arbour 1996).
Ashley Smith
At the age of 15 Ashley Smith was sentenced to one month in juvenile
custody for throwing crab apples at a postal worker in Moncton, New
Brunswick. While in custody, she accumulated numerous institutional
infractions, predominantly for self-injurious behaviour and resisting cor-
rectional guards’ efforts to subdue her (at times violently or by spitting
or throwing urine), which resulted in so much additional time to her
sentence that she ended up spending nearly three years in custody for
this minor index offence. She spent the vast majority of this time in isola-
tion. When she turned 18, an appeal was made for her to be transferred
to the adult federal correctional system, where it was believed she would
receive better access to mental health treatment and programming.
Smith continued to cut herself and to tie ligatures around her neck and
was subsequently housed in segregation for the duration of her time in
federal custody (11.5 months). Federal correctional staff used force
against Smith in more than 150 incidents and she was repeatedly tasered,
pepper-sprayed, strip-searched, forcibly removed from her cell, involun-
tarily injected with psychotropic medications and physically restrained in
the WRAP3 and the Pinel Board4 (Sapers 2008). The IERT was deployed
on several occasions to subdue her and prevent her from harming herself.
Similar to the events at P4W, all of these events were video recorded.
Ashley Smith died on October 19, 2007 while in segregation at the
Grand Valley Institution for Women; she asphyxiated from a hand-fash-
ioned ligature she had tied around her neck while correctional staff
filmed her from just a few feet away in the hall outside her cell, having
been instructed not to enter her cell on such occasions until she had
passed out.
On Being Seen and Disappeared

It is well documented that time in isolation in what Guenther (2013)
describes as the “control prison” leads to mental health distress and long-
term psychological harm for both male and female prisoners (Haney 2003,
2008; Rhodes 2004; Shalev 2009). Guenther’s (2013) treatise on solitary
confinement as a form of social and living death captures the ways in which
isolation causes prisoners to become ‘unhinged’:
126 J. M. KILTY
Solitary confinement deprives prisoners of the bodily presence of others,

forcing them to rely on the isolated resources of their own subjectivity, with
the (perhaps surprising) effect of eroding or undermining that subjectivity.
The very possibility of being broken in this way suggests that we are not
simply atomistic individuals but rather hinged subjects who can become
unhinged when the concrete experience of other embodied subjects is
denied for too long. (xii)
In this way, prolonged isolation works to dissolve our sense of self and our
sense of being-in-the-world, which is “structurally undermined by condi-
tions that do not allow for a mixture of contact with withdrawal in relation
to other living beings in a shared but open-ended space” (Guenther 2013,
153). Lacking touch, relationality with others and a social and kinship
support network, the isolated prisoner struggles to give meaning to their
life. While prisoners in segregation have access to the most basic require-
ments for survival (i.e., food, water, shelter), isolation inhibits their ability
to relate to others in a meaningful way, which threatens their sense of self.
Ironically, at the same time that the segregated prisoner is permanently
isolated, deprived of sensory stimuli and cannot see, touch or relationally
communicate with others, they are simultaneously hyper-visible. Living a
caged life on 24-hour-a-day CCTV monitoring, prisoners in solitary con-
finement are constantly seen by unseen others. They are anonymous
bodies,
… in that they are reduced to nameless, faceless existence in which they are
constantly reminded that they do not matter to anyone. But they are also
denied access to anonymity, in that they are unable to slip out of place, to
withdraw from the fixity of any given place, from their eight-by-ten cells,
and to withdraw from the meanings attached to those cells: “the worst of
the worst,” “beyond rehabilitation,” “a hopeless case,” and so on. (Guenther
2013: 153)
In this sense, isolated prisoners are “disappeared” (165) to a shadowed

existence that drains their lives of affective, social and relational meaning,
“like they are dead within life, no longer of space but merely in it” (175).
Figures 6.1 and 6.2 provide visual evidence that helps to demonstrate
this paradox of hyper-visibility/invisibility that occurs in segregated
spaces of solitary confinement. The images also demonstrate the hierar-
chical power-relations between prisoners and staff that constitute the
groups as oppositional.
Fig. 6.1 IERT pushing naked woman to the wall with Plexiglas shields
Fig. 6.2 Smith blurring the CCTV camera in her segregation cell before she died
Figure 6.1 is an image still from the videotaped recordings of the all-
male IERT that was called in to conduct cell extractions and illegal strip
searches of eight women in the Kingston Prison for Women in April 1994.
The individual identities of the IERT remain anonymized, their faces hid-
den from view by their riot gear, which includes a black hockey-style
128 J. M. KILTY
elmet with a full facial mask that maintains the physical and emotional
h
separation between prisoners and staff by preventing not only identifica-
tion but also eye contact. If we accept Young’s contention that “the gaze
of the victim can be unbearable to the assailant” (2010, 43), then prevent-
ing the penetration of that gaze by way of the masked helmet would make
it easier for IERT staff to commit their acts of violence.
The video is grainy, not only giving the content and already dark and
cold environment a particularly seedy quality, but also somewhat muffling
the sharp cracking sounds of the IERT hitting their batons against the
concrete walls beside the women’s heads in an effort to keep their atten-
tion and silence them as they try to warn one another to comply rather
than resist. These piercing clangs make the women, and by extension the
proximate spectator, wince and jump with alarm. The stark visual contrast
between eight naked and shackled women and their masked assailants cov-
ered head to toe in militarized riot gear is affectively dissociating and illus-
trates the intense degree to which segregated prisoners are denied
anonymity and how the bodies of incarcerated women are displayed,
gazed upon and manipulated at will by institutional authorities. It also
showcases how much of their relationality is confined to violent encoun-
ters with staff members that use force to reclaim control of them when
they are thought to be unruly. On this point, it is important to note that
while there was a violent confrontation between the women and staff four
days before the cell extractions and strip searches, at the time the IERT
were called in the women were fast asleep in their cells.
Figure 6.2 is an image still from the CCTV camera footage of Ashley
Smith in her segregation cell taken minutes before her death. It shows
Smith standing on the wall-mounted metal toilet that is typical of most
prisons and using a small tube of lip balm to blur the CCTV camera lens.
This act effectively demonstrates how well she understood her simultane-
ous hyper-visibility to correctional staff yet invisibility in terms of the rela-
tional connection that is required in order to feel as though one’s life
matters. The one-way gaze of the CCTV constituted Smith as an object
of carceral observation and chipped away at her subjectivity. The sparse-
ness of the cell is visible behind her; it contains nothing but a small cot
and the metal toilet and sink. There are no books, papers, clothes or other
personal items. Smith is wearing only a hospital gown, no bra and no
shoes—items that the CSC claimed she could use to harm or strangle
herself. In her effort to try to create a more private space and to block the
all-pervasive correctional gaze, the image positions the haptic spectator as
an unforeseen voyeur, squirming uncomfortably from their access to such

an intimate view. The image resonates the barest of existences, one that
conjures the social death of its inhabitant by way of intense and perma-
nent exclusion that in practice does not just exclude but also dominates
and humiliates the individual to the point that,
… the social dead may be subject to explicit disregard and disrespect, but
also to casual indifference; they may appear as abject others whose constant
threat of pollution helps reinforce the boundaries of the social world, or they
may not appear at all. This invisibility does not diminish the intensity of
social death; rather it may intensify it. (Guenther 2013, xxiii)
Smith felt her invisibility and social death deeply, expressing in a journal
entry that she felt her life did not matter and had no meaning; she described
how acutely she felt the pains of sensory deprivation, writing: “Most peo-
ple are scared to die. It can’t be any worse than living a life like mine”
(cited in Richard 2008, 23). There were few available avenues for Smith
to attempt to transcend the carceral power relations that bound her to this
liminal existence and like so many prisoners in solitary confinement, she
turned to self-injury (OCI 2013; Rhodes 2004; Sapers 2008; Shalev
2009). Cutting and tying ligatures were often the only ways she could
secure some form of physical contact with correctional staff, and although
these encounters were violent they were a way to experience relationality
with the only people with whom she interacted. In the next section I turn
to examine the violence inherent in these encounters as correctional staff
try to curb women’s strategies of resistance to being disappeared.
“Don’t Make Us Come in There!”

Humans are relational beings and need intercorporeal connection to pre-
vent the solitary subject from becoming unhinged (Guenther 2013).
Problematically, in both the P4W and Smith cases incarcerated women
were segregated for illegal periods of time. The women in P4W were
housed in segregation for nine months following their cell extractions and
strip and body cavity searches and Ashley Smith spent the entirety of her
11.5 months in federal custody in segregation after spending much of her
three years in youth custody completely isolated (termed therapeutic-
quiet) (Arbour 1996; Richard 2008; Sapers 2008). In response to these
experiences in solitary confinement, Smith and a number of the women in
130 J. M. KILTY
P4W engaged in self-injurious behaviour and other resistant practices,

including the destruction of CSC property by flooding their cell toilets
with their bedding and dirty protests (i.e., flinging urine through their cell
bars or the food slots in their cell doors). These practices, while disturbing,
are not unique (Rhodes 2004; Shalev 2009); they signify how for isolated
prisoners under constant surveillance, “the cuffport becomes both a
mouth and an anus, a site of possible interchange for the prisoner whose
full participation in an intercorporeality has been blocked” (Guenther
2013, 187).
As such, we must consider these resistant practices to be relational
statements, evidence of the women’s attempts to exemplify their very exis-
tence in a space where they are disappeared—where they are always seen,
but do not see out and are not heard. Ironically, these acts committed in
response and in resistance to the women’s experiences of social death
result from the very isolation that institutional authorities invoke to try to
manage risk in the control prison. Therefore, correctional practices and
standard operating procedures sustain and/or contribute to the creation
of the very behaviours that they are mobilized to try to restrict and elimi-
nate. In both cases, incarcerated women experienced violent intercorpo-
real relations with correctional staff on numerous occasions in response to
their acts of resistance. These state-sanctioned acts of violence consisted of
physical cell extractions, strip and body cavity searches, and in Smith’s
case, pepper spray, tasering and forced injections of psycho-pharmaceuti-
cals. Figures 6.3 and 6.45 provide visual evidence of some of these violent
encounters.
Figure 6.3 depicts six correctional guards holding Smith’s limbs down
so that a nurse can inject her with psycho-pharmaceutical medication to
sedate her. Watching so many guards struggling to hold the limbs and
body of one young woman in place so that they can forcibly inject her with
psychotropic medication that will make her drowsy and docile so that they
can place her in physical restraints makes the spectator squirm, feel anxious
and hold their breath with the hope that the violence will end quickly.
Figure 6.4 is an image taken from another video of Smith in a different
institution that shows her after she has been physically restrained in the
WRAP. The title of this section, “Don’t make us come in there!”, is a
direct quote from the video. Prior to extracting Smith from her cell, cor-
rectional staff can be heard threatening her with what will happen if she
fails to comply with their request to return an item she was using to harm
herself and if she does not put her hands through the meal slot in the door
Fig. 6.3 Smith receiving involuntary chemical injection
Fig. 6.4 Smith in the WRAP
so they can cuff her before entering. The video is expressly voyeuristic, the
opening frame filming Smith through the small window in her cell door
and proceeding to show guards entering the cell to physically subdue and
bind her in this oppressive form of restraint. At one point, once Smith is
132 J. M. KILTY
bound in the WRAP, you can hear her begging in a small little girl voice
to be released because she “pissed [her]self two hours ago.”
For the spectator, watching an 18-year-old girl pace a segregation cell
and be threatened with violence by her captors for continuing to harm
herself elicits frustration, despair and shock that this outcome could result
from throwing crab apples at a postal worker as a youth in Canada.
Watching trained federal correctional officials refusing to remove the
WRAP to allow a young woman to urinate, instead forcing her to sit in her
urine for several hours, is unnecessarily cruel, appalling and degrading.
That these practices are standard operating procedure prompts Young’s
(2010, 149) question regarding what the implications for justice might be
when there is no satisfactory conclusion (i.e., the criminal is apprehended
and punished) and “procedure is all there is.” If these actions reflect legiti-
mate state-approved correctional procedures, the images encourage us to
question in what contexts we as spectators will come to identify with the
criminal and see their actions as understandable and thus to see the legiti-
mate as illegitimate. I suggest that the video images in both cases lead the
spectator to identify with incarcerated women despite their criminal status;
to feel disgust at their conditions of confinement, horror by the force and
restraint used against them by state agents, and to long for their privacy,
for the return of their clothing and humility and for justice in response to
the violence they were subjected to by federal government employees. In
effect, these crime-images challenge the spectator’s view of who is criminal
and who is victim. In this way, the videos problematize normative crime
drama tropes about law and order by depicting the materiality of carceral
existence. Instead of relishing the pleasure of punishment, such as that
which is evoked by revenge thrillers, the spectator of these ‘real reels’
empathizes with the criminal subject rather than the correctional person-
nel and begins to question the validity of state sanctioned forms of
punishment.
In the final section I turn to consider the ways in which women segre-
gated in solitary confinement “find themselves haunted by a past that can-
not be undone and that may return obsessively to dominate the present
and drain the future of hope” (Guenther 2013, 200) and how proximity
to their violent encounters with correctional staff by way of the crime-
images in these correctional videos come to haunt the haptic spectator and
mobilize them to action.
Haptic Penal Spectatorship and (Secondary)

Haunting
The crime-images from these two cases were triply looked at: by the cor-
rectional staff filming the actions taken against the women in real time and
who watched at a distance via CCTV footage, by correctional administra-
tors and bureaucrats who reviewed the videos for institutional oversight
and by the public spectator watching The Fifth Estate episodes. There are
two important effects of these forms of spectatorship. First, the haptic
penal spectator disrupts the victim-perpetrator dynamic that expects crimi-
nalized women to be volatile and violent so as to justify the violence per-
petrated against them by state agents. Second, we witness how
“spectatorship can be a form of participation in the crime” (Young 2010,
52)—for example, when we consider the various spectators who partici-
pated by witnessing and facilitating the CSC’s efforts to conduct the cell
extractions, strip searches and uses of force and restraint (physical and
chemical) in both cases, and who tried to prevent the public from viewing
these scenes of violence.
While explanatory narratives of violence (often suggesting jealousy or
madness) can be reassuring for the viewer (Young 2010, 157), how do we
affectively interpret the narratives state officials mobilized to justify the
acts of violence taken against the incarcerated women in these cases;
namely, that frontline correctional staff were simply following institutional
procedure and bureaucratic orders? Given the reversal of roles that these
crime-images proffer—seeing the criminal as victim and state agent as
assailant—“when the enigma of violence is left unsolved [and there is no
arrest, trial or punishment]—when the criminal remains out of reach—
[we must ask ourselves] what then is left of criminal justice?” (Young
2010, 161). Under these circumstances, where the central trope of law
and order is undermined, I contend that a new political cleavage emerges
through which it becomes possible to garner sustained spectatorial sup-
port for prison reform and the abolition of solitary confinement.
It is through haptic penal spectatorship that “looking at violence and
doing violence thus become conjoined in and on the body of the injured
woman” (Young 2010, 72). By being implicated in the scene of violence,
the haptic penal spectator experiences embodied discomfort and mental
disquiet in their proximate witnessing of violence committed against a
group of powerless/disappeared women, which cultivates a sense of
responsibility and longing for something to be done.
134 J. M. KILTY
The spectator’s task is that of looking on in the face of violence. The specta-
tor, then, must live on as the one who actively looks, not as an “onlooker”
(whose gaze is both passive and exonerated from any sense of responsibility)
but as one who registers the crime-image in the body and who takes respon-
sibility for what and how she sees. (Young 2010, 171)
This sense of taking responsibility manifests as a call for justice, for some
consequence to occur to the perpetrators of the violence, without which
“the border that separates community from criminality, law from disorder,
body from violence, [] dissolve[s]” (Young 2010, 153). In calling for jus-
tice, the haptic penal spectator expresses their desire for accountability so
that these scenes of violence do not exist simply to be viewed then forgot-
ten or disregarded by passive onlookers. It is important to acknowledge
that the images examined in this chapter were gleaned from the correc-
tional videos as they were presented on a national investigative journalism
show, which used them to create narratives that were critical of CSC’s use
of isolation and restraint practices in lieu of adequate mental health care
(Crépault and Kilty 2017). These narratives certainly contributed to the
public’s emotional and affective response to the images and video content
and thus the surge in support for prison reform. Yet, in an era where we
are bombarded by crime-images and scenes of violence, both real and fic-
tional, we must take care to consider how calls for justice that flow from
haptic spectatorship grow, deepen and are sustained for the length of time
required to mobilize political action. I contend that this occurs by way of
(secondary) haunting,6 which can make the familiar (e.g., scenes of con-
finement) feel eerily unfamiliar (e.g., a youth ending up in federal prison
for an index offence of throwing crab apples at a postal worker) and can
bring what was invisible and hidden into full view (e.g., Smith asphyxiat-
ing while guards watch and do not intervene) (Gordon 2008, 2011;
Kuntsman 2011). In this way, “haunting always registers the harm inflicted
or the loss sustained by a social violence done in the past or being done in
the present” (Gordon 2011, 2). What is distinct about haunting, is that,
unlike trauma, it demands action—some sort of response to alleviate or
rectify the harm done (Gordon 2008, 2011; Lincoln and Lincoln 2015).
Haunting evokes and is evoked by an archive and “structure of feel-
ing” (Kuntsman 2011) that tethers affect, memory and witnessing within
the body and mind of the haptic spectator. It is therefore “an emergent
state” that can register as nostalgia, regret or as a kind of urgency that
operates as a “critical analytic moment” (Gordon 2008, 2011). Haunting
transpires when a ghost of the past resurfaces and demands your

attention—signalling that something occurring in the present is amiss
and that “something must be done” to respond to or to rectify what has
gone awry. In the same way that the spectator must “look on in the face
of violence” (Young 2010), haunting “is bound to the work of carrying
on regardless: to keeping urgent the repair of injustice and the care-tak-
ing of the aggrieved and the missing; to keeping urgent the systematic
dismantling of the conditions that produce the crises and the misery in
the first place” (Gordon 2011, 8).
During the 13-year period between the P4W and Smith cases, federal
corrections for women in Canada changed dramatically: notably, the P4W
closed in 2000 (six years after the cell extractions and strip searches) after
operating as the only federal prison for women in the country for more
than 70 years, six new regional multi-level security institutions were built
and a new approach to women’s corrections based on the Creating Choices
policy document was incorporated into the management style and gover-
nance structure for the new women’s prisons (Arbour 1996; Hannah-
Moffat 2001). The Smith case reignited public anger at carceral practices
and the poor conditions of confinement that were first revealed in the
P4W videos, thus altering “the way we normally separate and sequence the
past, the present and the future” (Gordon 2011, 2) and signifying how
the ghosts of the past return when that which they recall is haptically
remembered. In this way, the Smith case incited a renewed unease with
and deeply critical concern about how CSC controls prisoners deemed
difficult to manage. She became the poster-child for calls for prison reform
and the abolition of solitary confinement; the image and narrative of her
death lingering in the public and political consciousness, in part because it
recalls the devastating effect of the punitive carceral practices that are
explicitly shown in Fig. 6.5, which is certainly one of the most haunting
crime-images contained on any of the videos. Figure 6.5 shows a group of
IERT members cutting the clothes off of a woman as she lies on the con-
crete floor of her segregation cell in P4W.
Keeping in mind that a number of these IERT members are men (for
whom it is illegal to strip-search women) and that many incarcerated
women have been victimized by sexual and physical violence (Arbour
1996; CSC 2013; Sapers 2015), in witnessing this act of violence the
haptic spectator feels their stomach turn and their breath hitch as the
woman cries out then calmly states “you didn’t have to do it like that.”
What must it take to carry out this task, not simply with cool indifference,
136 J. M. KILTY
Fig. 6.5 Male IERT cutting the clothes off of a segregated female prisoner in
P4W
but with such aggression? The strip search signifies the body in the hands
of an other “whose insistent message is that the body of the person being
searched does not matter, that it does not even properly belong to that
person, and that it can only bear the meaning that is imposed on it by the
violence of others” (Guenther 2013, 190). The image haunts because it
makes you recoil, brow furrowed, gaze periodically averted so as to avoid
looking at it head-on. It conjures feelings of violation, sexual assault, tor-
ture, powerlessness and a liminal carceral existence—of being laid bare,
naked before the eyes of your masked assailants. It haunts by raising an
important political question: is this what we consider to be acceptable
punishment in Canada? If haunting is “a form of accountability, where we
‘stop turning back and become haunted not by the past but rather by our
responsibilities to the present and the future’” (Ferreday and Kuntsman
2011, 10), then we must recognize this image as shaping the public’s feel-
ings regarding the use of force and solitary confinement for incarcerated
women in Canada.
In 1996, Justice Louise Arbour concluded her year-long investigation
into the events at P4W, finding that the CSC broke the rule of law by
allowing male IERT members to strip-search women and by incarcerating
women in solitary confinement for more than nine months. She described
the women’s treatment as cruel, inhumane and degrading. During the

coroner’s inquest into her death, the same words were used to describe
Ashley Smith’s treatment, shown in Figs. 6.6 and 6.7.
Similar to CSC’s prolonged use of segregation for the women in P4W,
Ashley Smith was isolated the entire time she was held in federal custody;
to sidestep the policies that prevent sustained segregation, the CSC moved
Smith to different institutions 17 times in 11 months claiming that she was
not in segregation while in transfer and that this allowed them to “restart
the segregation clock” each time she was moved (Sapers 2008). This kind
of policy stretching and misappropriation is particularly disturbing when
viewing the image in Fig. 6.6, which depicts Smith while in air transport.
The video reveals that Smith’s captors audibly warn her not to physically
resist and not to bite or spit—instructing her that they will “hood” her if
she does; the image shows that staff not only put a mesh hood over her
head, they also duct-taped Smith to her airplane seat. As a result, when
Smith does spit in one of the videos the spectator experiences “pleasurable
empathy” (Young 2010, 40) after longing for her to retaliate and break
free from the hold of guards whose actions effectively dehumanize her.
Like the strip search, the totality of Smith’s bodily immobilization illus-
trates the degree of control correctional officials had over her body, and
how their use of that control demonstrates that her body “does not matter”
Fig. 6.6 Smith bound while in air transport to a different institution

138 J. M. KILTY
Fig. 6.7 Smith dying from self-tied ligature as guards watch from the hall
and does not even properly belong to her (Guenther 2013, 190). It is
impossible to miss the incongruity of trying to prevent Smith from self-
harming while simultaneously imposing such significant violence on her
body. In her final attempt to exert power and to reclaim her body from
carceral control, Smith tied a ligature around her neck and lay down on the
floor of her cell, wedged between her cot and the cell wall—depicted in
Fig. 6.7.
Correctional staff waited for more than 11 minutes before entering
Smith’s cell to see if she was still breathing, more than 15 minutes before
removing the ligature and nearly 45 minutes before calling paramedics
and beginning CPR. Identified as the “wait and see approach,” frontline
staff were instructed by administrators to wait until Smith passed out
before entering her cell to remove ligatures in order to avoid a physical
confrontation with her (Sapers 2008). Not only is this order immoral, it is
illegal. During those long minutes, staff filmed and watched Smith through
the small window in her cell door trying to see if her back was rising and
falling to ascertain whether or not she was still breathing. Guenther (2013,
xxvii) contends that “the social dead are excluded from full participation
in life, like ghosts who can still speak and act but whose speech and actions
no longer make an impact on the world,” but this position fails to consider
the ways in which the experiences of the social dead can come to haunt
and thus impact the world. As Lincoln and Lincoln (2015, 201) maintain,
secondary haunting is a “moment when and the means through which

repressed crimes and traumas break through ignorance, inattention, cal-
lousness, defensiveness, shame, and denial to galvanize a previously indif-
ferent public.”
Like the image of the IERT members cutting the clothes off of the
women in P4W, and with the knowledge that she died because correc-
tional staff failed to enter her cell to remove the cloth ligature from her
neck, the image of Smith’s prostrate body slightly obscured by a metal cot
in the corner of a bare segregation cell haunts. This image highlights
Smith’s youth, inexperience, the triviality of her index offence in relation
to the length of time she ended up serving in carceral institutions, the
denigrating treatment she experienced while incarcerated and the psycho-
logical effects of her social death. Subsequently, what is perhaps most
haunting about this image is that Smith’s liminality as a disappeared pris-
oner carries “a sharp double-edged message: it could be you. I could be
you” (Gordon 2011, 13).
The images depicting incarcerated women being strip-searched and, in
Smith’s case, left to die in a segregation cell, shocked, outraged and
haunted the Canadian public, but they also mobilized calls for prison
reform and the abolition of the use of solitary confinement for women and
for prisoners suffering from mental health distress. Not only was the new
liberal government elected on a platform that included progressive prison
reform, in 2015 the John Howard Society of Canada and the British
Columbia Civil Liberties Association (BCCLA) jointly filed a lawsuit with
the British Columbia Supreme Court against the federal government
alleging that the laws governing the isolation of prisoners in the federal
correctional system are unconstitutional. The Canadian Civil Liberties
Association (CCLA) and the Canadian Association of Elizabeth Fry
Societies (CAEFS) jointly filed a similar lawsuit shortly thereafter with the
Ontario Supreme Court, although CAEFS later withdrew from the law-
suit. Both cases cited Smith’s death as evidence that solitary confinement
is torture and noted that in spite of the unequivocal recommendation
made by the Ontario Coroner’s Inquest into Smith’s death that indefinite
forms of segregation be abolished, the CSC, in their problematic mainte-
nance of a culture of punishment (Arbour 1996; Brown 2009), refused to
end the practice. Several other carceral deaths—of Edward Snowshoe and
Kinew James to name but a few—have likewise inspired petitions to end
the practice of segregation in Canadian prisons.
140 J. M. KILTY
In December 2017, Associate Chief Justice Frank Marrocco of the

Ontario Superior Court struck down Canada’s laws on segregation as
unconstitutional, citing the lack of independent review and the harms
caused by isolation. While the CCLA applauded the decision, they are
now launching an appeal to prohibit segregation beyond 15 days and for
certain vulnerable groups (e.g., mentally distressed, young people and
those seeking safety). In January 2018, just one month after the Ontario
decision, the British Columbia Supreme Court went even further by
declaring that segregation laws violate sections 7 and 15 of the Charter of
Rights and Freedoms in that they permit prolonged indefinite isolation,
fail to provide an independent review of segregation placements, deprive
prisoners of the right to counsel at segregation review hearings, authorize
administrative segregation for the mentally distressed, and because the
regime has been found to discriminate against Indigenous prisoners. The
federal government intends on appealing the decision in part or in full.
Conclusion
In both the P4W and Smith cases, incarcerated women were segregated
for illegal lengths of time with very restricted access to basic needs, includ-
ing menstrual and other hygiene products like toilet paper and deodorant,
and were denied access to clothes, cutlery and even paper and writing
utensils, which is a methodical way to inhibit their ability to file formal
grievances about their conditions of confinement and human rights viola-
tions (Arbour 1996; Sapers 2008). This prolonged isolation created a
sense of not just social distance but of complete disconnection to the social
world—of social death. Without the ability to connect relationally and
intercorporeally with others, “the extreme boredom produced and rein-
forced by social and sensory deprivation can amount to a living death
sentence that compounds the violence of crime rather than demanding
something more or something different from the offender” (Guenther
2013, 197).
The experience of social death led Smith and the women in P4W to
come unhinged (Guenther 2013) and like so many prisoners in isola-
tion, many of them slashed and engaged in other forms of self-harm,
Smith repeatedly so (Arbour 1996; OCI 2013; Rhodes 2004; Sapers
2008; Shalev 2009). The correctional videos archive the women’s
haunted futurities; not only are they “sites of memory and preservation”
they are also “records of erasure and void,” “maps of knowledge and
interactions, readership and witnessing” and “signs of things to come, of

commemoration, or of oblivion” (Kuntsman 2011, 4–5). These archives
of feeling illustrate how scenes of violence are not static, but rather both
“momentary and ongoing” in that they project “an image of the future
at the same time as [they] show a continuous present laminated over a
perpetually receding past” (Young 2010, 11). Despite the dramatic
reforms to women’s corrections in the interceding years, the images of
Smith bound in the WRAP and in air transport, held down by staff to be
chemically injected against her will and asphyxiating in her cell haptically
recalled the images of the women being stripped by male IERT in P4W
in 1994. As such, they worked to merge past, present and future to
demonstrate the historic continuity of carceral violence committed
against women in segregation in Canada.
In actively looking at these images and scenes of violence, the distance
between the women on screen and the haptic spectator shrinks as they
begin to identify with known criminals and see state officials as violent
assailants. As the haptic spectator becomes haunted by the visual imagery,
their “initial bafflement, amnesia, and denial give way to compassion,
regret, and subsequent hypervigilance” (Lincoln and Lincoln 2015, 201).
This affective relationality pushes the haptic spectator to feel a sense of
responsibility and to call for justice for the women on film. By mobilizing
outrage, secondary haunting keeps the affective memory of the scenes of
violence alive (Lincoln and Lincoln 2015, 201) so that haptic spectators
can collectivize to demand and support political action regarding prison
reform and the abolition of solitary confinement. As Guenther (2013,
250) so persuasively argues:
The ethos of intensive confinement undermines both the agency of prison-

ers and their capacity for ethically meaningful lives. If critical reflection is
crucial for the cultivation of a responsible life and a commitment to justice,
then the justice system is structurally unjust to the extent that it forecloses
the ethical provocation of critique and seeks instead to manage, control, and
contain criminal offenders.
The recent lawsuits challenging the federal government’s use of segrega-

tion signify a political will to re-envision punishment in Canada. In that
vein, the haunting spectres of the women on the videos inspired greater
public awareness and sustained support for these legal challenges that are
questioning the correctional norm of locking people in cold storage when
142 J. M. KILTY
it is known to create and exacerbate mental and emotional distress. In this

way, haunting contributes to the production of aesthetic politics, in this
case to eliminate the use of solitary confinement, which deprives prisoners
not only of human rights and dignity but also the opportunity for ethical
transformation.
Notes
1. The Fifth Estate is a CBC hour-long investigative journalism show.
2. At the time, P4W was the only federal prison for women in Canada. A trans-
fer out of P4W entailed either being isolated in a men’s federal prison or in
a regional psychiatric treatment centre—both options created greater geo-
graphic dislocation for the prisoner.
3. The “WRAP” consists of applying restraint belts beginning at the individu-
al’s feet, all the way up to her shoulders, ceasing all possibility of bodily
movement; a hockey helmet is placed on the head to prevent injury in the
event that they topple over and to prevent the subject from biting anyone.
4. The Pinel Board involves strapping an individual to a board in five-
point restraints (hands, feet, head, chest, hips and legs) to cease bodily
movement.
5. In this section, I rely on two images generated strictly from the correctional
videos of Smith; I reserve one of the most violent and disturbing images of
the women being strip-searched in P4W for the final section of this
chapter.
6. Lincoln and Lincoln (2015) refine Gordon’s (2008, 2011) work by distin-
guishing primary haunting, which they contend involves considering ghostly
apparitions, from secondary haunting, which is mediated by a third party
that produces the texts and images that haunt (the focus of this chapter and
of Gordon’s work).
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———. 2014. Visual Criminology and Carceral Studies: Counter-Images in the
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———. 2014. Seeing Things: Violence, Voyeurism and the Camera. Theoretical
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Crépault, C., and J.M. Kilty. 2017. Mainstream Media and the F-Word:
Documentary Coherence and the Exclusion of a Feminist Narrative in The
Fifth Estate Coverage of the Ashley Smith Case. Canadian Journal of Law &
Society 32 (2): 269–290.
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———. 2011. Some Thoughts on Haunting and Futurity. Borderlands 10 (2):
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———. 2008. A Culture of Harm: Taming the Dynamics of Cruelty in Supermax
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the Carceral Context. Feminism & Psychology 22 (2): 162–182.
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CHAPTER 7
Gender Dysphoria and the Medical Gaze

in Anglo-American Carceral Regimes
Kyle Kirkup
Introduction
In the contemporary era, Anglo-American carceral spaces, including pris-
ons, jails, and detention centres, are invariably segregated on the basis of
sex. For those engaged in administering practices of punishment, gender
is treated as little more than an immutable fact—at birth, medical practi-
tioners identify individuals as either male or female, and the administrative
state’s assemblage of parts emerges to produce a series of identity docu-
ments that confirm the truth of this initial designation. Accordingly, deci-
sions about where and how to admit, place, and classify those ensnared in
the apparatuses of the criminal legal system flow from an initial act of
gendered interpellation, one that is reproduced over and over by a vast
array of actors.
Drawing on the stories of Katherine Johnson and Synthia Kavanagh—
two transgender women who launched complaints against the Correctional
Service of Canada (CSC), this chapter analyzes the ways in which non-
normative genders are constituted using biomedical discourses in carceral
K. Kirkup (*)
Faculty of Law, University of Ottawa, Ottawa, ON, Canada
e-mail: kyle.kirkup@uottawa.ca

https://doi.org/10.1007/978-3-319-89749-3_7
146 K. KIRKUP
spaces. By segregating individuals on the basis of sex, using diagnostic

categories such as ‘gender dysphoria,’ and imposing surgical requirements
on those who refuse to be subjugated by essentialist gender norms, car-
ceral spaces participate in a larger corporeal project.1 As Butler reminds us,
adhering to essentialist gender norms is a “strategy of survival within com-
pulsory systems” because society “regularly punish[es] those who fail to
do their gender right” (Butler 1999, 178). Accordingly, the advent of
carceral policies that move away from gender essentialism, along with a
broader project of decarceration, constitute important sites of resistance
to the imposition of biomedical discourses on transgender people.
The chapter proceeds in four parts. The first section uses Michel
Foucault’s account of the medical gaze to theorize the techniques through
which, beginning in the late eighteenth century, persons became refash-
ioned as medical objects (Linander et al. 2017). The second section pro-
vides a brief history of sex-segregation in Canadian federal prisons,2 focusing
on Katherine Johnson’s early challenges to the conditions of confinement
experienced by transgender women housed in men’s prisons. The third sec-
tion offers a close reading of the case of Synthia Kavanagh, underscoring the
ways in which medical practitioners and prison administrators constructed
her as an object and required that she undergo medical interventions,
including surgery, in order to be moved to a women’s prison. The fourth
section examines the ways in which recent changes to regimes of admission,
classification, and placement for transgender people in Canadian prisons,
along with a broader commitment to decarceration, constitute important
loci in the broader struggle to resist the imposition of biomedical discourses
onto those who refuse to be subjugated by regimes of gender essentialism.
Theorizing Gender Dysphoria and the Medical Gaze

