The Functions of the Mental Health System Under Capitalism

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In this blog I look at the functions of the mental health system as they relate to the economic and social structure of society using Marx’s economic framework. I conclude that the mental health system is essentially a system of care and control, that is legitimated by the concept of mental illness and that plays a particularly important role in capitalist and Neoliberal societies.

This blog summarises a paper I recently wrote called the Political Economy of the Mental Health System: a Marxist analysis.1 I wanted to work out what Marx’s economic analysis means for the role of the mental health system and also to consider the relevance of some other key Marxist ideas and some of the vast amount of Marxist literature on social institutions in general, and mental health in particular.

Why Marx? Because Marx looks through the surface to the deeper economic structure of modern capitalism and thereby brings to light the roles and functions of institutions and activities as they relate to the processes of production and exchange that form the essential basis of social life.

Most importantly, Marx describes what is distinctive about the capitalist method of production and how it differs from previous forms of production. Capitalist production involves the extraction of surplus value from wage labourers, meaning that labourers have to produce the value of their wages plus a bit more—and the bit more is the surplus value that forms the profit of the capitalists. This is the technical meaning of the term ‘exploitation’ in Marx. It is why capitalist industry gravitates to places where wages can be kept low, so that surplus value can be maximised, while keeping goods cheap to maintain market share.

Marx also reveals how social institutions evolve to support the prevailing economic system. As far as the mental health system is concerned, some of its functions are apparent in most social groups or societies and transcend particular economic arrangements, but some are more specific to capitalism. The modern mental health system (or much of it) can be understood as part of the Welfare State that started to develop in the early 20th century to ameliorate the worst ravages of capitalism in the face of potentially revolutionary insurrection by the working class.

Several influential previous works have drawn on Marxist ideas and principles, particularly the work of Michel Foucault and Andrew Scull, and I am indebted to these, while also embracing work on more recent trends in politics, economics and mental health services.

Mental disorder as a social problem

First I consider briefly what we mean when we speak of mental illness or mental disorder. I suggest that instead of equating mental health problems with medical conditions, we should think of them as problems of communities or societies. I acknowledge that bona fide brain diseases can sometimes cause challenging or problematic behaviour, but as most readers of this blog will be aware, there is no convincing evidence that any mental disorder barring those classified as ‘neuropsychiatric conditions’ or dementia result from specific, identifiable abnormalities of brain activity. I conclude that what we refer to as ‘“mental illness” is simply a collection of challenging situations that remain when those that are amenable to the criminal justice system and those that are caused by a specific, medical condition are taken out of the picture.’1

The process of uncovering the social functions of the mental health system helps to clarify what these situations consist of and what makes them problematic.

The origins and functions of the mental health system

Consistent with Marx, the modern mental health system evolved alongside capitalism as it emerged in Europe and the United States, and it is useful to consider how it arose, and also what predated it.

In England from the 16th century, a series of laws called the Poor Laws enabled local officials to manage various social problems linked to poverty, including the problems posed by people who would nowadays be labelled as having a mental disorder. Looking at material from the Poor Law records suggests the Poor Law fulfilled two main functions in this respect: it enabled the provision of care for those people who could not look after themselves (and for their families if it was the bread winner who was incapacitated) and it allowed for the control of behaviour that put the peace, harmony and safety of the community at risk, but was not amenable to the usual forms of community punishment or formal legal sanctions. The Poor Laws catered only for families who were not wealthy enough to make their own arrangements and they took over some of the functions of the monasteries that were destroyed under Henry VIII, particularly provision of care for the sick and disabled. They also formalised pre-existing local, informal arrangements of social control.

The rise of capitalism and industrialisation in England in the 18th and 19th centuries threw more and more people into poverty, and these local arrangements started to become increasingly burdensome, bringing the idea of institutional solutions into vogue. Following the Poor Law Amendment Act of 1834, those who were unable to provide for themselves were forced to enter the forbidding Victorian Workhouse to obtain public assistance. The regime in these institutions was deliberately designed to be harsh and punitive so that people would endure low paid work in terrible conditions to avoid having to resort to them. When people did turn to the Workhouse, in desperation, they would be motivated to leave as soon as possible.

