marxist theory health and illness

A Marxist View of Medical Care

This essay is reproduced here as it appeared in the print edition of the original Science for the People magazine. These web-formatted archives are preserved complete with typographical errors and available for reference and educational and activist use. Scanned PDFs of the back issues can be browsed by headline at the website for the 2014 SftP conference held at UMass-Amherst . For more information or to support the project, email [email protected]

by Howard Waitzkin

‘science for the people’ vol. 10, no. 6, november/december 1978, p. 31–42.

Reprinted, with modifications, from Annals of Internal Medicine, Vol. 89, No.2, Aug. 1978, with permission of the editor. 

This version has been condensed. Readers are referred to the original article for the complete text and unedited references. Reprints are available from Howard Waitzkin at La Clinica de Ia Raza, 1501 Fruitvale Avenue, Oakland, CA 94601. To cover postage and printing, $2 would be appreciated if possible. 

Howard Waitzkin is a health worker at La Clinica de Ia Raza, a community health center in Oakland, California. 

This article surveys the Marxist literature in medical care. The Marxist viewpoint questions whether major improvements in the health system can occur without fundamental changes in the broad social order. One thrust of the field—an assumption also accepted by many non-Marxists—is that the problems of the health system reflect the problems of our larger society and cannot be separated from those problems. 

Marxist analyses of health care have burgeoned in the United States during the past decade. However, it is not a new field. Its early history and the reasons for its slow growth until recently deserve attention. 

Historical Development of the Field  

The first major Marxist study of health care was Engels’ The Condition of the Working Class in England , originally published in 1845—three years before Engels co-authored with Marx The Communist Manifesto . This book described the dangerous working and housing conditions that created ill health. In particular, Engels traced such diseases as tuberculosis, typhoid, and typhus to malnutrition, inadequate housing, contaminated water supplies, and overcrowding. Engels’ analysis of health care was part of a broader study of working-class conditions under capitalist industrialization. But his treatment of health problems was to have a profound effect on the emergence of social medicine in Western Europe and, in particular, on the work of Rudolph Virchow. 

Virchow’s pioneering studies in infectious disease, epidemiology, and “social medicine” (a term Virchow popularized in Western Europe) appeared soon after the publication of Engels’ book. Virchow himself acknowledged Engels’ influence on this thought. In 1847, at the request of the Prussian government, Virchow investigated a severe typhus epidemic in a rural area of the country. Based on this study, he recommended a series of profound economic, political, and social changes that included increased employment, better wages, local autonomy in government, agricultural cooperatives, and a more progressive taxation structure. Virchow advocated no strictly medical solutions, like more clinics or hospitals. Instead, he saw the origins of ill health in societal problems. The most reasonable approach to the problem of epidemics, then, was to change the conditions that permtited them to occur.

During this period Virchow became committed to combining his medical work with political activities. In 1848 he joined the first major working-class revolt in Berlin. During the same year he strongly supported the short-lived revolutionary efforts of the Paris Commune. 1 In his scientific investigations and in his political practice, Virchow expressed two overriding themes. First, that there are many interacting causes of disease. Among the most important factors in causation are the material conditions of people’s everyday lives. Secondly, an effective health-care system cannot limit itself to treating the illnesses of individual patients. Instead, to be successful, improvements in the health-care system must coincide with fundamental economic, political, and social changes. The latter changes often impinge upon the privileges of wealth and power enjoyed by the dominant classes of society and encounter resistance. Therefore, in Virchow’s view, the responsibilities of the medical scientist frequently extend to direct political action. 

After the revolutionary struggles of the late 1840s suffered defeat, Western European governments heightened their conservative social policies. Marxist analysis of health care entered a long period of eclipse, and Virchow and his colleagues turned to relatively uncontroversial research in laboratories and to private practice. 

During the late nineteenth century, with the work of Ehrlich, Koch, Pasteur, and other prominent bacteriologists, germ theory gained ascendancy and created a profound change in medicine’s diagnostic and therapeutic assumptions. A single-factor model of disease emerged. Medical scientists searched for organisms causing infections and single lesions in non-infectious disorders. The discoveries of this period undeniably improved medical practice. Still, as numerous investigators have shown, the historical importance of these discoveries has been overrated. For example, the major declines in mortality and morbidity from most infectious diseases preceded rather than followed the isolation of specific “germs” and the use of anti-microbial therapy. In Western Europe and the United States, improved outcomes in infections occurred after the introduction of better sanitation, regular sources of nutrition, and other broad environmental changes. In most cases, improvements in disease patterns antedated the advances of modern bacteriology. 2

Why did the unifactorial perspective of germ theory achieve such prominence? And why have the investigational techniques based on this perspective retained a nearly mythic character in medical science and practice to the present day? A serious historical re-examination of early twentieth century medical science, that attempts to answer these questions, has begun only in the last few years. Some preliminary explanations have emerged; they focus on events that led to and followed publication of the Flexner Report on medical education in 1910. 3

The Flexner Report has held high esteem as the document that helped change modern medicine from quackery to responsible practice. One underlying assumption of the Report was that laboratory-based scientific medicine, oriented especially to the concepts and methods of European bacteriology, produced a higher quality and more effective medical practice. Although the comparative effectiveness of various medical traditions (including homeopathy, traditional folk healing, chiropractic, etc.) had never been subjected to systematic test, the Report argued that medical schools not oriented to scientific medicine fostered mistreatment of the public. The Report called for the closure or restructuring of schools that were not equipped to teach laboratory-based medicine. The Report’s repercussions were swift and dramatic. Scientific, laboratory-based medicine became the norm for medical education, practice, research, and analysis. 

Recent historical studies cast doubt on assumptions in the Flexner Report that have comprised the widely accepted dogma of the last century. They also document the un-critical support that the Report’s recommendations received from parts of the medical profession and the large private philanthropies. 4 At least partly because of these events, the Marxist orientation in medical care remained in eclipse. 