In The Birth of the Clinic: An Archaeology of Medical Perception, Michel
Foucault traces the history of the medical profession and the emergence of
what he terms the ‘medical gaze’ at the end of the eighteenth century
(Foucault 1973). Foucault argues that, in comparison with earlier periods,
practices of the Enlightenment transformed the body into an object of
knowledge that could be harnessed as a site of power. Foucault explains,
“At last, there emerges on the horizon of clinical experience the possibility
of an exhaustive, clear, and complete reading: for a doctor whose skills
would be carried ‘to the highest degree of perfection, all symptoms would
become signs’, all pathological manifestations would speak a clear, ordered
GENDER DYSPHORIA AND THE MEDICAL GAZE IN ANGLO-AMERICAN… 147
language” (Foucault 1973, 94–95). Over time, physicians honed their

ability to use the surface of their patients’ bodies to provide a series of
clues about the inner workings of their psychic and material lives. After
scrutinizing the body, physicians could develop a course of treatment that
would allow them to target any aspect of their patients’ beings.
Over the past century, transgender people have tended to adopt com-
plicated positions in relation to the biomedical discourses and the diagnos-
tic categories medical practitioners have imposed on them. While these
categories may hold the promise of providing access to social, legal, and
other support services, they invariably turn transgender people into medi-
cal objects in need of treatment (Connell 1987; Davy 2010). Indeed, the
American Medical Association’s Diagnostic and Statistical Manual of
Mental Disorders (DSM) has a long history of constructing those who
resist regimes that would have them obediently comply with norms of
gender and sexuality in terms of psychiatric pathology (American
Psychiatric Association 2013). For example, since its first iteration in
1952, the DSM classified homosexuality variously as a ‘paraphilia,’ as a
‘sexual orientation disturbance,’ and as ‘ego-dystonic homosexuality,’
until entirely removing the entry in 1987. As it constructs psychiatric dis-
orders and develops techniques to manage them, the DSM is deeply influ-
enced by changing understandings of acceptable social behaviours
(Drescher 2012; Kutchins and Kirk 1997; Frances 2013).
The most recent edition of the manual, the DSM-5, uses the language
of ‘gender dysphoria’ to describe the distress often experienced by trans-
gender people as they negotiate social norms that assume that an individ-
ual’s sex must always accord with their gender. The DSM-5 defines ‘gender
dysphoria’ in the following terms:
Gender dysphoria refers to the distress that may accompany the incongru-
ence between one’s experienced or expressed gender and one’s assigned
gender. Although not all individuals will experience distress as a result of
such incongruence, many are distressed if the desired physical interventions
by means of hormones and/or surgery are not available. The current term
is more descriptive than the previous DSM-IV term gender identity disorder
and focuses on dysphoria as the clinical problem, not identity per se.
(American Psychiatric Association 2013, 451)
In comparison with the DSM-IV, which used the language of ‘gender

identity disorder,’ the authors of the DSM-5 claim that this discursive shift
is designed to move away from understanding transgender people as
148 K. KIRKUP
intrinsically disordered, instead focusing on the distress caused when

medical interventions, such as hormone treatments, are not readily avail-
able to them.
Whether the diagnostic category is ‘gender identity disorder’ or “gen-
der dysphoria,” however, the DSM continues to construct transgender
people as medical objects—their bodies hold the promise of being ‘fixed’
by surgery and a lifelong commitment to hormone therapy, while their
minds can be ‘treated’ by psychopharmaceuticals designed to target con-
ditions such as anxiety and depression. As I explain in the next section,
when these biomedical understandings make their way into rigidly sex-
segregated carceral spaces, surgery and other interventions usually become
a requirement for placement in a facility that accords with an individual’s
gender identity and gender expression. Accordingly, carceral spaces incen-
tivize transgender people to participate in larger regimes of biomedical
governance.
Sex-Segregation and Carceral Regimes:

A Brief History
We tend to assume that Anglo-American carceral spaces have always been
segregated on the basis of sex. The existence of men’s and women’s pris-
ons, or so the conventional story goes, is treated as little more than an
unremarkable fact of modern life. A brief examination of carceral histories,
however, quickly unravels this assumption, instead highlighting the his-
torically contingent nature of the now seemingly axiomatic practice of
segregating people on the basis of the sex assigned to them at birth (Spade
2011; Pemberton 2013; Stanley and Smith 2011).
Tracing the historical development of sex-segregation in Anglo-
American prisons, historian Elise Chenier finds that most prisons did not
begin to be segregated until the late nineteenth century and that, when
they did, it was not always on the basis of sex. Chenier explains:
In the late nineteenth century, social reformers’ concern with the corrupting
influence of degenerate inmates over less dissolute prisoners led to demands
for the segregation of different types of inmates. By the early twentieth cen-
tury, most prisons and courts were beginning to separate the sane from the
insane, women from men, the merely poor from the criminal, and the chil-
dren from adults. However, while systems of classification were aspired to,
rarely were they fully implemented. (Chenier 2012, 170)
While we might be tempted to view sex-segregated carceral spaces as little

more than self-evident truths, they are historically specific inventions of
the modern era—ones that rely on strict, essentialist gender binaries and
invariably target those who dwell at the axes of race, poverty, disability,
and other marginalized categories of identity and experience. As I explain
in the conclusion, rather than simply tinkering with the edges of carceral
policies, a larger commitment to decarceration is required to resist the
imposition of gendered governance onto prisoners.
In Canada, the government did not have a freestanding federal prison
for women until 1934. As Justice Louise Arbour notes in the Commission
of Inquiry into Certain Events at the Prison for Women in Kingston, “The
history of Canada’s treatment of women prisoners has been described as
an amalgam of: stereotypical views of women; neglect; outright barbarism
and well-meaning paternalism” (Arbour 1996). Before the notorious
Prison for Women (P4W) opened in Kingston, Ontario, women were
housed with their male counterparts in the Kingston Penitentiary, an insti-
tution that was originally known simply as the Provincial Penitentiary. The
first three women arrived at the Provincial Penitentiary in 1835, and were
initially placed in the prison’s hospital. Within the Provincial Penitentiary,
women regularly encountered male prisoners during their daily activities,
and were often required to work in the kitchen or the laundry room. In
1839, prison administrators moved the women to a section of the North
Wing of the Provincial Penitentiary, making it the first prison for women
in Canada. Once the women moved to the North Wing, they interacted
far less with their male counterparts than they had in the early years of the
Provincial Penitentiary. The federal government assumed jurisdiction of
the Provincial Penitentiary at Confederation, eventually renaming it the
Kingston Penitentiary (Arbour 1996, 127). While the history of federal
prisons in Canada is uneven and haphazard, it is important to underscore
that men and women were not so rigidly segregated prior to 1934
(Correctional Service of Canada 2008). Put differently, the practice of
placing people in prison on the basis of the sex assigned to them at birth
is not inevitable—it is the product of the modern era, one that ultimately
participates in a larger project of disciplining those who refuse to be gov-
erned by rigid, essentialist gender norms.
There is virtually no historical record of early transgender experiences
in Canada’s federal prison system. In Prisoner of Gender: A Transsexual
and the System, Katherine Johnson recounts her thirty years living as a
transgender woman in Canada’s federal prison system (Johnson and Castle
150 K. KIRKUP
1997). Her first-person account of the system—where she was housed

between the 1960s and early 1990s—provides an unprecedented window
into the experiences of transgender women in prisons across the country.
Her work also underscores the ways that Johnson and other transgender
women engaged in advocacy that resisted attempts on the part of medical
practitioners and prison administrators to impose diagnostic categories
and medical interventions upon them.
Following her armed robbery conviction at the age of twenty, Johnson
was initially sent to the British Columbia Penitentiary in New Westminster
(Johnson and Castle 1997, 17). From an early age, Johnson describes
identifying as a woman, a fact she repeatedly communicated to medical
practitioners and prison administrators. As she had not undergone gender-
affirming surgery at the time of her admission to the British Columbia
Penitentiary in 1968, administrators deemed Johnson to be male for
admission and placement purposes. While in prison, Johnson describes
experiencing violence, discrimination, and harassment as a result of her
status as a transgender woman. In some instances, she would even decide
to take what is sometimes colloquially known as a prison ‘husband’—a
stronger, more dominant prisoner who would agree to protect her physi-
cal safety in exchange for sex. Johnson’s only alternative was to be placed
in administrative segregation, where she reports spending the better part
of a decade (Johnson and Castle 1997, 22). Given its devastating effects
on prisoners’ psychological and emotional wellbeing, the United Nations
Special Rapporteur has identified the long-term use of solitary confine-
ment as a form of torture (United Nations Special Rapporteur 2011). For
many transgender people, being placed in isolation is understood as an
additional punishment flowing from their refusal to be subjugated by gen-
dered norms (Arkles 2009).
After encountering prison administrators and physicians who failed to
recognize her identity as a transgender woman, Johnson felt she had no
choice but to castrate herself (Johnson and Castle 1997, 47). Following
this incident, where Johnson was seriously injured but ultimately unsuc-
cessful in removing her penis, medical practitioners and prison administra-
tors started to take Johnson’s status as a transgender woman more
seriously. In doing so, however, a wide range of actors in the prison system
emerged to identify, label, and explain her behaviour and mental health
status within a corpus of biomedical discourses, describing her using the
language of pathology and disorder. The institution’s psychiatrist, for
example, arranged for Johnson to have a series of meetings with two psy-
chiatrists who would later go on to found the Vancouver Hospital Gender
Dysphoria Clinic (Johnson and Castle 1997, 49).
Continuing to experience violence, discrimination, and harassment at
the hands of other prisoners and guards, Johnson started a letter writing
campaign to senior officials within the CSC beginning in the early 1980s.
Somewhat fortuitously, she wrote to the Honourable Robert Kaplan, who
served as Canada’s Solicitor General from 1980–1984. According to
Johnson, Kaplan sent her a reply, attaching a letter he had written to the
Director General of Health Care for the CSC. In his letter, Kaplan wrote:
“If you have transsexuals in prison, then there must be a policy formulated
in regard to the treatment of transsexuals” (Johnson and Castle 1997,
53). This letter would initiate the development of three decades’ worth of
policies and procedures that interpreted and characterized transgender
women using diagnostic categories such as ‘gender identity disorder’ and
‘gender dysphoria.’
After being reprimanded by Kaplan in his official capacity as Solicitor
General, the CSC began to study the issue of transgender prisoners, a
process that ultimately cumulated in an expert report written by Dr.
Chalke that attempted to make sense of the actuarial risks and needs asso-
ciated with housing transgender women in federal prisons. Dr. Chalke’s
report made three central recommendations. First, the report recom-
mended that no form of gender-affirming surgery be initiated while pris-
oners were incarcerated. Second, the report suggested that prisoners who
had already started taking hormone therapy prior to being incarcerated
should be dealt with on an individual, case-by-case basis—this meant that
transgender women who had been prescribed hormones before coming
into conflict with the criminal legal system ran the risk of having their
treatment plan discontinued in prison. Third, the report stated that, in the
rare case where a physician recommended gender-affirming surgery, it
should only be permitted near the end of a prisoner’s sentence, in anticipa-
tion for release back into the public (Kavanagh 2001, para. 30).
In response to the report, the CSC issued its first transgender prisoner
policy in 1982. The policy mandated that each transgender prisoner
should be dealt with on an individual, case-by-case basis. Further, the pol-
icy stipulated that gender-affirming surgery should not be initiated while
a prisoner was incarcerated. Physicians could, however, administer hor-
mones to transgender prisoners who were already being treated for gender
152 K. KIRKUP
identity disorder at the time of incarceration—but only if it appeared that

they would seek out gender-affirming surgery after being released from
prison (Kavanagh 2001, para. 31). This policy constitutes an extraordi-
nary exhibition of extra-carceral power. By only allowing transgender peo-
ple to access hormones if they intend to undergo surgery, the CSC
participates in the larger corporal project of creating incentives for people
to ‘fix’ their bodies through biomedical interventions even after they have
been released from custody.
In the same year, the CSC commissioned another expert report, this
time authored by Dr. Steiner and Dr. Hucker, that invoked and reinscribed
biomedical discourses. The report recommended that transgender prison-
ers should be ‘frozen’ at the stage of feminization or masculinization they
were at when they were first incarcerated. It further recommended that
prison administrators make decisions about where prisoners should be
placed solely on the appearance of their genitals. The report also explained
that hormone treatment could be provided, but clarified that surgery
would not be performed during an individual’s period of incarceration
(Kavanagh 2001, para. 32). In 1987, again for reasons that remain opaque,
the CSC revised its policy, taking an even more restrictive approach. This
version of the policy permitted prison officials to administer hormones to
transgender prisoners only in the nine-month period leading up to their
release—this policy meant that transgender people who had been pre-
scribed hormone therapy would be forced to undergo physical and emo-
tional upheaval as a result of having their treatment plan disrupted as they
served their sentences. The policy remained silent about the availability of
gender-affirming surgery in prison (Kavanagh 2001, para. 32).
Five years later, transgender people again became medical objects in
need of further study when the CSC commissioned yet another report,
this time authored by Dr. Lapierre. The report recommended that trans-
gender prisoners not receive any medical treatment related to their gender
identity and gender expression while incarcerated within the federal prison
system. While the report did not elaborate on this point, it suggested that
behavioural changes resulting from hormone therapy, such as increased
levels of aggression and violence, might cause difficulties in managing
transgender people in custody. The same year, the CSC consulted with
several other medical experts in the field. After the consultation period
ended, the CSC revised its policy again in 1993 to permit hormone ther-
apy throughout the entire period of incarceration. For reasons that are
again uncertain, the 1993 policy also permitted ‘sexual reconstructive
s urgery,’ a term that had never appeared in earlier iterations of the policy
or the medical literature. Even more strangely, the new policy made no
express reference to ‘sex reassignment surgery’ at all. Two years later, the
CSC revised this policy to expressly permit ‘sex reassignment surgery’ with
the approval of the Regional Deputy Commissioner and the Commissioner
of the CSC (Kavanagh 2001, para. 34).
The CSC again amended its policy in 1997, resorting back to the posi-
tion they took up in the 1982 report (Correctional Service of Canada
1997). In essence, the policy would ‘freeze’ transgender people at the
stage of transition they were at when they first entered the prison system.
For example, transgender people who were not being supervised by a cer-
tified gender specialist—or, to invoke the language of Foucault, subjected
to the medical gaze—before they were imprisoned, were unable to access
gender-affirming treatment such as counselling and hormone therapy. The
relevant sections of the policy provided:
Gender Dysphoria
29. If an inmate has been on hormones prescribed through a recog-

nized gender program clinic prior to incarceration, they may be
continued under the following conditions:
a) that the inmate be referred to and reassessed by a recognized
gender assessment clinic; and
b) that continuation of hormone therapy is recommended by the
gender assessment clinic.
30. Unless sex reassignment surgery has been completed, male inmates
shall be held in male institutions.
31. Sex reassignment surgery will not be considered during the

inmate’s incarceration.3
Section 30 of the policy made it clear that, unless surgery was ‘completed’
prior to incarceration, transgender women would be indefinitely held in
men’s institutions. In essence, this policy of ‘surgery completion’ required
transgender women who had penises to be housed with male prisoners,
regardless of their gender identity and gender expression. Further, section
31 of the policy made it impossible for prisoners who had taken steps to
undergo gender-affirming surgery before becoming incarcerated to “com-
plete” the process while in prison. As a result, transgender women who
154 K. KIRKUP
had not undergone surgery before being incarcerated could not be housed
in facilities that accorded with their gender identity and gender expression.
Rather, they were housed indefinitely with men, making them uniquely
vulnerable to discrimination, harassment, and violence. While transgender
prison policies changed between 1982 and 1997, one thing remained con-
stant: Medical practitioners and prison administrators routinely con-
structed those who refused to be subjugated by essentialist gender norms
into objects that needed to be managed and scrutinized using biomedical
discourses. This dynamic underscores the extent to which gender self-
determination is deeply connected to prison abolition.
The Story of Synthia Kavanagh

and the Construction of the Medical Gaze
in Carceral Regimes
While the often-overlooked advocacy of Katherine Johnson was central in

compelling the CSC to create its first set of transgender-specific policies in
the early 1980s, transgender women continued to experience discrimina-
tion, harassment, and violence within a carceral system predicated on
sharp, essentialist gender binaries. The story of Synthia Kavanagh, a trans-
gender woman who initiated a landmark human rights complaint against
the CSC, picks up where Johnson’s account leaves off. While Kavangh’s
story underscores the need for policy changes to address the immediate
needs of transgender people in custody, it also demonstrates the relation-
ship between decarceration and the larger struggle for gender self-deter-
mination—in order to reduce the prison’s ability to impose gendered
categories, society must move away from carceral systems altogether.
Like Johnson, Kavanagh’s story is one of being constructed by medical
practitioners and prison administrators as a medical object that needed to
be scrutinized and ‘fixed.’ By the time she was sentenced to life imprison-
ment for second-degree murder in 1989, Kavanagh had commenced hor-
mone therapy, but had not undergone gender-affirming surgery (Kavanagh
1989). The judge in her murder case recommended that she be allowed to
serve her sentence in a prison for women. He explained that “simple
humanity would justify making such arrangements as will accommodate
[her self-identification as a woman]” (Kavanagh 1989). In the face of this
recommendation, however, the CSC denied Kavanagh’s repeated requests
to be transferred to a women’s prison.
While in a men’s institution, Kavanagh received inconsistent access to

hormone therapy and was sexually assaulted on a number of occasions by
male prisoners. Like Johnson, Kavanagh even attempted to cut off her own
penis, hoping that it would force administrators to transfer her to a wom-
en’s facility. In the aftermath of attempting to cut off her own penis,
Kavanagh submitted three complaints to the Canadian Human Rights
Commission alleging discrimination on the basis of sex and disability—the
terms gender identity and gender expression had not yet been added as
protected categories of discrimination in the Canadian Human Rights Act.4
In her human rights complaint, Kavanagh sought reinstatement of her
hormone therapy, consideration for gender-affirming surgery, and place-
ment in a correctional facility for women. Before Kavanagh’s case reached
the Canadian Human Rights Tribunal, however, the CSC entered into a
settlement agreement with her. The settlement allowed her to undergo
surgery at her own expense—if she underwent surgery, the CSC would
allow her to be transferred to a women’s facility. Given the public interest
issues at stake, however, the Tribunal decided to hear the case, ultimately
ordering the CSC to develop a new policy within six months of the deci-
sion (Kavanagh 2001).
Kavanagh’s claim was successful in part. Writing about Kavanagh’s chal-
lenge to the placement of transgender women in prison who had not under-
gone gender-affirming surgery, the Tribunal found that the CSC’s policy
requiring that prisoners with penises be held in male institutions clearly had
an adverse, differential effect on transgender women. Cisgender people are
placed in prisons that accord with both their sex and their gender.
Transgender prisoners, by contrast, are placed in prisons according to their
sex, but not their gender. As such, this policy constituted prima facie dis-
crimination on the basis of sex and disability (Kavanagh 2001, para. 141).
Having found a prima facie case of discrimination on the basis of sex
and disability, the onus then shifted to the CSC to establish that it had a
bona fide justification for its exclusionary placement policy. Under
Canadian human rights law, there are three elements that must be estab-
lished to demonstrate the existence of a bona fide justification—rational
connection, good faith, and undue hardship. Counsel for Kavanagh con-
ceded that there was a rational connection between the placement of
transgender prisoners and the overarching goal of promoting safety in the
prison population (Kavanagh 2001, paras. 143–144) and further con-
ceded that there was no evidence to suggest that the CSC had acted in bad
faith (Kavanagh 2001, para. 145).
156 K. KIRKUP
As such, the central issue for the Tribunal was the third question, which
focuses on whether the CSC’s policy is reasonably necessary to accomplish
its goal, in the sense that it cannot accommodate persons with the charac-
teristics of the complainant without incurring undue hardship (Kavanagh
2001, para. 146). After balancing the safety concerns expressed by trans-
gender women such as Kavanagh against the impressionistic safety con-
cerns that prison administrators had about cisgender women, the Tribunal
concluded that placing transgender people in prisons in accordance with
their gender identity and gender expression constituted undue hardship
(Kavanagh 2001, para. 147–159). In essence, the prison officials’ percep-
tions of the safety of the cisgender women already housed in prisons
trumped the safety concerns expressed by transgender women such as
Kavanagh about being placed in men’s facilities. The Tribunal concluded
that refusing to place transgender people who had not ‘completed’
gender-affirming surgery in prisons for their targeted sex was reasonable
(Kavanagh 2001, para. 161–164).
Having analyzed the placement issue, the Tribunal then considered
whether the CSC’s surgery policy constituted discrimination on the basis
of sex and disability. Again, the bulk of the discussion turned on the issue
of undue hardship (Kavanagh 2001, para. 168–174). Under this branch
of the analysis, the Tribunal was tasked with determining whether the
CSC had successfully established that its policy of prohibiting gender-
affirming surgery was reasonably necessary to accomplish the overarching
goal of providing health care for prisoners without incurring undue hard-
ship. The Tribunal found that a contextual, case-by-case approach was
required to bring the CSC’s policy into compliance with the Canadian
Human Rights Act.
In order to qualify for surgery, however, the Tribunal agreed with the
CSC’s experts about the importance of the so-called real life test, which
requires transgender people to live ‘full-time’ in their gender for a period
of one to two years before accessing surgery. In a curiously reasoned part
of the decision, the Tribunal explained that life in prison is not ‘real life’:
We agree with the experts called by CSC that the real life experience require-
ment of the treatment protocol cannot be satisfactorily fulfilled within the
[prison] setting. It appears from all of the evidence that pre-operative trans-
sexuals need to be able to interact with both men and women in their day to
day lives in order to properly fulfill the requirements of the real life experi-
ence. We have already concluded that it is not appropriate to place pre-

operative male to female transsexuals in women’s prisons. Can these
individuals then obtain an appropriate real life experience while incarcerated
in male penitentiaries? We think not. (Kavanagh 2001, para. 178)
The Tribunal ultimately found that the CSC’s blanket prohibition against
gender-affirming surgery, even for transgender people who had already
completed all of the supposedly necessary ‘real life’ steps prior to being
incarcerated, constituted discrimination on the basis of sex and disability
(Kavanagh 2001, paras. 175–183). It further explained that, if the trans-
gender prisoner’s physician deemed surgery to be an essential procedure,
then the CSC would be expected to cover the costs of the surgery, as they
would for any other essential treatment (Kavanagh 2001, paras. 184–191).
The Tribunal ordered the CSC to amend its policy within six months of
the decision (Kavanagh 2001, para. 198).
The Kavanagh decision underscores the ways in which medical practi-
tioners, legal actors, and prison administrators engage in practices that
constitute transgender people as medical objects. While recognizing trans-
gender women’s unique vulnerability in carceral spaces, the Tribunal
refuses to order the CSC to cease applying the policy of housing transgen-
der women who have not undergone surgery in male institutions
(Kavanagh 2001, para. 197). In arriving at this conclusion, the Tribunal
invokes prison officials’ impressionistic understandings of the mental and
physical health of cisgender women already housed in Canadian prisons,
reasoning:
The difficulties that female inmates have in dealing with men are based, in
part on lack of knowledge, but are also based on painful life experience. It
appears from the evidence that many of these women are psychologically
damaged, as a consequence of the physical, psychological and sexual abuse
they have suffered at the hands of men…
There is also no guarantee that pre-operative male to female transsexuals
will be unable to function sexually, notwithstanding their ingestion of female
hormones. As a result, pre-operative male to female transsexuals pose a
potential risk to female inmates. In our view, this is a factor to consider,
although its significance should not be overstated: The unfortunate fact is
that non-consensual sexual activity already occurs in the prison setting,
although the evidence suggests that it happens less frequently in women’s
prisons than it does in male institutions. (Kavanagh 2001, paras. 158, 161)
158 K. KIRKUP
Having deferred to prison officials’ mental and physical health arguments

about the need to maintain a system of strict, essentialist gender binaries
in absence of an evidentiary foundation, the decision merely requires that
the CSC “formulate a policy that ensures that the needs of transsexual
inmates are identified and accommodated” within six months of the deci-
sion being released (Kavanagh 2001, para. 198). Not only does the deci-
sion again reflect unquestioned adherence to essentialist gender categories,
it also casts transgender women as inherently sexually predatory, regard-
less of their sexual preferences or even the type of crime they committed.
Moreover, the decision appears to cast all individuals who were identified
at male as birth as incapable of controlling themselves sexually—transgen-
der women are simply too risky to be placed with cisgender women.
While the decision orders the CSC to cease applying the blanket pro-
hibition against gender-affirming surgery (Kavanagh 2001, para. 199), it
seems difficult to imagine a scenario where a transgender person could
actually meet the biomedical requirements developed by the Tribunal. In
order to access surgery while in prison, the transgender woman imagined
by the Tribunal would have had to seek out medical practitioners willing
to construct her using the language of pathology and disorder long
before ever coming into conflict with the criminal legal system. Moreover,
she would have had to carry out her daily activities for one to two years
as a woman in order to meet the ‘real life’ test. At this point, the trans-
gender person imagined by the Tribunal could then access gender-affirm-
ing surgery. Once doctors performed the surgery and the CSC, in
consultation with medical professionals, conducted an individualized
assessment, the transgender person imagined by the Tribunal could then
be housed in a women’s facility. In short, this chain of events seems
highly unlikely to occur.
At the same time that the Kavanagh decision attempts to draw lines of
carceral inclusion and exclusion around something we might call real life,
it implicitly instantiates biomedical discourses about transgender people—
the Tribunal’s decision proceeds from the essentialist assumption that
gender must always accord with sex, and encourages transgender people
to ‘fix’ themselves by seeking out medical interventions, such as hormone
treatments and surgery (Kirkup 2009). The Tribunal explains, for exam-
ple, that the only juncture at which a transgender woman can properly be
moved to a women’s prison is after gender-affirming surgery has been
‘completed.’ This means that the person who self-identifies as a woman
but, for a variety of complex reasons, cannot or does not want to undergo
gender-affirming surgery—including the prospect of forced sterilization—
will be indefinitely housed in a men’s institution.
Given her gender identity and gender expression as a woman, however,
the transgender woman imagined by the Tribunal is likely to experience
significant levels of violence, discrimination, and harassment at the hands
of her male counterparts if she remains in a men’s facility (Heilpern 1998;
Cooley 1993). If the transgender woman makes the decision to report the
abuse to prison administrators, it is likely that she will be placed in admin-
istrative segregation as a so-called precautionary safety measure. There is a
growing body of empirical evidence to suggest that the harmful mental
health implications associated with administrative segregation, particularly
over long periods of time, are acute—the practice has been shown to cause
everything from hallucinations to increased suicidal ideations (United
Nations Special Rapporteur 2011; Jackson 2002; Haney 2003; Wynn and
Szatrowski 2004; Grassian 2006). Given the Tribunal’s strict, essentialist
understanding of the relationship between sex and gender, transgender
women who have not ‘completed’ gender-affirming surgery are left to
make an impossible decision: Do they value their physical safety over their
mental health, or their mental health over their physical safety? The deci-
sion in Kavanagh, which reflects a biomedical understanding of transgen-
der identity and experience, requires those who have not ‘completed’
gender-affirming surgery to make this impossible decision for as long as
they are ensnared in the apparatuses of the carceral state.5
After unsuccessfully appealing the decision in Kavanagh, the CSC had
no choice but to enact a new ‘Gender Identity Disorder’ policy in 2001
(Correctional Service of Canada 2001). The CSC’s new policy largely
codified the central findings of the Tribunal. Section 36 of the updated
policy requires prison administrators to conduct individual, case-by-case
assessments about housing requirements and expressly notes the vulner-
ability of transgender people. It states: “For all placement and program
decisions, individual assessments shall be conducted to ensure that
offenders diagnosed with gender identity disorder are accommodated
with due regard for the vulnerabilities with respect to their needs, includ-
ing safety and privacy” (Correctional Service of Canada 2001). In further
keeping with the decision in Kavanagh, section 37 of the updated policy
provides that, in order to qualify for gender-affirming surgery in prison,
transgender prisoners must complete the ‘real life’ test where they live
160 K. KIRKUP
openly in their gender for at least one year. The policy specifies that the
environment of the prison does not meet the requirement of the ‘real life’
test. In April 2015, the CSC made minor revisions to the policy
(Correctional Service of Canada 2016). Despite calls from organizations
such as Prisoners’ Legal Service to move towards a system of self-identi-
fication rather than a system of gender essentialism, the CSC’s most sig-
nificant revision was to replace ‘gender identity disorder’ with the
DSM-5’s new term, ‘gender dysphoria’ (Metcalfe 2014).
More recently, however, the federal government signalled a shift in the
logics of gendered prison administration. At a town hall event held in
early 2017, a transgender woman asked Prime Minister Justin Trudeau
whether the government would be updating the transgender policy in
Canada’s federal prisons, describing the current approach as ‘torture.’
After acknowledging that the issue had not been on his radar, Prime
Minister Trudeau replied, “I will make sure we look at it and we address
it and we do right in recognizing that trans rights are human rights and
we need to make sure we are defending everyone’s dignity and rights in
every way we can” (Harris 2017). After previously suggesting that it
would maintain its 2015 policy, the CSC subsequently indicated that it
would be moving away from housing prisoners on the basis of the sex
assigned to them at birth. One day after Prime Minister Trudeau’s
comments, a spokesperson for the CSC explained: “We are currently
assessing—on a case-by-case basis—individual inmates’ placement and
accommodation requests to ensure the most appropriate measures are
taken to respect the dignity, rights and security of all inmates under our
custody” (Harris 2017). This approach is consistent with recommenda-
tions set out in the 2015–2016 Annual Report of the Office of the
Correctional Investigator (Correctional Investigator of Canada 2016),
along with recent changes to admission, classification, and placement
policies in provincial jurisdictions such as Ontario and British Columbia
(Kirkup 2016). While Canada’s federal prison system may not have aban-
doned its project of constructing transgender people as medical objects
that need to be ‘fixed’ altogether, this new approach constitutes a wel-
come shift away from imposing surgical requirements on those who refuse
to be subjugated by regimes of gender essentialism. At the same time, a
larger commitment to decarceration is required to better resist the pris-
on’s power as a tool of gendered governance.
Conclusion: Decarceration and the Struggle

of Gender Self-Determination
Since the advent of sex-segregated carceral spaces beginning in the late

nineteenth century, prison administrators have invariably participated in a
larger project of deciding which bodily signs they will use to draw lines of
gendered inclusion and exclusion. Accordingly, decisions about where and
how to admit, place, and classify those trapped in the apparatuses of the
criminal legal system flow from the assumption that sex is a binary concept
fixed at birth and instantiated in a series of identity documents produced
by the administrative state.
Drawing on the stories of Katherine Johnson and Synthia Kavanagh—
two transgender women who launched human rights complaints against
the CSC for placing them in men’s prisons, this chapter has examined the
ways in which non-normative genders are constituted using biomedical
discourses in carceral spaces. By segregating individuals on the basis of sex,
constructing diagnostic categories such as ‘gender dysphoria,’ and impos-
ing surgical requirements on those who refuse to be subjugated by essen-
tialist gender norms, carceral spaces participate in a larger corporeal
project. These spaces punish those who refuse to be subjugated by norms
that would have them obediently engage in gendered performances that
flow from the sex assigned to them at birth.
As the foregoing analysis suggests, recent signals from the federal gov-
ernment suggesting that transgender people will soon be able to self-iden-
tify their gender for placement, admission, and classification purposes are
best understood as a small victory in a much larger project of gender self-
determination. Yet it would be naïve to place too much optimism in mak-
ing small changes to how carceral spaces constitute regimes of
sex-segregation. The criminal legal system has a long history of punishing
those engaged in non-normative performances of gender and sexuality,
particularly when they dwell at the axes of race, poverty, disability, and
other marginalized categories of identity and experience. While a system
of gender self-identification may help to redress some of the immediate
concerns of transgender women ensnared in prisons, it will do little to
disrupt the larger violence of Anglo-American carceral regimes. While it
may not be immediately obvious, decarceration constitutes an important
site in the larger struggle for gender self-determination (Spade 2012;
162 K. KIRKUP
Lamble 2013; Stanley and Smith 2011; Shaylor 2008). Ultimately,

abolishing the violent apparatuses of the carceral state constitutes an

important next step in the movement towards gendered justice.
Notes
1. When I use the term ‘gender essentialism,’ I am referring to the societal
assumption that men and women behave differently because of innate, sex-
based characteristics.
2. By and large, the history in Canada’s provincial and territorial jails has also
been to rigidly segregate carceral spaces on the basis of sex. In 2015, Ontario
and British Columbia both developed policies that allow transgender pris-
oners to self-identity for the purposes of admission, classification, and place-
ment. For further discussion, see K. Kirkup, “How Ontario’s Prisons
Pioneered Sensitivity to Transgender Inmates,” TVO, January 26, 2016,
http://tvo.org/article/current-affairs/shared-values/how-ontarios-prisons-
pioneered-sensitivity-to-transgender-inmates.
3. There was no comparable provision in the CSC policy dealing with the
placement of transgender men. However, transgender men appear to have
been held in women’s institutions.
4. In June 2017, Bill C-16, which added ‘gender identity or expression’ as
protected categories of discrimination in the Canadian Human Rights Act,
along with the hate crimes provisions of the Criminal Code, received Royal
Assent. For further discussion, see K. Kirkup. 2018. ‘The Origins of Gender
Identity and Gender Expression in Anglo-American Legal Discourse,’
University of Toronto Law Journal 68 (1): 80–117.
5. Critics of my approach may suggest that the goal of punishment is—by defi-
nition—to restrict prisoners from their preferred life paths. For example,
should prison officials deny a prisoner’s request to remove their tattoos?
There are two answers to this question. The short answer to this question is
that, as the Tribunal rightly notes in Kavanagh, [2001] 41 CHRR 119, the
CSC already allows prisoners to request ‘non-essential’ medical procedures
such as tattoo removal. At paragraph 170 of the decision, it states:
Consideration of the treatment accorded to non-transsexual inmates
seeking non-essential medical treatment demonstrates that it is the
inmate’s status as a transsexual that gives rise to the differential treat-
ment: An inmate who wants to have an elective procedure such as a tat-
too removal can obtain a letter from his or her doctors, and will be able
to have the tattoo removed at his or her own expense. The same is true
of any other type of elective medical treatment, with the exception of sex
reassignment surgery.
The longer answer to this question is that, at a fundamental level, access

to medical treatments such as gender-affirming surgery differs from tat-
too removal because of its centrality to some transgender people’s identi-
ties. For a thought-provoking discussion of the complex relationships
between surgery and identity, see L. J. Shrage, ed. 2009. You’ve Changed:
Sex Reassignment and Personal Identity. Oxford: Oxford University Press.
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PART III
The Asylum and Beyond