The public mental asylums arose in this context and were designed to provide a pleasanter, more therapeutic space for those residents or potential residents of the Workhouse who were mentally disturbed. Right back in the Elizabethan Poor Law a distinction was made between the deserving and undeserving poor, with the idea that the undeserving poor were the lazy and unmotivated who could be forced back to work, while the deserving poor were the sick and incapable who could not. The asylum arose to cater for a section of the deserving poor and it was believed that the gentle, but structured regime (as it was intended) would help restore the mad to sanity and thereby render them fit to work.

In other words, the capitalist system made it necessary to separate the deserving and undeserving poor, so as not to undermine efforts to make the majority fit for exploitation in the exacting environment of early capitalism. Asylums provided a place for the care of the unproductive and for the containment of disruptive behaviour that might threaten social harmony and make other people less willing or able to be exploited.

In recent decades, the functions of the public asylum have been privatised and re-distributed among a network of private providers of secure facilities, residential homes, home care teams and, of course, families. This was designed to reduce costs to the public sector through the provision of less intensive care by a lower paid, less skilled workforce, and to increase opportunities for the generation of profit.

Welfare

Alongside institutions and associated health and care services, state provision for people with mental health problems includes welfare benefits. Like the early Poor Laws, welfare benefits provide assistance to people who are unable to support themselves, including those suffering from forms of mental distress. Marxist disability literature has made the point that capitalism creates dependency by requiring that people are productive enough to produce surplus value in order to be employable. Whereas in pre-capitalist societies most people could do some useful work in the community, in the capitalist system labour only has economic value if it attains levels of productivity sufficient to generate profit for the capitalist. Therefore, ‘one of the major roles of the welfare state is to provide financial or material support for those who cannot work intensively enough to generate surplus value.’1

In recent decades the number and proportion of people who receive benefits for mental health problems has increased dramatically in association with the rise of Neoliberalism. In the mid 20th century, as a response to agitation by workers and the 2nd World War, wages and working conditions improved. Since the 1980s those gains have been eroded and work has become highly competitive and insecure, driving many people out of the workforce and onto benefits. People become demoralised and marginalised and are diagnosed as being mentally unwell. As a consequence, mental health problems are now the most common reason for receiving sickness and disability benefits, which, like the asylums, help to keep ‘the non-working population quiet and secluded so the rest can be effectively exploited.’1

Hegemony

Another Marxist concept that is useful in understanding the mental health system is ‘hegemony’—that is, influencing people’s behaviour through persuasion and consent rather than force. The previous functions of the mental health system—both institutional psychiatry and welfare—are dependent, at least for now, on the idea that mental disorders are medical conditions that, like other medical conditions, arise from the body and are therefore independent of the individual’s agency. This means the individual’s wishes can be conveniently over-ridden when their behaviour is causing a nuisance or a danger. By placing people in the sick role, the notion of mental illness also justifies the payment of sickness and disability benefits.

The ‘psychiatric re-shaping of personhood,’5 as Nikolas Rose called it, has been gaining momentum in recent years thanks to the efforts of the Pharmaceutical Industry, and the majority of the population in many countries have now absorbed the widely marketed narrative of the chemical imbalance. The misery and worry that is the natural response to poverty, discrimination and insecurity are transformed into individual medical problems. In this way, the idea that mental health problems are diseases or illnesses can be thought of as an ‘ideology,’ to use another Marxist term, which refers to a false set of beliefs that obscure the reality of life under capitalism.

Conclusion

Although it is presented as a medical system, aiming to treat medical disorders, I suggest that the functions of the psychiatric system really consist of providing care and facilitating control. These functions have endured across the centuries, but have expanded with the evolution of capitalism that demands that workers not only work to provide for or contribute to their own upkeep, but produce surplus value. Regardless of the evidence or lack of it, it is necessary to regard the recipients of the mental health system as being medically sick in a way that can be aligned with physical illness or disease in order to legitimate current arrangements. The concept of mental illness justifies the use of force against people in situations where the criminal justice system cannot be applied, and authorises the provision of financial support and care for people who cannot work or look after themselves in other ways.