Although some of Virchow’s works gained recognition as classics, the multifactorial and politically oriented model that guided his efforts has remained largely buried. Without doubt, Marxist perspectives had important impacts on health care outside Western Europe and the United States. For example, Lenin applied these perspectives to the early construction of the Soviet health system. Salvador Allende’s treatise on the political economy of health care, written while Allende was working as a public health physician, exerted a major influence on health programs in Latin America. The Canadian surgeon, Norman Bethune, contributed analyses of tuberculosis and other diseases, as well as direct political involvement, that affected the course of post-revolutionary Chinese medicine. 5 Che Guevara’s analysis of the relations among politics, economics, and health care—emerging partly from his experience as a physician—helped shape the Cuban medical system. 6

Perhaps reflecting the political ferment of the late 1960s and widespread dissatisfaction with various aspects of modern health systems, serious Marxist scholarship of health care has grown rapidly. 7 The following sections of this review cover some of the current areas of research and analysis. 

Class Structure 

Marx’s definitions of social class emphasized the social relations of economic production. He noted that one group of people, the capitalist class or bourgeoisie, own and/or control the means of production—the machines, factories, land, and raw materials necessary to make products for the market. The working class or proletariat, who do not own or control the means of production, must sell their labor for a wage. But the value of the product that workers produce is always greater than their wage. Workers must give up their product to the capitalist; by losing control of their own productive process, workers become subjectively “alienated” from their labor. The need to maintain profits motivates the capitalist to keep wages low, to change the work process (by automation and new technologies, close supervision, lengthened work day or overtime, speed-ups and dangerous working conditions), and to resist workers’ organized attempts to gain higher wages or more control in the workplace. 

While acknowledging the historical changes that have occurred since Marx’s time, recent Marxist studies have reaffirmed the presence of highly stratified class structures in advanced capitalist societies and Third World nations. 8 Another topic of great interest is the persistence or reappearance of class structure, usually based on expertise and professionalism, in countries where socialist revolutions have taken place; 9 a later section of the review focuses on this problem. These theoretical and empirical analyses show that relations of economic production remain a primary basis of class structure and a reasonable focus of strategies for change. 

Control over health institutions. Navarro has documented the pervasive control that members of the corporate and upper-middle classes exert within the policymaking bodies of American health institutions. These classes predominate on the governing boards of private foundations in the health system, private and state medical teaching institutions, and local voluntary hospitals. Only on the boards of state teaching institutions and voluntary hospitals do members of the lower middle class or working class gain any appreciable representation; even there, the participation from these classes falls far below their proportion in the general population. Navarro has argued, based partly on these observations, that control over health institutions reflects the same patterns of class dominance that have arisen in other areas of American economic and political life.  

Stratification within health institutions . As members of the upper middle class, physicians occupy the highest stratum among workers in health institutions. Comprising 7 percent of the health labor force, physicians receive a median net income (approximately $53,900 in 1975) that places them in the upper 5 percent of the income distribution of the United States. Under physicians and professional administrators are members of the lower middle class: nurses, physical and occupational therapists and technicians. They make up 29 percent of the health labor force, are mostly women, and earn about $8,500. At the bottom of institutional hierarchies are clerical workers, aides, orderlies, kitchen and janitorial personnel, who are the working class of the health system. They have an income of about $5,700 per year, represent 54 percent of the health labor force, and are 84 percent female and 30 percent black. 10

Recent studies have analyzed the forces of professionalism, elitism, and specialization that divide health workers from each other and prevent them from realizing common interests. These patterns affect physicians, 11 nurses, and technical and service workers who comprise the fastest growing segment of the health labor force. 12 Bureaucratization, unionization, state intervention, and the potential “proletarianization” of professional health workers may alter future patterns of stratification. 

Occupational mobility. Class mobility into professional positions is quite limited. Investigations of physicians’ class backgrounds in both Britain and the United States have shown a consistently small representation of the lower middle and working classes among medical students and practicing doctors. 13 As Ziem has found, despite some recent improvements for blacks and women, recruitment of working-class medical students as a whole has been very limited since shortly after publication of the Flexner Report. In 1920, 12 percent of medical students came from working-class families, and this percentage has stayed almost exactly the same until the present time. 

Emergence of Monopoly Capital in the Health Sector  

During the past century, economic capital has become more concentrated in a smaller number of companies—the monopolies. Monopoly capital has become a prominent feature of most capitalist health systems and is manifest in several ways. 

Medical centers . Since about 1910, a continuing growth of medical centers has occurred, usually in affiliation with universities. Capital is highly concentrated in these medical centers, which are heavily oriented to advanced technology. Practitioners have received training where technology is available and specialization is highly valued. Partly as a result, health workers are often reluctant to practice in areas without easy access to medical centers. The nearly unrestricted growth of medical centers, coupled with their key role in medical education and the “technologic imperative” they encourage, has contributed to the maldistribution of health workers and facilities throughout the United States and within regions(12, 16). 

Finance capital . Monopoly capital also has been apparent in the position of banks, trusts, and insurance companies—the largest profit-making corporations under capitalism. For example, in 1973, the flow of health-insurance dollars through private insurance companies was $29 billion, about one-half of the total insurance sold. Among commercial insurance companies, capital is highly concentrated; about 60 percent of the health-insurance industry is controlled by the ten largest insurers. Metropolitan Life and Prudential each control over $30 billion in assets, more than General Motors, Standard Oil of New Jersey, or International Telephone and Telegraph. 14

Finance capital figures prominently in current health reform proposals. Most plans for national health insurance would permit a continuing role for the insurance industry. Moreover, corporate investment in health maintenance organizations is increasing, under the assumption that national health insurance, when enacted, will assure the profitability of these ventures. 15

The “medical-industrial complex.” The “military-industrial complex” has provided a model of industrial penetration in the health system, popularized by the term, “medical-industrial complex.” Investigations by the Health Policy Advisory Center 16 and others have emphasized that the exploitation of illness for private profit is a primary feature of the health systems in advanced capitalist societies. 17 Recent reports have criticized the pharmaceutical amd medical equipment industries for advertising and marketing practices, 18 price and patent collusion, 19 marketing of largely untested drugs in the Third World, and promotion of expensive diagnostic and therapeutic innovations without controlled trials demonstrating their effectiveness. 