CHAPTER 8
Uncovering the Heteronormative Order

of the Psychiatric Institution: A Queer
Reading of Chart Documentation
and Language Use
Andrea Daley and Lori E. Ross
Introduction
In this chapter, we use a case study approach to examine the ways that
psychocentrism operates as a dominant discourse within the psychiatric
institution to contain queer madness. Using a critical discourse analysis,
with attention to analytical tools associated with socio- and queer linguis-
tics we interrogate the psychiatric chart to reveal how one woman’s
(whom we call Sheena) mental and emotional distress associated with
A. Daley (*)
School of Social Work, York University, Toronto, ON, Canada
e-mail: adaley@yorku.ca
L. E. Ross
Dalla Lana School of Public Health, Social & Behavioural Health Sciences
Division, University of Toronto, Toronto, ON, Canada
e-mail: l.ross@utoronto.ca

https://doi.org/10.1007/978-3-319-89749-3_8
170 A. DALEY AND L. E. ROSS
same-sex intimate partner violence (SSIPV) is subsumed by a psychocen-

tric logic that authorizes heteronormative gender relations and illegiti-
mates queerness. Psychocentric discourse promotes the individualization
and pathologization of structurally produced mental and emotional dis-
tress, as well as the responsibilization of individuals for such distress
(Rimke 2016). We use the term “queer madness” to refer to mental and
emotional distress experienced by queer (lesbian, gay, bisexual, pansexual,
etc.) people as a result of interpersonal and structural sexual and gender
oppression. Our analysis suggests that queer madness is less culturally
intelligible than non-queer (i.e., heteronormative) madness within the
psychiatric institution. We contextualize this phenomenon in relation to
the psychiatric legacy of discursively constructing and regulating ideal
(hegemonic) conceptualizations of femininity (Schippers 2007) (e.g.,
borderline personality disorder functions to delimit women’s behaviour
by pathologizing women who express anger, aggression, and impulsive
behaviour as hysterical and dangerous; while on the other hand, depen-
dent personality disorder functions to delimit women’s behaviour by
pathologizing submissive and dependent women, despite historic and
continued patriarchal efforts to maintain women’s submission to men)
and pathologizing queer sexualities (King 2003).
Our analysis identifies four documentation patterns and associated lan-
guage that emerged from a review of Sheena’s chart, including: (1) the
lack of accurate and consistent IPV-related documentation; (2) simultane-
ous disclosures of IPV and sexual orientation; (3) ambivalent talk about
IPV; and, (4) partner ambiguity. We analyze the documentation patterns
and associated language through the lens of psychocentrism to consider
how they accomplish the erasure of same-sex intimate partner violence
with the productive effect of authorizing heterosexuality as culturally
intelligible while illegitimating queer sexuality by rendering it culturally
unintelligible. More specifically, we use four characteristics of psychocen-
trism—pathological individualism, victim-blaming, ahistoricism, and eth-
nocentrism—to illustrate how they operate to contain queer madness
within the heteronormative order of the psychiatric institution through
the marginalization and erasure of same-sex intimate partner violence.
While our exploration is largely theoretical, we briefly address the material
effects of containing queer madness for queer women experiencing mental
and emotional distress related to same-sex intimate partner violence.
UNCOVERING THE HETERONORMATIVE ORDER OF THE PSYCHIATRIC… 171
Psychocentrism, Critical Discourse Analysis,

and Queer Linguistics
The concept of psychocentrism, developed by Heidi Rimke (2016), refers

to the “dominant Western view that pathologies are intrinsic to the per-
son, promoting an individualistic perspective at the expense of social,
political, economic, historical and cultural forces that shape human experi-
ence” (Croft et al. 2016, 2). Intertwined with the values of neoliberalism,
psychocentrism is conceptualized as a governing neoliberal rationality (Dej
2016) that is circumscribed by ten characteristics1 (Rimke 2016). These
characteristics variously coalesce across institutional sites to promote and
enact understandings of distress that ignore the impact of social and struc-
tural inequality and social relations of power on mental and emotional
well-being (Croft et al. 2016). We use four of the ten characteristics to
guide our critical discourse analysis of chart documentation: pathological
individualism, victim-blaming, ahistoricism, and ethnocentrism (Rimke
2016). An analysis of the case scenario that integrates all ten characteristics
of psychocentrism is possible. However, we focus on the four characteris-
tics that we believe are most evident in their operation in the psy narrative
of Sheena’s distress to authorize heteronormative gender relations and
illegitimates queerness. Pathological individualism refers to “the modern
master status of the person defined in terms of ab/normalization and/or
self/categorization and/or expert classification” (Rimke 2016, 8). Victim-
blaming happens when individuals are held responsible for their experi-
ences of distress and trauma. Ahistoricism is evident in institutional and
service provider practices that fail to account for history in current indi-
vidual and collective understandings of the self. For example, psy narra-
tives promote the notion of trauma as an individual “disorder” rather than
a (normative) reaction to historical and unrelenting systemic oppression
and violence. This is notable in institutional, treatment, and service pro-
vider practices that fail to consider Indigenous Peoples’ distress as an
expression of colonial violence (historical and contemporary), relying
instead on psy language such as depression and anxiety to label and explain
their distress (Burch 2014; Kanani 2011; Vaughan 2007). And finally, eth-
nocentrism is signalled in the privileging of one’s cultural practices and
beliefs as “normal” in comparison to other cultural practices and beliefs,
and therefore as superior to them (Rimke 2016). Rimke (2016) proposes
the use of psychocentrism as a “critical analytical tool” to “provide an
alternative or counterhegemonic reading” (6) of dominant psychiatric

narratives of “mental illness,” while revealing the operations of oppression
and inequalities (e.g., sexism, racism, heterosexism, cisgenderism, and
classism) in experiences, understandings of, and responses to, distress. Our
analysis uses these four characteristics of psychocentrism to reveal how it is
operationalized by mental health service providers (MHSPs) in chart doc-
umentation practices.
Critical discourse analysis (CDA) examines the role of language in
organizational texts to “establish identities, social relationships and sys-
tems of knowledge and belief” (Tupper 2008, 224) by making transparent
taken-for-granted assumptions and categories. We use discourse to mean
“textually mediated social action in which speakers and writers draw on
linguistic resources and socio-cognitive representations, including of the
self and others, to establish, maintain or challenge power relations” (Koller
2013, 574). In this regard, interrogating the psychiatric chart as an his-
torical, managerial, and legal document serves to uncover its role in not
only centring and legitimating the authority of the physician (i.e., profes-
sionalization of medicine), but also constructing patients in ways that
reflect societal presuppositions and that depoliticize their lives (Daley et al.
2012). As a research method, and using the characteristics of psychocen-
trism to guide our analysis, we apply CDA to probe underlying philo-
sophical assumptions, ideological commitments, and implicit
knowledge-power dynamics in the psychiatric chart to reveal how psycho-
centricity is validated as a structure of domination within the psychiatric
institution (Tupper 2008). From this perspective, chart documentation
within the organizational setting of the psychiatric institution is conceptu-
alized as a social practice (action) that “set[s] the parameters and the con-
ditions of possibility, for what can be perceived, articulated, and
experienced” (Tlili 2007, 285).
Of particular importance to our goal of revealing the impact of psycho-
centrism on queer madness through an analysis of the psychiatric chart are
some of the analytical tools associated with socio-linguistics. Specifically,
we draw on the intersubjective tactics of authorization and illegitimation
as outlined by Bucholtz and Hall (2004):
Authorization is the use of power to legitimate certain social identities as

culturally intelligible, while illegitimation is the revoking or withholding of
such validation from particular identities. (503)
The notion of intersubjectivity as referenced in the tactics of authoriza-

tion and illegitimation positions identities as “ideological constructs pro-
duced by social discourse” (Bucholtz and Hall 2004, 490). This is a
particularly relevant concept to our analysis that centres sexuality and
sexual identities within the essentializing tendencies of the psychiatric
institution. The concept of intersubjectivity serves to resist essentialism by
prioritizing (sexual) identities as outcomes of “intersubjectively negoti-
ated practices and ideologies” (Bucholtz and Hall 2004, 493) during, for
example, psy dominated hierarchical patient-psychiatrist interactions, and
then as narrated through psychocentrically oriented documentation prac-
tices. As an analytical tool, the tactics of authorization and illegitimation
offer “a more concise vocabulary” (Bucholtz and Hall 2004, 493) through
which to articulate the role and impact of language in organizational texts
in terms of establishing “the parameters and the conditions of possibility,
for what can be perceived, articulated, and experienced” (Tlili 2007, 285).
To more explicitly focus the intersubjective tactics of authorization and
illegitimation on the subject of sexuality within the psychiatric institution
we link CDA with queer linguistics. Queer linguistics refers to the linguis-
tic analysis of the “regulation of sexuality by hegemonic heterosexuality”
(Bucholtz and Hall 2004, 471) by “uncover(ing) and destabiliz(ing) nor-
mativity through the analysis of text and discourse (Koller 2013, 572).
Previously, queer linguistics has more exclusively focused on “the linguis-
tic practices of sexually marginalized subjects” (i.e., LGBTQ language),
but in recent years has broadened to interrogate the ways in which linguis-
tic practices and social organization are connected and “reflect, reproduce
and validate the heteronormative order; and by doing so, [they] expose
the regulatory processes lending authority and privilege to certain—but
not all—forms of sexuality” (Leap 2013, 643). Through the integration of
CDA, the intersubjective tactics of authorization and illegitimation, and
queer linguistics, we aim to concisely name regulatory processes associated
with the operation of psychocentric discourse as it operates on sexuality
and queer madness within the psychiatric institution.
Design and Methodology
The pilot project from which this case study is derived was exploratory in
nature and identified as its primary objective the examination of the inter-
pretative nature of psychiatry in relation to the construction of women’s
distress and gender (by way of diverse femininities), sexuality, race, and
class within an urban Canadian, clinical psychiatric setting. Our project
was premised on the understanding that any chart entry is deemed signifi-
cant by virtue of its very inclusion in the chart. That is, our analysis assumes
that all documented patient and mental health service provider’s ideas,
utterances, and behaviours are marked as having significant meaning for
the psychiatric institution and its understanding of, and response to, men-
tal distress. A total of twenty-five women’s psychiatric inpatient charts
were reviewed including five charts each from the following programs:
women’s, schizophrenia, mood disorders, geriatrics, and women and law
(Daley et al. 2012). The research project received ethics approval from the
participating psychiatric institution. For a more detailed account of the
data analysis process, see Daley et al. (2012).
Overall, our analysis found that mental health service provider (MHSP)
documentation practices functioned to construct narrow, medicalized rep-
resentations of women’s mental distress through the use of pathologizing
language and the minimal inclusion of the socio-structural factors in their
lives (e.g., structural oppressions related to gender, sexuality, race, and
class) (Daley et al. 2012). In addition, an unintended finding involved the
documentation of women’s experiences of violence, including childhood
sexual and physical abuse, stranger assault and rape, and intimate partner
violence (IPV). Of the twenty-five charts reviewed, nineteen included
some documentation of past and/or present violence in the women’s
lives. The analysis offered in this chapter focuses on the responses of
MHSP, or lack thereof, to SSIPV as indicated by documentation excerpts
from Sheena’s chart.2
Case Study: Sheena and the Documentation

of Distress
Sheena is a twenty-seven-year old woman who presented to the psychiatric

emergency department with suicidal ideation and a twelve-year history of
depression. On a multidimensional assessment form completed by a
MHSP in the emergency department, demographic information identified
her as white, female, heterosexual,3 and unemployed with no source of
income. It is reported by the emergency psychiatrist that Sheena is experi-
encing multiple stressors in her life related to her relationship, employ-
ment and finances, and precarious housing:
27 yo [year old] female, single (recently broke up with girlfriend), not work-
ing, no current income.
SI [suicidal ideation]—started 8 days ago—11/2 wks ago she got an
eviction notice from her landlord, 8 days ago. [Patient] felt hopeless and
overwhelmed. Decided suicide was a good plan. Called ex-girlfriend [to see]
if she could care for her cat & give her a good home. Since then—been with
people all the time.
The emergency psychiatrist elaborates further upon Sheena’s relationship

in the admission note, writing:
Patient is 27 yo female that currently lives in an apartment with a roommate.

She is not currently in a relationship. She had broken up with her female
partner and claims the relationship was abusive emotionally and physically.
Sheena’s psychiatric admission was a total of twenty-three days. During

this period, intervention largely focused on stabilization in relation to sui-
cidality and depression by way of mental status examinations, voluntary
medication adjustment, and individual, limited discussions with a nurse
and psychiatrists, yet with minimal to no intervention related to SSIPV
and psychosocial stressors related to finances, employment, and housing.
The specifications presented below are derived from an abbreviated
timeline of MHSP documentation extracted from Sheena’s psychiatric
chart that specifically referenced her relationship and/or SSIPV. The tim-
ing of particular documentation is indicated by the day number of admis-
sion (e.g., Day 15).
Interpreting Documentation
Through a Psychocentric Lens
In this section, we examine four characteristics of psychocentrism (patho-
logical individualism, victim-blaming, ahistoricism, and ethnocentrism) in
relation to four documentation patterns and associated language that
emerged from our review of Sheena’s chart, including: (1) the lack of
accurate and consistent IPV-related documentation; (2) simultaneous dis-
closures of IPV and sexual orientation; (3) ambivalent talk about IPV; and,
(4) partner ambiguity. In the course of Sheena’s twenty-three-day admis-
sion there were a total of fourteen charting entries (including emer
gency department documentation) that included only minimal relationship
and/or SSIPV content, and no documentation that directly indicated the

formal inclusion of SSIPV as part of her treatment/care plan. The entries
were limited to the same four MHSPs: one entry by an emergency psychia-
trist (Day 1); eight entries by one inpatient nurse4 (Days 5, 11, 14, 15, 16,
17, 19); four entries by one inpatient psychiatrist (Days 7, 16, 17, 23), and
one entry by a clinical clerk (psychiatrist in training) (Day 10). Our review
of the chart indicated that other health professionals including social work-
ers and professional groups that might typically be involved with patients
in matters related to violence and other interpersonal and psychosocial
issues (e.g., finances, employment, and housing) did not document SSIPV-
related content. In what follows, we examine the four key factors of psy-
chocentrism as they presented in Sheena’s psychiatric chart.
Pathological Individualism
Overall, documentation of the emotional and physical violence Sheena
described as experiencing points to the operation of pathological indi-
vidualism. Documentation by the emergency psychiatrist is severely lack-
ing in substantive content including information about the duration,
frequency, severity, and context of the abuse.5 Sheena’s initial disclosure
of SSIPV to the emergency psychiatrist did not appear to elicit a detailed
assessment; rather, his documentation is limited to: “claims the relation-
ship was abusive emotionally and physically” (Day 1, our emphasis). It is
possible that the psychiatrist’s use of the word, “claims” is a signifier of
Sheena’s master status of “mental patient” as it serves to cast the readers’
doubt on her reliability and trustworthiness with respect to “truth” tell-
ing about the specific and general nature of the relationship. Conversely,
documentation patterns that do not question Sheena’s claims of “depres-
sion” and “suicidality” as they are aligned with the psy (expert) classifica-
tions of “disorder” serve to further solidify Sheena’s master status of
“mental patient.” Relatedly, our previous analysis of psychiatric chart doc-
umentation (Daley et al. 2012) suggests that women’s claims of gendered
violence are often questioned by MHSPs in chart documentation. More
specifically, documentation patterns that we describe as dichotomizing
practices rely on the mutually exclusive psy constructs of hallucinatory/
non-hallucinatory and delusional/non-delusional to invalid women’s
claims of violence. This was often manifest in chart documentation that
cited women’s expressions of distress related to gendered violence and
pregnancy, birth, and the apprehension of children by child protection
authorities as unquestionable delusional content. In these situations, the

medical expert’s side of the dichotomy (gendered violence as hallucina-
tory/delusional) is assumed to be correct while the women’s side (gen-
dered violence as non-hallucinatory/non-delusional) is assumed to be
incorrect. These types of documentation practices (e.g., use/non-use of
the term “claims” and reliance on psy constructs of hallucinatory/non-
hallucinatory and delusional/non-delusional) achieve the master status of
“mental patient” by marginalizing patient narratives on the social and
structural sources of their distress and (re)centring psychiatric narratives
on biological understandings of distress.
To further articulate this point, we note that while the first inpatient
documentation in Sheena’s chart by a unit nurse includes a summary of
information provided in the admission note authored by the emergency
psychiatrist along with an update on Sheena’s mood and affect, and assess-
ment of vitals, sleep, weight, and drug and alcohol abuse, it does not
include mention of the emotional and physical violence reported by
Sheena while in the emergency room:
Received patient. Patient is a 27 yo F [female] with MDD [major depressive

disorder]. Reported received by [name of RN] on [name of unit] that this is
her 1st hospitalization. She has hx [history] of OD [overdose]. No reports
of drug or alcohol abuse. Regarding her housing, she is worried since she
received an eviction notice. She is currently unemployed, and has reported
not being able to keep a job due to her mental health. Has had trouble
sleeping recently. Admission paper work complete. Mood and affect level.
Vitals were stable and weight taken. Belongings were checked and sharps
and objects of concern kept in nursing station. (Day 1)
Documentation of SSIPV is also absent in nursing entries on Days 2 through

4, despite the fact that during this time Sheena’s ex-partner visited her on the
unit. Rather, charting entries focus on Sheena’s orientation to the inpatient
unit, history of depression and related treatment, assessment of mood, and
activities, and visitors received. It is not until Day 5 of Sheena’s admission
that documentation related to SSIPV (re)appears after she returned from an
accompanied outing with a “friend” to her home. A nurse documented:
Affect blunt, anxious, superficially bright. Patient described mood as “anx-

ious, I’m really anxious.” Reports has suffered from “Social Phobia” and
major depression since age 15. Patient reports is in current relationship with
a woman who has been physically and emotionally abusive in the past. Patient
reports relationship is “tumultuous at the best of times”—is ambivalent

about maintaining the relationship and admits it is not healthy but defends
partner saying partner is “getting therapy to deal with her issues.” Writer
provided support, encouragement and positive feedback: patient reports sat-
isfaction with “being heard.” Affect brighter, reports feels more calm.
The writer notes a shift in Sheena’s affect and mood over the duration
of their discussion. While the structure of the excerpt may lead the reader
to infer Sheena’s improved affect and mood to be an impact of talking
about her experience of relationship violence, this is not explicitly detailed
by the writer. Importantly, this documentation reifies Sheena’s status as
“mental patient” as her “bright” affect is legitimized—or becomes
“real”—through or only after the nurse’s intervention (i.e., “affect
brighter” is not qualified by the descriptor “superficial” as it is at the
beginning of the documentation excerpt). Importantly, the truth value of
the nurse’s claim is supported in her uncritical acceptance of Sheena’s
claim of “being heard.” This circular logic is implicated in establishing
Sheena’s master status as “mental patient.”
Beyond this analysis, the reader is left wondering why Sheena’s descrip-
tion of her relationship as “tumultuous at best” and the writer’s inclusion
of physical and emotional abuse in the charting entry does not appear to
prompt the nurse to conduct a more detailed assessment. The nurse’s
assessment of Sheena’s affect and mood bookend (i.e., “pre and post mea-
sures”) her charting entry, conceivably signalling the prioritizing of psy-
chocentric (i.e., biological) distress and wellness and associated indicators
in the assessment process. Nowhere in the chart is there documentation
that suggests attention to Sheena’s own understanding of whether and
how the nature and extent of violence is informing her distress.
Other references to SSIPV exist in the chart, albeit indirectly and mini-
mally, with excerpts that refer to Sheena’s own account of her relationship
as “tumultuous” (Day 10) and “difficult and tumultuous” (Day 14).
Other entries suggest that Sheena is perceived as ambivalent about taking
up the issue of IPV with MHSPs. For example, the nurse describes Sheena
as “wary and guarded” when asked if she’d like to meet to talk about her
relationship (Day 11), and documents that “she has broken up with her
partner as of yesterday but denies wanting to elaborate at this time” (Day
14). Even when Sheena’s explanation of why she may not talk about rela-
tionship violence to MHSPs is documented, her pathology is simultane-
ously inferred by her characterization as avoidant:
There was a lot of avoidance noticed … where things would bother her but
she would not really talk about them because she stated that this was how
she was raised—not to bother people with her issues. (Day 23)
Sheena emerges from the lack of accurate and consistent SSIPV-related

documentation and associated deficit-based language as—unreliable
(“claims”), “wary,” “guarded,” in denial (“denies”), and avoidant—as a
singular pathological figure, or rather the “mental patient.” This docu-
mentation pattern and associated language obscure Sheena’s SSIPV narra-
tive, limiting the possibility of her being seen as anything other than or
beyond a “mental patient.” The dominance of the master status “mental
patient” within the psychiatric institution serves to flood out all other
aspects of Sheena’s identity including sexuality/queerness as it may relate
to her mental distress. In this way, pathological individualism illegitimates
queer madness as culturally intelligible.
Victim-Blaming
Relatedly, the language of pathology in these instances serve to victim-
blame, or rather hold Sheena individually responsible (i.e., responsibiliza-
tion) for her distress as documentation infers that these attitudes and
behaviours prevent her from taking full advantage of the support (e.g.,
talking) being offered by at least one MHSP, and the psychiatric institu-
tion more generally. Victim-blaming is more obvious in the documenta-
tion of Sheena’s “admission” that her relationship is “not healthy” and in
her implicit compassion for her partner who is “getting therapy to deal
with her issues.”
Victim-blaming may be compounded by MHSPs’ cisgender-
heteronormative assumptions that women are passive and non-aggressive,
and therefore, not capable of violence—or at least not capable of the forms
and severity of violence considered to seriously impact emotional and
mental distress. This inability to imagine the possibility of violent interac-
tions between women may be implicated in the psychiatrist’s use of the
term “claims” and subsequent invalidation of Sheena’s experience of rela-
tionship violence (as described above) in relation to her distress. Finally, as
discussed below, MHSPs’ apparent lack of interest in even knowing
whether or not Sheena’s partner was visiting and/or accompanying her on
outings may be a manifestation of victim-blaming as it is rooted in hetero-
normativity and/or homophobia. Regardless, victim-blaming further
obscures Sheena’s SSIPV narrative, and the likelihood of it being seriously

considered as an important therapeutic issue, by reconfiguring “the prob-
lem” to address as Sheena’s attitudes and behaviours rather than the struc-
tural and relationship sources of her emotional and mental distress.
Ahistoricism
We interpret the intersection between the documentation patterns and
associated language of simultaneous disclosures of IPV and sexual orienta-
tion and ambivalent talk about SSIPV as particularly relevant to the opera-
tion of ahistoricism. In terms of the former, we found that MHSPs’ chart
entries fail to acknowledge risks and vulnerabilities within the psychiatric
institution for Sheena as a result of the implicit disclosure of queerness
(i.e., same-sex relationship) through her reporting of same-sex relation-
ship violence. Undoubtedly, concern about risk and vulnerability is war-
ranted and should be considered by MHSPs as an important therapeutic
issue given the ongoing potency of the psychiatric legacy of regulating
women’s sexualities (Daley et al. 2012; Ussher 2011) and pathologizing
queerness (King 2003). Critical race and post-colonial theorizing have
explored the ways in which psychiatric diagnoses and interventions reify
dominant raced and classed norms and values associated with idealized
femininity (Beauboeuf-Lafontant 2007; Bondi and Burman 2001; Gibson
1997) (see Daley et al. 2012). Within psychiatric discourses, the sexual-
ized, racialized, and classed characteristics of marginalized femininities as
manifest in queer women’s lives have been inherent to their demarcation
as deviant and stigmatized (Schippers 2007). That is, deviations from het-
eronormative sexualized, raced, and classed ways of being gendered/
doing gender often undergird psychiatric classifications related to wom-
en’s queer sexuality and are problematically assigned to queer bodies (e.g.,
sexual inversion, homosexuality, egodystonic sexual orientation, sexual
orientation disturbance) (Drescher 2009, Gibson 1997, 1998).
Evidence of “historical amnesia” (Rimke 2016, 7) by the psychiatric
institution is found in the cavalier manner in which “data” about patients’
sexual and gender identities are collected during an individual’s point of
contact (i.e., crisis) with the psychiatric institution. Our chart review indi-
cated that patients are routinely asked about sexual orientation (and other
demographics) in emergency contexts through the use of a multidimen-
sional assessment form, which offers a range of options including: hetero-
sexual, gay, lesbian, bisexual, queer, questioning, and other (specify), and
that instructs MHSPs to complete the form in “the client’s own words.”
However, as in Sheena’s chart, our chart review noted frequent discrepan-
cies between the multidimensional assessment form and charting entries.
In Sheena’s case, the multidimensional assessment form identifies her as
“heterosexual” yet the psychiatrist’s note references her “girlfriend” and
“female partner” despite the fact that both forms of documentation were
completed on the same day and in the same setting (upon admission to the
ER), although by two different MHSPs. Conceivably, the identification of
Sheena’s sexual orientation as “heterosexual” on the multidimensional
assessment form may signal her discomfort, fear, or concern about disclos-
ing a same-sex relationship within a psychiatric context marked by histori-
cal and contemporary heteronormative discourses and corrective
“treatments” related to women’s sexuality and “homosexuality.”
Of course, there are other possible explanations for the discrepancy
between the demographic intake form and psychiatrist’s note, including:
Sheena being asked about sexual orientation and describing it “in her own
words” as “heterosexual,” distinguishing between her sexual identity (het-
erosexual) and sexual behaviour (sex with women) (i.e., a woman who has
sex with women but does not take on sexual identity labels such as lesbian
or queer); or the MHSP failing to ask (perhaps due to discomfort) Sheena
about her sexual orientation, assuming her heterosexuality based on ste-
reotypical feminine appearance, gestures, and behaviours, and completing
the form as such. Our point here is not to suggest or support an institu-
tional need/desire for disclosure and consistency of sexual identities.
Rather, our intent is to underscore how an institutional expectation of
patient disclosure of sexual identity within the likely context of crisis and
the absence of an established therapeutic relationship becomes imaginable
because of ahistoricism. This constitutes institutional disregard for its past
and present harms done to women who express non-normative sexuality.
In terms of the ambivalent talk about SSIPV, some chart entries suggest
that MHSPs perceived Sheena as minimizing relationship violence and
rationalizing her partner’s abusive behaviour, and therefore, not taking
seriously the issue of relationship violence. For example, the verbatim doc-
umentation of Sheena’s description of her relationship as “tumultuous at
best” (Day 5) may have been deemed noteworthy because it was inter-
preted by MSHPs as a minimization of violence. Similarly, Sheena’s
expressed understanding of potential stressors experienced by her partner
such as “issues with coming out to friends and colleagues” (Day 19); her
acknowledgment that her “partner is getting therapy to deal with her
issues” (Day 5); and her stated intent to be “more patient and compas-
sionate toward her partner” (Day 10) may have been documented because
they were interpreted by MHSPs as pathological minimizations and ratio-
nalizations of violence. Conceivably, institutional ahistoricism fostered the
inability of MHSPs to consider Sheena’s response as an outcome of his-
torical and contemporary cultural homophobia that positions lesbian rela-
tionships as amoral, deviant, and inherently pathological. Some sexual
minority women may deny or minimize SSIPV due to fear that it will be
taken as evidence of their relationships as amoral, deviant, and inherently
pathological by MHSPs within the heteronormative space of the psychiat-
ric institution (Ristock 2002). In other words, some queer women may
deny or minimize SSIPV in response to historical denigrating societal ste-
reotypes about non-normative sexuality, and a desire for social acceptance
(Davis and Glass 2011; Duke and Davidson 2009; West 2002).
Ahistoricism operates in chart documentation to shear Sheena and her
mental distress from the structural context of historical and contemporary
psychiatric regulatory processes related to sexuality, which disconnects her
behaviours and responses from the local socio-political context of the insti-
tution and beyond (e.g., lesbophobia, heterosexism). A counter narrative
that imagines Sheena “past” the boundaries of the institution would locate
her, and her mental and emotional distress, within proximity to experi-
ences of sexual minority individual and collective marginalization. Attitudes
and behaviours interpreted by MHSPs as “wary,” “guarded,” in denial,
and avoidant could be alternatively interpreted as justified responses within
the heteronormative context of the psychiatric institution. In the absence
of a counter narrative that historicizes Sheena’s mental distress, her behav-
iours and responses are interpreted by MHSPs as indicators of an internal
pathology rather than the productive effect of the psychiatric institution.
Ethnocentrism-Heterosexism
Ethnocentrism in the form of heterosexism operates in Sheena’s chart in
the documentation pattern we identify as partner ambiguity. First, het-
erosexism among MHSPs is most evident in what appears to be their
uncertain understanding of the nature of the relationship between Sheena
and her female partner. That is, often staff did not seem to be aware of, or
acknowledge, Sheena’s partner. This is evidenced by MHSPs’ documenta-
tion that variously use the following language when documenting Sheena’s
female visitor(s): “partner,” “female friend,” “friend,” and “visitor.”
At times, the documentation clearly identifies her partner as a visitor: “Pt.