The organisation of production under capitalism generates many of the problems we call mental disorders. An economic system that distributed resources more equitably, that provided security of income, housing, education and healthcare and enabled more people to participate meaningfully in economic and social life would wipe away much of the current mental health epidemic that is so closely linked to financial insecurity, debt, lack of housing, loneliness, fear or feelings of failure and lack of purpose.

However, unlike some other critics of psychiatry, I believe some of the functions of the mental health system remain necessary in any society, though this does not mean that they need to be carried out as they are today. History suggests there will always be people who become disturbed from time to time and need care and or containment of some sort. What is important is to confront these problems honestly so we can address them in as fair and humane a way as possible.

Show 5 footnotes

  1. Moncrieff J. The Political Economy of the Mental Health System: A Marxist Analysis. Front Sociol. 2022;6:771875. https://www.ncbi.nlm.nih.gov/pubmed/35242843
  2. Moncrieff J. The Political Economy of the Mental Health System: A Marxist Analysis. Front Sociol. 2022;6:771875. https://www.ncbi.nlm.nih.gov/pubmed/35242843
  3. Moncrieff J. The Political Economy of the Mental Health System: A Marxist Analysis. Front Sociol. 2022;6:771875. https://www.ncbi.nlm.nih.gov/pubmed/35242843
  4. Moncrieff J. The Political Economy of the Mental Health System: A Marxist Analysis. Front Sociol. 2022;6:771875. https://www.ncbi.nlm.nih.gov/pubmed/35242843
  5. Rose N. Becoming neurochemical selves. In: Stehr N, editor. Biotechnology, Commerce and Civil Society. New Brunswick, New Jersey: Transaction Publishers; 2004. p. 89-128.

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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

42 COMMENTS

  1. This blog is a very good overview of the history and the role of the “mental health” system in a Neoliberal capitalist world.

    BUT it does lack the necessary urgency needed to understand and respond to the current intensity of world contradictions within these systems that is placing the planet in great peril.

    And we must emphasize that this world is based on (and cannot exist without) the fundamental underlying principle of *exploitation* that is inherent within a class based capitalist society. AND this *exploitation* leads to ALL SORTS of stressors and forms of trauma that push humanity and the human mind to very extreme forms of psychological distress.

    This psychological distress is “medicalized” (and drugged) by psychiatry and Big Pharma in order to serve the larger power structure’s need to control and contain ANY form of disruption and dissent within the larger social order.

    The proliferation of psych drugging of the broader population, and the incarceration of “malcontents” within psychiatric prisons, has now become an absolute NECESSITY within today’s capitalist societies for its future survival. AND the high profit margins and growth of Big Pharma’s psych drug industry has also become an essential feature within the stabilization and growth of today’s capitalist economy.

    In today’s world the future of psychiatry (and their entire Medical Model), and the continuation of a class based capitalist system have an inseparable destiny. They are both totally interdependent, and CANNOT exist, OR continue on the planet without the other.

    All this has VERY important implications when developing strategies for trying to end all forms of psychiatric abuse in the world.

    It is essential when analyzing all the problems within the “mental health” system to make the very DIRECT connections the Medical Model has to the very existence of capitalism and imperialism in the world.

    To NOT do this, is to promote the ILLUSION that somehow we can reform psychiatry and their Medical Model, and we can also make “adjustments” to capitalism whereby it will magically become something it can never ever be – a fair and just society. You CANNOT ask (or expect) Dracula to suck water or some other liquid besides blood; he WILL NOT, and CANNOT exist without blood.