In this context, “cost-effectiveness” analysis has yielded useful appraisals of several medical practices and clinical decision making, based in part on analysis of cost relative to effectiveness. 20 While recognizing its contributions, Marxist researchers have criticized the cost-effectiveness approach for asking some questions at the wrong level of analysis. This approach usually does not help clarify the over-all dynamics of the health system that encourage the adoption of costly and ineffective technologic innovations. The practices evalvated by cost-effectiveness research generally emerge with the growth of monopoly capital in the health system. Costly innovations often are linked to the expansion of medical centers, the penetration of finance capital in the health system, and the promotion of new drugs and instrumentation by medical industries. Cost-effectiveness research and clinical decision analysis remain incomplete unless they consider broader political and economic trends that propel apparent irrationalities in the health system. 21

The State and State Intervention  

Marx and Engels emphasized the state’s crucial role in protecting the capitalist economic system and the interests of the capitalist class. The state comprises the interconnected public institutions that act to preserve the capitalist economic system and the interests of the capitalist class. This definition includes the executive, legislative, and judicial branches of government, the military, and the criminal justice system, all of which hold varying degrees of coercive power. It also encompasses relatively non-coercive institutions within the educational, public welfare, and health-care systems. Through such non-coercive institutions, the state offers services or conveys ideologic messages that both stabilize and legitimate the capitalist system. Especially in periods of economic crisis, the state can use these same institutions to provide public subsidization of private enterprise. 

The private-public contradiction. Within the health system, the “public sector,” as part of the state, operates through public expenditures and employs health workers in public institutions. The “private sector” is based in private practice and in companies that manufacture medical products or control medical finance capital. Nations vary greatly in the private-public duality. In the United States, a dominant private sector coexists with an increasingly large public sector. The public sector is even larger in Great Britain and Scandinavia. In Cuba and China, the private sector has been essentially eliminated. 22

A general theme of Marxist analysis is that the private sector drains public resources and health workers’ time, in behalf of private profit and to the detriment of patients using the public sector. This framework has helped explain some of the problems that have arisen in such countries as Great Britain 23 and Chile, where private sectors persisted after the enactment of national health services. In these countries, practitioners have faced financial incentives to increase the scope of private practice, which they often have conducted within public hospitals or clinics. In the United States, the expansion of public payment programs such as Medicare and Medicaid has led to increased public subsidization of private practice and private hospitals, as well as abuses of these programs by individual practitioners. 24

Similar problems have undermined other public  health programs. These programs frequently have obtained finances through regressive taxation, placing low-income taxpayers at a relative disadvantage. Likewise, the deficiencies of the Blue Cross-Blue Shield insurance plans have derived largely from the failure of public regulatory agencies to control payments to practitioners and hospitals in the private sector. When enacted, national health insurance also would use public funds to reinforce and strengthen the private sector, by assuring payment for hospitals and individual physicians and possibly by permitting a continued role for commercial insurance companies. 25

Throughout the United States the problems of the private-public contradiction are becoming more acute. In most large cities, public hospitals are facing cutbacks, closure, or conversion to private ownership and control. This trend heightens low-income patients’ difficulties in finding adequate health care. It also reinforces private hospitals’ tendency to “dump” low-income patients to public institutions. 26

General functions of the state within the health system . The state’s functions in the health system have increased in scope and complexity. In the first place, through the health system, the state acts to legitimate the capitalist economic system based in private enterprise. 27 The history of public health and welfare programs shows that state expenditures usually increase during periods of social protest and decrease as unrest becomes less widespread. 28 Recently a Congressional committee summarized public opinion surveys that uncovered a profound level of dissatisfaction with government and particularly the role of business interests in government policies: ” … citizens who thought something was ‘deeply wrong’ with their country had become a national majority …. And, for the first time in the ten years of opinion sampling by the Harris Survey, the growing trend of public opinion toward disenchantment with government swept more than half of all Americans with it.” Under such circumstances, the state’s predictable response is to expand health and other welfare programs. These incremental reforms, at least in part, reduce the legitimacy crisis of the capitalist system by restoring confidence that the system can meet the people’s basic needs. The cycle of political attention devoted to national health insurance in the United States appear to parallel cycles of popular discontent. 29 Recent cutbacks in public health services to low-income patients follow the decline of social protest by low-income groups since the 1960s.

The second major function of the state in the health system is to protect and reinforce the private sector more directly. As previously noted, most plans for national health insurance would permit a prominent role and continued profits for the private insurance industry, particularly in the administration of payments, record keeping, and data collection. 30 Corporate participation in new health initiatives sponsored by the state—including health maintenance organizations, preventive screening programs, computerized components of professional standards review organizations, algorithm and protocol development for para-professional training, and audiovisual aids for patient education programs—is providing major sources of expanded profit. 31

A third (and subtler) function of the state is the reinforcement of dominant frameworks in scientific and clinical medicine that are consistent with the capitalist economic system, and the suppression of alternative frameworks that might threaten the system. The United States government has provided generous funding for research on the physiology and treatment of specific diseases. As critics even within government have recognized, the disease-centered approach has reduced the level of analysis to the individual organism and, often inappropriately, has stimulated the search for single rather than multiple causes. More recently, analyses emphasizing the importance of individual “life style” as a cause of disease 32 have received prominent attention by state agencies in the United States and Canada. Clearly, individual differences in personal habits do affect health in all societies. On the other hand, the lifestyle argument, perhaps even more than the earlier emphasis on specific etiology, obscures important sources of illness and disability in the capitalist work process and industrial environment; it also puts the burden of good health squarely on the individual, rather than seeking collective solutions to health problems. 33

The issues that the state has downplayed in its research and development programs are worth noting. For example, based on available data, it is estimated that in Western industrialized societies environmental factors are involved in approximately 80 percent of all cancers. In its session on “health and work in America,” the American Public Health Association in 1975 produced an exhaustive documentation of common occupational carcinogens. 34 A task force for the Department of Health, Education and Welfare on “Work in America,” published by a non-government press in 1973, reported: “In an impressive 15-year study of aging, the strongest predictor of longevity was work satisfaction. The second best predictor was overall  ‘happiness’ … Other factors are undoubtedly important—diet, exercise, medical care, and genetic inheritance. But research findings suggest that these factors may account for only about 25 percent of the risk factors in heart disease, the major cause of death … “. 35 Such findings are threatening to the current organization of capitalist production. They have received little attention or support from state agencies. A framework for clinical investigation that links disease directly to the structure of capitalism is likely to face indifference or active discouragement from the state. 