[patient] had partner and a female friend visiting this evening” (Day 1)
and “She’s doing fine according to her and she had a good time with her
partner this evening” (Day 8). Other documentation requires the reader
to infer that her partner is visiting, for example, the following documenta-
tion uses the language, “friend” but also makes reference to “their place”:
“Pt. [patient] mentioned that she will be out for lunch, friend is coming
to pick pt. up and they will have lunch at their place” (Day 5). However,
by and large, documentation is less clear about whether Sheena is spend-
ing time with her partner: “Pt. had uneventful evening had 2 female visi-
tors and went for a walk with them” (Day 2) and “Pt. female friend came
to visit earlier but she was not around … patient returned to the unit
while a friend waited for her” (Day 8). Moreover, the inconsistent use of
ambiguous language such as “female friend,” “friend,” and “visitor” in
close charting proximity leaves the reader uncertain about when Sheena’s
intimate partner is visiting. For example, the following sequential charting
excerpts use the language “partner” and “visitor” to refer to the same
person during the same visit:
Pt. [patient] is up at this time having dinner and she is presently having her
partner visiting. (Day 3)
Pt. has been visible on the unit throughout the evening, went out x1 for a
walk with her visitor. (Day 3)
It is conceivable that Sheena felt more or less discomfort about disclosing

her relationship with different staff members, and therefore, referred to
her partner as a friend and/or roommate during their interactions.
However, within the context of reported relationship violence it is alarm-
ing that documentation dating back to the admission date fails to clearly
identify Sheena’s partner. Even in the potential absence of MHSPs being
informed of SSIPV by reading her chart in full, it is reasonable that the
issue of SSIPV would be communicated to MHSPs through other means
during the duration of Sheena’s stay, for example, during team rounds.
We read the documentation pattern of partner ambiguity, as described
above, as indicative of MHSPs’ understanding of IPV and the victim/
perpetrator binary embedded within heteronormative gender relations.
Heterosexism perpetuates the normative centring of the perpetrator-
male/victim-female dyad in IPV. Thinking about the operation of
ethnocentrism-heterosexism in this way extends our interpretation of the
operation of ahistoricism, cultural homophobia, and MHSPs’ perception

of Sheena’s minimizations and rationalizations of violence to consider a
counterhegemonic reading that allows for difference in terms of responses
to relationship violence. For example, the “lesbian utopia myth” whereby
relationships between women are seen as constituting ideal egalitarian
relationships (Barnes 2010; Duke and Davidson 2009) and feminist prin-
ciples of equal and non-violent woman-to-woman relationships may lead
some lesbian and queer women to be hesitant about constructing an abu-
sive partner negatively out of concern that their queer community would
marginalize her or deny her support (Barnes 2010). In this regard, a desire
for community responses that “create a space for non-oppressive power
and empowerment for all lesbians” (Davis and Glass 2011) may supersede
the desire to name a victim and perpetrator. As such, SSIPV may create a
challenge for MHSPs by “necessitating the extension of power analyses to
include those relationships that do not fit neatly into the male/female
dyad” (Duke and Davidson 2009, 28). A counterhegemonic reading of
relationship violence that imagines Sheena “past” the heteronormative
order of the institution would allow for an alternative but equally valid
conceptualization of relationship violence that is dislodged from hetero-
normative gender relations, and subsequently, allows for diverse responses
to violence. From this perspective, ethnocentrism-heterosexism operates
through the documentation pattern of partner ambiguity and associated
language to pathologize the non-binary perspective on the perpetrator/
victim dyad espoused by Sheena. This signals the loss of yet another piv-
otal moment of queer intelligibility within the psychiatric institution.
Our analysis illustrates how psychocentrism operates through four of
its characteristics—pathological individualism, victim-blaming, ahistori-
cism, and ethnocentrism (heterosexism)—to produce documentation
“moments” that marginalize at best, and erase at worst, SSIPV from
Sheena’s distress narrative across the temporal space of the psychiatric
chart. That is, the marginalization and erasure of SSIPV emerge from min-
imal and unsubstantial documentation and associated language that (1)
obscures Sheena’s SSIPV narrative through the inclusion of deficit-based
language that implies an internal pathology; and (2) decontextualizes
Sheena’s attitudes, behaviours, and responses related to SSIPV from the
homophobic and heteronormative legacy of psychiatry and the psychiatric
institution, broader context of cultural homophobia, and queer conceptu-
alizations of relationship violence. In the psychiatric chart, Sheena’s sexual
identity is “intersubjectively negotiated” through MHSP documentation
practices that reflect and validate the local socio-linguistic context of the
psychiatric institution as it is governed by the discourse of psychocentrism.
More precisely, MHSPs’ documentation practices are guided by the socio-
linguistic context of psychocentrism with the outcome of illegitimating
Sheena’s queerness and authorizing heterosexuality through the marginal-
ization and erasure of SSIPV. The intersubjective tactics of authorization
and illegitimation manifest in the operation of characteristics of psycho-
centrism in chart documentation patterns and language to achieve institu-
tional heteronormativity. In this discursive climate, Sheena’s queer
madness is rendered culturally unintelligible as it is contained within the
heteronormative order of the psychiatric institution.
While our analysis is largely theoretical, we would be remiss to con-
clude this discussion without pointing to the very real effects or impacts
of institutional regulatory processes that lend authority and privilege to
heterosexuality to the detriment of queer women. In Sheena’s case, for
example, as what might be expected in a situation of IPV in a heterosex-
ual relationship, nowhere in the chart did documentation suggest that
service providers explored and developed a safety plan with Sheena,
including plans to explicitly identify her partner when she visited, address
visits by her partner and weekend passes to her partner’s home. In addi-
tion, our review of Sheena’s chart suggests that she was discharged with-
out referral to community- based IPV and/or local LGBTQ-specific
counselling services despite the psychiatrist’s acknowledgement in the
discharge summary of Sheena’s relationship as “quite rocky” and an
“ongoing stressor” (Day 23). Importantly, theorizing the ways in which
dominant psychocentric discourse authorizes heterosexuality and illegiti-
mates queer sexualities through documentation practices and language
use calls to attention the urgency for institutional change that moves
towards institutional recognition of different sexualities rather than their
ongoing structural marginalization.
Conclusion
In this chapter, we consider the relationship between dominant psycho-
centric discourse and heteronormativity within the specific socio-political
context of the psychiatric institution through an interrogation of chart
documentation practices and language use. Our analysis illustrates the
ways in which language is used to reflect, reproduce, and validate the het-
eronormative order of the psychiatric institution, which then authorizes
heterosexuality and illegitimates queer sexuality. While our analysis holds

potential as an important contribution to critiques of psychocentrism and
the decontextualizing of mental and emotional distress from social struc-
tural inequalities, it is not without its limitations.
As indicated previously, the pilot study did not use a case study approach
to provide an in-depth and detailed examination of the phenomenon of
SSIPV documentation in psychiatric inpatient charts. We acknowledge
that the lack of detailed information available about Sheena’s own percep-
tion of her experiences is a limitation in our analysis. In addition, our
analysis must be read within the context of limitations inherent in a retro-
spective chart review design that prevented a fuller understanding of
MHSPs knowledges and practices related to SSIPV including incomplete
documentation, information that is unrecoverable or unrecorded, diffi-
culty interpreting information found in the charts (e.g., acronyms), and
variance in the quality of information recorded. Therefore, we understand
that the psychiatric chart is more likely a proxy measure of MHSPs’
responses to this particular situation.
Notwithstanding these limitations, our analysis is an important contri-
bution to theorizing queer madness within the psychiatric institution. We
introduce the integrated use of CDA, the intersubjective tactics of autho-
rization and illegitimation, and queer linguistics to concisely name regula-
tory processes associated with the operation of psychocentric discourse as
it operates on sexuality and queer madness within the psychiatric institu-
tion. The integration of these analytical tools support an analysis that: (1)
considers how documentation patterns and associated language reflect
and validate the characteristics of psychocentrism; (2) centres documenta-
tion patterns and associated language related to sexual identity; and (3)
examines how the characteristics of psychocentrism operate through lan-
guage as regulatory controls that authorize heterosexuality and illegiti-
mate queerness.
Notes
1. Rimke (2016) identifies ten characteristics of psychocentrism including
reductionism, determinism, essentialism, presentism or ahistoricism, natu-
ralism, ethnocentrism, double-standard, victim-blaming, positivism, and
pathological individualism.
2. This was the only chart from the pilot project that indicated SSIPV. However,
our analysis of the charts indicated that in different ways, different experi-
ences of gendered violence were largely ignored within the treatment plan.
Psychocentrism played out in different ways through chart documentation

in relation to institutional responses to women’s experiences of violence and
the various ways that they were differently positioned in relation to sexuality,
race, and class.
3. It is not uncommon to see conflicting or contradictory demographic infor-
mation in psychiatric charts. For example, demographic information on
sexual orientation and race collected through the use of a multidimensional
form in the ER would be contradicted by descriptions of patients in MHSP
progress notes. We explore this in more detail below under the subheading
“Ahistoricism.”
4. We note, based on our review of the chart, that this particular nurse is the
only nurse who included any information about Sheena’s relationship and
SSIPV in her charting entries. We acknowledge the nurse’s ongoing attempts
to engage Sheena in discussion about her relationship while speculating that
in her absence the issue of SSIPV would have been fully neglected during
the inpatient admission. It is conceivable that this nurse is Sheena’s primary
nurse, and therefore, the detail about Sheena’s relationship falls primarily
within her scope of reporting responsibility. However, if this is the case, we
point to serious concern about inadequate attention to the issue of SSIPV
during the nurse’s absence (e.g., days off, vacation leave, etc.).
5. Women’s health care encounters, whether in emergency departments, fam-
ily physician offices, or obstetrical and gynecological services, have been
identified as representing opportunities to address intimate partner violence
(IPV) (Freedberg 2006; O’Campo et al. 2011). Given the impacts of IPV
on women’s well-being (e.g., psychocentrically described as depression,
post-traumatic stress disorder, anxiety, insomnia, social dysfunction and sub-
stance abuse in the research literature) (Campbell 2002; Lacey et al. 2013;
Rees et al. 2011), it would seem reasonable that psychiatric care settings also
represent significant places whereby IPV in women’s relationships should be
addressed. Sheena’s case scenario suggests that this may not be the case,
which may be an outcome of psychocentric practices that decontextualize
women’s experiences of distress from the social and structural context of
their lives (i.e., gendered violence)—especially in cases involving same sex
intimate partner violence, which is less well documented/recognized.
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CHAPTER 9
Assessing ‘Insight’, Determining Agency

and Autonomy: Implicating Social Identities
Merrick D. Pilling, Andrea Daley, Margaret F. Gibson,

Lori E. Ross, and Juveria Zaheer
Introduction
In this chapter, we draw on a critical analysis of 120 inpatient charts from
a large psychiatric institution in Toronto, Ontario to examine the con-
cept of ‘insight’ as it is operationalized by psychiatrists in chart docu-
mentation. Insight, generally understood as the degree to which patients
believe they have a mental illness and comply with psychiatric treatment
M. D. Pilling (*) • A. Daley • M. F. Gibson

School of Social Work, York University, Toronto, ON, Canada
e-mail: mpilling@yorku.ca; adaley@yorku.ca; mfgibson@yorku.ca
L. E. Ross
Dalla Lana School of Public Health, Social & Behavioural Health Sciences
Division, University of Toronto, Toronto, ON, Canada
e-mail: l.ross@utoronto.ca
J. Zaheer
Centre for Addiction and Mental Health, Toronto, ON, Canada
Department of Psychiatry, University of Toronto, Toronto, ON, Canada
e-mail: juveria.zaheer@camh.ca

https://doi.org/10.1007/978-3-319-89749-3_9
192 M. D. PILLING ET AL.
(Mosher 2017), is clearly linked to patient acceptance of the medical

model of mental illness. Social constructionist critiques of the use of
‘insight’ in psychiatry demonstrate that patient rejection of diagnoses,
hospitalization, and/or medical treatment is interpreted as evidence of
poor insight, and, therefore, as justification for further professional inter-
vention (Diesfeld and Sjöström 2007; Galasiński 2010; Galasiński and
Opaliński 2012; Galasiński and Ziólkowska 2013; Hamilton and Roper
2006; Høyer 2000).
Such critiques clearly demonstrate that assessments of insight are laden
with power dynamics in which biomedical explanations of mental distress
and associated treatments are reflected and reproduced. Notwithstanding
the importance of these existing critiques of ‘insight’, they are limited by
their tendency to homogenize ‘patients’ and ‘clinicians’, eliding the larger
context of structural oppression and the ways in which power operates
across social differences such as gender, race, sexuality, and class. More
specifically, such constructions of essentialized patients do not attend to
power differentials during psychiatric interactions based on social identity
and social location that are imbricated within the hierarchical patient/cli-
nician relationship. In contrast, the current project expressly considers the
social construction of insight in relation to the social locations of patients
as they are understood and recorded by clinicians, and the larger context
of structural oppression.1
Our analysis shows that the professional practices and processes of
attributing ‘insight’ are mitigated by factors such as gender, sexuality, race,
and class. We argue that psychiatrists use insight as a discursive means to
delegitimize patient perspectives that diverge from the medical model of
mental illness, particularly those that are more likely to be held by margin-
alized people, such as cultural or spiritual beliefs about sources of distress,
and trauma narratives. Patients who expressed the logics and lived realities
of white, middle class, male heteronormativity were often accorded more
respect and were more likely to be perceived as insightful. These findings
warrant attention considering the fundamental role of the construct of
‘insight’ in the justification of coercive measures such as involuntary hos-
pitalization or detention and compulsory treatment. Thus, the attribution
of ‘insight’ and its associated discursive logic has serious implications for
patient agency and bodily autonomy.
ASSESSING ‘INSIGHT’, DETERMINING AGENCY AND AUTONOMY… 193
Methods
Our research used theories and methods as informed by institutional eth-
nography (IE) (Smith 1999, 2005), using the discursive invocation of
‘insight’ as a means to investigate psychiatric discourses and social arrange-
ments that extend beyond any particular institution. We consider the psy-
chiatric chart as integral to human relations and lived experiences, even
when not all forms of data are available (as in the patient’s own accounts
of their experiences or exact transcripts of practitioner-patient interviews).
Therefore, charts are seen as both products and producers of people’s
activities with material, everyday implications. Our intent is not to evalu-
ate the ‘truth’ of whether any given patient has ‘insight’. Rather, we seek
to better understand the everyday implications of this discursive construct
on patient agency and autonomy within the psychiatric institution and in
relation to admission and treatment decisions.
A total of 120 psychiatric inpatient charts from a large psychiatric hos-
pital in Toronto, Canada were reviewed with 15 women’s and 15 men’s
charts2 (a total of 30 charts) selected from four inpatient programs that
provide treatment related to particular diagnoses and/or symptoms
including schizophrenia, bipolar disorder, major depression disorder, and
generalized anxiety disorder.3 We selected programs that typically have a
lot of patients with longer stays (to allow for rich and plentiful charting
data) as well as a range of diagnoses that have been shown to vary by
gender, sexuality, race, and class (Ussher 1997, 2011; Metzl 2009;

Beauboeuf-Lafontant 2007; Chesler 2005; Blum and Stracuzzi 2004;
Jimenez 1997).
All charts were reviewed sequentially according to the sample frame
until the target number of 30 charts from each unit was met. During the
chart selection process, we attended to representation across the catego-
ries of gender, sexuality, race, and class by maintaining a demographic
table of the selected charts during the selection process. We relied on the
multidisciplinary assessment form completed during admission to collect
patient demographic data on gender, sexual orientation, race, and socio-
economic status/class.
Each chart was read to identify and extract content related to gender,
sexuality, race, and class. This content included, for example, the follow-
ing: relationship status/history, descriptions of physical presentation (e.g.,
hygiene, dress, skin colour), references to sexual behaviour and sexual
identity, sexuality-related concerns such as relationships, sex, and contra-
ception, and references to housing status, income/social assistance needs,

and education. De-identified extracted data from each chart were manu-
ally transferred into individualized, corresponding Word documents that
served as a ‘text’ for analysis (Daley et al. 2012). The project received
ethics approval from the psychiatric institution from which charts were
reviewed and from all participating universities.
Once all relevant data were extracted from the total 120 charts, the fol-
lowing steps were undertaken by two research team members (MP, AD):
(1) all texts were read and a summary for each text was created; (2) each
summary was read and an associated memo document was created for
each summary to capture key themes across the texts; and (3) MP and AD
exchanged and read each other’s memo document towards refining key
themes. In this regard, critical discourse analysis (CDA) was used to high-
light the social and organizational categories related to gender, sexuality,
race, and class that already exist within the charts and that may function to
shape chart documentation. Our readings explored ideological commit-
ments underlying psychiatric charts including gendered, sexualized, racial-
ized, and classed assumptions, meanings, and values (Lupton 1992;
Tupper 2008).
Theoretical Frameworks
Our chart analysis is informed by feminist, critical race, and post-colonial
understandings of the interconnected nature of gender, sexuality, race,
and class (Collins 2000; King 1988; Weber 1998), and the ways in which
psychiatry has participated in the social structures of patriarchy, racializa-
tion, and class (Beauboeuf-Lafontant 2007; Chesler 2005; Bondi and
Burman 2001; Gibson 1997; Metzl 2009; Ussher 1997, 2011). While this
chapter explores the relationship between psychiatric discourses and social
identities and social locations it departs from this body of literature by
focusing more exclusively on the discursive construction of ‘insight’ rather
than of ‘disorder’ (i.e., diagnostic classification), per se.
Our analysis is also informed by critiques of the medical model of men-
tal illness (Boyle 2011; Coles et al. 2013; Johnstone 2000; LeFrançois
et al. 2013). Our critique of ‘insight’ fits within Mad Studies, an interdis-
ciplinary field of study that provides an alternative to “psy-centred ways of
thinking, behaving, relating, and being” and critiques current concep-
tions of mental illness as a biological condition that can be scientifically
evidenced and universally applied (LeFrançois et al. 2013, 13). In what
follows, we explore the meaning of ‘insight’ before outlining our analysis

in detail through three key themes: (1) assessing ‘insight’: delegitimizing
disagreement; (2) what constitutes insightful objection to psychiatric
treatment?; and (3) challenging findings of incapacity.
What Is ‘Insight’?
The inpatient charts centred in our analysis are replete with references to
‘insight’ as it is continuously assessed throughout the duration of admis-
sion by psychiatrists, and to a lesser extent, nurses and social workers.
Assessments of insight appear on intake forms at the point of emergency
department and unit admissions, as well as on the Mental Status Exam4
(MSE), which is normally administered by nurses and psychiatrists on a
regular basis throughout the admission period, sometimes several times a
day. Insight is almost always assessed at the end of every daily encounter a
patient5 has with a physician. Notably, this construct is highly visible in the
charts of people who are assessed by psychiatrists to determine their capac-
ity to make decisions about health treatment (i.e., consent to treatment)
and/or finances. Despite the crucial role of insight in determinations of
capacity, this term does not appear in legislation governing involuntary
detention or hospitalization and compulsory treatment (in our setting, the
Ontario Mental Health Act and Health Care Consent Act).
A review of the relevant literature shows that, the term ‘insight’ has
multiple meanings within various discourses, including “everyday lan-
guage, clinical practice and research, mental health law and international
guidelines about patient rights” (Diesfeld and Sjöström 2007, 89). In psy-
chiatry, ‘insight’ is characterized as an objective, scientifically measurable
concept referring to the degree to which a patient is cognizant of their
condition/illness (Jacob 2010). That is, ‘insight’, generally understood as
the degree to which patients believe they have a mental illness, is explicitly
and implicitly linked to patient acceptance of the biomedical model of
mental illness (Mosher 2017, para. 2). Scholars using critical discourse
analysis and social constructionist approaches have challenged psychiatric
representation of ‘insight’, positing that it is in fact a deeply subjective
construct (Diesfeld and Sjöström 2007; Galasiński 2010; Galasiński and
2006; Høyer 2000). Social constructionist critiques of the use of ‘insight’
in psychiatry demonstrate that patients rejections of and/or resistance to
diagnoses, hospitalization, and/or medical treatment may be interpreted
as evidence of poor ‘insight’, and therefore, as justification for further

professional intervention (Diesfeld and Sjöström 2007; Galasiński 2010;
Galasiński and Opaliński 2012; Galasiński and Ziólkowska 2013; Hamilton
and Roper 2006; Høyer 2000). Unlike other branches of medicine, psy-
chiatry has no biological markers of illness on which to base diagnosis
(Rimke 2016). Psychiatric diagnoses are based on patients’ self-reports
(i.e., language), rather than on tests (i.e., technology) more widely consid-
ered to be ‘objective’ (Johnstone 2006). ‘Insight’, like other concepts in
psychiatry, is enculturated and derives meaning through social processes
(Hamilton and Roper 2006). Dariusz Galasiński (2010) argues that
‘insight’ is a dynamic, context-dependent construct that is co-created by
patients and clinicians. He demonstrates that ‘insight’ is discursive, in that
“it is a characteristic of what a person says” as opposed to an unchanging,
observable trait (Galasiński 2010, 74). Following this tradition, we under-
stand ‘insight’ to be a social construct discursively brought into being
during patient/clinician encounters, rather than a fixed and objectively
measurable trait.
Assessing ‘Insight’: Delegitimizing Disagreement

A primary finding from this study of psychiatric charts is that assessments
of ‘insight’ do not take place on neutral ground between equal parties, but
that psychiatrists can use ‘insight’ as a discursive means to delegitimize
patient perspectives. As Eugenie Georgaca (2013) states, patients “often
have to negotiate and actively dispute their positioning as a patient and the
meaning of that positioning in order to regain credibility and self-
determination … or to legitimate their version of reality” (60). As other
scholars have argued, mental health professionals undermine patient
attempts to disagree with biopsychiatric explanations of their distress
experiences and refusals of treatment by reframing disagreement and
refusal as lack of ‘insight’ into illness (Hamilton and Roper 2006; Høyer
2000). Our analysis of psychiatric inpatient charts substantiates this asser-
tion and we also contend that a more nuanced analysis shows that race and
gender are important factors that shape assessments of insight.
For example, in one chart we encountered a description of a Black man
who disagreed with the psychiatrist’s diagnosis of bipolar disorder, instead
attributing his mental state to increased stress due to his mother being
recently diagnosed with a terminal illness. This was charted by the psychia-
trist as follows: ‘He said he did not think he had a disorder but felt the
medications were helpful. He was willing to accept he was vulnerable to

“stress” and that the diagnosis of his mother’s illness had increased stress
levels’ (A-008). In the mental status exam directly following this disagree-
ment, the psychiatrist evaluates this patient’s ‘insight’ as ‘partial to poor’.
Correspondingly, it was apparent in chart documentation that patients
who agreed with clinician assessments were perceived as having good
insight. An excerpt from the chart of a white man reads as follows: ‘He
reports he is very sensitive to the environment, given his manic state
(astute observation). He is suggesting an increase in his meds to help him
cope (an [sic] wise suggestion)’ (B-011). At various points throughout
this patient’s admission, his insight was documented as ‘good’. These
examples support the contention made in the literature that evaluations of
‘insight’ hinge on patient agreement with biopsychiatric explanations of
mental distress and treatment.
However, a closer look at the two charts excerpted above demonstrates
that race and gender are also salient factors in how these patients are per-
ceived and their ‘insight’ is evaluated. Both men are diagnosed with
Bipolar Disorder I, and as experiencing episodes with ‘psychotic features’
at the time of institutionalization. As noted, A-008 disagrees with his
diagnosis, while B-011 acquiesces, which certainly has a direct impact on
the assessments of insight. However, the two men are characterized differ-
ently in terms of dangerousness, speaking to the different ways in which
Black and white men are positioned within the normative white psychiat-
ric institution.
B-011, the man who agrees with his diagnosis and treatment is a white,
heterosexual, economically marginalized man frequently noted to be
wearing sunglasses on the unit (which could potentially be perceived as
threatening, but is never described as such). He is charted as having
‘thoughts about hurting women on the streets’ as well as being ‘currently
on probation for assault with a weapon’. During his hospitalization, he
had two altercations with female co-patients, and made several overtly
sexually violent comments to female staff and co-patients. For example,
he is charted as having said the following to a female physician and nurse:
‘taking all my control not to pound you both right now’. The social
worker describes a conversation in which B-011 inquires as to ‘what
would happen if he did something on the unit to strike out at someone
else’, whether he would ‘get charged’ and removed from the unit by
police. When told that he would ‘likely be charged’, he asked ‘Well even
if I’m a mental health patient?’ Despite these overt and implied threats
and incidents of gendered violence, the physician characterizes B-011 as

having formed a ‘strong therapeutic relationship with the staff, the social
worker and me’. B-011 is also characterized as ‘not rude’ in the following
excerpt written by a nurse: ‘Loud speech. Abrupt in his mannerisms, but
not rude. Shouts into the nurses’ station “Is RN there … where is he …
I need him now”’ [our emphasis]. These positive descriptions of B-011
suggest that assessments of his insight as good are linked not only to his
agreement with the medical model, but also with the ways in which white
masculinity is positioned as benign and rational as well as an institutional
culture in which threats of violence against women are minimized.
The characterization of B-011 stands in contrast to that of A-008, a
Black, heterosexual, economically marginalized man whose chart often
reads as if the service providers are afraid of him. There is one incident in
particular where this is especially noticeable. The physician visits A-008 in
his room because the nurses told him that A-008 had plans to kill him:
I went to see him with other staff members to try and understand these
threats as they were out of keeping with the friendly tone of our previous
interactions. X refused to see me in the interview room on [name of unit]
and insisted on seeing me in his room. I did meet him there with several
other staff members. He engaged in unusual behaviour during that meeting
including slowly and deliberately taking off his shoes and socks and then
beginning to take off his shoes [sic]. He did not provide an explanation for
this but repeatedly asked me if my mother was alive during this interaction.
Ultimately, he turned to me and although he did not threaten me, I was
concerned that he was going to attack me. I retreated and called additional
staff and security. We convinced X to take oral chemical restraint. He agreed
to do so after some prodding.
Following this interaction, A-008 was detained in locked seclusion. The

patient’s behaviour that is positioned as bizarre or threatening (inquiring
about the physician’s mother) makes more sense when it is known that
the conditions that led to A-008’s institutionalization include having
recently learned that his mother is terminally ill. Further, while certainly
a death threat warrants attention, the confrontation described above in
which the removal of socks and shoes is seen as threatening and is
responded to with chemical restraint speaks to the fear inspired by Black
men based on racist stereotypes of Black masculinity as dangerous and
animalistic (hooks 2004).
Taken together, these excerpts illuminate the ways in which psychia-

trist’s delegitimizing of patients’ disagreements through assessments of
insight are racialized. The two men are clearly positioned differently based
on race, which arguably affects the way in which their insight is evaluated;
the Black patient is clearly seen as bizarre and threatening, while the white
patient is seen as affable and as forming strong relationships with the prac-
titioners. It is important to consider the response to A-008 in light of the
colonial and racist legacy of psychiatry, which used scientific language and
diagnoses to manage the minds and bodies of colonial subjects (Gilman
1985; Vaughan 2007) and the logic of whiteness that pervades the con-
temporary psychiatric institution. As other scholars have noted, many
mental health professionals fear Black clients based on racist stereotypes of
dangerousness (Keating and Robertson 2004). As Suman Fernando
(2010) contends, Black men in particular may be perceived as ‘angry’ or
threatening (69).
Further, these excerpts are relevant to the links between assessments of
insight and ‘treatment compliance’ or the degree to which patients agree
and comply with the course of treatment prescribed by clinicians. Other
scholars have critiqued the troubling links between ‘insight’ and ‘treat-
ment compliance’, showing how those who refuse or stop psychiatric
medication and/or other interventions are constructed as lacking ‘insight’,
as if ‘noncompliance simply means lack of “insight’”’ (Galasiński and
Opaliński 2012, 1464). This characterization is often applied even though
patients may refuse medical treatment for mental distress based on
thoughtful and careful considerations of past experiences of side effects
(Cappleman et al. 2015; Galasiński and Opaliński 2012; Høyer 2000;
Norvoll and Pedersen 2016).
Our analysis supports these assertions about the links between ‘insight’
and ‘treatment compliance’. However, the above discussion demonstrates
that it may be especially risky for marginalized people, in this case a Black
man, to refuse treatment given that he is already positioned as ‘dangerous’
and subjected to chemical restraint and locked seclusion. As noted above,
A-008 rejects a diagnosis while accepting psychiatric medication. The
unequivocal resistance to the medical model—the rejection of both diag-
nosis and medication—by a racialized man may result in a harsher assess-
ment of his perspective/insight, and hence, more severe impacts on his
agency and autonomy.
As this discussion illustrates, our analysis of the charts for this project
supports the assertions made in the literature that assessments of lack of
insight reflect the extent to which patients believe in biomedical explana-
tions for their mental distress, and comply with treatment.
However, a close reading of the charts suggests that this is also miti-
gated by the different ways in which patients are positioned within the
normative white psychiatric institution. The next section will consider
what kinds of disagreements with the biomedical model of mental distress
are especially likely to be seen as lacking in insight in order to further
investigate the relevance of social location in assessments of insight.
What Constitutes Insightful Objection

to Psychiatric Treatment?
As outlined above, there seems to be no way to ‘insightfully’ object to

medical explanations and treatment of mental distress. The following
examines more closely what kind of beliefs tend to be dismissed and recon-
figured as lack of ‘insight’ into illness. When patients’ explanations for
mental distress involve cultural or spiritual beliefs, or trauma narratives
professionals tend to write psychiatric assessments that the patients lack
‘insight’; when patients invoke more normative concerns (e.g., lack of
work productivity; failed heterosexual relationship), their interpretations
are seen as more insightful by professionals. This has a disproportionate
impact on women and people of colour, who are thereby positioned as
irrational and lacking ‘insight’. This finding is consistent with feminist and
anti-racist scholarship, which has shown how knowledge production about
madness and mental illness have long been gendered and racialized.
Psychiatry has positioned women as less rational than men, people of
colour as less ‘civilized’ and ‘evolved’ than white people, and gender and
sexual dissidence as pathological (Gilman 1985; Fernando 2010; Pilling
2014; Showalter 1985; Somerville 2000; Terry 1999; Ussher 2011;
Waldram 2004). These ideas, which are embedded within psychiatry, have
become institutionalized so that they influence daily practices regardless of
the practitioners’ intents.
One theme that arose from the chart analysis was the way in which
belief systems or ways of making sense of distress that draw on cultural or
spiritual belief systems may be seen as evidence of lack of ‘insight’. For
example, B-025, a Black, heterosexual, economically marginalized woman
is assessed as follows:
Today, the patient denied that she had schizophrenia, attributing her recent
difficulties to it being a ‘spiritual issue’. She denied that she required medi-
cations to help with her symptoms, and indicated that she had no intention
of taking her medications. She fails the arm of failure to appreciate the con-
sequences6 with respect to a capacity assessment. (B-025)
Throughout her chart, this individual’s spiritual belief is characterized as

evidence of psychosis; as the quote illustrates, it is seen as directly relevant
to the psychiatrist’s evaluation of her incapacity for making treatment
decisions. In her discharge note, the psychiatrist writes, ‘Insight in illness
only partial, believes “spirits” are real. (although this could be cultural
belief, as pt’s mother also believes this.)’ Despite the acknowledgement
that her beliefs may be ‘cultural’, the physician only understands this indi-
vidual’s explanation of her distress as evidence of compromised insight.
This finding supports the contention that ‘insight’ is based on Eurocentric
conceptualizations of health and illness (Jacob 2010; Saravanan et al.
2007), and therefore, those who espouse cultural or spiritual beliefs in
relation to experiences of distress may be disproportionately likely to be
assessed as lacking ‘insight’.
In another example, the chart of a Middle Eastern, economically mar-
ginalized, heterosexual woman includes her explanations of her experi-
ences as Kundalini energy, as opposed to a manic episode resulting from
Bipolar Disorder I.
Went into length describing this energy that moves from the right side of
her brain and moves all over her body to her vagina. These energy waves
have started about 1 year ago and give her super powers and usually she is
able to control them with nature. Denies any manic symptoms. Relates all
her symptoms to Ayurvedic medicine. (D-015)
The experiences named by the patient as Kundalini energy are also referred
to throughout the chart as ‘grandiose delusions’, and her ‘insight’ is evalu-
ated as ‘completely absent’. This patient also ‘refused’ anti-psychotic med-
ications, which was noted as follows: ‘Given the patient’s refusal to take
treatment, making her incapable to consent to her treatment was largely a
moot point, as the family is not in agreement with the treatment either’
(D-015). This excerpt underscores the link between patient compliance
with biopsychiatric treatment and findings of incapacity. In other words,
the physician blatantly states (‘a moot point’) that the only reason to
declare D-015 incapable is to force her to undergo treatment. This sug-

gests that findings of incapacity are more about whether a patient agrees
with biopsychiatric treatment than about assessing capability to make
treatment decisions, and makes clear that the risk of ‘non-compliance’
includes forced treatment.
Another theme that arose from the chart analysis was that explanations
of mental distress due to experiences of trauma are also met with evalua-
tions of lack of ‘insight’ in the selected charts. For example, D-001, a
heterosexual, economically marginalized woman who is variously identi-
fied as ‘mixed heritage’, ‘Indian-Caribbean’, and ‘Black-Caribbean’
expresses disagreement with the diagnosis of schizophrenia. She explains
that her experiences of sexual violence led to her mental distress:
We talked about her understanding of her illness. She continues to disagree

with her diagnosis. She is adamant that ‘only [name of institution] thinks
(she’s) Schizophrenic’. She does not agree that she has ever had psychotic
symptoms. She said that she [has] PTSD [post traumatic stress disorder]
from sexual trauma, and this is why she takes the injection [of anti-psychotic
medication], although she really does not understand why she needs it. We
talked about the upcoming CTO [community treatment order]. (D-001)
In the mental status exam completed as part of this encounter with the
psychiatrist, her ‘insight’ is assessed as ‘poor’. As this quote shows, the
patient’s violence narrative is dismissed and taken as evidence of lack of
‘insight’, and as indicated by the reference to ‘the upcoming CTO’ she is
subjected to a forced community treatment order7 upon her discharge
from hospital. Given the wider and entrenched culture of disbelieving and
minimizing sexual violence against women (Ryan 2011) as well as the
‘culturalization’ of violence against women (Jiwani 2011), this kind of
dismissal of trauma as an explanation for mental distress is likely to have a
disproportionate impact on patients who are women of colour. As Yasmin
Jiwani (2011) argues, violence in the lives of women of colour is normal-
ized and dismissed as ‘cultural’: ‘if gendered violence tends to be dis-
missed on the basis of women asking for it or women deliberately putting
themselves in such a situation, culturalized violence is similarly dismissed
as a pattern that is common to a particular cultural community…’ (159).
In contrast, consider the following excerpts from the charts of patients’
who were perceived as having ‘good insight’ or ‘fair insight’. A white,
middle-class, heterosexual man who is consistently described as having

‘good’ and ‘fair’ ‘insight’ throughout the admission period is described as
follows:
X describes a history of depressive symptoms dating back to December

2013. He describes that at that time a sexual relationship with a woman
15 years his junior came to an end. In addition, he began evaluating his life
and lamenting the fact that at the age of 43 he is unmarried and has not
accomplished all the things he has set out to do. (A-009)
This patient is similarly described in another note as feeling ‘low and weak’
following the ‘loss of relationships with a younger girl in January because
she made comments that made him feel inadequet [sic] sexually’ as well as
‘an altercation with some guy at work following an e-mail that made
refrence [sic] to him being homosexual’. He is diagnosed with Major
Depressive Disorder and is advised to start psychiatric medication and
therapy: ‘I offered medications and X will think that over … I spoke to X
about various pharmacologic and nonpharmacologic approaches to the
treatment of depression. We spoke about medications, [out-patient pro-
gram], psychotherapy. He will think it over and we will speak again tomor-
row’ (A-009).
While this chart includes hints at negative judgment in the repeated
marking of the former girlfriend’s younger age, this individual’s fears and
feelings are associated with living up to the norms of white, hegemonic
masculinity such as weakness, sexual prowess, fear of being seen as gay, and
heteronormative expectations of marriage. As such, these fears and feel-
ings seem unremarkable yet at the same time valorized to the clinicians.
He is permitted the luxury of ‘thinking that over’, and ‘nonpharmacologic
approaches’, such as therapy. He is kept as a voluntary patient, and is at no
point found incapable of treatment decisions.8 In fact, he continues to
refuse medications, and is discharged without them.
Similarly, the chart for A-006, a white, heterosexual, middle-class man
consistently characterizes his insight as ‘understands illness’, ‘good,’ and
‘fair’. His narrative regarding the distress that led to his admission is
described as ‘work stress combined with stress of building a dream home
for his family. This caused much financial stress, and guilt, as his wife and
family had to take over finishing this house in preparation to sell as it was
clear it was not financially feasible to keep’. This individual is diagnosed
with Bipolar Disorder II and Generalized Anxiety Disorder and is advised

to see a therapist as well as to undergo electroconvulsive therapy (ECT)9:
‘Discussed medication options and ECT at length. My strong recommen-
dation was to proceed with ECT and info pamphlet given and referral
initiated, but made clear patient could cancel referral/withdrawal consent
at any time, as he was having ambivalence regarding procedure’ (A-006).
As in the previous example, this excerpt suggests that this patient’s agency
and autonomy is recognized and promoted, in that his ambivalence about
ECT is respected, he is encouraged to try therapy, is kept as a voluntary
patient, and is at no time found incapable of consenting to treatment
decisions.
These charts suggest that class and heteronormativity may also operate in
less obvious ways to support or undermine patients’ perceived ‘insight’ and
options in refusing treatment. As discussed above, one patient’s family sup-
ported her decisions about treatment refusal, and conceivably her spiritual
beliefs (regarding Kundalini energy). For those who do not have supportive
families, treatment refusal may become more difficult, if not impossible.
Conceivably, this outcome is particularly detrimental for individuals who are
socioeconomically marginalized. For example, the disproportionate poverty
experienced by women and people of colour may mean that they have less
access to kin networks and/or social capital through relationships with for-
mal and informal advocacy sources. Patients who are found incapable of
making treatment decisions are assigned a substitute decision maker (SDM),
generally a family member or partner. People who are living in shelters or on
the streets are less likely to have someone to serve as a SDM, resulting in the
Public Guardian and Trustee (PGT) being assigned. In this case, the physi-
cian does not have to negotiate with someone who has a personal connec-
tion with the patient. Amongst the 120 charts included in this study, there
was no evidence of a PGT, as substitute decision maker, refusing what the
physician thinks is best for the patient, making this group more vulnerable
to non-consensual or coercive treatment. As with all social institutions,
interlocking systems of oppression operate within the PGT to subjugate the
subjective knowledge (i.e., that of the patient) of diversely situated people
to that of objective and expert professional knowledge; as noted above,
women and people of colour who experience disproportionate poverty may
be particularly susceptible to this phenomenon.
As these examples suggest, our nuanced analysis of psychiatric docu-
mentation practices raises important questions about psychiatric assess-
ments of ‘insight’ in relation to gender, race, sexuality, and class. It seems
more likely that patients who express white, middle-class, heteronormative

ideals can refuse or express misgivings about psychiatric diagnoses and
treatments while still being assessed as having an ‘acceptable’ level of
‘insight’. Such a finding suggests that patients with dominant social identi-
fies are afforded more control over their treatment. Conversely, the charts
reviewed suggest that expressing refusal or misgivings can subject racial-
ized people and those living in poverty to harsher evaluations of their
insight, and therefore, coercive treatment and institutional control.10
Challenging Findings of Incapacity