    With bourgeois democracies in the world facing imminent threats, along with the dire existential threat of climate collapse and inter imperialist nuclear world war, it is BEYOND THE TIME, when we must reevaluate alternatives to the class based capitalist systems of social organizations that will NO LONGER work (or exist much longer) on this planet.

    The first socialist experiments on this planet, which only lasted a mere 5-6 decades at best, MUST BE *reimagined* by summing up past shortcomings and mistakes. If we we fail to make these efforts, then the entire planet is doomed to destroy itself.

    Human nature has much greater diversity and potential than “dog eat dog” and “look out for number one.” This is the human nature taught and nurtured within class based capitalist societies.

    Human beings also have the capacity for high levels of cooperation and human compassion for others. Doesn’t the Russian invasion of Ukraine reveal to us both extremes of human nature? It is imperative for us to find the type of environment (and related societal structures) that allow the very best form of human nature to flourish and thrive in the world.

    Dare to Struggle, Dare to Win! Richard

  2. This article deals with complex issues so I can only touch on a few things.

    First, employers certainly can exploit workers and often do.

    But the worker can also exploit the system ( I’ll concede to a far lesser extent than the bosses). I have no doubt many people claiming mental illness are faking it.

    But my biggest problem is the implication that poverty, discrimination and insecurity are transformed into medical problems to a greater extent than is the case with those who are more well to do. I’ve seen plenty of relatively wealthy people who suffer from depression, misery, anxiety, drug over doses, alcoholism, suicide and psychosis. What proof is there that the poor have any more mental issues than the rich?

    Life is very hard. Certainly wealthier people and people who do not experience discrimination have tremendous advantages. But is better mental health one of those advantages? I’m not so sure.

    • I have no doubt many people claiming mental illness are faking it.

      All “mental illness” is fake. Please go to szasz.com.

      Capitalism is not simply rich people exploiting the poor, it involves the nature of work and production, and the alienation of people’s personal aspirations from the wage labor they perform as a means of survival.

      • By faking it, I simply meant that lots of people claim to have disorders that will allow them to receive disability benefits.

        As for exploitation, the nature of work has often been exploitive or whatever you want to call it. The ancient Greeks and Romans, the Inca and Mayan civilizations, the ancient Egyptians all exploited the masses and slavery was common.

        Capitalism certainly has its faults, but most people, today at least, are better off under it than they would have been in, say, Ancient Greece.

          • I have no idea why you would say that life was less oppressive in Ancient Greece. Thirty percent of the citizens of Athens were slaves (there was apparently a bright spot though, flogging was illegal). Parents were allowed to abandon their babies. Others could take them in, but then the child became a slave. Historians say most people in Ancient Greece had a very low standard of living.

      • The only issue here, for me, is that if you think people are more mentally disabled today than in the past you have to have accurate statistics. If it’s easier to get disability checks more people may apply. So are people really more disabled or are the disability figures distorted. I don’t know, but if you’re claiming things are worse you should take into account what I just discussed.

    • I think this would require looking at the breadth of his work and at how it has been used. Or at least the specific ways in which his work has helped Moncrief (and others) develop their analyses.

      Or at least that’s my view of it. But I think it’s worth considering how virtually all important writers a) get some things wrong, and b) are put to bad uses by people who draw on them. So, for instance, what you say about Marx also applies to Adam Smith and Thoreau–both incredibly insightful and helpful, both wrong about some important things and both put to unfortunate and sometimes truly awful uses. Is it possible the problem does not lie with any of these (human, fallible) writers so much as in the simplistic and short-sighted ways we interpret them?

    • As the above comment demonstrates, people at MIA for the most part are not well versed in Marxism is and not particularly qualified to discuss it here. Since everyone means something different when they use the term, this should be considered a form of “advanced study”; talking about “capitalism” off the cuff can only spread confusion, and tends to divert the more specific matter at hand.

      What’s important to understand is that psychiatry will adapt to ANY oppressive governmental system if it is allowed to. Since the only existing form of government right now is capitalism I think we should focus on psychiatry, the rest is sort of redundant.