Medical Ideology  

Ideology is an interlocking set of ideas and doctrines that form the distinctive perspective of a social group. Along with other institutions like the educational system, family, mass media, and organized religion, medicine promulgates an ideology that helps maintain and reproduce class structure and patterns of domination. Medicine’s ideologic features in no way diminish the efforts of individuals who use currently accepted methods in their clinical work and research. Nevertheless, medical ideology, when analyzed as part of the broad social superstructure, has major social ramifications beyond medicine itself. Recent studies have identified several components of modern medical ideology: 

1) Disturbances of biological homeostasis are equivalent to breakdowns of machines. Modern medical science views the human organism mechanistically. The health professional’s advanced training permits the recognition of specific causes and treatments for physical disorders. The mechanistic view of the human body deflects attention from environmental causes of disease, including work processes or social stress. It also reinforces a general ideology that favors industrial technology under specialized control. 36

2) Disease is a problem of the individual human being. The unifactorial model of disease has always focused on the individual rather than the illness-generating conditions of society. More recently, attempts have been made to blame disease on an individual’s “life style” (smoking, overeating, etc.). In both cases, the responsibility for disease and cure rests at the individual rather than the collective level. In this sense medical science offers no basic critical appraisal of class structure and relations of production, even in their implications for health and illness. 37

3) Science permits the rational control of human beings. The natural sciences have led to a greater control over nature. Similarly, it is often assumed that modern medicine, by correcting defects of individuals, can enhance their controllability. The quest for a reliable work force has been one motivation for the support of modern medicine by capitalist economic interests. 38 Physicians’ certification of illness historically has expanded or contracted to meet industry’s need for labor. 39 Thus, medicine is seen as contributing to the rational governance of society, and managerial principles increasingly are applied to the organization of the health system. 40

4) Many spheres of life are appropriate for medical management . This ideologic assumption has led to an expansion of medicine’s social control function. Many behaviors that do not adhere to society’s norms have become appropriate for management by health professionals. The “medicalization of deviance” and health workers’ role as agents of social control have received critical attention. 41 The medical management of behavioral difficulties, such as hyperactivity, and aggression, often coincides with attempts to find specific biological lesions associated with these behaviors. 42 Historically, medicine’s social control function has expanded in periods of intense social protest or rapid social change. 

5) Medical science is both esoteric and excellent . According to this ideologic principle, medical science involves a body of advanced knowledge and standards of excellence in both research and practice. Because scientific knowledge is esoteric, a group of professionals tend to hold elite positions. Lacking this knowledge, ordinary people are dependent on professionals for interpretation of medical data. The health system therefore reproduces patterns of domination by “expert” decision makers in the workplace, government, and many other areas of social life. The ideology of excellence helps justify these patterns, although the quality of much medical research and practice is far from excellent; this contradiction recently has been characterized as “the excellence deception” in medicine. 43 Ironically, a similar ideology of excellence has justified the emergence of new class hierarchies based on expertise in some countries, like the Soviet Union, that have undergone socialist revolutions. Other countries, such as the People’s Republic of China, have tried to overcome these ideologic assumptions and to develop a less esoteric “people’s medicine.” 

Studies of medical ideology have focused on public statements by leaders of the profession (in professional journals or the mass media), as well as state and corporate officials whose organizations regulate or sponsor medical activities. However, health professionals also express ideologic messages in their face-to-face interaction with patients. 44 The transmission of ideologic messages within doctor-patient interaction currently is the subject of empirical research. 45

Comparative International Health Systems  

Health care and imperialism . Imperialism may be defined as capital’s expansion beyond national boundaries, as well as the social, political, and economic effects of this expansion. One basic feature of imperialism is the extraction of raw materials and human resources which move from Third World nations to economically dominant countries. Navarro has analyzed how the “underdevelopment of health” in the Third World follows inevitably from this depletion of natural and human resources. The extraction of wealth limits underdeveloped countries’ ability to construct effective health systems. Many Third World countries face a net loss of health workers who migrate to economically dominant nations after expensive training at home. 46

Through imperialism, corporations also seek a cheap labor force. Workers’ efficiency was one important goal of public health programs sponsored abroad, especially in Latin America and Asia, by philanthropies closely tied to expanding industries in the United States. 47 Moreover, population control programs initiated by the United States and other dominant countries have sought a more reliable participation by women in the labor force. 48 At the same time, workers abroad who are employed by multinational corporations also face high risks of occupational disease. 

Another thrust of imperialism is the creation of new markets for products manufactured in dominant nations and sold in the Third World. This process is nowhere clearer than in the pharmaceutical and medical equipment industries. The penetration of these multinationals, with its stultifying impact on local medical research and development, has led to the advocacy of nationalized drug and equipment formularies in several Third World countries. 

As in the United States, medical professionals in the Third World most often come from higher income families. Even when they do not, they frequently view medicine as a route of upward mobility. As a result, medical professionals tend to ally themselves with the capitalist class—the “national bourgeoisie”—of Third World countries. They also frequently support cooperative links between the local capitalist class and business interests in economically dominant countries. The class position of health professionals has led them to resist social change that would threaten current class structure, either nationally or internationally. Similar patterns have emerged in some post-revolutionary societies. In the U.S.S.R., professionals’ new class position, based on expertise, has caused them to act as a relatively conservative group in periods of social change. Elitist tendencies in the post-revolutionary Cuban profession also have received criticism from Marxist analysts. 49

Frequently imperialism has involved direct military conquest; recently health workers have assumed military or paramilitary roles in Indochina and Northern Africa. Health institutions also have taken part as bases for counterinsurgency and intelligence operations in Latin America and Asia. 

Health care and the transition to socialism . The number of nations undergoing socialist revolutions has increased dramatically in recent years, particularly in Asia and Africa but also in parts of Latin America, the Caribbean, and Southern Europe. Socialism is no panacea. Numerous problems have arisen in all countries that have experienced socialist revolutions. The contradictions that have emerged in most postrevolutionary countries are deeply troubling to Marxists; these contradictions have been the subject of intensive analysis and debate. 

On the other hand, socialism can produce major modifications in health-system organization, nutrition, sanitation, housing, and other services. These changes can lead, through a sometimes complex chain of events, to remarkable improvements in health. The remarkable improvements in morbidity and mortality that followed socialist revolutions in such countries as Cuba and China now are well known. 50 The transition to socialism in every case has resulted in reorganization of the health system, emphasizing better distribution of health care facilities and personnel. Local political groups in the commune, neighborhood, or workplace have assumed responsibility for health education and preventive medicine programs. Class struggle continues throughout the transition to socialism. During Chile’s brief period of socialist government, many professionals resisted democratization of health institutions and supported the capitalist class that previously and subsequently ruled the country. 51 Countries like China and Cuba eliminated the major source of social class—the private ownership of the means of production. However, as mentioned previously, new class relations began to emerge that were based on differential expertise. Health professionals received larger salaries and maintained higher levels of prestige and authority. One focus of the Chinese Cultural Revolution was the struggle against the new class of experts that had gained power in the health system and elsewhere in the society. 52 Other countries, including Cuba, have not confronted these new class relations as explicitly (see article on Health Care in Tanzania elsewhere in this issue). 