Theoretically, patients should be able to temper the consequences of
oppressive dynamics (e.g., assessment of incapacity) by appealing findings
of incapacity to make treatment decisions (and therefore, coercive treat-
ment) at the Ontario Consent and Capacity Board (CCB).11 While it is
beyond the scope of this chapter to fully examine the results of these chal-
lenges, it is worth noting that it is possible that assessments of insight can
once again work to undermine patient agency in these settings. In their
examination of mental health court decisions in Victoria, Autralia, Kate
Diesfeld and Stefan Sjöström (2007) found that decision-makers employed
tautological arguments. First, lack of ‘insight’ leads to non-compliance,
and second, non-compliance demonstrates lack of ‘insight’. Decision-
makers made use of whichever argument was most convenient, sometimes
employing both in the same case, making it ‘virtually impossible to coun-
ter such circular logic’ (Diesfeld and Sjöström 2007, 94). While there is
no analogous examination of Canadian mental health court decisions that
we know of, these tautological arguments about ‘insight’ and compliance
mirror the dynamics of the psychiatric institution as discussed in this chap-
ter. Further, it is unlikely for an appeal to the CCB to result in a favourable
decision for the patient. Bonnie Burstow (2015) reports that in 2011 only
‘10 percent of involuntary confinement reviews resulted in the certificate
being rescinded … and … 5 percent of treatment incapacity reviews
resulted in the finding being overturned’ (128).
It was apparent that for some patients who were assessed as lacking
‘insight’ and found incapable, discharge only took place when they capitu-
lated to biopsychiatric explanations of distress and submitted to psychiatric
treatment. For example, B-022, a Black woman, files the necessary paper-
work to challenge the finding of incapacity at the CCB. The hearing is
delayed by an additional week, at which point she begins taking the medi-
cation prescribed to her. This is described by the physician as follows,
She stated that she took her 1st dose of Risperidone since her admission
because, ‘I want to get out of here … don’t think the medication does any-
thing but you guys keep prescribing it’. Writer clarified that it’s not just the
Risperidone that [name] refers to as not helping her but past trials of other
AP [anti-psychotic] medications as well, ‘AP doesn’t help … these things
(AP medications) don’t help … I ain’t sick, you gave me medications but I
don’t have SCZP’. She refers to past documentation of experiencing robust
responses to AP treatment and her unsafe and hostile b/h [behaviour] when
not on medications as ‘inaccuracies’ in the documentation and ‘stories’ that
her health care teams have made up. She added, ‘I can lead a normal life
without anti-psychotics … I’ve been doing good’. (B-022)
A week later, this patient requests to see the psychiatrist, and ‘stated that
she does have SCZP’. The psychiatrist expresses doubt about her change
of heart, but ultimately believes her,
Writer questioned this significant change because of the resistance [name]

had displayed during the majority of her admission. [Name] offered that
when she’s not well she has a tendency to dismiss the illness and the benefit
of her AP treatment; however, recalls the problems she’s had in the past and
does not want to be ill…’. (B-022)
At the end of this chart entry, the psychiatrist notes that B-022 displays
‘markedly improved insight and judgment that appears genuine’ and
decides to discharge her the following day, cancelling the [CCB] hearing.
As this indicates, it is possible that some patients may feel like there is no
other choice but to submit to biopsychiatric explanations or narratives of
distress and treatment in order to be discharged from the hospital. In con-
texts where the consequences of disagreeing with those in power can
result in further sanctions, (in this case, the possibilities include a longer
involuntary committal and depot (injected) medications) marginalized
people may ‘feign complacency’ thereby asserting agency (Munn and
Bruckert 2010). As has been found in a carceral context, prisoners may
comply with psychiatric medication as a way to secure parole release and
avoid further institutional sanctions (Kilty 2012). While we do not know
whether B-022 ultimately chose to continue taking the medication beyond
discharge, nor do we know if she genuinely changed her beliefs about her
distress, she initially identifies her reason for initiating medication as
‘want[ing] to get out’, that is, be discharged. This powerful example indi-
cates the social pre-conditions and material effects of ‘insight’, and shows
the resistance and strategies that patients may deploy in this context in
order to secure some agency in their treatment and distance from the psy-
chiatric experts that can maintain their in-patient committal.
Concluding Thoughts
In this chapter we use ‘insight’ as a discursive window into how power
operates within select psychiatric inpatient charts from one institutional
setting, in order to better understand the everyday implications of this
discursive construct in relation to the social locations of patients and the
larger context of structural oppression. Overall, our analysis of the charts
for this project supports the assertions made in previous literature that
assessments of lack of insight reflect the extent to which patients believe in
biopsychiatric explanations of their mental distress, and comply with treat-
ment (Diesfeld and Sjöström 2007; Galasiński 2010; Galasiński and
2006; Høyer 2000). Consequently, discursive notation of a patient’s poor
or lack of ‘insight’ can render disagreement with biopsychiatric explana-
tions of distress and associated treatments unintelligible as such, instead
reconfiguring disagreement as further evidence of mental illness.
It is important to note that this enforcement of the biopsychiatric
model via the reconfiguration of disagreement and refusal as ‘lack of
insight’ is not a ‘deliberate’ act performed by ill-intentioned individual
psychiatrists, but rather reflects the operation of power within an inher-
ently hierarchical, coercive ‘helping’ system (Norvoll and Pedersen 2016).
While psychiatric institutions may be experienced as performing a sup-
portive and therapeutic function by some people, this is entangled with a
punitive, ‘warehousing’ function as they work in tandem with legal sys-
tems to enforce coercive measures such as involuntary detention and treat-
ment, with a disproportionate impact on marginalized groups such as
racialized people and those living in poverty.
Indeed, a close reading of the charts also suggests that assessments of
‘insight’ are also mitigated by factors such as gender, sexuality, race, and
class. Patients whose narratives reflect cultural or spiritual beliefs or attri-
bute the origins of mental distress to trauma can be seen as lacking ‘insight’
and in need of professional intervention. Comparatively, those who are
relatively more privileged (white, middle class, cisgender, male, hetero-
sexual) and who express more normative concerns (e.g., lack of work pro-
ductivity; heterosexual relationship concerns) are accorded more respect,

agency, and autonomy in expressions of their distress and treatment
decisions.
Our analysis supports the contention in the literature that there is a
circular relationship between ‘insight’ and agreement with the medical
model of mental illness that delimits the range of permissible truths within
the psychiatric institution, such that the possibility that a patient may
express disagreement with biopsychiatric explanations and treatment and
have good insight is limited. However, paying attention to social location
pushes analyses of the discursive use of ‘insight’ further and suggests that
disagreement with the medical model is perhaps more permissible for
some (those in positions of privilege) than others (those marginalized by
racism, classism, heterosexism, and other forms of structural oppression).
As such, it is under the guise of objectivity that ‘insight’ assessments are
one way in which power operates in the psychiatric institution to reify
dominant values and norms related to gender, race, sexuality, and class.
Notes
1. Our review of the psychiatric inpatient charts did not allow for the identi-
fication of clinicians’ social identities. Having this type of information may
contribute to a more robust analysis of power dynamics during patient-
clinician interactions. Similarly, our analysis may be limited in that the chart
excerpts centred in our analysis are those of various psychiatrists, rather
than a single psychiatrist. This means that our analysis is limited in terms of
the specific ways that gender, sexuality, race, and class are implicated in
psychiatric assessments of insight, generally. However, while it is important
to attend to power dynamics within the specificities of a patient-clinician
dyad, we also understand power dynamics as shaped by the ways in which
patients are positioned in relation to normative whiteness that undergirds
the psychiatric institution. Thus, we might consider that all psychiatrists
(and other mental health professionals), regardless of gender, sexuality,
race, and class represent and operationalize the norms and values of the
psychiatric institution.
2. This includes trans and cisgender women and men. The institution’s
method of taxonomizing gender does not explicitly allow for those who
identify as non-binary.
3. While we structured the chart selection and review in relation to these
inpatient programs and associated diagnoses, we recognize that individuals
often receive multiple and/or inaccurate diagnoses that are not fully
aligned with the programs to which they are admitted. As such, there are
more than the four identified diagnoses shaping inpatients’ experiences

related to psychiatric documentation of ‘insight’, and therefore, our analy-
sis is not organized around particular diagnoses.
4. The MSE is used to assess a patient’s current functioning and mental state.
It is considered objective and analogous to a physical examination
(Trzepacz and Baker 1993). Components of the MSE beyond insight and
judgment include appearance, attitude, behaviour, level of consciousness,
orientation, speech and language, mood, affect, thought process/form,
thought content, suicidality and homicidality, and intellectual functioning
(http://psychclerk.bsd.uchicago.edu/mse.pdf).
5. We are politically aligned with psychiatric survivor/mad movement cri-
tiques of medicalizing labels such as ‘patient’ (Burstow 2015). We employ
it here to indicate how the people whose charts we analyzed were interpel-
lated by the psychiatric institution.
6. The ‘arm of failure to appreciate consequences’ presumably refers to the
Guidelines for Conducting Assessments of Capacity in Ontario under the
Substitute Decisions Act, 1992, which states that in order to be considered
mentally capable one must be able to ‘understand information relevant to
decision-making, and to appreciate the consequences of a decision or non-
decision’ (for more information see https://www.attorneygeneral.jus.gov.
on.ca/english/family/pgt/incapacity/capacity_assessment.php#assessor).
7. ‘Section 33.1 (3) of the MHA [Mental Health Act] stipulates that a physi-
cian may issue a CTO if the criteria spelt out in Section 33.1 (4) are satis-
fied … these are that within the last three years, a patient either has been an
inpatient on two occasions or has for at least 30 days or has been on a CTO;
the physician has examined the patient in the last three days; the person is
suffering from a mental disorder such that in the absence of the care spelt
out in the Community Treatment Plan (CTP) they would be committable
involuntarily. Additionally, they must be seen as able to comply with the
accompanying treatment plan; and the necessary services in the commu-
nity must be available’ (Burstow 2015, 124–125).
8. It is possible that findings of incapacity to consent to treatment may often be
reserved for patients who are deemed psychotic (Cairns et al. 2005). This
brings up larger questions about bias in diagnosis and who is more likely to
be perceived as psychotic that are beyond the scope of this chapter. For a
discussion of the gendered, raced, classed, and sexualized character of diagno-
sis see Fernando (2010), Metzl (2009), Somerville (2000), and Terry (1999).
9. In our sample of 120 charts, we noted that ECT was commonly used in
cases where several trials of medication were perceived to have failed, as
was the case for A-006. However, the respect for A-006’s ambivalence
about ECT and the promotion of his agency in making a decision about it
was remarkable.
10. In making this assertion, we recognize that various bodies are read as more
or less likely to be ‘insightful’ even before expressing refusal or misgivings
about psychiatric diagnoses and treatments. In other words, the perception
of patients’ embodiment (for example as white, heterosexual, middle class,
masculine, cisgender) works in tandem with the worldviews they express.
11. ‘In Ontario … there are two different tribunals with jurisdiction over the
“mentally disordered.” One, the Consent and Capacity Board (CCB), is
civil and falls under the general health and mental health legislation. The
other, the Ontario Review Board (ORB), falls under the criminal code and
applies to people found not criminally responsible or unfit to stand trial. In
both cases: (a) appeals can be made to the courts; (b) panel members are
drawn from a working group appointed by the provincial cabinet; (c) pan-
els are chaired by members of the legal profession; (d) hearings occur at the
hospital where the detainee resides (ORB hearings are also commonly heal
in court rooms)’ (Burstow 2015, 127–128).
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CHAPTER 10
When a Man’s Home Isn’t a Castle:

Hegemonic Masculinity Among Men
Experiencing Homelessness
and Mental Illness
Erin Dej
Introduction
The conceptualization of hegemonic masculinity in Connell’s seminal
book Gender and Power (1987) sparked a robust body of scholarship on
how men perpetuate hyperbolic expressions of masculinity. Hegemonic
masculinity—the legitimization of structural forces and practices that
endorse and fortify the dominance of men and the subordination of
women—was developed from feminist accounts of patriarchy and has
become a fundamental concept through which to study institutional
spaces and processes through a gendered lens. Much of the literature
employing hegemonic masculinity examines stereotypically masculine sub-
jectivities and activities within security organizations such as in the military
and police (Hinojosa 2010; Johnston and Kilty 2015; Prokos and Padavic
E. Dej (*)
e-mail: edej@wlu.ca

https://doi.org/10.1007/978-3-319-89749-3_10
216 E. DEJ
2002), in the criminal justice context (Jewkes 2005; Messerschmidt 1993,

2014), and in sport (Adams et al. 2010). Over the past 30 years, scholars
have considered the masculinity of those who do not fit normative
expectations, namely Black, gay, and working-class men (Connell and
Messerschmidt 2005; Demetriou 2001; Pyke 1996). Still, gaps remain in
how marginalized men who lack financial and social capital experience and
perform masculinity in ways that reinforce perceptions of men as power-
ful, especially in relation to women.
This chapter seeks to fill one of these gaps by exploring the ways that
men experiencing homelessness, and who reside in highly regulated spaces
such as emergency shelters, seek to embody hegemonic masculinity. With
a few notable exceptions (Brown et al. 2013; Kennedy et al. 2013; Nonn
1995), the specific social and cultural context facing men1 experiencing
homelessness has been ignored by masculinities research. I argue that
men’s status as homeless, and in many cases where they are identified as
mentally ill, prevents them from using traditional ‘macho scripts’ (Zaitchik
and Mosher 1993) to meet the elusive standards for hegemonic masculin-
ity. Despite these limitations, many men experiencing homelessness engage
in compensatory masculinity, emphasizing whatever hypermasculine traits
they can within their stratified social status. There is also a small counter-
narrative to hegemonic masculinity where men confront, display, and
work through their emotions, adding to the complexity of what it means
to be masculine.
This analysis is based on a larger research project that looks at how
men and women experiencing homelessness make sense of their mental
health status. Research was conducted in two emergency shelters in
Ottawa, Canada, consisting of 296 hours of participant observation, a
focus group with professionals in the sector, and 38 semi-structured
interviews with people experiencing homelessness. Twenty-seven partici-
pants were men and 11 were women, in keeping with the gender ratio
among the homeless population in Canada (Gaetz et al. 2013).
Participants ranged in age from 29 to 63 years with an average age of
37 years. Seventy-three percent of respondents were white, approximately
16 percent identified as Indigenous, and 8 percent identified as Black or
bi-racial. Seventy-five percent of respondents identified as heterosexual
and 24 percent identified as gay, lesbian, bisexual, or asexual. The average
length of time participants remained in the homeless community was four
years, although not all this time was spent in emergency shelters. Almost
all (84 percent) of respondents identified as suffering with distress2 in
WHEN A MAN’S HOME ISN’T A CASTLE: HEGEMONIC MASCULINITY… 217
their lifetime and 73 percent had taken psychotropic medication at some

point. Eighty-nine percent identified as having an addiction.
In order to assess the ways hypermasculinity is performed among men
experiencing homelessness, I first explore the theoretical scholarship on
hegemonic masculinity, in particular the emerging literature on compensa-
tory masculinity. Next, I provide an overview of the ways that men experi-
encing homelessness are at an extreme deficit in their ability to perform
masculinity as it is typically imagined. However, many of the men in this
study continue to buy into the ideology of hegemonic masculinity and
attempt to assert their masculinity by blaming their homeless status on
malignant women and by objectifying women psy-professionals3 or position-
ing them as motherly figures. The chapter ends with an examination of the
counter-narrative to hegemonic masculinity that embraces emotionality.
Hegemonic and Compensatory Masculinity

Making sense of hegemonic masculinity entails a constructionist perspec-
tive of how gender is understood, performed, and acts as a governing
rationality. West and Zimmerman’s analysis of ‘doing gender’ (1987,
2009), and of ‘doing difference’ to include race and class (West and
Fenstermaker 1995), compels us to think of gender presentation as a ‘situ-
ated accomplishment’. Gender is understood as normative conceptualiza-
tions of actions and ways of being that correspond with membership to a
sex category. We engage with gender in how we shape our personal iden-
tity, in our interactions with others, and in how practices and institutions
are socially arranged (Coston and Kimmel 2012). In this way, ‘doing’
gender is ‘…both an outcome of and a rationale for various social arrange-
ments and as a means of legitimating one of the most fundamental divi-
sions of society’ (West and Zimmerman 1987, 126). Hegemonic
masculinity is a conceptual tool to unpack the ways people ‘do’ masculin-
ity; that is, how it is socially oriented and performed. Borrowing from
Gramsci’s notion of hegemony as social ascendancy through the consent
of the subaltern (Connell 1987), hegemonic masculinity denotes the
reproduction of male dominance:
Hegemonic masculinity can be defined as the configuration of gender prac-

tice which embodies the currently accepted answer to the problem of the
legitimacy of patriarchy, which guarantees (or is taken to guarantee) the dom-
inant position of men and the subordination of women. (Connell 1995, 77)
218 E. DEJ
Hegemonic masculinity is associated with physical strength, virility, aggres-

siveness, rationality, intellect, emotional stability, independence, and per-
sonal and social power (Coston and Kimmel 2012; Zaitchik and Mosher
1993). In their reassessment of the concept 20 years later, Connell and
Messerschmidt (2005) argue that masculinity has no fixed traits and that
historical, social, geographical, and cultural arrangements create variation
in how masculinity is understood and performed. Gender, as a construct,
is multidimensional (Comack 2008) and historically mobile (Connell
1995), in particular as it interacts with race, class, and sexuality. How these
dimensions interact with one another is always shifting, with some factors
being more significant in some settings than others (Messerschmidt 2014).
If gender is not based in ontological reality (Butler 1990), masculinity
consists of performances, not a set of pre-determined characteristics. In
light of the complexity and fluidity of hegemonic masculinity, scholars
have had to tackle what masculinity truly means and where it derives its
power. For Whitehead (2002), hegemonic masculinity can be continually
redefined, but men’s dominance over women is constant. While there are
no features that are inherently masculine through time and space, much of
the masculinity scholarship has underscored the negative and aggressive
characteristics associated with masculinity, especially where masculinity is
taken up by criminologists (Messerschmidt 1993; Comack 2008; Jewkes
2005). However, Connell and Messerschmidt (2005) argue that imbuing
hegemonic masculinity with necessarily ‘toxic traits’ fails to capture the
ways that hegemony works through consensus to maintain dominance of
the ruling class.
Notwithstanding the possibility that in some instances the discourses
and actions associated with hegemonic masculinity may serve the interests
of women (i.e. ‘family man’, financial provider) (Connell and Messerschmidt
2005), at its core hegemonic masculinity is about maintaining the
patriarchal order. The patriarchy is defined ‘…as a system of social struc-
tures and practices in which men dominate, oppress and exploit women’
(Walby 1990, 20). Theorizing hegemonic masculinity is based on the fun-
damental principles of feminist theory: that gender inequality is pervasive
in the formation and perpetuation of our social structures, and intersects
with race and class to create systems of oppression (Butler 1990; Hill
Collins 2000; hooks 2000). Masculinity, according to Connell (1987), is
not simply about privileging hypermasculine traits but is necessarily con-
stituted by characterizing stereotypically feminine traits, such as emotion-
ality and compassion, as inferior.
Not only is the subordination of women central to hegemonic mascu-

linity, so too is the subversion of alternative forms of masculinity. While
there is fluidity in masculinities over time, space, and culture, hierarchies
exist. Not surprisingly, the privileging of certain kinds of masculinities
falls along racial, class, and sexuality based lines. Subordinated masculin-
ity acts as the antithesis of hegemonic masculinity; in this way, hegemonic
masculinity is defined in part by what it is not: ‘These other masculinities
need not be as clearly defined—indeed, achieving hegemony may consist
precisely in preventing alternatives gaining cultural definition and recog-
nition as alternatives, confining them to ghettos, to privacy, to uncon-
sciousness’ (Connell 1987, 186). The literature on subjugated
masculinities focuses prominently on gay (Kimmel 2001), Black (Iwamoto
2003), and working- class men (Haywood and Mac an Ghaill 2003;
Johnston and Kilty 2015; Tolson 1977). These studies emphasize the
marginalization of some kinds of masculinity over that of white, wealthy,
heterosexual, cismen and the ways that members of these groups have
negotiated and resisted the dominant discourses of masculinity. These
analyses are valuable in studying how men experiencing homelessness
perform masculinity. Indeed, approximately 16–28 percent of people
experiencing homelessness in Canada are employed, often in precarious,
low-skilled, low-paying work; approximately 10 percent of adults and 30
percent of youth experiencing homelessness identify as LGBTQ2S4 (City
of Toronto 2013; Gaetz et al. 2016); and while there are no reliable sta-
tistics on the number of Black men experiencing homelessness in Canada,
racialized minorities are disproportionately represented in the homeless
population, especially Indigenous Peoples (Gaetz et al. 2014). The sub-
ordinated masculinities literature does not speak to the unique challenges
facing men experiencing homelessness and how those residing in the
homeless community mediate masculinity performances, a gap this chap-
ter seeks to fill.
To understand how and why men experiencing homelessness attempt
to perform masculinity in prescribed ways we must consider complicity. A
common critique in the masculinity literature is that few men can live up
to the ideal of hegemonic masculinity. The George Clooneys and Hugh
Jackmans of the world are rare. Few men have the economic, social, and
cultural capital to perform hegemonic masculinity as it is envisioned.
Rather, these ‘models of masculinity’ are used as ‘fantasy figures’ through
which ordinary men aspire to be, and in so doing, perpetuate the unattain-
able ideal (Connell 1987, 184–185). Hegemony, in Gramsci’s sense of the
220 E. DEJ
term, is built on the notion of implied consent of the subordinates to be

dominated. Those men characterized as embodying subordinated mascu-
linities are complicit in their own subjection by glorifying dominant
notions of hegemonic masculinity. Connell and Messerschmidt (2005)
expand on the notion of complicity, arguing that hegemonic masculinity is
not made up of traits that exemplify the ‘average’ man; instead, men privi-
lege hegemonic masculinity by positioning themselves in relation to its
standards. However, those who cannot meet the standards of hegemonic
masculinity have an interest in maintaining its discourses. Many men ben-
efit from hegemonic masculinity because of what Connell (1995, 79)
terms ‘the patriarchal dividend’, that is: ‘the advantages typically conferred
on men as a group for enacting hegemonic masculinity’ (Ezzell 2012,
192). It is the systematic and pervasive nature of the patriarchy that dis-
courages men from resisting the confines of hegemonic masculinity and
presenting true alternatives.
Rather than push back against unachievable ideals of masculinity, many
men who belong to subordinated groups engage in compensatory mascu-
linity. Compensatory masculinity entails ‘…acts that signify a masculine
self and that arise as part of a refusal or inability to enact the hegemonic
masculine ideal’ (Ezzell 2012, 191). Compensatory masculinity involves
emphasizing the few attributes that men do possess to align with hege-
monic masculinity. Certain qualities are exaggerated to ‘compensate’ for
their inability to meet the ideals set by hegemonic masculinity. For exam-
ple, working-class men who have little personal autonomy and financial
independence are more likely to play up their physical strength and role as
provider (Haywood and Mac an Ghaill 2003). Because hegemonic mascu-
linity is, at its core, about the subordination of women, men who engage
in compensatory masculinity may use physical dominance over women as
a means to assert their masculinity. Feminist scholars have fought for years
to demonstrate that sexual violence against women is a result of unequal
power dynamics rather than a sexual conquest (Brownmiller 1975; Donat
and D’Emilio 1992). The literature on compensatory masculinity furthers
that position, arguing that domestic violence can be traced in part to men’s
failure to live up to the standards of hegemonic masculinity (Coston and
Kimmel 2012). A similar argument plays out amongst criminologists who
characterize violence and crime as acts displaying hypermasculine traits
(Comack 2008; Jewkes 2005). This can be likened to Merton’s strain the-
ory, where those who accept the dominant norms but do not have the
means to achieve these cultural objectives will use alternative, often illegal
means to reach these goals (Taylor et al. 1973). Hegemonic masculinity is

a cultural goal in and of itself as well as an ideology through which other
goals, such as wealth, power, and status, are normalized.
Interestingly, compensatory masculinity opens up avenues for thinking
about a counter-narrative of hegemonic masculinity. Working-class men,
for example, provide an alternative discourse on what constitutes mascu-
linity, by positioning physically demanding manual labour as a truer form
of masculinity than their male superiors whom they reposition as weak,
effeminate ‘paper pushers’ (Coston and Kimmel 2012). Although men
who work in management fit traditional notions of hegemonic masculin-
ity, given the power they have over the working-class employees and a
higher income, the fact that the traits that make up hegemonic masculinity
are not fixed leaves room to renegotiate how masculinity is understood
and experienced. While the examples provided by the working-class litera-
ture (Tolson 1977) may not present a fundamental shift in how masculin-
ity is understood, it opens up analytic space to consider the ways hegemonic
masculinity can be redefined.
In the next section, I explore the deficits men experiencing homeless-
ness face in performing masculinity in order to present a potential counter-
narrative of hegemonic masculinity in the conclusion.
Homelessness as Masculinity Deficit

It is not surprising that men experiencing homelessness fail to meet the
standards of hegemonic masculinity, given that many housed men who are
financially and socially stable also struggle to reach the ideal. However, I
argue that the marginalization facing men living in the homeless commu-
nity limits men’s performative abilities in unique ways.
As described above, to be homeless does not necessarily mean to be
unemployed. Many of the research participants in this study worked5 at
some point while experiencing homelessness; most worked in manual
labour, such as construction, landscaping, moving, and painting. There
are significant barriers to finding and maintaining work while residing in a
homeless shelter, such as providing an address and phone number on a
resume; transportation issues to make it to a work site; having enough,
good quality sleep to function properly; and arranging work hours around
other obligations, such as methadone treatments or check-in times to
obtain a bed at the shelter for the night. These issues can be compounded
by those managing distress and/or using substances (Zuvekas and Hill
222 E. DEJ
2000) or who have a criminal record (Visher et al. 2011). Given the chal-
lenges of finding and maintaining regular employment, many people expe-
riencing homelessness use day labour services to secure temporary work.
Day labour is notoriously precarious, low paying, and often physically
demanding (Williams 2009) and for these reasons is not a viable or desir-
able option for many people experiencing homelessness.
The lack of suitable employment for people experiencing homelessness
impacts how masculinity can be presented. Masculinity discourses are
shaped around work and many workplaces are dominated by masculine
culture (Tolson 1977). According to Haywood and Mac an Ghaill (2003),
unemployment disrupts the masculine ideal to such a significant degree
that creating an alternative masculinity void of work is extremely difficult.
Those who do not work are not able to build professional relationships,
exert power, or make an income required to fulfill many of the other attri-
butes of hegemonic masculinity. As such, the unemployment and/or pre-
carious employment of the homeless population leave men at a deficit for
fulfilling the standards of hegemonic masculinity.
Some of the men who participated in this study were keenly aware of
the deficits they faced in being able to perform masculinity as it is typically
envisioned. This was felt most astutely by men who identified as mentally
ill. For them, distress and masculinity were irreconcilable. In describing
‘macho scripts’ Zaitchik and Mosher (1993) note that even those men
who do not use violence to exert their dominance maintain the ideology
of machismo, specifically, a man who is fearless, strong, and in control. For
men who experienced depression, anxiety, and other manifestations of
distress, they felt they could not live up to the masculine ideal on account
of their mental illness. Julien was a 45-year-old white man who lived in
emergency shelters for six years and was diagnosed with severe anxiety.
When discussing how he copes with his anxiety, he revealed his deep
shame: ‘Well remember, you know, I’m ashamed that I have problems.
Like, guys in our society are not supposed to have problems. They’re sup-
posed to be like an island’. Julien’s comment that men are meant to be
‘like an island’ reinforces the stereotype that masculinity requires emo-
tional numbness. While it is understandable why someone facing such
debilitating emotions may revel in the idea of feeling nothing, the fact that
this is a way of being that all men should emulate is deeply problematic.
When I probed Julien further, asking if being an island was a realistic
expectation for men, he responded ‘no’, but with little conviction. For
Julien, his anxiety was in contradiction with his sense of masculinity and
was quite troubling for him.
Ron felt similar to Julien. Ron suffered from significant distress and was
diagnosed with a host of mental illnesses throughout his childhood and
adult life, including depression, bipolar disorder, anti-social personality
disorder, and post-traumatic stress disorder (PTSD). To cope, Ron used a
number of illicit substances, including cocaine, alcohol, and heroin. Unlike
Julien, Ron had only become homeless within the last seven months and
was still coming to terms with his circumstances. His pathway to home-
lessness rested in part from his depression, which took a heavy physical toll
on him. At age 41, Ron had trouble walking, breathing, and eating, losing
a significant amount of weight over the course of three months before
entering the shelter. He described his condition:
Like my lungs were so pathetic. I’ve never been scared, you know, people
say, women or whatever say, oh I’m scared of walking outside at night. Like,
I can’t imagine that, well I did. I walked down the street and, like, a little
girl could have killed me. That’s how weak I was. And I was actually scared.
I’m like, wow.
Ron positions his sense of weakness and vulnerability in relation to women.