  3. Thank you for this. So important.

    Your comment about “mental illness” reflecting problems in the wider community reminds me of Lewis Mehl-Madrona, who likes to point out that in indigenous communities, if someone is going through mental distress the assumption tends to be, right out of the gate, that it is a symptom or indicator of something being wrong and needing fixing in the community. He also likes to say that psychiatry is the only profession in which the client is always wrong.

    On Marx, I keep meaning to look into something and never get around to it. It seems to me that the final contradiction or crisis of capitalism, in his terms, may be that profit increasingly depends precisely on both selling and degrading human consciousness with addictive “devices” and screens. What I can’t recall is if that would be a new contradiction or if it might be covered in the ones he wrote about. But it could be the one that finally pushes capitalist set of contradictions into a new synthesis, especially to the degree that it reinforces the old contradiction/crisis of Marx’s “ecological rift” as it now takes the form of climate change. You add those two contradictions together (or multiply them) and it could be not a utopian synthesis, as Marx hoped and worked for, but, well curtains. Which makes these sorts of new interpretations of Marx all the more helpful–than you again!

    P.S. People here might especially appreciate this interview, which speaks to Marx’s (to me) surprisingly domestic home life and his enormous affection for and devotion to–and dependence on–his wife and daughters. There’s a lot of love there. The image that came to me was of him being held and nourished there and then every day donning one of those old diving helmets and suits with the air line attached and diving deeply into the awful satanic hot swampy mucky depths of the capitalist swamp every day, but always tethered to the oxygenic warmth of his family. https://radioopensource.org/marx-at-200/

    • Despite the general inability of people at MIA (and everywhere) to intelligently discuss Marxism, you nonetheless raise some interesting thoughts, such as your speculation on Marx’s personality and home life. However in the end such considerations must always be secondary to the analysis he produced (which is why Capital is still up there close to the Bible as one of the most widely read books).

      One also must avoid mistaking revisionism for “new interpretations,” not that the latter are always revisionist. In the end the aim of Marxism as a science is not achieving “socialist” society but a classless society with no state whatsoever. So any evaluation of how it is “interpreted” should keep that in mind.

  4. It is, at present, terribly incorrect to assume America, is a “capitalist” society. It is still an aspiration no fully realized. Our economic system is a jumble of both good and bad and is sadly easily exploited. Big Pharma and Psychiatry are only one piece of a larger puzzle. To throw Marx into the mess, sounds admirable, at first, for some, whose belief systems might entertain them, but in the end it only produces another deflection and distraction from the problems that we might be facing. It will always be useless to blame any one economic system or conversely to falsely believe any one economic system is the answer to our problems. L.e. Cox has mentioned “spirit.” Until we finally accept that we are spiritual beings and our mind comes from God and that which proceeds from the Mind is our brain/body; all attempts at true success. When we do accept that truth, then and only then, will we be able to distinctly characterize any “disorders” and apply correct knowledge as to any possible “cures” or “adaptations” that might be made to the individual for a better life. Until then, it will be a struggle we really don’t need or deserve. Thank you.

  5. Sadly, so many people have lost sight of God and even Jesus Christ in the extent of things. It is God who is charge of the planet, not us mere Humans. And, in God, we will find our answers. There is absolutely no political or economic system that has the answer that even comes close to the answer found only in God. “In Him, (Christ), we live, and move, and have our being.” Perhaps, the answer to all the crises in the world, including psychiatry and big pharma, etc. is Prayer. In fact, in my humble opinion, it is the only answer. All other answers are human-oriented and are thus essentially flawed. Prayer is the only answer that leads us flawed human beings to communicate with the perfection that only belongs to God. Thank you.