Contradictions of capitalist reform. While retaining the essential features of their capitalist economic systems, several nations in Europe and North America have instituted major reforms in their health systems. Some reforms have produced beneficial effects that U.S. policy makers view as possible models for this country. However, recent Marxist studies, while acknowledging many improvements, have revealed troublesome contradictions that seem inherent in reforms attempted within capitalist systems. 

Great Britain’s national health service has attracted great interest. Serious problems have balanced many of the undeniable benefits that the British health service has achieved. Chief among these problems is the professional and corporate dominance that has persisted since the service’s inception. Decision-making bodies contain large proportions of professional specialists, bankers, and corporate executives, many of whom have direct or indirect links with pharmaceutical and medical equipment industries. 53

The private-public contradiction, discussed earlier, has remained a source of conflict in several countries that have established national health services or universal insurance programs. Use of public facilities for private practice has generated criticism focusing on public subsidization of the private sector. In Britain, for example, this concern (along with more general organizational problems that impeded comprehensive care) was a primary motivation for the recent reorganization of the national health service. 54 In Chile, the attempt to reduce the use of public facilities for private practice led to crippling opposition from the organized medical profession. The private-public contradiction will continue to create conflict and to limit progress when countries institute national health services while preserving a strong private sector. 

The limits of state intervention also have become clearer from the examples of Quebec and Sweden. Both have tried to establish far-reaching programs of health insurance, while preserving private practice and corporate dealings in pharmaceuticals and medical equipment. Recent studies have demonstrated the inevitable constraints of such reform. Maldistribution of facilities and personnel have persisted, and costs have remained high. The accomplishments of Quebec’s and Sweden’s reforms cannot pass beyond the state’s responsibility for protecting private enterprise. 55 This observation leads to skepticism about health reforms in the United States that rely on private market mechanisms and that do not challenge the broader structures within which the health system is situated. 56

Historical Materialist Epidemiology  

Historical materialist epidemiology relates patterns of death and disease to the political, economic, and social structures of society. The field emphasizes changing historical patterns of disease and the specific material circumstances under which people live and work. These studies try to transcend the individual level of analysis, to find how historical social forces influence or determine health and disease. 

Many different diseases have been examined from this viewpoint. The incidence of mental illness, for example, has been shown to correlate with economic growth or recession. 57 The cause of stress and stress-related problems, such as coronary heart disease, anxiety, suicide, hypertension, and cancer, generally has been viewed as a problem at the individual level. Historical materialist epidemiology shifts the emphasis to stressful forms of social organization linked to capitalist production and industrialization. 58

The social causes of occupational disease have become more apparent. Diseases such as asbestosis, mesothelioma, and complications of vinyl chloride all point to the contradiction between profitability and improved health in capitalist countries. Sexism also can be seen as a factor in the differential production of ill health among women and men. Men, for instance, generally die younger than women, and this may be a result of their greater exposure to occupational hazards in jobs from which women traditionally have been excluded. Historically, a woman’s access to health facilities and the way she is treated by doctors have been strongly influenced by her social class. The history of the birth control movement, 59 the sexist assumptions of psychiatric diagnosis (see article on the Worcester Ward in this issue) and the misuse of gynecologic surgery all illustrate the social and sexist nature of women’s health problems. 60

One unifying theme in this field is modern medicine’s limitations. 61 Traditional epidemiology has searched for causes of morbidity and mortality that are amenable to medical intervention. While acknowledging the importance of traditional techniques, historical materialist epidemiology has demonstrated causes of disease and death that derive from broad social structures beyond the reach of medicine alone. 

Health Praxis  

Marxist research conveys another basic message: that research is not enough. “Praxis,” as proposed throughout the history of Marxist scholarship, is the disciplined uniting of thought and practice, study and action. 

Contradictions of patching . Health workers concerned about progressive social change face difficult dilemmas in their day-to-day work. Clients’ problems often have roots in the social system. Examples abound: drug addicts and alcoholics who prefer numbness to the pain of confronting problems like unemployment and inadequate housing; persons with occupational diseases that require treatment but will worsen upon return to illness-generating work conditions; people with stress-related cardiovascular disease; elderly or disabled people who need periodic medical certification to obtain welfare benefits that are barely adequate; prisoners who develop illness because of prison conditions. 62 Health workers usually feel obliged to respond to the expressed needs of these and many similar clients. 

In doing so, however, health workers engage in “patching.” On the individual level, patching usually permits clients to keep functioning in a social system that is often the source of the problem. At the societal level, the cumulative effect of these interchanges is the patching of a social system whose patterns of oppression frequently cause disease and personal unhappiness. The medical model that teaches health workers to serve individual patients deflects attention from this difficult and frightening dilemma. 63

The contradictions of patching have no simple resolution. Clearly health workers cannot deny services to clients, even when these services permit clients’ continued participation in illness-generating social structures. On the other hand, it is important to draw this connection between social issues and personal troubles. Health praxis should link clinical activities to efforts aimed directly at basic sociopolitical change. 

Reformist versus nonreformist reform . When oppressive social conditions exist, reforms to improve them seem reasonable. However, the history of reform in capitalist countries has shown that reforms most often follow social protest, make incremental improvements that do not change overall patterns of oppression, and face cutbacks when protest recedes. Health praxis includes a careful study of reform proposals and the advocacy of reforms that will have a long-term progressive impact. 