Although Ron suffered physical abuse as a child, his tall stature and build
have allowed him the privilege that many men, and few women, are privy
to—not being ‘scared of walking outside at night’. He was shocked to
discover the feeling of vulnerability when he became physically unable to
defend himself if the situation arose. This vulnerability is the antithesis of
hegemonic masculinity, and therefore falls in the realm of femininity, usu-
ally equated with passivity and requiring the ‘bravery’ of men for their
protection. Not only does Ron feel threatened in the way he imagines
women feel, but he also uses the example of a ‘little girl’ as a potential
aggressor to explain his level of vulnerability. For Ron, the feminine sub-
jectivity acts as the ultimate exemplar of physical weakness and the most
absurd hyperbole of who constitutes a threat.
Ron takes his analogy of equating his level of physical weakness to that
of women a step further, embodying femininity to describe his substance
abuse treatment:
224 E. DEJ
So, I got on methadone, ok, I’m still on methadone and I’m at fifty-two
milligrams and I hate it because I have to go get it every day and I’m depen-
dent and it’s physically like, I feel like, uh, like, uh, menstruating, almost
[small laugh]. I’m sure that’s not what it feels like … Like my stomach is
just, like, crampy.
Using menstrual cramps, a sensation Ron has admittedly never felt, to

describe the side effects of methadone treatment is telling of Ron’s felt
masculinity status. His addiction, depression, and homelessness statuses
interact to strip Ron of the qualities that project hegemonic masculinity,
and in so doing, leave him to draw upon the feminine subjectivity; how-
ever, he does so with an air of shame. Ron’s portrayal of himself as ‘scared
like a girl’ and feeling menstrual cramps may be related to his recent iden-
tification as bisexual, an identity that he came to with a great deal of trepi-
dation. For Ron, he has failed to live up to the basic tenets of hegemonic
masculinity: physical strength, vitality, and heterosexuality.
In this section I have outlined various ways that men experiencing
homelessness are distinctly disadvantaged in their attempts to live up to
the ideal of hegemonic masculinity. Despite these obvious deficits, in the
next section I analyze the ways that men continue to buy into and privi-
lege notions of hegemonic masculinity.
Compensatory Masculinity: Demonizing

and Objectifying Women
In response to the deficits facing men who experience homelessness, many

participants took up narratives and actions that I position as compensatory
masculinity. In some ways, this is surprising given the multiplicities of
exclusion and marginalization that come with homelessness. On the other
hand, the benefits men receive from the ‘patriarchal dividend’ acts as an
explanatory tool for why men experiencing homelessness perpetuate the
hegemonic ideal that they do not meet. Many of the men in this study
sought to assert their dominance over women within the parameters that
their status would allow. Two tactics most often employed by men experi-
encing homelessness are, on the one hand, blaming women for their
homelessness and/or mental illness while, on the other hand, objectifying
women staff and mental health professionals or otherwise revering them as
motherly subjects whose role is to take care of them.
This analysis requires two important qualifiers. First, as described

above, compensatory masculinity is often used to understand men’s vio-
lence, especially in prison settings (Comack 2008; Jewkes 2005). Given
the high level of victimization among men and women experiencing
homelessness (Huey 2012) one might deduce that men would use vio-
lence in the homeless community to engage in compensatory masculinity.
In this study, men rarely reported using violence as a form of self-defence,
protection, or criminal behaviour. While some men spoke of altercations
they had in the past, and previous experience with the criminal justice
system on account of violence, violent behaviours did not appear to be a
common occurrence at the time of the interview. There are two possible
explanations for this. First, there were no questions in the interview guide
that related specifically to violent behaviour, although there were ques-
tions probing participants’ interactions with police and the criminal justice
system more broadly. Perhaps more direct questions would have elicited
different information. Second, the average age of the sample was 37 years
old. This is in keeping with the average age of men using emergency shel-
ters across Canada, which is 40 years old (ESDC 2016). Criminological
literature tells us that as people age they desist in criminal activity (Sampson
and Laub 2003). Age likely plays a factor in why the men used other
means besides violence to employ compensatory masculinity.
Second, with the exception of Mustang (who we will meet later in the
chapter), an Indigenous man, all of the other participants that claimed to
have engaged in compensatory narratives and behaviours were white. This
is important because hegemonic masculinity is rooted in whiteness (Epstein
1998). Hegemonic masculinity is constituted in juxtaposition to other,
subordinated identities, most notably femininity and Black masculinity
(Connell 1995). Although masculinity varies within and outside of par-
ticular races or ethnicities, Black masculinity is ‘…reduced to m onolithic
forms of masculinity’ (Bucholtz 1999) when contrasted with the domi-
nant, white masculinity. There is a small pocket of literature on Indigenous
masculinity that points to the ways in which historical and ongoing forms
of colonization and the importation of Eurocentric norms on Indigenous
Peoples have perpetuated reductionist and derogatory impressions of what
McKegney (2014) terms the ‘masculindian’. Indigenous hypermasculinity
is often associated with the ‘noble savage’, the ‘warrior’, or more contem-
porarily the ‘corrupt band councillor’ or the ‘drunken absentee’ (McKegney
2014, 1). Stereotypical conceptions of Indigenous masculinity mirror
Black masculinity in its lack of appreciation for the wide array of people,
226 E. DEJ
communities, and traditional cultures that make up Indigeneity. These ste-

reotypes are projected by Western, white ideologies that have the effect of
ignoring the traditional matrilineal cultures found in many Indigenous
communities. Indigenous traditions have been eroded by the cultural
genocide that took place through the residential school system, the sixties
scoop, and the ongoing overrepresentation of Indigenous Peoples in child
protection (Statistics Canada 2016) and the criminal justice system (OCI
2016). As Innes and Anderson (2015) discuss, white male privilege seeks
to subordinate Indigenous knowledges of masculinity and works to render
Indigenous men complicit in their own subordination, for example as vic-
timizer to their own people. The ways in which Indigenous forms of mas-
culinity are performed requires further research; in this study, the more
nuanced and complex roles Indigenous men take on in the context of
homelessness were not captured.
The Malignant Woman

The most common example of compensatory masculinity took the form
of men blaming the women in their lives, specifically their spouses, for
their mental distress and becoming homeless. Some claim that their wives
cheated on them, others that they spent all their money, while still others
characterized their wives and girlfriends as emotional, vindictive, and
manipulative, feeding into common tropes of the ‘fallen woman’. Women
were consistently characterized as malicious, devious, promiscuous, and
who willed the men’s fall into homelessness. Many men made claims about
their wives that were filled with anger and resentment, such as Mark who
suggested his ex-wife ‘…helped me prepare for a shelter, and jail proba-
bly’. Mick and Otto provide a more complex narrative of their spouses and
how the women’s flaws caused their marginalization.
Mick, a 53-year-old man, was diagnosed with PTSD, obsessive-
compulsive disorder (OCD), social phobia, and attention-deficit disorder
(ADD), and used cocaine and alcohol. He amicably separated from his
wife in 2004, and in 2006, he met Chelsea, whom he described as ‘a great
girl’ but that ‘she was toxic too’. Mick recounted the downward spiral that
came when he began a relationship with Chelsea, eventually moving in
with her and being financially responsible for her and her children. Mick
noted that both he and Chelsea were using drugs recreationally and
acknowledged that Chelsea used substances to cope with past trauma.
However, he goes on to describe Chelsea’s ‘double life’:
She had a double life going and she was doing a lot more drugs than I knew
about and she was hanging around the people that we also mutually knew in
the bars that I would not hang out with. And these were drug dealers and
dirt bags, I call them. That was my term for them. She was hanging around
them, and this whole dysfunctional, toxic thing evolved in this relationship.
Now I was also doing drugs but I was trying to pull her back, right, and I
wouldn’t let go and she got deeper and deeper and I was going in and fol-
lowing her in there, and eventually at some point, it’s just a big haze right
now but a lot of bad shit happened. A lot. And I ended up in jail. I’d never
had handcuffs on until I was 50 years old, you know?
Here, Mick suggests that Chelsea is responsible for his transition from
casual drug user to addict, a move that resulted in his first serious interac-
tion with the criminal justice system and eventual incarceration. Mick
engages in compensatory masculinity, positioning himself as Chelsea’s sav-
iour, saying ‘I was trying to pull her back’. Harkening back to the virtues of
bravery and rationality that make up hegemonic masculinity, Mick presents
Chelsea as a vulnerable, dependent, and passive feminine subject, one need-
ing male protection. Over time, however, Mick suggests that Chelsea comes
to reject this feminine ideal and takes on the role of deviant, offensive, and
unruly woman, a subjectivity exemplified by the historical persecution of
women dating back to the witch hunts. The deviant woman is underserving
of the protections offered by hypermasculine men (Faith 2011). Mick
details Chelsea’s manipulations as the cause of his homelessness:
When I got out of jail by this time she had had three other boyfriends that
she just rotate from … My probation officer said this is a toxic relationship.
‘You’ve become an addict and you’re not going to change unless you get
away from her’. Well I didn’t. I kept going back. That’s the co-dependency.
Anyways I dumped all my RRSPs and went on a hotel tour, and I spent like
$60,000 in about three months going from hotel to hotel and, and crack
and booze, and Chelsea was there, or she wasn’t there. I woke up one morn-
ing, my money was gone and she was gone too and the week before that
when money was down to the last bit, it was like, you know what? Don’t
worry. She used to say ‘don’t worry we’ve got each other you can count on
me’, you know, and then she was gone.
Mick describes in detail how Chelsea paved the way for his becoming
homeless. No longer the dependent woman in need, Chelsea became the
cause of his subordinated status. Through sexual promiscuity, deception,
228 E. DEJ
and theft, Mick suggests it is Chelsea, the unruly woman, who strips away
his ability to adequately perform masculinity by stealing his money, reject-
ing his offer for protection, and being unfaithful. Mick orients his narra-
tive as a man doing all he can to live up to the standards of hegemonic
masculinity, but who is thwarted by a woman refusing to be subordinated
by him. Of course, there are the lived realities of what it means to be strug-
gling with substance abuse, trauma, poverty, and criminalization that may
explain Chelsea’s actions, but these factors exist within a patriarchal soci-
ety that is historically suspect of women ‘in need’6 and women who do not
assume the subordinate position. Mick compensates for his failure to live
up to the ideals of hegemonic masculinity by claiming he is a man with no
‘deserving’ subordinate woman to dominate.
Like Mick, Otto blames his spouse for his homelessness status. Otto, a
43-year-old man, had experienced homelessness for six years. At the time
of the interview he had recently begun to explore the ADHD diagnosis he
had received years before but rejected the bipolar diagnosis. He also used
OxyContin and identified as an alcoholic. Otto spoke harshly about the
role his wife played in his addiction and homelessness:
I was common-law married to this manipulative, horrible, devil in disguise

woman. We ended up having a beautiful child together and she ended up
turning me into some sort of crazy monster that I wasn’t. Oddly enough I
ended up becoming the alcoholic that she had projected me as … Ended up
being that her lifelong ambition was to be the tragic but brave single mom
raising her child against the world and raging against the abusive ex-husband,
which I never was. In fact of the relationship I was the only one that ever got
hit [small laugh], so that was another, probably, piece of the puzzle to my
ultimate demise.
Otto’s story shares similarities with Mick’s (and others’) in that he relies
on the unruly woman subjectivity to present his wife as ‘manipulative’,
‘horrible’, and ‘the devil in disguise’. In so doing, they position themselves
as victims of women’s scorn, posing a discursive conflict in how compensa-
tory masculinity is performed amongst marginalized men. Otto presents
the woman he blames for his ‘ultimate demise’, not as someone who needs
saving, but as actively seeking to destroy him and drive him to addiction.
He rejects his wife’s storyline that he physically assaulted her, alluding
instead to the idea that he would not hit a woman even when provoked.
Otto engages in compensatory masculinity by arguing that he is not weak,
irrational, or lacking self-control; instead, it is his wife’s vindictiveness and

coercion that brought him to homelessness. Drawing parallels to the
femme fatale trope in film and literature, Otto equates his wife as a villain,
one who actively sought to undermine his masculinity. By blaming his wife
for his addiction and homelessness, Otto projects the causes of his home-
lessness onto a woman, contrasting a skewed sense of femininity with his
attempt at performing masculinity.
There is no denying that Otto holds strong negative feelings against his
ex-wife. This is why it is so fascinating that after describing her as the devil,
Otto goes on to concede that his ex-wife is a good mother: ‘My daugh-
ter’s fine. She’s living in a very well-established home with her Mom. I
could come up with expletives to describe my ex until the cows came
home but if nothing else I will give her that she would do whatever she
could to protect my daughter’. Even when all other traits of traditional
femininity are lost from his perspective, her role as mother remains intact.
In this vein, I now explore how men essentialize women as motherly fig-
ures in order to engage in compensatory masculinity.
Mental Health Professionals and Emphasized Femininity

While many men looked at the women from their past as having a pro-
foundly negative impact on their lives, they spoke much more positively
about women who they interacted with either as shelter workers or, more
often, as psy-professionals. The comments made by men engaging in com-
pensatory masculinity fall along two discourses—either the objectification
of women or by situating them as motherly figures. Both describe what
Connell (1987) calls ‘emphasized femininity’, a cultural and ideological
constitution of femininity that rests upon acquiescing to the dominance of
men, in particular through sexual permissibility.
Men experiencing homelessness participated in what Pyke (1996, 532)
calls ‘the ritualistic put-down of women’. This is not surprising, per se,
given that most men benefit from the patriarchal dividend. What is inter-
esting is that some men in this study objectified women in positions of
power as a way to compensate for their reduced autonomy and in response
to a woman dominating them. For example, when Ron described his par-
ticipation in a group therapy program run by the shelter, he remarked that
it was not very effective because he was too distracted by the psy-
professional running the group: ‘I tried [the addiction group] and basically
230 E. DEJ
I was always looking at our teacher’s butt or something … I haven’t been

with a woman in six years, and I’m looking at [psy-professional], like, I
wish I was 26 again’. Sexualizing the psy-professional became a way for
Ron to disengage from therapy. Rather than make claims about the thera-
peutic approach, group dynamic, or other factors that contribute to suc-
cess or failure in addictions therapy, Ron’s reflections situate the
psy-professional as an object of sexual desire, which supersedes other con-
siderations of the benefits and/or pitfalls of therapeutic engagement. In
this way, Ron attempts to reclaim his masculine dominance over the female
psy-professional by refusing to recognize her as useful beyond the param-
eters of sexual conquest.
Ron’s referral to the psy-professional’s age is important. Youthful
women embody the typification of emphasized femininity. Some men, like
Max, use age to further objectify women. Max was in and out of homeless-
ness for six years at the time of the interview, struggling with depression
and an addiction to alcohol. He took part in dozens of mental health and
addictions treatment programs over the years and when asked what he
thinks is missing from Ottawa’s homelessness sector, he replied: ‘Well
actually, more access to psychiatrists … I don’t want some girl who’s gone
to [the local college] for 18 months, no, I’m sorry’. While Max has serious
concerns about the high turnover rate of psy-professionals in the commu-
nity and the nature of their qualifications, he couches them in a gendered
lens. He goes on to tell the story of ‘young girls’ who he was partying
with, smoking marijuana, who he later found out were attending the local
college to become addictions counsellors. Referring to them as ‘girls’ and
questioning their legitimacy as service providers stands in stark contrast to
Max and many other participants’ unabashed praise of a male addictions
counsellor who was described as ‘awesome’, ‘formulaic’, someone who
‘makes sense’, and has ‘a fan club’. While certainly a number of factors are
at play in how participants speak about psy-professionals, minimizing
women’s expertise while simultaneously objectifying them and their bod-
ies exemplifies compensatory masculinity in action.
On the other side of the emphasized femininity coin stands the moth-
erly figure, evoking notions of compassion, selflessness, and virtuousness.
Those men who did not describe women psy-professionals as young sexual
objects were apt to have them fill the mother role. As one participant,
Mark, remarked: ‘I’ve got that “I miss my Mommy” syndrome carrying
over from when I was a kid’. In times of distress, emotional vulnerability,
and uncertainty, many men were looking for the comforts provided by a
motherly figure. Situating women psy-professionals as pseudo-mothers

rests upon the construction of emphasized femininity, assuming that
women are meant to take up the caretaker role.
Mustang, a 38-year-old Indigenous man who spent time in prisons and
psychiatric hospitals, spoke highly of the female psychiatrist working in the
hospital:
We had a doctor, awesome lady. And I mean she’s short, she’s fragile, and
she could be very direct if she needs to but she’ll walk around that hospital
without fear. She treats us like people and I remember watching when I first
got there I was like, wow, she’s got balls, you know what I mean? You’re in
a mental hospital, you’ve got a bunch of freaks here, you know, but not at
all. She was respected by all the patients and I mean if you dared, well for the
most part, a lot of the guys if you were out of line with one of the females
they’d take care of you in the washroom.
When not outright objectified, women working with homeless, mentally

ill, and/or criminalized men were held up as pillars of womanhood.
Mustang’s description of the female psychiatrist as both having ‘balls’—
reinforcing maleness as desirable—as well as ‘short’ and ‘fragile’—rein-
forcing femininity as connoting gentleness, meekness, and in need of male
protection—provides insight into how compensatory masculinity plays
out in the homeless community. Of particular interest is the way that
Mustang notes that an informal punishment regime exists in the hospital,
much like the prison, where if a man behaves disrespectfully to female staff
someone will ‘take care of [him] in the washroom’. In a setting where
women professionals garner much more power than male patients, men
continue to present as dominant, acting as women’s guardians and sav-
iours, protecting them from other violent (hypermasculine) men.
Given the gender dynamic at play among men experiencing homeless-
ness, men commonly noted that they are only comfortable speaking to
women service providers about their distress or emotional well-being.
Lenny, for example, described his psychologist in this way: ‘…she was
compassionate, she understood me, she talked to me, she didn’t talk down
to me’. From field notes, another man said that ‘…he prefers talking to
women because he was raised by his mother … and he feels like he can
only talk to men about math and business…’. Because hegemonic mascu-
linity is associated with rationality and emotional numbness, when men
experiencing homelessness have to acknowledge their emotions, usually in
relation to mental health treatment, they prefer to do so with women. Ron
232 E. DEJ
and Lenny both suggested that the women psy-professionals they worked
with were willing to give them whatever prescriptions or referrals they
asked for, seemingly without question. We have no way of knowing why
these psy-professionals gave the prescriptions they did; however, for Ron
and Lenny their interactions allow them to feel a sense of power and domi-
nation over the women psy-professionals, despite the doctor-patient power
dynamic.
In the next section, I consider the role of emotionality in hegemonic
masculinity, probing the question of whether a counter-narrative exists
among men experiencing homelessness.
Emotional Men: Counter-Narrative or

Compensatory Masculinity?
We return to Julien’s comment that men are meant to be ‘islands’. Men
experiencing homelessness who are in distress and/or who participate in
mental health or addictions treatment are compelled to engage in ‘emo-
tion work’; that is, making a conscious effort to regulate emotions in
particular ways (Hochschild 1979). The emotion work that comes along
with addressing distress and addiction exists in contrast to the ‘feeling
rules’ (Hochschild 1979) associated with hegemonic masculinity, namely
stoicism, pride, and in some instances, anger and aggression (Zaitchik
and Mosher 1993). Most therapies call for a level of emotional expres-
sion that asks people to be vulnerable and that are aligned with feminine
affects such as shame or fear, especially when confronting trauma
(Coston and Kimmel 2012). Many of the men who discussed the emo-
tion work involved in addressing their distress did so with apprehension.
Doug, a 55-year-old man who lived in the homeless community for
more than three years and who identified as having bipolar disorder and
anxiety, stated:
Doug: I’m going to try and not get too emotional … If I get too emo-
tional, I cry, and guys, you know, don’t cry. Guys aren’t supposed
to cry.
Erin: You think, eh?
Doug: Well no I don’t think, that’s, one of those things. Like guys don’t
cry. I do cry sometimes.
For Doug, the idea that men suppress their emotions is not a suggestion
but a demand brought upon all men through gender-laden feeling rules.
Emotional inexpressiveness (Ezzell 2012) is essential to performing mas-
culinity. Doug’s admission that he sometimes cries comes with a deep
sense of embarrassment. Emotional numbness is just ‘one of those things’
for men.
There were, however, a handful of men who challenged the notion that
men cannot engage in emotion work. A few men spoke proudly of how far
they had come in accepting their emotional vulnerabilities, trauma, and
took ownership over their mental health. They rejected the assumption
that men cannot cry, instead suggesting that it is imperative that men get
in touch with their feelings in an effort to achieve wellness and become
housed. Vince had high emotional intelligence and was clear about the
importance of being comfortable taking stock of one’s emotional state:
When I’m clean and life’s going good that’s because I’m surrounding myself
with people who are positive, pro-life,7 and it’s about sharing. Huge part of
things is with sharing. It’s going to meetings every day or every second day,
whatever I need at the time and just hearing other addicts speak and be posi-
tive and relating to that. Stuffing things, not dealing with emotions, that’s
what sends me over the top. You can only last so long … You have to kind
of do all this to get better. You have to make yourself vulnerable and what
that looks like to me is taking risks with [the psy professional], letting her
inside because I know if I don’t trust and I don’t let go then I’m not going
to get the help I need.
It is especially poignant that Vince explained his need for emotional open-
ness because at the time of the interview he was going through a relapse and
was grappling with his own troubled thoughts and feelings. Vince was
36 years old, homelessness for four years, and had experienced extreme
forms of victimization as well as criminalization on account of his OxyContin
and heroin addictions, while also facing challenges with severe clinical
depression, PTSD, and ADHD. Even in the midst of a difficult time for
Vince where he admittedly closed himself off to others—especially his sup-
port network—he was steadfast in his conviction that healing from addic-
tion and distress required deliberate emotion work. As Vince articulates, for
many men experiencing homelessness, ‘taking risks’ involves rejecting hege-
monic masculinity and carving out alternative representations of masculinity
234 E. DEJ
that are prefaced upon emotional liberation (hooks 2004). In this sense,
bearing witness to a spectrum of emotions acts as a re-writing of the feeling
rules of masculinity.
When men experiencing homelessness discussed their emotionality, it
appeared to be a radical departure from hegemonic masculinity. However,
Whitehead (2002) reminds us that given hegemonic masculinity’s fluidity,
adaptations to the ideal do not mean that men’s dominance over women
is abolished. As Ezzell’s (2012) study of men in an in-patient drug treat-
ment program observed, addiction, like distress, is equated with being
‘out of control’; accordingly, treatment acts as a form of compensatory
masculinity by attempting to recover a central tenet of hegemonic mascu-
linity. This narrative plays out among men experiencing homelessness as
well. Among those men who were immersed in the addiction and mental
health treatment programs, many framed their road to recovery as an
effort to reclaim their autonomy and escape their subordinate position.
Daniel, for example, found the goal of mental health treatment was to get
back to ‘driving your own bus’. JJ found that addiction and mental health
treatment gives people the ‘control to make up your own mind’ and
‘assertiveness, which was a huge thing that I had over two years of coun-
selling’. This is not to say that building assets and resilience is not a posi-
tive, worthwhile endeavour; it is to suggest, however, that these narratives
do not diverge from the hegemonic masculine ideal. These discourses are
a departure from traditional notions of masculinity but are not counter-
narratives because it allows for an emotionally situated form of masculinity
to prevail without necessarily challenging the patriarchal foundation upon
which it rests.
Conclusion
In this chapter I explored the ways that men experiencing homelessness
and mental distress perform masculinity within the homeless community.
Men who are marginalized and living in extreme poverty face unique defi-
cits in their ability to identify and behave in hypermasculine ways.
Masculinity is heavily tied to work, and although many people facing
homelessness do work, it is often precarious and low paying. Men staying
in emergency shelters also struggle with practical challenges that come
with trying to maintain a job while abiding by the rules of the shelter and
living in an often-chaotic environment. A number of men felt a great deal
of shame for being unable to perform hypermasculinity, aligning them-

selves with subordinate feminine traits because of their failure to live up to
the ideals of masculinity.
Despite these limitations, a common theme identified in this research
was how men experiencing homelessness engage in compensatory mascu-
linity. Knowing their subordinated status, many men drew on, and exag-
gerated, the traits they felt aligned with hegemonic masculinity in order to
maintain a sense of manliness. A common discourse was blaming women,
especially spouses, for their mental distress, addiction, and homelessness.
Men also engaged in compensatory masculinity in their relationships with
women psy-professionals. This is especially relevant because of the tension
between women psy-professionals holding a great deal of power within an
ideology premised on the dominance of men. In some instances, men
objectified the female psy-professionals, while in others they revered them
for their motherly demeanour, reinforcing emphasized femininity. A few
men presented a counter-narrative to the hegemonic ideal by suggesting
the emotion work involved in mental health and addiction treatment sits
in opposition to hegemonic masculinity; however, because it does not dis-
rupt the dominance of men and subordination of women, it should be
categorized as another form of compensatory masculinity
This research fills a gap in the literature on masculinities by consider-
ing how men experiencing homelessness engage in compensatory mascu-
linity. Theoretically, this research adds to the small but valuable
scholarship on hegemonic masculinity among men who do not meet tra-
ditional standards of masculinity. Having a clear sense of the discreet
ways that hegemonic masculinity permeates all corners of the social world
is essential to resisting patriarchal ideologies, discourses, and institutional
arrangements upon which society is built. How those experiencing
homelessness specifically fit into this paradigm is under-theorized and
under-researched. Given that men make up two-thirds of Canada’s
homeless population, it is essential that interventions that seek to prevent
and end homelessness take into account the complex gender dynamics at
play as individuals use services and supports. With this awareness, pro-
grams can be designed and services can be provided in such a way as to
mitigate the troubling ways that compensatory masculinity manifests
(such as the objectification of professional women) and introduce men to
alternative understandings of masculinity.
236 E. DEJ
The field requires further research into hegemonic masculinity among

marginalized men. Future research that builds on McKegney’s (2014) and
Innes and Anderson’s (2015) work on the connection between coloniza-
tion and Indigenous presentations of masculinity are worthwhile.
Moreover, an investigation of how women experiencing homelessness
navigate the masculine terrain and pursue their own gendered perfor-
mances would be of great value. As conversations on the social construc-
tion of gender continue, we must remain vigilant in understanding the
ways in which women’s subordination is maintained.
Notes
1. While beyond the scope of this project, it is important to note that anyone
along the gender spectrum, including women, can and do perform mascu-
linities (Schippers 2007).
2. Following other critical scholars (Ussher 2010), I use the term distress to
describe the physical and emotional challenges people face without privileg-
ing the medical model concept of mental illness.
3. Psy-professional refers to those who work in psychology, psychiatry, and
other disciplines related to these areas.
4. LGBTQ2S refers to lesbian, gay, bisexual, transgender, queer, and
two-spirit.
5. Here I am referring to traditional employment. Many people experiencing
homelessness rely on informal employment, such as dealing drugs, sex work,
and panhandling.
6. The surveillance and punishment of ‘welfare queens’ is an example of the
kind of discourse (Cassiman 2007).
7. Vince uses the term ‘pro-life’ to mean full of life, and is not stating a position
on abortion.
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CHAPTER 11
Dangerous Discourses: Masculinity,

Coercion, and Psychiatry
Christopher Van Veen, Mohamed Ibrahim,

and Marina Morrow
Introduction
In 2013, the City of Vancouver and the Vancouver Police Department
took to the media to vividly recount several violent incidents involving a
small number of people who were said to be mentally ill, addicted to illicit
substances, dangerous to the public, and in urgent need of psychiatric
attention. The dramaturgy of what was described, through anecdotal
reports from police, was infectious for local journalists who summarized
for the public gruesome details provided by the officers:
C. Van Veen (*)

Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
e-mail: cvanveen@sfu.ca
M. Ibrahim
School of Social Work, University of British Columbia, Vancouver, BC, Canada
e-mail: Mohamed.ibrahim@ubc.ca
M. Morrow
School of Health Policy and Management, York University,
Toronto, ON, Canada
e-mail: mmmorrow@yorku.ca

https://doi.org/10.1007/978-3-319-89749-3_11
242 C. VAN VEEN ET AL.
In one of those cases, a man viciously beat three elderly women, kicking and
stomping each of them in the head. In another case, a man walking his dog
was stabbed multiple times and was eviscerated, with his internal organs
being visible to the responding officer. In a third case, [police chief] Chu
said, a mentally-ill person stabbed an innocent woman at a convenience
store so hard that the knife broke off in her head. (Lee 2013)
When evoked, the myth that individuals, especially men, said to be experi-
encing ‘mental illness’ and/or addictions are prone to spectacular out-
bursts of indiscriminate violence often leads to several proposals about
what needs to be done about it and whom is responsible. Rose (1996, 3)
describes how public inquiries following similar—although empirically
rare1 events in the United Kingdom, problematized mental health in con-
temporary times in ways rife with contradiction and contestation. In these
forensic accounts, ‘madness figures variously as the sign of a community
that doesn’t care, as a threat to a community that naturally cares for itself,
as an instance of the uncaring nature of a fiscally straightened state, as an
object of pity and of fear’.
Our analysis is less about these highly publicized events in Vancouver
than it is about the effects of how subsequent mental health policy and
practice has come to carve out new populations to monitor, contain, and
control through apprehension under the British Columbia Mental Health
Act, involuntary treatment orders, and growing use of police officers in
Assertive Community Treatment (ACT)2 teams. The increased use of the
Act as an apprehension tool has been significantly influenced by Vancouver
Police Department reports on mental illness, violence, and safety with a
strong focus on the city’s poorest and most marginalized neighborhood,
the Downtown Eastside (DTES) where men make up a larger proportion
of the population living in poverty (see Lewis et al. 2008; Wilson-Bates
2008; Thompson 2010; VPD 2013). Other local researchers have criti-
cized how the reports have considerably influenced local policy discussions
regarding re-institutionalization and a reordering of community social
services for those said to be chronically mentally ill (Boyd and Kerr 2015;
Van Veen et al. 2017). We build on this body of critical scholarship by rais-
ing alarm at how ACT teams and their locally specific coercive practices
have been enabled by the BC Mental Health Act and increasingly rely on
the police to enforce compliance.
This chapter also draws attention to attempts to puncture the logics of
psychiatric control—ones advanced by critical researchers and activists and
through legal challenges. Using available statistics, analysis of discourses
DANGEROUS DISCOURSES: MASCULINITY, COERCION, AND PSYCHIATRY 243
found in public policy and local research, and the professional experiences
of the authors—two of whom have worked closely with ACT teams, this
chapter explores the intersections of masculinity, psychiatric diagnosis, and
discourses of dangerousness as they play out in coercive practices in com-
munity-based settings. We suggest that mental illness for men is often
constructed through the lens of violence, which both justifies certain coer-
cive practices in the mental health system—especially by including police
officers in the management of mental illness—and at the same time pathol-
ogizes violence in a way that undermines a discussion of its social causes.
The intent of our work is to expose how these discursive practices con-
tinue to crop up in new forms in community-based mental health treat-
ment, giving lie to the promise of recovery and person-centred models of
mental health care and violating the rights of psychiatrized people. We use
the term discourse, following Foucault, to describe knowledge(s) that are
historically contingent and central to the construction of subjects like ‘the
mad’ or ‘addicts’, situations like a ‘crisis’, and practices such as forced
treatment. Discursive practices can be found in local environments where
social relations, ‘what is said and what is done, rules imposed and reasons
given, the planned and the taken for granted meet and interconnect’
(Foucault 1991, 75). Although our focus is recent developments in British
Columbia (BC), we contextualize our discussion through an historical
examination of discursive practices of psychiatric confinement in Canada
and its links to colonialism and intersecting forms of oppression, and
discuss the implications of ‘new’ forms of psychiatric violence and coer-
cion for the lives of men diagnosed with mental illness.
Coercion, Confinement, Colonialism,

and Masculinities
Coercive psychiatric practices as sanctioned through mental health law,

policy, and protocol have been shown to contravene Canada’s commit-
ment to the UN Convention on the Rights of Persons with Disabilities to
which she is a signatory (Chammartin et al. 2011), and yet, these rights
violations continue to pervade emerging clinical interventions with signifi-
cant repercussions for the lives of people diagnosed with mental illness.
While coercive psychiatric practices are carried out on both male and
female bodies, there are highly gendered, raced, and classed responses to
mad bodies that are seen as deviating from white, middle class, and sanist3
norms. For example, men are more likely than women to be seen as vio-
lent and thus subject to dual processes of criminalization and psychiatriza-

tion, and certain male bodies (Indigenous, poor, and Black) are subjected
to the forensic gaze more frequently than white, male, middle-class bodies
(Harrison 2002). Obscuring these deleterious logics, psychiatric and legal
systems conduct discursive practices (i.e., clinical assessments, psychiatric
review panel hearings, residence reporting requirements) that, performed
with the assumption of scientific and professional neutrality, enact legis-
lated forms of psycho-social control.
Discourses of masculinity and dangerousness when bumped up against
mental illness take particular forms, ones that serve to pathologize vio-
lence by equating it with illness, which then prevents societal discussions
on the causes of violence and how violence is socially reinforced and,
indeed, to some extent required by men in order to conform to dominant
hegemonic ideals of masculinity. Connell and Messerschmidt (2005)
remind us that notions of hegemonic masculinity must focus less on trait
concepts of gender and more on the dynamic intersections of masculine
hegemony in particular geographies. Part of our aim is to challenge the
trait concept of gender that constructs ‘mentally ill’ men as necessarily
violent. Of specific interest to us is excavating how certain male bodies
come to be marked as mentally ill and dangerous through discursive prac-
tices that result in concrete and specific kinds of state sanctions—sanctions
that ought to themselves be considered violent.
Increasingly, intersectional analyses are revealing the complex ways in
which mental health diagnoses and criminalization prop up existing sys-
tems of power based on colonialism, sexism, racism, and classism (see
Ibrahim 2014; Ibrahim and Morrow 2015; Morrow and Halinka Malcoe
2017). Metzl (2009) for example, traces the historiography of the diagno-
sis of schizophrenia in the United States as it moved from a diagnosis
more frequently applied to women (with attendant traditionally feminine
traits pathologized) to being applied to Black men during the rise of the
civil rights movement, as a way of containing and controlling Black male
protest against racism. Consequently, the reclassifying of schizophrenia as
a Black male disease permeated the psychiatric system and persists in con-
temporary times as Black and other racialized men continue to be over-
represented amongst those diagnosed with schizophrenia, and are more
likely to be detained under mental health laws (see Harrison 2002;
Sharpley et al. 2001; McGovern and Cope 1987).
Moreover, the tools of psychiatry—assessment, psychopharmacology,
and confinement—along with the lives of racialized ‘patients’—are histori-
cally bound to ‘political institutions such as slavery, scientific racism, and

eugenicist discourses’ (Kanani 2011, 1). Any examination of the intersec-
tion of madness and race must thus consider that psychiatry is bound to
scientific rationalism and colonial roots. Particularly relevant for our work
in BC is the history of colonialization of Indigenous Peoples and its impact
on Indigenous men, who are disproportionately represented among those
living in poverty on the streets of DTES in Vancouver—a neighbourhood
intensely targeted for psychiatric outreach programs and policing—and in
prisons throughout the province. Lewis et al.’s (2008) study on DTES
demographics and social housing reveals significantly higher levels of pov-
erty, health problems, and more men than women living in the neighbour-
hood (see Lewis et al. 2008; Owusu-Bempah et al. 2014).
The intersections of racism, colonialism, and eugenics can be traced
through violations of human rights perpetrated in BC on people in psychi-
atric institutions throughout the twentieth century (Roman et al. 2009;
Menzies 1999). Rampant sexual and physical abuse of inmates at the
Woodlands School (Roman et al. 2009), the regulation of male patients at
Colquitz Mental Home for the criminally insane (Menzies 1999), and the
forced sterilization of patients at Riverview Psychiatric Hospital (Hall
2003) all serve as disturbing reminders of this history. Woodlands was one
of BC’s first residential institutions established in the mid-1800s on First
Nations land in Victoria (Roman et al. 2009). Colquitz was established in
1919 also on First Nations land (Vancouver Island) to house men deemed
criminally insane. Historical records reveal the close ties the establishment
of Woodlands had to colonial settlement of the region. Analyzing the
institutional records from Woodlands and Colquitz show that routine
practices of segregation ensured that Indigenous and Asian men were kept
separate from the white European settler patient populations (Menzies
1999, 2002). Research by Menzies and Palys (2006) illustrates how
Indigenous Peoples in BC mental hospitals were treated with a particular
brutality that resulted in numerous deaths in institutions. These examples,
amongst so many others, render visible the colonial project as an enter-
prise propped up by discourses of scientific racism practiced by psychia-
trists and other mental health professionals—a process Roman et al.
(2009) describe as ‘medical colonization’, referring to how medical pro-
fessionals become the emissaries of colonialism through the ways they use
the tools of science to enact discrimination based on race (Roman et al.
2009; Ibrahim 2017).
Detailed historical analyses of how this played out on the African con-
tinent also uncovered how the development of psychiatric diagnostic cat-
egories served colonial interests by pathologizing Black people and any
others who resisted enslavement or denigration. In colonial Africa, many
subjects resisting colonial discourses were epistemologically discredited,
declared insane and dangerous through the Mental Health Act, and rou-
tinely incarcerated in psychiatric hospitals across the continent. For
instance, under British rule in Kenya and South Africa, spiritual and politi-
cal figures agitating for decolonization were incarcerated in colonial psy-
chiatric hospitals under the Mental Health Act. While in French colonized
North Africa, psychiatric treatments such as electroconvulsive therapy
became one of the tools in France’s repressive colonial toolbox for inter-
rogation to counter the rise of the liberation movement (Ibrahim 2017;
Ibrahim and Morrow 2015; Keller 2007). Contemporarily, independent
African countries such as Nigeria and Kenya maintain colonial psychiatric
laws that grossly undermine the human rights of their psychiatrized citi-
zens and, as such, a new wave of African resistance movements have
emerged to confront neo-colonial discourses (see Ibrahim 2017).
Particular implications of these discourses for contemporary BC become
apparent by examining the ongoing legacy of the colonization of the
Musqueam, Tseil-Waututh, Stó:lō , and Squamish Peoples and the psychi-
atric and legal practices that have continuity with that legacy; and, indeed,
have produced new ways of containing and controlling Indigenous and
psychiatrized peoples. For instance, provincial data shows that racialized
sentencing practices mean that Indigenous men in Canada ‘can expect to
spend 3.8 and 6.2 times longer in custody than non-Indigenous males
within the provincial and federal justice systems’ (Owusu-Bempah et al.
2014, 589). Black men are also overrepresented in Canadian correctional
institutions in rates similar to those so widely publicized in the United
States (Owusu-Bempah and Wortley 2014). Studies have also demon-
strated that Indigenous men in BC federal prisons are two to three times
more likely than the general population to be diagnosed with schizophre-
nia and/or substance use disorders (Brink et al. 2001). Discussing the
discursive coiling of law and health care throughout BC’s colonial history,
Razack (2015, 162) reminds us:
If we consider medicalization as a biopolitical tactic, designating some bod-

ies as pathologically fragile, or, paradoxically, as physically threatening, and
consider what is enabled by the entrenchment of this view in law, we come

to understand the taboo about race and coloniality … as reflecting not only
settler anxieties about Indigenous presence, but more fundamentally, a will-
ful division of populations into the respectable and the degenerate.
Thus, colonialist, racist, and sexist beliefs and structures are woven intri-
cately into the very understanding of what constitutes sanity or insanity.
Much has been written about the ways socialized femininity is patholo-
gized through psychiatric diagnoses and the treatment of women in psy-
chiatric institutions (e.g., Morrow 2017; Appignanesi 2007; Ussher
1991, 2011). Likewise, particular forms of socialized masculinity have
resulted in the overwhelming image of men with mental health problems
as violent, menacing, and unpredictable. Nowhere is this more evident in
contemporary North American culture than in the myriad images and
news stories that construct white male mass shooters as ‘deranged’ and
mentally ill. Reports of mass shootings by men racialized as Arab, Brown,
or Black likewise sidestep any discussion of the societal causes and sup-
ports for expressions of male rage through violence, as is evidenced in the
numerous commentaries following ‘terrorist’ attacks that describe the
attacker in highly individualized terms and as disconnected from wider
imperialist geopolitics. As Haider (2016, 558) reflects, ‘If violence is con-
stitutive of masculinity, then violence becomes the mode by which one
asserts one’s masculinity’. Indeed, men who do not conform to hege-
monic masculinities are subject to derision and often to violent assaults
(Johnson and Kilty 2015; Pelias 2007). In their study of male hospital
security guards, Johnson and Kilty (2015) found that (hyper)masculine
male guards engaged in violent practices in order to subordinate female
and other male guards and patients who did not conform to hegemonic
masculinity (queer or feminine men). While it is true that violence has
become inexplicitly linked to ‘toxic masculinity’ there is no proof to sug-
gest that men suffering from mental distress or diagnosed with mental
illness are any more violent than ‘normal’ men (CMHA 2011). In fact,
evidence supports the inverse; that for men struggling with mental dis-
tress, homelessness, poverty, and other factors interact with gender to
predict increased rates of victimization from violence (Teasdale 2009).
Despite the proliferation of media images and policing discourses that
conflate the threat of violence to public safety with mental illness, there is
no truth to this relationship.
De (Re) Institutionalization and the Law