  6. Hi Joanna, nice article, however your brief history doesn’t account for how come these ‘social problems’ came under the jurisdiction of welfare, and then health. Foucault provides me with a stronger clue by saying that in the early 19th century medicine put up its hand when the magistrates were asking who could predict dangerousness. It was that claim that got medicine (later operating as psychiatry) the key to the asylum. If we acknowledge that was a false claim, and no one can predict dangerousness better than anyone else; then presumably that function would fall back into the hands of the police. Currently there is a ‘movement’ to transform policing to ‘policing by consent’ – which is a move to humanise policing. If these ‘social problems’ were tackled in a solution-focused manner, (which ultimately stems from Wittgenstein), then police could be educated in a SF philosophy, and people wouldn’t get bogged down in endless analysis of the problem(s). This newly emerging shoot needs nourishment.

  7. Very Worthwhile Blog,

    With the the internet, information technology advances and media cooperation, society looks like its fallen under control.

    I don’t know if “neoliberalism” is the right way to describe the situation, but most of the wealth seems to be going in one direction, and a lot of what we’re being told is very hard to believe.

  8. During World War l the mental death profession reached such an extreme level of power that the momentum of this runaway torture steamroller has only continually increased to the point where they can torture any human being of any age from the cradle to the grave . Certainly the number of victims world wide is beyond staggering and growing exponentially .
    When growing numbers of soldiers refused to march across “no man’s land” because of what we today might call “shell shock “. The Generals in charge in the Austrian army decided that these men who had bravely fought for so long were now malingerers and made it their mission that these men would not receive a military pension , not be sent home for rest and relaxation , but that they would be returned as soon as possible to the battlefield on which they the General’s themselves never marched across. And here’s where the practionor’s of the mental death profession volunteered their services and were given “carte blanche” . They invented extreme tortures to apply to the ” malingering ” soldiers with the goal that they, the soldiers would prefer to march across “no mans land ” to almost certain death rather than to endure any further extreme torture from the psychiatrists , the certified members of what should always be called the mental death profession. They continue to torture today from the inside out , and from the outside in . Being a baby , a child, a war hero does not stop them from capturing and torturing . Their tools are a mixed bag of chemicals and biological junk akin to pesticides for humans plus electricity (high voltage applied to the brain ). GOD save us from these ignorant , sadistic pieces of shit and all the “true believers” and organizations that support , enhance, multiply , morph, and hybrid their evil enterprise .


  9. During World War l the mental death profession reached such an extreme level of power that the momentum of this runaway torture steamroller has only continually increased to the point where they can torture any human being of any age from the cradle to the grave . Certainly the number of victims world wide is beyond staggering and growing exponentially .

    YES!

    And CA Governor Gavin Newsom is targeting the homeless, trying to create Mental Health Courts in every county, and to subject the homeless to forced procedures.

    Joshua

  10. Excellent and essential reading for anyone working in the MHIC; thank you Dr. Moncrief. As usual, excellent observations and comments, too.

    One observation, not too far removed from some of the above, if not (obviously) part and parcel. Given the nature of the superstructure (SS) Dr. Moncrief has (rather accurately, IMHO) critiqued here, there’s not much of a mystery as to how we got here, in pretty much every sector of the MHIC. Until this SS is fundamentally changed, change is little more than SS accommodation and or cosmetic. I know there’s nothing remotely profound in my comment here, but just wrote it to state the obvious.

  11. Capitalists excel at finding ways to profit from disaster.
    When it comes to protecting human beings, capitalists are absolutely abysmal. Extracting capital from human labor creates massive social and environmental harm. Capitalists cannot reduce this harm without lowering their profits and becoming less competitive. Susan Rosenthal—-Rebel Minds

    • With automation and changes in work practice everybody’s job is becoming less skilled, so even normal people can be pushed under. If professionals like doctors are prepared to cover up abusive behaviour for the sake of their jobs, what’s to stop the legal system being rigged?

      Suicide Homicide and Familicide have become extremely common in Ireland in the past 20 years – but I have not heard of any Irish defense lawyer presenting ‘paradoxical drug reaction’ as a possible cause – even though this danger is warned about on ‘patient information leaflets’.

      Expressing the possibility in Ireland, that Psychiatric Drugs can cause Suicide and Homicide is completely ‘Verboden’ – even though it is Factually accepted – that they Do!

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