A distinction developed by Gorz clarifies this problem. “Reformist reforms” provide small material improvements while leaving intact current political and economic structures. These reforms may reduce discontent for periods of time, while helping to preserve the system in its present form. “A reformist reform is one which subordinates objectives to the criteria of rationality and practicability of a given system and policy … (it) rejects those objectives and demands—however deep the need for them—which are incompatible with the preservation of the system”. 64 “Nonreformist reforms,” on the other hand achieve true and lasting changes in the present system’s structures of power and finance. Rather than obscuring sources of exploitation by small incremental improvements, nonreformist reforms expose and highlight structural inequities. Such reforms ultimately increase frustration and political tension in a society; they do not seek to reduce these sources of political energy. As Gorz puts it: ” … although we should not reject intermediary reforms … , it is with the strict proviso that they are to be regarded as a means and not an end, as dynamic phases in a progressive struggle, not as stopping places”. 65 From this viewpoint health workers can try to discern which current health reform proposals are reformist and which are nonreformist. They also can take active advocacy roles, supporting the latter and opposing the former. Although the distinction is seldom easy, it has received detailed analysis with reference to specific proposals. 66

Reformist reforms would not change the overall structure of the health system in any basic way. For example, national health insurance chiefly would create changes in financing, rather than in the organization of the health system. This reform may reduce the financial crises of some patients; it would help assure payment for health professionals and hospitals. On the other hand, national health insurance will do very little to control profit for medical industries or to correct problems of maldistributed health facilities and personnel. Its incremental approach and reliance on private market processes would protect the same economic and professional interests that currently dominate the health system. 67

Other examples of reformist reforms are health maintenance organizations, prepaid group practice, medical foundations, and professional standards review organizations. 68 With the rare exception of those organized as consumer cooperatives, these innovations preserve professional dominance in health care. There have been few incentives to improve existing patterns of maldistributed services. Moreover, large private corporations have entered this field rapidly, sponsoring profit-making health maintenance organizations and marketing technologic aids for peer review. 69

Until recently, there has been little support for a national health service in the United States. For several years, however, Marxist analysts have worked with members of Congress in drafting preliminary proposals for a national health service. These proposals, if enacted, would be progressive in several ways. They promise to place stringent limitations on private profit in the health sector. Most large health institutions gradually would come under state ownership. Centralized health planning would combine with policy input from local councils to foster responsiveness and to limit professional dominance. Financing by progressive taxation is designed explicitly to benefit low-income patients. Periods of required practice in underserved areas would address the problem of maldistribution. The eventual development of a national drug and medical equipment formulary promises to curtail monopoly capital in the health sector. 

Although these proposals face dim political prospects, support is growing. For instance, the Governing Council of the American Public Health Association has passed two resolutions supporting the concept of a national health service that would be community-based and financed by progressive taxation. 70 While advancing a model for a more responsive health care system, this reform also contains contradictions that probably would generate frustration and pressure for change. In particular, these proposals would permit the continuation of private practice and help expose the inequities of the private-public dichotomy. 

Health care and political struggle. Fundamental social change,however, comes not from legislation but from direct political action. Currently, coalitions of community residents and health workers are trying to gain control over the governing bodies of health institutions that affect them. 71 Unionization activity and minority group organizing in health institutions are exerting pressure to modify previous patterns of stratification. 72

Recognizing the impact of medical ideology has motivated attempts to demystify current ideologic patterns and to develop alternatives. This “counterhegemonic” work often involves opposition to the social control function of medicine in such areas as drug addiction, genetic screening, contraception and sterilization abuse, psychosurgery, and women’s health care. A network of alternative health programs has emerged that tries to develop self-care and nonhierarchical, anticapitalist forms of practice; these ventures then would provide models of progressive health work when future political change permits their wider acceptance. 73

In anti-imperialist organizing, several groups have assisted persecuted health workers and have spoken out against medical complicity in torture. Health and science workers also have used historical materialist epidemiology in occupational health projects and unionization struggles. A common criticism of the Marxist perspective is that it presents many problems with few solutions. Clearly, however, this approach has clarified some useful directions of political strategy. This struggle will be a protracted one, and will involve action on many fronts. The present holds little room for complacence or misguided optimism. Our future health system, as well as the social order of which it will be a part, depends largely on the praxis we choose now.

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A Marxist view of medical care

• PMID: 354452
• DOI: 10.7326/0003-4819-89-2-264

Marxist studies of medical care emphasize political power and economic dominance in capitalist society. Although historically the Marxist paradigm went into eclipse during the early twentieth century, the field has developed rapidly during recent years. The health system mirrors the society's class structure through control over health institutions, stratification of health workers, and limited occupational mobility into health professions. Monopoly capital is manifest in the growth of medical centers, financial penetration by large corporations, and the "medical-industrial complex." Health policy recommendations reflect different interest groups' political and economic goals. The state's intervention in health care generally protects the capitalist economic system and the private sector. Medical ideology helps maintain class structure and patterns of domination. Comparative international research analyzes the effects of imperialism, changes under socialism, and contradictions of health reform in capitalist societies. Historical materialist epidemiology focuses on economic cycles, social stress, illness-generating conditions of work, and sexism. Health praxis, the disciplined uniting of study and action, involves advocacy of "nonreformist reforms" and concrete types of political struggle.

Publication types

• Historical Article
• Research Support, U.S. Gov't, Non-P.H.S.
• Delivery of Health Care / history
• Delivery of Health Care / organization & administration*
• Health Services*
• History, 19th Century
• History, 20th Century
• Internationality
• Philosophy, Medical*
• Public Policy
• Social Change
• Social Conditions
• United States

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Section 1: The theoretical perspectives and methods of enquiry of the sciences concerned with human behaviour

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Section 1:  The theoretical perspectives and methods of enquiry of the sciences concerned with human behaviour

This section covers:

• Disciplines concerned with human behaviour
• Theoretical perspectives 

• Defining the field of medical sociology
• Research methodologies

1.  Disciplines concerned with human behaviour

Psychology, anthropology, history and sociology are all disciplines concerned with human behaviour.  While these approaches differ in terms of their perspectives and methodologies, there is also considerable overlap between them. Rather than contradict each other, they complement one another in developing our understanding of human behaviour and a multi-disciplinary approach to public health. Applying theories and research from these disciplines can help to explain the behaviours of individuals, groups within populations, and healthcare organisations. In doing so we can begin to understand how different concepts of health, wellbeing and illness evolved through changes in societies and cultures.

Psychology is the scientific study of people, the mind and behaviour. It is both an academic discipline and an applied science or professional practice. [1] By developing our understanding of how we think, feel, act and interact, individually and in groups, psychology can contribute to developing solutions for social problems. In terms of public health theory and practice, health psychology and social psychology are particularly relevant, although there is also considerable overlap with other psychological disciplines including developmental and cognitive psychology. Health psychology is concerned with people’s attitudes, beliefs and behaviours about health, including models to predict and enable behaviour change. Social psychology is concerned with the behaviour of individuals and groups as part of their wider societies.