A contributing factor to the current context surrounding community-
based mental health care in BC, where the police are fomenting a kind of
panic around the dangerousness of so-called severely addicted and men-
tally ill people on the streets (Wilson-Bates 2008; Vancouver Police
Department 2013), is the downsizing of Riverview Psychiatric Hospital
(BC Ministry of Health 1987; BC Mental Health and Addictions Services
2010). Although psychiatric deinstitutionalization began in the 1960s and
1970s across Canada, BC was the last province to close the doors (in
2012) on its largest hospital (Riverview at its peak held upwards of 5000
patients). Patients were relocated across the province with an attempt to
repatriate them to their home communities (Morrow et al. 2010). In all
instances, patients were transferred to other secure psychiatric facilities but
the mandate changed from custodial care to a recovery-oriented system
where patients were meant to move through these facilities and back into
communities (Morrow et al. 2010). However, the fiscal arrangements
made by the province were such that no new resources went to communi-
ties to support housing and other community-based mental health
supports (Morrow et al. 2010). The result over time has been a gross
disparity between the idea of a recovery model of care, which is meant to
address the wide range of medical and social needs of people suffering
from mental health problems, and the reality of the scarce resources avail-
able in the community to support recovery and meaningful inclusion.
Although very few people who have been transferred from Riverview in
recent years have ended up on the streets of DTES Vancouver, arguably
mental health difficulties and addictions have become more visible in the
absence of a large psychiatric hospital to send people to. This has led to calls
from several quarters to re-open Riverview and indeed, the province of BC
announced in 2015 that it has plans to construct several new buildings to
house existing mental health programs across different parts of the city and
to make way for a new secure facility (Judd 2015). Notwithstanding the fact
that some have questioned whether the closure of Riverview amounted to a
real shift away from institutionalization given that patients were typically
transferred to other secure facilities and/or continue to be heavily moni-
tored by psychiatry in the community (see Morrow et al. 2008; Morrow
2013) it can still be said that the re-opening of Riverview is tantamount to
publicly announcing the failure of the project of psychiatric deinstitutional-
ization. Re-opening Riverview signals a return to institutional forms of care
that are widely understood as detrimental to recovery because of the ways

in which they are unable to meet the specific needs of individuals, under-
mine autonomy, and have often functioned as incubators for the abuse of
people’s rights (United Nations 2006; Hall 2003). Riverview became a
lightning rod for discussions about mental health in BC and its closure
brought about debates regarding the control and containment of people
with mental health difficulties to the fore.
Historically, one of those debates has surrounded the legitimacy of leg-
islative mechanisms used to forcibly contain and control people deemed
mentally ill. The most striking legal device for psychiatric control is the BC
Mental Health Act. The Act is one of the most coercive of all Canadian
provinces, broadly stipulating the need for forceful detention in a psychi-
atric hospital due to ‘dangerousness and illness of an individual’. It also
provides physicians with the legal means to ‘treat’ the individual without
his or her consent (Schizophrenia Society of Ontario 2013). These aspects
of the Act have been so contentious that it recently became the subject of
a constitutional challenge by the Council of Canadians with Disabilities
(CCD). With the support of Community Legal Assistance Society (CLAS)
and two BC residents affected by the BC Mental Health Act, a case was
filed in 2016 at the BC Supreme Court claiming that the Act contravenes
section 7 of the Canadian Charter of Rights and Freedoms, the right to
life, liberty, and security of the person (CLAS 2016). The two plaintiffs in
the case, who were subjected to practices of forced injections of anti-psy-
chotic medications and electroconvulsive therapy, argue that in addition to
violating their Charter rights, the Act perpetuates the paternalistic stereo-
type that people struggling with mental illness are not able to make deci-
sions about their own lives (Woo 2016).
The BC Mental Health Act finds its genealogy in various legislation in
the province that singularly, or collectively, sought to address mental
health issues affecting adults, children, and those involved with the crimi-
nal justice system. In 1964, these myriad laws, the Clinics of Psychological
Medicine Act, Mental Hospitals Act, Schools for Mental Defectives Act,
Provincial Child Guidance Clinics Act, and Provincial Mental Health
Centres Act, were combined to form the BC Mental Health Act (Legislative
Library of BC 2008). The Act has its roots in the British colonial system
where such laws like the Lunatic and Imbecile Acts existed across the
globe in British colonized nations including those in Asia and Africa
(Ibrahim and Morrow 2015).
In contemporary times, individuals who are committed under the BC

Mental Health Act are held for assessment in a psychiatric hospital until
they are deemed ready for release by a physician appointed by the regional
health authority. If the attending psychiatrist is not confident in the
patient’s ability or intention to continue voluntary treatment, they may be
released on Extended Leave. Similar to Community Treatment Orders in
other provinces, patients discharged on Extended Leave are subjected to
specific conditions (most commonly forced medication regimens and
mandated requirements on where one can or cannot reside), which, if not
met, can result in forcible detention and readmission to inpatient units. In
BC, data released by the Vancouver Police Department and reported in
the media over the period 2009–2014 showed a steady increase in the
number of involuntary psychiatric committals and discharges to Extended
Leave (Lupik 2015a). In 2014, officers detained 3010 people under
Section 28 of the Act, an increase of 2278 from 2009 (Lupik 2015b).
Further data from Providence Health Care (which includes two of
Vancouver’s main hospitals) and from BC Housing (the main provider of
subsidized housing options in Vancouver) reveals that emergency mental
health visits and visits related to substance use increased dramatically dur-
ing the same time period. Most concerning are the statistics from BC
Housing, which show a dramatic upswing in waiting times for housing
(Lupik 2015a). Thus, the correlations between lack of affordable housing,
emergency room visits for mental health-related concerns, and apprehen-
sions under the Mental Health Act appear indisputable. Despite claims
that new ACT teams have been successful in reducing hospitalizations,
data updates provided by the Vancouver Police Department regarding
apprehensions under section 28 of the Mental Health Act for 2015 show
only a very tiny decrease in apprehensions (personal communication with
Travis Lupik 2015). Taken together these statistics support our argument
that due to lack of housing and community-based supports for people suf-
fering mental distress, increasingly coercive measures are being used to
contain people, especially marginalized men.
One way of enforcing Extended Leave criteria that has been evident
through the authors’ years of experience in front-line mental health ser-
vice provision is via the growing roles and resources for ACT teams in
community-based mental health care. In Vancouver, ACT teams were
established in the wake of several important events: the closure of
Riverview, the release of the Vancouver Police Department reports, and
the release of the findings of the national At Home/Chez Soi Study
s ponsored by the Mental Health Commission of Canada. It is within this

context that the Vancouver Police Department and the Vancouver
Coastal Health authority entered into a data-sharing and service partner-
ship to establish two ACT teams staffed by inter-disciplinary team mem-
bers, including full-time police officers, who are given powers under the
BC Mental Health Act to apprehend individuals if officers deem that a
person is ‘acting in a manner likely to endanger that person’s own safety
or the safety of others … and is apparently a person with a mental disor-
der’ (Vancouver Coastal Health 2016, bold and italics in original). It is
to a description of ACT teams and their discursive and material functions
as a form of control in the current context that we turn to next.
ACT in Vancouver: Research, Policy Development,

and Practice
Although coercive practices are most often associated with institutional

and inpatient forms of care, they are routinely used in community-based
mental health care (see Shimrat 2013). Practices of involuntary commit-
tals and restrictive and controlling interventions are disproportionately
shown to impact men (Mah et al. 2015). We argue that in the Vancouver
context, discursive practices surrounding violence and mental health have
made possible a host of involuntary psychiatric treatments forced upon
men (and some women) said to be ‘severely mentally ill and addicted’.
Specifically, the so-called mental health crisis characterized by extremely
violent acts of men became a way for the police to pressure the City of
Vancouver and its health care services into a collaborative relationship for
managing, monitoring, and controlling people with mental illness.
Assertive Community Treatment (ACT) is a form of multi-disciplinary
community-based treatment and emerged as a result of the de-institu-
tionalization era in the United States when physicians and nurses in a
psychiatric hospital in the US state of Wisconsin started experimenting
with a 24-hour, 7 days a week community treatment approach in the early
1970s. Ever since, the ACT model has been extensively researched with
more than 25 randomized control trials, and widely implemented across
North America, parts of Western Europe, Australia, and New Zealand. It
is regarded as an evidence-based community mental health intervention
and has been adopted by US federal agencies such as the Substance Abuse
and Mental Health Services Administration (SAMHSA) and US Veteran
Affairs (Udechuku et al. 2005; Phillips et al. 2001).
New ACT Teams that directly involve police on the front lines of men-
tal health care have provided one particularly troublesome mechanism for
a variety of psychiatric practices of control in Vancouver. What is particu-
larly distressing about this new police and health services collaboration is
that it may be operating outside the boundaries of the Mental Health Act,
which clearly stipulates the criteria of certification and detention and the
respective roles of service providers who are regulated through the BC
Health Professions Act, of which the police are not accountable to.
Over the years, the ACT model, as an evidence-based community inter-
vention, has incorporated well-researched interventions, such as Housing
First where individuals with significant mental health and substance use
challenges, who are homeless or precariously housed, are offered housing
in addition to optional clinical and substance use treatments. The Housing
First ACT model as it is now known has been extensively studied in Canada
as part of the federally funded At Home/Chez Soi project conducted across
five cities from the Maritimes to BC (Currie et al. 2014). Vancouver was
one of the key sites and garnered much attention because of its well-
known challenges regarding homelessness, substance use, and mental
health (Currie et al. 2014). The federally funded At Home/Chez Soi study
lasted for three years, and consisted of randomly assigning homeless indi-
viduals to several different treatment options that all included housing
(ACT, intensive case management, and single-site supportive housing in a
renovated motel) and to a control group described as ‘treatment as usual’,
which, for people structurally subjected to living on the margins in
Vancouver, typically means homelessness, high rates of police interaction,
and little access to basic health care services.
The At Home/Chez Soi study design was subject to heavy criticism by
Vancouver activists, critical-thinking health and social service providers,
who were distressed about the fact that people assigned to the control
condition would continue to live in unacceptable circumstances while the
government was providing funds for housing for other participants. There
was also deep concern about what would happen after the study ended
and the government withdrew the housing funds. Indeed, a prominent
local sociologist charged that the study was ‘distasteful’ and that it is ‘fun-
damentally problematic to subject human rights [the right to housing] to
Randomized Controlled Trials that are finally about costing’ (Patton
2012, 10). Despite the controversy, the study went forward and the
researchers have gone on to advocate for ACT models based on their
study results (Currie et al. 2014). Findings largely focused on ‘success’
defined as cost savings to government and biomedical management of

study participants in the form of ‘improved adherence to antipsychotic
medication’ (Rezansoff et al. 2017). Absent from the discussion on these
supposed ‘successes’ is reference to the political contexts of poverty, colo-
nization, and the simple fact that many study participants were forced to
take medication involuntarily through Extended Leave provisions under
the Mental Health Act—practices that fly in the face of recovery-oriented
care and ‘Housing First’. These omissions reflect the power of psychiatric
discourses and the normalized disregard of the rights of those targeted for
study by researchers and health systems.
It is important to note that the At Home/Chez Soi study did not include
police involvement as part of its ACT model, yet, following the comple-
tion of the study, the Ministry of Health mobilized the enthusiasm of the
researchers and their emerging evidence and began to establish several
ACT teams with police departments in Vancouver and Victoria, BC. Critical
researchers in Vancouver have pointed to a decade of increasing security
discourses connected to mental health policy as setting the context to
make this departure from the original model possible (Van Veen et al.
2017), and others direct us to the unusual position of the Vancouver
Police Department (VPD) as a dominant claims-maker on issues related to
mental health and addictions policy and practice (Boyd and Kerr 2015).
Indeed, over the past decade the VPD have self-published a number of
policy reports with recommendations on health policy changes to the
mental health and addictions system and have strongly advocated for more
defined roles for their officers. These recommendations have been taken
up by local health authorities. From their very onset, Vancouver ACT
teams were modified to include police in a way that is inconsistent with
‘the evidence’ and in contradiction with established fidelity rules of the
ACT and Housing First models. With fidelity scales focused on client
autonomy and choice, formalized roles for officers and aggressive forced
medication regimes represent, at best, a significant departure from the
evidence base, and at worst, the deliberate on-going criminalization of
individuals, mostly men, who are said to be ‘ill’ and structurally vulnerable
to homelessness.
In other jurisdictions across North America, ACT pledges to be client-
centered and consciously avoids coercive approaches to service provision.
Many ACT teams accept individuals who were or are involved with the
criminal justice system, but the service models do not vary as a result of
their inclusion. A few specific ACT teams, especially across the United
States, serve only forensic clients (Forensic Assertive Community

Treatment or FACT) and have a working relationship with the justice
system, usually the parole department. While some of these teams include
parole officers to address issues of jail diversion and recidivism, it must be
noted that there is no research to support the incorporation of armed
police officers into interdisciplinary ACT teams (Lamberti et al. 2004).
Whereas inclusion of the parole system is meant to increase engagement in
treatment and diversion from incarceration, the role of active law enforce-
ment agencies in the ACT model is unclear (Lamberti et al. 2004). The
ACT model’s client-centered approach that fosters respect, choice, and
independence is diametrically at odds with including police and a coercive
element into mental health services. In fact, studies have shown that the
coercive nature of monitoring treatments utilized by the parole system has
been associated with an increase in incarceration among clients in the jus-
tice/mental health system (Lamberti et al. 2004).
Whereas the ACT and Housing First models are based on evidence
from randomized control trials, the same cannot be said for forced com-
munity treatment interventions such as Community Treatment Orders
(CTOs) and Extended Leave (EL). In fact, to the contrary, the few
randomized control trials on the effectiveness of CTOs show that their use
does not necessarily reduce hospital re-admission. In other words, indi-
viduals under CTOs (which are similar to EL) do not symptomatically
improve or improve in terms of overall wellbeing as compared to those
receiving care voluntarily (Steadman et al. 2001; Burns et al. 2013; Nagra
et al. 2016).
The inclusion of police on ACT teams may constitute serious ethical
and human rights abuses. Working with traumatized, marginalized, and
psychiatrized individuals requires an understanding of and critical reflexiv-
ity that interrogates the inevitable power dynamics present in the relation-
ships between service providers and those who seek their help. The
addition of police on ACT teams introduces a particularly coercive ele-
ment of power, one that is backed by the state and legal system. Many men
with mental health struggles have extensive exposure to the use of force by
police, a practice that has historical intersections with colonialism, racism,
homelessness, and poverty. Indeed, a report published by the BC Civil
Liberties Association details high rates of police contact amongst
Indigenous people and police in BC, and highlights the disproportionate
number of Indigenous deaths that occur while in police custody in com-
parison to the deaths in custody of non-Indigenous Peoples (MacAlister
2012). One of the most notable examples of this problematic is the death
of Frank Paul in 1998. After being detained by officers for public intoxica-
tion and later refused entry into the local ‘drunk tank’, officers dumped
Frank Paul in an east Vancouver alley where he would later die of hypo-
thermia. The publicity of the subsequent inquiry and the apparent crimi-
nalization by those struggling with mental health distress and addictions
in Vancouver leaves one to wonder if the inclusion of police officers on
ACT teams represents an omnipresent threat for individuals served by the
interventions. It should also make policy makers, researchers, and practi-
tioners consider that including police on the ACT teams inevitably under-
mines the potential for a therapeutic relationship altogether.
Currently, Vancouver has five ACT teams that ‘serve’ approximately
380 ‘clients’ (with a male-to-female ratio of 2.5:1) and approximately 80
percent of these are on EL (personal communication Ministry of Health,
2016), which includes forced antipsychotic medication injections.
Should a client resist with non-compliance, they can be picked up by the
police and returned to the hospital at any time—a process that can be
violent and traumatic. The threat of apprehension thus looms over every
clinical encounter with nurses, social workers, and doctors that are regu-
larly accompanied by police officers to client visits. One police officer
works across the five ACT teams but additional police officers are
attached to other partnership programs in mental health and can act as
resources to the ACT teams. ACT clients are flagged in the police data-
base, so patrol officers can contact the police officer on the ACT teams.
Police in Vancouver now have access to a range of biomedical and psy-
chosocial treatment information about clients despite not being profes-
sionally trained or regulated by the health care system. The Ministry has
indicated that a formal Information Sharing Agreement is in place
between the Vancouver Police Department and Vancouver Coastal
Health that limits how this information can be shared—that is, only for
the purposes of obtaining ‘support’ for the client. Police often act as
referral agents for the ACT teams when a client is deemed seriously men-
tally ill and is not receptive to receiving traditional mental health ser-
vices. Indeed, when the first ACT team was started police were the sole
source of referral for the first 20 clients (personal communication,
Ministry of Health 2016).
The ACT teams with police involvement introduce a new coercive ele-
ment into the mental health care system in BC and exacerbates previously
documented concerns with the BC Mental Health Act and the historical
abuses of people’s rights in institutions like Riverview, Colquitz, and

Woodlands. This combined with the over-reliance on the biomedical para-
digm, where psychopharmacology remains central to treatment orders,
makes it hard to imagine how individuals subject to these interventions
can make meaningful choices about their care. In fact, for some clients the
EL period can feel indefinite, since it is renewed every six months by the
psychiatrist and can go on for years without any success of legal appeal.
The Panel Review Board, which is the sole legal pathway to seek redress,
provides little or no support for people to access representation or assis-
tance with the complex process (BC Ministry of Health 2005).
Contesting Confinement and Coercion

The BC Mental Health Act is an outlier in the context of mental health
laws across Canada (Nunnelley 2015; Dhand and Grant 2016). The fact
that the Act is now facing a constitutional court challenge at the BC
Supreme Court reflects concerns that advocates have been raising about
its coercive reach. Although there has been civil and legal resistance to the
lack of patient rights in the Act over the years, more critical attention must
be focused on its legislative intersection with emerging forms of psychiatric
control taking shape in the community. ACT, and other methods of polic-
ing marginalized populations under the pretext of mental health ‘care’,
requires coalitions of psychiatrized people, critical researchers, policy mak-
ers, and practitioners to jointly, and in their own ways, work to offer criti-
cal challenges. These challenges can come in the form of court cases,
critiques of the effectiveness of interventions and the problematic dis-
courses that research evidence relies upon, and through appeals to policy
makers to consider the human rights of those encountering the mental
health system.
British Columbia has a strong history of resistance to psychiatric dis-
courses with the formation of the Mental Patients Association (MPA) in
the early 1970s; the MPA consisted of individuals who were discharged
from Riverview Hospital and formed Canada’s first organization led by
people with experiences of the psychiatric system. The MPA gained inter-
national attention in the 1970s and 1980s for its innovations in providing
social support and housing and its challenges to psychiatry. The organiza-
tion was formed in line with the campaigns focused on equality and jus-
tice when social change was sweeping across North America regarding
civil, women’s, and gay rights. The MPA was the antithesis of institution-
alized care prevalent at the time and proved the power, resiliency, ingenu-
ity, and resourcefulness of psychiatrized people (Davies et al. 2016;
Beckman and Davies 2013). The founding members of the MPA envi-
sioned a future devoid of social isolation, prejudice, and discrimination
(Beckman and Davies 2013). The legacy of the MPA has lived on in
contemporary organizations like the West Coast Mental Health Network
and Unity Housing in BC, where the leadership and activism of people
who have experienced the psychiatric system informs responses to people
struggling with mental health difficulties. The recent establishment of the
Mad Society of Canada (see https://madsocietyofcanada.wordpress.
com/) as a national community of practice that stands against psychiatric
coercion and proffers innovative community-based mental health models
is further evidence of dedicated resistance strategies.
However, paths to carve out resistance to dominant discourses and
practices are not easy. Drawing on findings regarding cost efficiency and
medication adherence from the At Home/Chez Soi study, and the BC
Ministry of Health’s continued endorsement of ACT as a ‘best-practice’,
City Council in Victoria, BC recently approved funds to embed two police
officers in the region’s four operational ACT teams. However, contesta-
tion also worked its way into debate on the new policy. Advocates from
the Mad activism community and critical social service workers organized
through a closed Facebook group to strategize how to keep officers off
the teams. When the new funding for police was debated in council cham-
bers, activists lined up to point out that the proposal ‘sends the message
that people with mental illnesses are dangerous’ and that the new configu-
rations of police-involved ‘care’ could actually make some people appre-
hensive to reach out for help (Derosa 2017).
The point that coercive practices in mental health care models can deter
people from seeking help when in distress is well founded in our commu-
nity. In response to this dynamic, compassionate activists in Vancouver set
up a ‘Warm Line’ for people who want help but are fearful of apprehen-
sion and subsequent EL orders under the BC Mental Health Act. Although
recently deactivated, the Warm Line functioned as ‘a peer run support line
that anyone in the (psychiatrized) community is welcome to call’ (Mad
Society of Canada 2017). As further evidence of the ways in which the BC
Mental Health Act is preventing people from accessing care are media
reports that one of the plaintiffs in the current Supreme Court case in BC
has moved to Ontario to avoid the reach of the legislation (Brown 2016).
Emerging research on the experiences of Somali immigrants suggests that
leaving BC to avoid the coercive reach of the Act is occurring in other
instances as well (Ibrahim unpublished).
Intersecting discourses of dangerousness, psychiatry, and masculinity,
especially when bolstered by legislative mechanisms and mobilized
through research practices from ‘evidence bases’ that normalize violations
of Charter rights, can serve to bring new ways of containing and control-
ling men into community-based mental health practices. That these pater-
nalistic practices are performed under the guise of ‘treatment’ makes them
even more reprehensible and contradictory.
Just as we witnessed in Vancouver, the recommendations from the
Victoria Police Department were passed and officers will soon be opera-
tional on ACT teams in that region. However, the efforts of activists to
wage nimble expressions of resistance should not go unrecognized. The
lengths that those resisting psychiatrization are willing to take to avoid
confinement and loss of control over their lives reflects the severity of the
violations taking place, but it also reminds us that subjects are not passive
recipients of new politics in mental health policy. In non-ideal situations,
many activists continue to perform practices that counter the discourses
that connect mental illnesses to dangerousness or criminality. Indeed, the
resistance to the BC Mental Health Act and other coercive psychiatric
practices is multi-dimensional, with scholars from diverse backgrounds
also challenging human rights abuses and the ‘science’ that underlies
coercive interventions (see Patton 2012; Dhand and Grant 2016; Boyd
and Kerr 2015; Van Veen et al. 2017). Taken together, expressions of
resistance have the potential to counter psychiatric control and foster
human rights.
Notes
1. The Canadian Mental Health Association (2011) reminds us that people
who struggle with mental distress are more often the victims, than the
perpetrators, of violent acts; and that individuals with ‘mental health
conditions’ pose no more danger to the public than those considered to
be members of ‘the general population’. For a more in-depth analysis of
the connection between mental illness and violence, see Elbogen and
Johnson (2009).
2. ACT teams are community-based, recovery-oriented, interdisciplinary men-

tal health care models administered by professionals such as psychiatrists,
nurses, addictions counsellors, social workers, and occupational therapists.
The teams are intended to care for individuals with ‘severe mental illnesses’
and sometimes co-occurring substance use. Teams operating under a
‘Housing First’ model, where participants are offered immediate access to
rent-supplemented market-apartments, have been particularly endorsed by
researchers and policy makers. Fidelity measures hold that Housing First
ACT programs should not require clients to maintain sobriety or engage in
psychopharmaceutical treatment. Instead, treatment should be made
optional but available and encouraged. In Vancouver, the housing service
component of ACT has been neglected throughout implementation, and
teams have been modified to include police officers—a significant departure
from the practices’ evidence-base.
3. Sanism is a term used to describe the very specific kinds of prejudice and
discrimination faced by people thought to be mentally ill (see Perlin 1992,
1999). The concept of sanism is also used to describe the specific ways in
which society values certain forms of human consciousness and being over
others (e.g., rationality over madness as possibly a productive experience).
For more on sanism see Ingram (2011) and Fabris (2011).
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CHAPTER 12
Conclusion: Expanding the Concept

of ‘Containment’
Erin Dej and Jennifer M. Kilty
Sitting around a kitchen table a couple of years ago, the editors of this col-
lection were deep in conversation about their respective projects—Jennifer’s
work on carceral spaces and Erin’s immersion in the homeless community.
The conversation kept coming back to the same questions: how do these
very different institutional contexts shape the production and treatment of
mental illness/distress? And how does gender mediate institutional dis-
courses and material experiences of institutional containment in its multi-
farious forms? Containing Madness is our initial response to some of these
big questions—a starting place to probe, break apart, and interrogate the
relations between institutions, gender, mental health, race, sexual identity,
and the construction and reproduction of psy-knowledges.
If we are to think critically about the notion of ‘containment’ and how
we can use it to explore the gendered power relations inherent in the iden-
tification and management of mental distress, we must begin by recogniz-
E. Dej (*)
e-mail: edej@wlu.ca
J. M. Kilty

https://doi.org/10.1007/978-3-319-89749-3_12
268 E. DEJ AND J. M. KILTY
ing some of the early thinking on the concept. Walter Reckless’ (1961)
containment theory in the discipline of criminology posits that there are
internal push factors (i.e., psychological drives and impulses), external
environmental push factors (i.e., poverty, deprivation, and blocked oppor-
tunities), and external pull factors (i.e., positive inducements to criminality
such as gang and subcultural connections) that lead youth to engage in
delinquent acts unless they are counteracted by inner and outer forms of
containment. Inner forms of containment include such things as a positive
self-concept, moral compass, and conscience, while outer forms of con-
tainment include a strong pro-social sense of group cohesion and institu-
tional supervision and discipline by way of the family and school. Perhaps
more obvious is how the notion of containment is taken up in the realm
of public health, where it is conceived as a primary method of preventing
the spread of disease.
Although these ideas about how containment works can certainly be
traced throughout the book, the discussions found in this collection pri-
marily utilize the notion of containment to describe the diverse institu-
tional arrangements and strategies that are mobilized to secure control of
individuals marked as ‘mad’ and thus as dangerous in some way—either to
themselves or to others. Following in the tradition of Foucault’s (1979)
conceptualization of the ‘carceral archipelago’ and Cohen’s (1985) model
of transcarceration, by conceiving of the idea of ‘institutional contexts’
broadly so as to include different networks of surveillance rather than just
sites of physical or spatial confinement, the discussions offered herein re-
centre consideration of how socio-structural barriers come to bear on
material experiences of different forms of psy-containment. More specifi-
cally, contributors explore how gender (and in some chapters, the intersec-
tion of gender with other markers of oppression—notably, race, class, and
heteronormativity) mediates these institutional efforts at containment.
The chapters that make up this edited volume present a diverse collec-
tion of critical thought on the ways that bodies and minds are subject to
different forms of containment. The contributing authors work across the
intellectual boundaries of various disciplines—critical criminology, gender
studies, law, disability studies, health, social work, geography, and his-
tory—and study different populations—prisoners, psychiatric patients,
immigrants, those experiencing homelessness, as well as the psy and aca-
demic professions. By way of conclusion, this chapter explores the impor-
tant differences between these spaces, places, and populations, and perhaps
CONCLUSION: EXPANDING THE CONCEPT OF ‘CONTAINMENT’ 269
more significantly, the areas of convergence that expose the fundamental

quality of containment: a quintessential power imbalance that stems from
and perpetuates discrimination, abuse, and inequality at the individual and
social-structural levels. In what follows, we consider three of the key con-
nective threads that run throughout the various chapters; namely, we dis-
cuss the impact of power relations on the recognition of ‘voice’, the
punitiveness of psy’s efforts to contain, and what it means to contain gen-
dered bodies.
Power and Voicelessness
Throughout the chapters in this edited volume, the contributing authors
disassembled the notion of containment across various sites, practices and
platforms. In their efforts to unpack and disrupt the very idea of contain-
ment, the authors examined themes of control, power imbalance, and
‘Othering’ across traditional institutional settings, such as the prison and
psychiatric institution, as well as within sites that do the work of contain-
ment without the brick walls and barbed wire fencing, such as techniques
and policies used to manage marginalized and vulnerable people. Common
to all forms of containment is that it occurs within and through unequal
power relations. Referring to Goffman’s study of institutionalization prac-
tices, containment is defined as ‘…a process in which the selves of others
are deconstructed by those with institutional power … with the goal of
preventing the disruption of social order that is inherent in the inmate’s
effort to defend himself against the assault on his self’ (Hancock and
Garner 2011, 321). Containment is desirable and positioned as necessary
by those who benefit from the current social arrangement, be it capitalism,
the patriarchy, white privilege and supremacy, colonialism, ableism,
homophobia, or transphobia. Efforts to contain can be understood as
techniques to subsume those who challenge the advantages gleaned from
the dominant arrangement of power relations so as to render them invisi-
ble in some way—whether it be that they are unseen, unheard, or
unbelieved.
Discussions of unequal power relations and the dominance of those in
positions of power are prominent throughout this collection. For exam-
ple, Dej’s analysis in Chap. 10 of men experiencing distress and homeless-
ness performing compensatory masculinity was revealing for two reasons.
First, it exemplifies the materiality of what it means to be marginalized
and, like so many of the other chapters, it showcases how powerlessness is
more than a theoretical concept. Whether it be transgender women forced

to castrate themselves (Kirkup), men dying in immigration detention cen-
tres (Joseph), or the suffering women prisoners’ experience in carceral
segregation (Kilty), the discourses that inform legislation, policies, and
practices reflect the unequal power relations between psy practitioners and
other social control agents and the populations they treat, govern, and
manage. As Foucault (1980, 88) noted, the economic functionality of
power is present ‘to the extent that power is conceived primarily in terms
of the role it plays in the maintenance simultaneously of the relations of
production and of a class domination which the development and specific
forms of the forces of production have rendered possible’. For those who
are repressed by these power arrangements, the effects can be totalizing.
Inequality at the structural level makes for unequal interactions between
those who work within and align themselves with the discourses and prac-
tices that maintain these structures, and those who are oppressed by said
technologies. Conversely, Dej’s analysis also bears witness to the extent to
which these power differentials are embedded into ways of life. Even for
those men who are excluded from society in many ways, their attempt to
assert male dominance through misogynistic attitudes and interactions
with women in positions of power is a stark reminder of the depths to
which various forms of power—here of hegemonic masculinity—are
assumed and maintained.
Institutionalized power imbalances are designed to further disenfran-
chise already marginalized people. This silencing is acute in the psychiatric
institution, where the medical staff’s opinions, positions, and judgments
have the power to render mute the perspectives and insights of the patients.
Pilling et al. found that this silencing was codified in psychiatric charts as
having ‘poor’ or ‘good’ insight, depending on whether or not the patient
agreed with the physician’s diagnosis and treatment plan. Not surprisingly,
these mechanisms of power reinforce one another, and assessments of
insight were found to fall along racialized, sexualized, and classed lines. In
this case, privileging the physician’s assessment and failing to recognize
and consider the patient’s voice and narrative resulted in forced medica-
tion requirements. Painting a similar picture of patient voicelessness, Jacob
et al.’s research on the use of mechanical restraints among female psychi-
atric patients demonstrates how patients have no corporeal autonomy in
instances where restraints are used, and that the feeling of powerlessness
this practice engenders reverberates in the ongoing relationship between
nurses and patients.
Lacking voice is one of the main subjects of analysis in Rembis’ work on

the Groupe d’Information sur les Prisons (GIP), where Foucault and his
contemporaries in France sought to provide a platform for prisoners to
speak out about the atrocious conditions of French prisons. As Rembis
articulates, without careful consideration of the intersectional effects of
different identity markers of structural oppression (Crenshaw 1989) and
when those in positions of relative power act as gatekeepers for the narra-
tives of the subjugated, ‘…we close off our benevolence by constructing a
homogeneous Other referring only to our own place in the seat of the
Same or the Self’ (Spivak 1988, 28). In this sense, containment operates
by creating a ‘master status’ whereby the individual is primarily under-
stood and treated or managed based on their status as a prisoner, a mental
patient, an immigrant, or a homeless person. The scholarship in this col-
lection complicates this simplified understanding of subjectivity, examin-
ing the ways that gender, race, heteronormativity, and class intersect with
interpretations of madness to produce unique experiences of institutional-
ization. The analyses also reject the dichotomies that systems of contain-
ment proliferate between ‘us’ and ‘them’, the powerful and the weak, the
voiced and the silenced.
The issue of voicelessness is one that women in particular have been
subject to—both historically and in modern times. In this volume, Rimke
uncovers the ways that the psy-complex has worked to silence women.
From the witch hunts to concerns over the psychiatric diagnoses of hyste-
ria and borderline personality disorder, women continue to be patholo-
gized for expressing their positions and resisting male-dominated ways of
knowing that contribute to the sustainability of the patriarchy. Daley and
Ross provide a contemporary example of how this form of pathologization
occurs in practice, finding that experiences of gendered violence are
described as delusional and are dismissed as symptoms of mental illness
rather than taking seriously women’s experiences of same-sex intimate
partner victimization.
In this vein ‘to contain’ necessarily means to stifle the voices of those
being oppressed. Containment involves discrediting the knowledges and
perspectives of people with lived experience, as witnessed by the mad
movement, in critical disability studies, and among prisoners. Silencing
can take on a more insidious but equally unjust tendency, as influential
third-wave feminists have long argued (Davis 1983; Hill Collins 2000;
hooks 2000), whereby attempts to reclaim voice by those with relative
privilege can result in the assertion of a homogenized voice, causing the
erasure of divergent experiences, particularly those of people of colour. As