Anthropology is the study of various aspects of human life (e.g. societies, cultures and languages) within societies of the past and present. Within this discipline, social anthropology and medical anthropology are especially relevant to public health. Social anthropology is the study of human society and cultures, seeking to understand how people live in societies and how they make their lives meaningful. Medical anthropology draws upon other anthropological sub-disciplines including social, cultural, biological, and linguistic anthropology to examine individual, population and environmental health from the perspective of interactions between humans and other species; cultural norms and social institutions; micro and macro politics; and forces of globalisation.

History is the recording and interpretation of past events. Understanding history puts current social structures, norms and behaviours into context, and is crucial for learning lessons for the future. The history of medicine demonstrates how approaches to health and illness in societies have changed over time. Developments in medicine, science and technology have both influenced and been influenced by understanding of anatomy; beliefs about health and illness; treatment paradigms; and the social and political environments in which healthcare systems operate.

Sociology is the study of social behaviour or society, including its origins, development, organisation, networks, and institutions. It is a social science that uses empirical research and critical analysis to understand social order, disorder and change.  The simplest view of the academic discipline of sociology is that it is somehow concerned with the understanding of human societies. However, this does not take us very far as most people feel they know a good deal about the society in which they live because they experience it every day; this can be described as 'common-sense' or experiential knowledge. Another approach would be to define sociology as a research-based study of society. However, there are other academic disciplines such as history, politics, economics, anthropology and social psychology that also have human society as the object of study. Probably the best way of defining the contribution of sociology is by looking at the key questions that originally stimulated the development of the academic discipline and which continue to underpin sociological research today:

• What gives social life a sense of stability and order?
• How does social change and development come about?
• What is the nature of the relationship between the individual and the society in which they live?
• To what extent does the society into which people are born shape their beliefs, behaviours, and life chances (including health outcomes)        

Understanding and explaining social phenomena

• Sociology, in   pursuing an objective scientific approach to answering the questions posed above, attempts to explain why social life is not a random series of events, but is structured and shaped by particular sets of rules (both obvious and hidden). This is not to say that social structures determine human behaviour, rather that social structure is both the ever-present condition for , and reproduced outcome of , intentional human agency or actions.
• Sociology, like any other academic discipline, is theory-based. That is, in order to understand how societies work (or why particular bio-chemical processes occur), we must go beyond a simplistic description of the phenomenon under investigation.
• Sociology, also like any other academic discipline which has as its object of study the human and social world, consists of a range of competing explanatory paradigms. Empirical research necessarily involves making assumptions about the nature of social reality.
• Sociology challenges both naturalistic and individualistic explanations of social phenomena ( see Activity 1) . These understandings arise as a consequence of growing up (`being socialised') within a particular culture and set of social structures, and can result in people seeing their everyday roles and behaviour as being somehow `natural'. Equally, when looking at other people`s behaviour, i.e. `unhealthy lifestyles' or lack of motivation for example, the focus is all too often on particular individual characteristics, ignoring the social factors that influence such behaviour and beliefs.

2.  Theoretical approaches within Sociology

A single unified sociological perspective concerning the nature of social reality does not exist. In this respect sociology is no different to any other academic discipline, for all embrace competing perspectives or paradigms - this is how subject knowledge is advanced.

The major long-standing epistemological divide that exists within sociological theory is that between those sociologists who argue that society can be studied in an objective way through identifying and examining the structures of society, and those who argue for an interpretative or subjective approach to social phenomena more focused on social actors . Structuralist approaches often tend to focus on the macro level while subjectivist approaches tend to focus on the micro level of interaction. However, in more recent times a third position has developed which attempts to breakdown this duality between the relative importance attached to social actors versus social structures. These three approaches are explored below.    

a.  Social structural approaches: Societies as objective realities

Social structural approaches to exploring social reality include those empiricist sociologists who believe that an objective 'science of society' is possible in much the same way as a physical science such as biology or physics. This empirical sociology seeks to explain the norms of social life in terms of various identifiable linear causal influences. Social structural approaches would also include those sociologists who see human society as being shaped by an underlying material social and economic structure. These are structures that may not always be visible, but nevertheless are fundamental in explaining social and individual processes.

In relation to health, a predominantly social structural approach would draw upon quantitative data derived from social surveys, epidemiological studies and comparative studies in order to point to the relative influence of societal structures and processes in determining health outcomes for social groups.

Within the academic discipline of sociology, two major theoretical perspectives exist which seek to analyse human societies utilising a social structural or systems approach. These perspectives are structural functionalism and Marxism, and their very different organising principles are described in relation to the social determination of health outcomes below. As a brief illustration of the two approaches to structural analysis we will briefly examine the issue of poverty. The functionalist explanation would set poverty in the context of social stratification and the unequal distribution of rewards associated with complex economies where different tasks are performed by different groups within society. Some groups are relatively less well off than others because they have less skills and knowledge and so their contribution to the functioning of society is not as extensive as other groups. The Marxist explanation, on the other hand, would set poverty in the context of the class structure, specifically the relationship of social groups within a capitalist system of economic production in which there are the exploited and the exploiters (with some intermediate groups of managers and supervisors).

The functionalist perspective of health and illness

This theoretical perspective stresses the essential stability and cooperation within modern societies. Social events are explained by reference to the functions they perform in enabling continuity within society. Society itself is likened to a biological organism in that the whole is seen to be made up of interconnected and integrated parts; this integration is the result of a general consensus on core values and norms. Through the process of socialisation we learn these rules of society which are translated into roles. Thus, consensus is apparently achieved through the structuring of human behaviour. Within medical sociology, this approach is essentially concerned with the theme of the 'sick role', and the associated issue of illness behaviour. Talcott Parsons, the leading figure within this sociological tradition, identified illness as a social phenomenon rather than as a purely physical condition. Health, as against illness, being defined as:

'The state of optimum capacity of an individual for the effective performance of the roles and tasks for which s/he has been socialised.'  Parsons, 1951


Health within the functionalist perspective thus becomes a prerequisite for the smooth functioning of society. To be sick is to fail in terms of fulfilling one's role in society; illness is thus seen as 'unmotivated deviance'. The regulation of this sickness/deviance comes about through the mechanism of the 'sick role' concept and the associated 'social control' role of doctors in allowing an individual to take on a sick status.