Hill Collins (1993, 39) describes: ‘Rather than seeing women of color as
fully human individuals, we are treated as the additive sum of our catego-
ries’. Containment has the latent, if not manifest, objective of stripping
people of their subjectivity in an effort to more easily surveil, manage, and
control individuals and populations deemed threatening or sick. Founded
on the scholarship and teachings of feminists, critical race theorists, mad
studies scholars, critical criminologists, and critical disability studies schol-
ars, Containing Madness challenges these institutional discourses and
endeavours to consider how those individuals who find themselves on the
derogated side of a power relationship complicate and resist forces that
construct them as inherently mad or bad or that seek to reduce their iden-
tity to a single master status characterization.
Punitiveness
Containment imbues notions of immobility, restraint, and restriction.
Punitiveness, where inflicting harm and exacting revenge has become the
modus operandi of systems of punishment (Garland 2001), is inherently
linked with containment in two ways. First, the act of incapacitation, exile,
and exclusion from the social world is a form of punishment. Indeed, the
explicit purpose of the prison is to punish by separating prisoners from the
outside world. In other words, containment via the prison is the punish-
ment. But as others have argued (Garland 2001; Loader 2009; Pratt 2002;
Sim 2009), and as is evident in the chapters outlined in this book, physical
institutions of containment are spaces that not only allow for, but are
designed to include extra-punitive measures. The level of abuse, violence,
and death found across these institutional contexts signals the role of con-
tainment as an inherently punitive technology.
Not surprisingly, the prison provides the clearest example of the use of
extra-punitive population and individual body management techniques.
Due in part to the reduction of programming and rehabilitative efforts
and the growing emphasis on managing the exponential expansion of the
prison population over the last three decades (Feeley and Simon 1992;
Garland 2001), the conditions of confinement across jail and prison sites
and the abuses of power committed by frontline correctional and prison
management staff have received much deserved attention by scholars and
activists alike. In Chap. 6, Kilty provides a haunting description of the
similarities in correctional policies and practices over time that led to the
violent assault of six women at the Kingston Prison for Women in 1994
and Ashley Smith’s death in 2007 in a segregation cell while correctional
staff watched from the hall. Kilty describes the physical and mental suffer-
ing these women experienced as a result of their time in solitary confine-
ment. She argues that the women’s prolonged experiences of segregation
amounted to their social death as they were corporeally and relationally
disconnected, not only from the broader social world or even the internal
social world of the prison but from basic human connection to other peo-
ple. Kilty’s chapter resonates with Kirkup’s analysis in Chap. 7 of the
modes of punitiveness exacted on transgender women in the federal cor-
rectional system in Canada. Prisoners who do not fit the narrow parame-
ters of sex-segregated carceral spaces face extraordinary levels of suffering:
being forced to reside in an institution that does not match their gender
identity unless and until they undergo sex affirmation surgery; denial of
medication; violence; psychiatric pathologization; and isolation in segre-
gation. These two chapters in particular identify how the ways that we
physically contain subjects considered to be both mad and bad largely rely
on punitive measures.
The punitive quality of containment is not limited to the prison, how-
ever. As described by Joseph in Chap. 3, the recent death of two men in
Canadian immigration facilities offers eerie parallels between the two insti-
tutional spaces. Ibrahim Hassan, who died in immigration detention in
July 2016, struggled with emotional distress and his four-month sentence
turned into years in detention because he was declared a danger to the
public. The Hassan case mirrors a number of elements in the Ashley Smith
case; just as Hassan died in segregated custody during what became an
indefinite period of detention, Smith’s one-month youth sentence
morphed into a four-year prison term that eventually led to her untimely
death. Moreover, both subjects were punished by way of isolation for
expressing their feelings of emotional distress. Immigration detention,
whose purpose is meant strictly to contain, inevitably becomes a space of
suffering, abuse, and neglect, which subsequently reinforces the notion
that to contain necessarily means to punish. Even the threat of contain-
ment can be used to transform a supposed therapeutic encounter into one
premised on punishment. As Van Veen et al. note, including police officers
in Vancouver’s Assertive Community Treatment (ACT) teams not only
fails to keep fidelity to the self-determinist model of ACT teams but also
creates a coercive relationship between mental health care providers and
those in need by transforming community-based care into a threatening
and forceful experience where a failure to comply with treatment sugges-

tions can result in involuntary institutionalization in a psychiatric hospital.
The constant risk of ‘being contained’ transforms community spaces into
a punitive city where, ‘the ideology of community is trying once more to
increase the visibility—if not the theatricality—of social control’ (Cohen
1979, 360). Ironically, punitiveness itself cannot be contained.
Containing Gendered Bodies/Gendering

Contained Bodies
Containment is a psychological, emotional, and embodied experience as
institutional discourses and practices have immense control over not only
the mobility of bodies but also accepted gender and sexuality identities,
and personal autonomy. Carceral spaces in particular create and exacerbate
emotional, mental, and physical distress (Guenther 2013; Kilty this vol-
ume) as institutional practices control bodies through different forms of
assessment (typically of various considerations of risk and need), mental
illness diagnoses, and treatment plans. As the scholarship in this edited
volume shows, psy discourses promulgate gendered explanations of emo-
tional distress and behavioural differences that legitimize medicalized
understandings of mental illness and reinforce different containment strat-
egies and management technologies. As Rimke explains, women’s historic
characterization as emotional, irrational, and dramatic led to the early psy-
chiatric diagnosis of hysteria and later to the modern diagnoses of border-
line personality disorder and pre-menstrual dysphoric disorder. Similarly,
people of colour have long been depicted as ‘uncivilized’ and ‘savage’,
leading to the creation of ‘draptomania’ in the nineteenth century to
pathologize a slave’s desire to escape their owner. While draptomania is no
longer a designated mental illness, race continues to affect how symptoms
and mental illness diagnoses are interpreted. For example, in Chap. 9,
Pilling et al. use contemporary psychiatric inpatient charts to describe how
a Black woman’s spiritual beliefs are characterized as psychosis. The chap-
ters by Pilling et al. and Rimke highlight the individualizing nature of
using gender and race to validate mental illness diagnoses and subsequent
containment strategies. Pilling et al. contend that structural oppressions
are ignored in favour of biopsychiatric explanations and Rimke identifies
the ‘pathologies of patriarchy’ that allow for the feminization of certain
mental illnesses. Adding further complexity to this dynamic, Kilty argues
that, at times, institutional discourses buck gender stereotypes in order to

justify violent reactions toward women prisoner’s efforts at resistance,
portraying them as emotional and ‘unhinged’ but also as manipulative and
dangerous—behavioural and personality characteristics that are typically
ascribed to men.
In contrast to perceptions of women’s over-emotionality, psy-discourses
typically describe men as cold, unresponsive, and dangerous. Joseph’s his-
torical exposition of immigration detention reveals how men of colour
were historically and continue to be characterized as threats to the safety
of the largely white Canadian public, and perhaps more importantly, to
the health and vitality of the (white) nation-state. The ideological legacy
underpinning the development of immigration detention centres is
uncomfortably relevant today, where neo-Nazi, anti-immigration, and so-
called alt-right white supremacy groups have become emboldened by
political events such as Brexit and Donald Trump’s presidency in the
United States. Contemporary immigration detention efforts see men of
colour labelled terrorists that require pre-emptive containment with little
or no verifiable evidence (see Joseph, this volume) despite domestic and
international human rights laws that prohibit these actions.
Similarly, albeit in a different context, Van Veen et al.’s work with
homeless and marginalized people reveals that the men who are managed
by ACT teams are identified as inherently violent, which is then used to
justify police presence and coercive practices, including involuntary insti-
tutionalization. The authors argue that because violence is constructed as
central to men’s mental illness, men often find themselves subject to both
the psychiatric and criminal justice systems. Of course, the privilege men
experience on account of the continual perpetuation of the patriarchy
cannot be ignored. As Dej points out in Chap. 10, the prevalence of
hegemonic masculinity discourses is so strong that even those men with
little social or financial capital (such as those experiencing homelessness)
attempt to assert their dominance by way of their masculinity. In this way,
men and women’s experiences in sites of containment are quite different.
As Rimke’s work attests, women start from a place of being ‘Othered’,
ignored, objectified, and discounted in ways that men are not, and their
experiences of constraint and containment are largely invoked to rein-
force the gendered power relations that differentially regulate women and
men and uphold patriarchal systems of domination. However, given this
collection’s emphasis on intersectional analyses, it is clear that men of
colour, immigrant men, men living in poverty or with a disability, and gay,
transgender, and other marginalized men experience containment differ-
ently and in ways that are worth probing.
Several chapters in this book challenge the traditional gender binary
and make messy our understanding of gendered experiences of contain-
ment. As revealed by Kirkup in Chap. 7, transgender women are subject
to discriminatory and harmful biomedical discourses in the carceral con-
text that deny self-expression, pathologize gender identity, and fail to pro-
vide necessary medical care. Until recently, these abuses had not been
subject to institutional scrutiny because the gender binary was thought to
be an impenetrable norm. As sexual difference has become the ‘question
of modernity’ (Butler 2004, 178) we now have the language and tools to
deconstruct the gender binary, along with other oppressive binaries, such
as sane/insane, normal/abnormal, and free/contained. Daley and Ross
engage in this kind of deconstructionist analysis by pointing out the ways
that intimate partner violence is disregarded in the case of same-sex cou-
ples and that the victim’s reaction to violence is unaccounted for in psychi-
atric assessments. This collection acts as a call for future scholarship to take
up an intersectional lens that considers how gender, race, ethnicity, class,
age, ableism, and sexuality coalesce and to do so with an eye for disman-
tling binaries that limit our ways of knowing and appreciating the diversity
of the human condition.
Future Directions
Our goal in editing Containing Madness was to bring together scholarship
that critically explores discourses and practices of containment, mental
health, and gender. As we come to understand more about how structural
disadvantage, systematic racism, misogyny, and other forms of oppression
are individualized and pathologized, it is imperative that we, as a commu-
nity of academics, service providers, activists, social justice advocates, pol-
icy makers, and students, render visible the inequality, abuses, and in some
cases deaths, that people experience through different forms and sites of
containment.
Taken together, the chapters in this edited volume work to broaden the
scope of what we typically consider as constituting containment. Following
Foucault’s (1979) conceptualization of the ‘carceral archipelago’, Cohen’s
(1979) ‘punitive city’, and Beckett and Murakawa’s (2012) ‘shadow car-
ceral state’, our understanding of containment does not rest solely on
brick-and-mortar buildings. Instead, we seek to re-write the definition of

containment to include discourses, technologies, techniques, and systems
of social control that contain people in ways that are not dissimilar to the
effects of being confined in a more traditional total institution, such as the
prison or the asylum. Containment entails a loss of freedom, whether it be
through some form of institutional detention (see, Kilty, Kirkup, Joseph,
Pilling et al., and Daly and Ross—this volume), mechanical constraints
that physically limit movement (see Jacob et al. this volume), or social
marginalization that compels vulnerable individuals to submit to coercive
psy-interventions in the community (see Van Veen et al. this volume). The
dispersion of the carceral net through new systems and institutions of sur-
veillance and management requires that we re-conceptualize containment
to include the various array of actors and social control agents, discourses,
policies, and techniques that are invoked to contain bodies, minds, and
behaviours rather than limiting ourselves to the consideration of specific
archetypal sites or physical spaces of containment. In this way, we are
keeping true to Lowman et al.’s (1987, 9) transcarceral model where
‘control comprises and infiltrates many levels of discourse, and many are-
nas of action’. We encourage scholars to adopt our modified and expanded
conceptualization of containment as a pathway toward critically studying
gender and experiences of psy intervention. On this point, we are pleased
that De Giorgi and Fleury-Steiner edited a special issue of Social Justice
(2017) that examines different forms of neoliberal confinement, which
they conceptualize as a range of spaces and capitalist practices that are
invoked to contain racialized and marginalized social groups.
Similarly, we need to be vigilant in our examination of the expansion of
the psy-medical gaze beyond psychiatric institutions. The fact that the
‘grammar of psy’ has creeped into common parlance beyond hospital walls
is alarming, especially when we see how mental health discourses and prac-
tices are gendered, racialized, classed, and heteronormative. We are right to
be concerned when a discipline with a long history of individualizing and
pathologizing particular groups of people gains prominence throughout
the social sphere (Rimke this volume). For example, prisons use adminis-
trative segregation as a primary tool for managing prisoners in emotional
distress, despite the recognition that solitary confinement itself is psycho-
logically traumatizing and can amount to torture (Guenther 2013).
Moreover, in some cases correctional officers are tasked with providing
group therapy programs. Not only are correctional officers not trained as
psy-professionals, but given that their primary function is to maintain the
order and security of the institution it is inappropriate and in many cases
harmful that they be involved in therapeutic intervention efforts.
The proliferation of psy language, practices, and treatments through-

out the social body has the effect of diffusing notions of trauma and dis-
tress and making the normal appear abnormal. General practitioners
(family physicians), social workers, and front-line staff in a host of different
community social assistance agencies have become accustomed to using
psy-discourses to explain behaviour. This has the effect of limiting assess-
ments of how structural factors impact people’s lives, choices, and actions.
Racism, poverty, sexism, and institutional discrimination affect access to
employment, housing, health care, the development and maintenance of
connections with kin, and the process of building social capital. Suggesting
that individual factors alone are the cause of distress and trauma, irrespec-
tive of the social context, renders silent the systematic failures that cause
the ongoing marginalization of particular individuals and groups.
Moreover, medicalizing feelings of distress, identities, ways of being, and
emotional reactions, disrupts normal affective responses to negative situa-
tions and circumstances. For example, that people confined in prison resist
authoritative control or experience feelings of isolation, loneliness, fear,
depression, or sadness is arguably a normal reaction to the exceptional
experience of imprisonment. Instead, many prisoners are pathologized
and deemed mentally ill and disruptive for displaying their emotional
response. This is not to minimize the distress that many people facing
adversity experience; rather, it is an acknowledgement that these feelings
are in part created by the very conditions (of physical confinement as well
as other institutional arrangements) that are meant to contain them.
Critical research on the socio-structural factors that repress and restrain
marginalized groups is vital as we move our thinking forward.
Not only do we need critical theory to help us make sense of how inter-
sectional oppressions shape discursive power-relations (in this case, those
that maintain psy-hegemony), but we also need sound policy reforms that
facilitate a movement away from containment strategies and towards
greater social inclusion. Some of the chapters in this edited collection
clearly align with this call for system changes. For example, while Kirkup
identifies the importance of self-determination in gender placement in car-
ceral settings, he also suggests the imperative of a broadly conceived dec-
arceration movement. Similarly, Van Veen et al. problematize how ACT
teams have taken shape to include police and the coercive nature of the BC
Mental Health Act. Finally, Jacob et al.’s analysis of mechanical restraint
use in acute psychiatric settings reveals how institutional policy would be
improved if it were to be informed by and reflect the lived experience of

those who are subject to that form of containment.
Above all, our intention with this book was to make strides in intersec-
tional thinking about gender, psy, and containment, with special attention
paid to the ways that racialized, classed, and heteronormative factors influ-
ence and shape discourses, technologies, and experiences of confinement.
For, as Emma Lazarus so eloquently stated, ‘Until we are all free, we are
none of us free’.
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Index1
A C
Aboriginal, see Indigenous Canada, 5, 41–61, 79, 80, 93,
Abuse of power, 7, 272 121–123, 132, 135, 136, 139,
Activism, 81, 257 141, 142n2, 149, 160, 193, 216,
academic activism, 81 219, 225, 226, 243, 246, 248,
Agency, 6, 18, 24, 33, 41, 49, 96, 251, 252, 256, 257
141, 191–208 Care, 2, 5, 6, 9, 10, 16, 41, 53, 57,
Anger, 30–32, 108, 120, 135, 170, 68, 95, 97, 98, 100, 102–104,
226, 232 107, 110–114, 134, 175, 176,
Assertive Community Treatment 187n5, 206, 209n7, 224, 242,
(ACT) Teams, 10, 242, 251, 273 248, 251, 254, 256, 257,
Asylum, vii, 3, 4, 55, 60, 277 259n2, 273
Autonomy, 9, 24, 35, 95, 107, 109, Chart documentation, 169–186,
191–208, 220, 229, 234, 249, 187n2, 191, 194, 197
253, 270, 274 Christianism, 26, 27
Class, vi, 2, 4, 10, 16, 20, 27, 28, 32,
35, 46, 50, 68, 79, 80, 83, 96,
B 174, 187n2, 192–194, 203–205,
Biopsychiatry, 8, 17, 18, 196, 197, 207, 208, 208n1, 210n10,
201, 202, 205–208, 274 217–219, 243, 244, 268, 270,
Borderline personality disorder (BPD), 271, 276
22, 170, 271, 274 Coercion, vii, 10, 113, 229, 241–258
Note: Page numbers followed by ‘n’ refer to notes.

1

https://doi.org/10.1007/978-3-319-89749-3
282 INDEX
Colonialism, vi, 10, 43, 60, 61, Ethnocentrism, 18, 19, 170, 171, 175,
243–247, 254, 269 182–185, 186n1
Colonization, 42–47, 50, 225, 236, Eugenics, 5, 26, 41–44, 48, 49, 60, 245
245, 246, 253
Containment, v, vi, 1–10, 72, 80, 249,
267–279 F
Correctional Service of Canada (CSC), Femininity, 3, 20, 170, 180, 223, 225,
122, 145, 149, 153, 159, 160 229–232, 235, 247
Criminalization, 55, 228, 233, 244, hegemonic femininity, 21, 23
253, 255 Feminism/t, v, vii, viii, 2, 3, 5, 6,
15–35, 49, 68, 70, 76, 79–83,
85, 96, 97, 184, 194, 200, 215,
D 218, 220, 271, 272
Dangerous/ness, vi, 7, 10, 42, 44, 49, Foucault, Michel, v, 3, 5, 6, 67–77,
50, 53, 54, 57, 58, 61, 97, 170, 82, 84, 85, 85n1–3, 97, 146,
197–199, 241–258, 268, 275 147, 153, 243, 268, 270,
Dependent personality disorder 271, 276
(DPD), 22, 170
Depression, 31, 32, 148, 171,
174–177, 187n5, 193, 203, G
222–224, 230, 233, 278 Gender, 1–10, 16, 60, 67–85, 95,
Detention, 1, 2, 5, 9, 41–62, 145, 145–162, 170, 192, 215, |
192, 195, 207, 249, 250, 252, 244, 267
270, 273, 275, 277 gender binary, 3, 19, 21, 61, 276
Determinism, 18, 24, 27, 186n1 Gender dysphoria, 8, 145–162
Diagnosis, 2, 3, 10, 22, 23, 31, 196, Gender surgery, 150–152, 154–159
197, 199, 202, 209n8, 228, 243, Goffman, Erving, vii, 3, 97, 269
244, 270, 274 Grand Valley Institution for Women,
Disability, 4, 60, 68, 70, 76, 77, 79, 7, 125
82–85, 86n7, 149, 155–157, Groupe d’Information sur les Prisons
161, 268, 276 (GIP), 5, 67, 70, 271
critical disability studies, 3, 271, 272 Guenther, Lisa, 125, 126, 129, 130,
Double-binds, 18, 19, 22, 23, 25 132, 136, 138, 140, 141,
274, 277
E
Electroconvulsive therapy (ECT), H
29–31, 204, 209n9, 246, 249 Haptic spectator, 121, 122, 128, 132,
Emotion 134, 135, 141
emotion work, 9, 232, 233, 235 haptic spectatorship, 120, 121, 134
Essentialism, 8, 18, 24, 26, 146, 160, Haunting, 7, 123, 133–142,
162n1, 173, 186n1 142n6, 272
INDEX
283
Hauntology J
critical hauntology, 7 Johnson, Katherine, 8, 97, 145, 146,
Hegemony, vi, 5, 16, 17, 19, 34, 61, 149–151, 154, 155, 161, 247,
77, 80, 217–219, 244 258n1
Heteronormativity, 3, 8, 83, 179, 185, Judgement, 9, 121, 203, 209n4
192, 204, 268, 271
heteronormative, 3, 4, 8, 29,
169–186, 203, 205, K
277, 279 Kavanagh, Synthia, 8, 145, 146,
Histrionic personality disorder 151–161, 162n5
(HPD), 22 Kingston Prison for Women (P4W), 7,
Homelessness, vi, viii, 9, 10, 215–236, 122, 124, 127, 273
247, 252–254, 268, 269, 275
Hysteria, 21, 24, 31, 271, 274
M
Madness, v–viii, 3, 4, 16, 20, 27–29,
I 35, 48, 67–85, 123–125, 133,
Immigration, 5, 41–61, 169, 170, 172, 173, 179, 185,
62n7, 273 186, 200, 242, 245, 271
immigration detention, vi, 5, 41–61, Mad subjectivities, 27
270, 273, 275 Marginalization, 18, 170, 182, 184,
Incarceration, v, 1–4, 6, 10, 26, 67, 185, 219, 221, 224, 226,
69, 73, 78–80, 82, 152, 153, 277, 278
227, 254 marginalized, 4, 10, 16, 21, 28, 29,
Indigenous, vi, 26, 27, 32, 43, 54, 32, 34, 35, 69, 72, 79, 80, 84,
62n6, 80, 123, 140, 216, 219, 149, 161, 173, 180, 192,
225, 226, 231, 236, 197–202, 204, 206–208, 216,
244–247, 254 228, 234, 236, 242, 250, 254,
Individualism, 5, 15–19, 170, 171, 256, 269, 270, 275, 276, 278
175–179, 184, 186n1 Masculinity
In-patient care, 9 hegemonic masculinity, 23, 29, 203,
Insight, 3, 8, 9, 46, 68, 76, 95, 215–236, 244, 247, 270, 275
191–210, 231, 270 hypermasculinity, 9, 217, 225, 235
Institutional practice(s), vi, 7, Mechanical restraints, 6, 7, 10,
112, 274 93–114, 270
gendered institutional practice(s), Medical gaze, v, vii, 2, 7, 145–162
112, 113 Medicalization, 17, 246
Interpretive Phenomenological Medical model, 2, 9, 79, 192, 194,
Analysis (IPA), 94, 99, 102 198, 199, 208, 236n2
Investigation, the, 6, 55, 67 Medication, 1, 10, 17, 33, 57, 80,
Isolation, vii, 70, 125, 126, 106, 111, 125, 130, 175, 197,
130, 134, 139, 140, 150, 199, 201–206, 217, 249, 250,
257, 273, 278 253, 255, 257, 270, 273
284 INDEX
Men, vi, 3, 19, 41, 71, 94, 123, 148, Poverty, 10, 31, 32, 48, 60, 149, 161,
170, 197, 215–236, 242, 269 204, 205, 207, 228, 234, 242,
Mental illness/disorder, vi, viii, 2, 3, 245, 247, 253, 254, 268,
8–10, 23–25, 29, 31, 32, 42, 48, 276, 278
51, 55, 60, 79, 106, 172, 191, poor, 48
192, 194, 195, 200, 207, 208, Power
215–236, 242–244, 247, 249, power-relations, 126, 267, 269,
251, 257, 258, 258n1, 267, 271, 270, 275, 278
274, 275 Prescription medication, 1, 17, 57
Murphy, Emily, 43 Presentism, 18, 19, 186n1
Prison, vii, 2–8, 45, 53, 54, 56, 57, 67,
69–76, 78, 80, 82, 83, 85n2,
N 86n6, 86n8, 87n9, 121, 123, 124,
Narcissistic personality disorder 130, 133–135, 139, 141, 142n2,
(NPD), 22 146, 149–161, 162n5, 225, 231,
Naturalism, 18, 19, 27, 186n1 269, 272, 273, 277, 278
Neoliberal(ism), 5, 16–18, 28, 30, 33, French prison, 5, 6, 67, 69–71, 73,
34, 35n3, 54, 84, 171 74, 77, 79, 86n6, 271
Prison segregation, 7
Psychiatric care, 98, 113, 114, 187n5
P Psychiatric violence, 10, 243
Pathology Psychiatry, viii, 2, 15–35, 44, 57, 68,
pathologization, 5, 16, 21, 22, 24, 94, 95, 97–99, 110–112, 173,
25, 29, 30, 170, 271, 273 184, 192, 194–196, 199, 200,
psychopathology, 25 236n3, 241–258
Patriarchy/patriarchal, 5, 15, 16, Psychocentrism
21–27, 29–35, 50, 58, 194, 215, psychocentric heteronormativity,
217, 218, 220, 224, 228, 229, 8, 185
234, 235, 269, 271, 274, 275 psychocentricity, 16, 25, 32, 172
Performance/performative, vi, 4, 9, Psychology, 2, 99, 236n3
161, 218, 219, 221, 236 Psychopharmaceutical(s), 26, 32, 34,
Personality 148, 259n2
borderline personality disorder, 22, Psychotherapy, 203
170, 271, 274 Psychotropic medications, 1, 10, 33,
personality disorder, 21–23, 28, 57, 125, 130, 217
30, 223 Psy-hegemony, 15, 278
Police, 10, 51, 55, 56, 197, 215, 225,
241–243, 248, 250–255, 257,
258, 259n2, 273, 275, 278 Q
Political prisoners, 6, 67, 76–78 Queer linguistics, 8, 169,
Positivism, 18, 20, 27, 186n1 171–173, 186
Poststructural feminism, 93–114 Queer sexualities, vi, 8, 170, 185
INDEX
285
R Transgender
Race transgender patient, 147
racialization, 18, 20, 24, 32, 194 transgender prisoner, 151, 152,
racism, 18, 26–29, 54, 172, 208, 155, 157, 159, 162n2
244, 245, 254, 276, 278 Treatment, vi–viii, 1, 2, 4, 9, 17, 21,
Reductionism, 18, 186n1 24, 29, 31, 33, 56, 57, 71, 80,
Restraint(s), vii, 1, 6, 7, 10, 11n1, 70, 106, 113, 125, 137, 139, 142n2,
93–114, 124, 130–134, 142n3, 147–149, 151–153, 156–158,
142n4, 198, 199, 270, 272, 278 162–163n5, 171, 176, 177, 181,
186n2, 191–193, 195–197,
199–208, 209n7, 209n8,
S 210n10, 221, 223, 224,
Sanism, 18, 30, 54, 259n3 230–232, 234, 235, 242, 243,
Segregation, vii, 1, 7, 10, 48, 49, 246, 247, 250–252, 254–256,
119–142, 148, 150, 159, 245, 258, 259n2, 267, 270, 274, 278
270, 273, 277
Smith, Ashley, 7, 122, 125, 127–131,
134, 135, 137–141, 142n5, 273 U
Social identity, vii, 172, 191–208 Ussher, Jane, 2, 20, 22, 25, 26, 30,
Social location, 68, 74, 84, 85, 192, 180, 193, 194, 200, 236n2, 247
194, 200, 207, 208
Solitary confinement, 1, 57, 125, 126,
129, 132, 133, 135, 136, 139, V
141, 142, 150, 273, 277 Victim, 31, 33, 128, 132, 133, 183,
Spivak, Gayatri Chakravorty, 6, 67, 68, 184, 228, 258n1, 276
72, 271 Victim-blaming, 18, 19, 170, 171,
State use of violence, 121, 122, 175, 179–180, 184, 186n1
130, 133 Violence/t, vi–viii, 7, 8, 10, 19, 20,
Stereotype, 21, 22, 34, 49, 182, 198, 26, 29–33, 41–61, 71, 97–99,
199, 222, 226, 249, 275 113, 119–142, 150–152, 154,
Stigma, 5, 16, 18, 22–24, 29, 30, 180 159, 161, 170, 171, 174,
Structural oppression, 2, 32, 174, 192, 176–184, 186n2, 187n5, 198,
207, 208, 274 202, 220, 222, 225, 242–244,
Subjectivity, v, 84, 96, 126, 128, 215, 247, 251, 258n1, 271–273,
223, 224, 227, 228, 271, 272 275, 276
Visual criminology, 7, 119
Voice, 6, 70, 71, 78, 80, 82–84, 94,
T 109, 112, 132, 269–271
Terror/ism, vii, 21, 247, 275 Vulnerable/vulnerability, vi, vii, 9, 98,
Therapy, 5, 16, 32, 34, 97, 113, 148, 103, 113, 114, 140, 154, 157,
151–155, 178, 179, 181, 203, 159, 180, 197, 204, 223, 227,
204, 229, 230, 232, 246, 249, 277 230, 232, 233, 253, 269, 277
286 INDEX
W X
Witch, 20–26, Xenophobia, 59
227, 271
Women, vi, 3, 15, 43, 48–50,
77, 80, 94, 119–142, 145, Y
170, 193, 215, 224–232, Young, Alison, 7, 119–122, 128,
242, 243, 270 132–135, 137, 141, 221

Containing Madness

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Containing Madness

Gender and ‘Psy’ in

Edited by Jennifer M. Kilty and Erin Dej

ISBN 978-3-319-89748-6 ISBN 978-3-319-89749-3 (eBook)

Library of Congress Control Number: 2018944585

© The Editor(s) (if applicable) and The Author(s) 2018

Cover credit © yngsa / GettyImages

Printed on acid-free paper

Containing Madness is a collection about the power of various types of

­ risons and nineteenth-century asylums, as evidenced by both physical

gender and sexuality, feminist genealogical approaches, queer linguistic

University of Newcastle Catharine Coleborne

1 Introduction: Psy, Gender, and Containment 1

Part I Historical ‘Psy’ Discourses Revisited 13

2 Sickening Institutions: A Feminist Sociological Analysis

3 Traditions of Colonial and Eugenic Violence:

4 Gender, Madness, and the Legacies of the Prisons

Part II Containing Bodies 91

5 Patients’ Perspective on Mechanical Restraints in Acute

6 Carceral Optics and the Crucible of Segregation:

7 Gender Dysphoria and the Medical Gaze in Anglo-­

Part III The Asylum and Beyond 167

8 Uncovering the Heteronormative Order of the Psychiatric

9 Assessing ‘Insight’, Determining Agency and Autonomy:

10 When a Man’s Home Isn’t a Castle: Hegemonic

11 Dangerous Discourses: Masculinity, Coercion,

12 Conclusion: Expanding the Concept of ‘Containment’ 267

Catharine Coleborne is Professor and Head of School of Humanities and

fellow with the Canadian Observatory on Homelessness. She is currently

Heidi Rimke is Associate Professor in the Department of Sociology at

Introduction: Psy, Gender, and Containment

It is now well documented that mass incarceration has resulted in increas-

© The Author(s) 2018 1

provide more mental health support in the community rather than in

critical disability studies, critical race studies, critical nursing studies,

Heidi Rimke’s feminist genealogy of psy hegemony in Chap. 2 ana-

methodological approach of ‘the investigation’ as a means of document-

mechanical restraints embody the authoritative (masculine) psychiatric cul-

judgment. Drawing on data from 120 inpatient charts from a psychiatric

Historical ‘Psy’ Discourses Revisited

Sickening Institutions: A Feminist

© The Author(s) 2018 15

of therapy in contemporary neoliberalism as a ‘sickening society’ invested

Psychocentrism: Theoretical Overview

result of impaired cognition, neurochemical failures, mutant genes, or

Presentism (The Problem of Ahistoricism or Historical Amnesia): Typical

Positivism (The Social Prestige of Science in Medicine): Psychocentrism

Witches, Hysterics, and Disordered Personalities:

Christianist1 Church along with local governments instigated a reign of

(DPD) falls, is referred to as ‘anxious or fearful behaviour’ (APA 2013).

Scientific Hetero/Sexism, Racism, and Classism

determinism, naturalism, and positivism to psychiatrize a slave’s patholo-

ahistorical—determinations rather than the organization of social rela-

Pathologizing Resistance to Patriarchy

Burstow shows how the interrelationship between ageism, sanism, and

which women have been regulated and mistreated throughout patriarchal

Depression, anxiety, psychological distress, sexual violence, domestic vio-

The cumulative degradation and inferiorization rituals endemic to life and

2013; Moncrieff et al. 2013). Even general practitioners of medicine—the

of patriarchy that historically targets and then blames the marginalized

Didi-Huberman, G. 2004. Invention of Hysteria: Charcot and the Photographic

———. 2003. Constituting Transgressive Interiorities: C19th Psychiatric Readings

Viruell-Fuentes, E.A., P.Y. Miranda, and S. Abdulrahim. 2012. More than Culture:

risons and nineteenth-century asylums, as evidenced by both physical

University of Newcastle Catharine Coleborne

1 Introduction: Psy, Gender, and Containment 1

Part I Historical ‘Psy’ Discourses Revisited 13

2 Sickening Institutions: A Feminist Sociological Analysis

3 Traditions of Colonial and Eugenic Violence:

4 Gender, Madness, and the Legacies of the Prisons

Part II Containing Bodies 91

5 Patients’ Perspective on Mechanical Restraints in Acute

6 Carceral Optics and the Crucible of Segregation:

7 Gender Dysphoria and the Medical Gaze in Anglo-

Part III The Asylum and Beyond 167

8 Uncovering the Heteronormative Order of the Psychiatric

9 Assessing ‘Insight’, Determining Agency and Autonomy:

10 When a Man’s Home Isn’t a Castle: Hegemonic

11 Dangerous Discourses: Masculinity, Coercion,

12 Conclusion: Expanding the Concept of ‘Containment’ 267

c ommunists. She is represented within moral and gendered discourses that

The document outlines, in section 3.2: Regulatory Factors and Condi

identified and managed without recognition of the social, historical, and