The Marxist perspective of health and illness

A key assertion of the Marxist perspective is that material production is the most fundamental of all human activities - from the production of the most basic of human necessities such as food, shelter and clothing in a subsistence economy, to the mass production of commodities in modern capitalist societies. Whether this production takes place within a modern or a subsistence economy, it involves some sort of organisation and the use of appropriate tools; this is termed the 'forces of production'. Production of any type was recognised by Marx as also involving social relations. In modern capitalist societies these 'relations of production' lead to the development of a division of labour reflected in the existence of different social classes. For Marxists, it is these forces and relations of production together that constitute the economic base (infrastructure) of society. The superstructure of a society - the political, legal, educational, and health systems and so on - are shaped and determined by this economic base.

The orientation of this approach as applied within medical sociology is towards the social origins of disease. Health outcomes for the population are seen as being influenced by the operation of the capitalist economic system at two levels.

First, at the level of the production process itself, health is affected either directly in terms of industrial diseases and injuries, stress-related ill health, or indirectly through the wider effects of the process of commodity production within modern societies. The production processes create environmental pollution, whilst the process of consuming the commodities themselves has long-term health consequences associated with eating processed foods, chemical additives, car accidents and so on. Second, health is influenced at the level of distribution. Income and wealth are major determinants of people's standard of living - where they live, their access to educational opportunities, their access to health care, their diet, and their recreational opportunities. All of these factors are significant in the social patterning of health.
  

b.  Interpretative aproaches:  Societies as subjective realities

Sociologists within this wide tradition would argue that the social world cannot be studied in the same way as the physical world because people:

'Engage in conscious intentional activity and, through language, attach meanings to their actions... [therefore] sociologists should be less concerned to explain behaviour than to understand how people come to interpret the world in the way they do.'  Taylor and Field, 1993:15

In attempting to achieve this goal of interpretative understanding, reliance is placed on essentially qualitative research methodologies in order to get as close as possible to the world of the subjects or social actors being studied. In terms of health and illness, this interpretative approach focuses upon the (symbolic) meanings of what it is to be ill in our society, and would not confine its interest in health to what would be perceived as the closed world of clinical biomedicine (this would not rule out the study of the interactions of clinicians themselves both with patients and with colleagues).

Within this interpretative sociological tradition two distinct perspectives stand out; symbolic interactionism and social constructionism. These approaches are outlined below in relation to health and illness.

The Symbolic Interactionist perspective of health and illness

This perspective developed from a concern with language and the ways in which it enables us to become self-conscious beings. The basis of any language is the use of symbols that reflect the meanings that we endow physical and social objects with. In any social setting in which communication takes place, there is an exchange of these symbols: that is, we look for clues in interpreting the behaviour and intentions of others. Communication being a two-way process, this interpretative process involves a negotiation between the parties concerned. The negotiated order that develops therefore involves:

'People construct[ing] understandings of themselves and of others out of experiences they have and the situations they find themselves in. These understandings have consequences in turn for the way in which people act, and the manner in which others react to them.' Aggleton, 1990:91


Interactionist sociology asserts that the social identities we possess are influenced by the reactions of others. So if we demonstrate some abnormal or 'deviant' behaviour it is likely that the particular label that is attached within a society at a particular time to this behaviour will then become attached to us as individuals. This can bring about important changes in our self-identity. A disease diagnosis could be one such label: for example, clinical depression and the assumptions about the person so labelled that then follow; here Goffman's (1968) work on this form of social stigma is particularly influential and will be discussed in detail in Section 3 of this module.

Within this perspective, medicine too would be viewed as a social practice and its claims to be an objective science would be disputed. In the doctor-patient interaction, patient dissatisfaction can result if the doctor too rigidly superimposes a pre-existing framework (disease categories) upon the subjective illness experience of the patient. For example, by presuming that they can understand what that individual is suffering because of an interpretation of their signs and symptoms without reference to their health beliefs (explored in Section 4 ).

See Activity 2

The Social Constructionist perspective of health and illness - The relativity of social reality

This sociological perspective derives from the phenomenological approach of Berger and Luckmann (1967), who argued that everyday knowledge is creatively produced by individuals and is directed towards practical problems. 'Facts' are therefore created through social interactions and people's interpretations of these 'facts'. This essentially subjectivist approach embraces a number of very different sociological paradigms, but what such paradigms do have in common in relation to health and illness is a focus on the way we make sense of our bodies and bodily disturbances. Social constructionism refuses to draw a distinction between scientific (medical) and social knowledge. Nor would it ignore disease in favour of examining the illness experience, unlike the interactionist perspective. Rather, it maintains that all knowledge is socially constructed. We are seen to come to know the world through the ideas and beliefs we hold about it, so that it is our concepts and categories which are the realities of the world (For further reading see Bury:1986 - a sociological paper which focuses on social constructionism in relation to biomedicine).

Foucault (1973,1980,1985,1986) and the work of so-called post-structural social theorists are included within this perspective, though their concerns are frequently different from those researching within the tradition of phenomenology. Foucault was interested in power in itself, not as reduced to an expression of some other conceptual starting point such as class, the state, gender or ethnicity. He sought to approach the relationship between agency and structure not through an essentialist analysis but by using an 'interpretative analytics' of practices and discourses, discerning the workings of power and knowledge in social relations.

In terms of health and illness, this Foucauldian approach to cultural constructionism draws attention to the ways in which we experience ourselves and our bodies not in some naturalistic way, but in what is termed a 'symbolically mediated fashion' - the body as a 'field of discourse'. As David Armstrong put it, in describing the development of medical knowledge in the latter half of the nineteenth century:

'The fact that the body became legible does not imply that some invariant biological reality was finally revealed to medical enquiry. The body was only legible in that there existed in the new clinical techniques a language by which it could be read.'  Armstrong, 1983  

c. Societies as a synthesis of agency and structure

Anthony Giddens' work (1979,1984) is concerned with attempting to overcome the traditional sociological dualities between agency and structure, and between the ideal and the material, which are discussed above. According to May (1996), Giddens seeks to examine the structural reproduction of social practices, whilst also insisting upon the opportunities which exist for individual innovation in social conduct:

'Structure enters into the constitution of the agent and social practices and 'exists' in the generating moments of this constitution.'  Giddens, 1979:5

Here Giddens is referring to what he describes as the 'duality of structure'. This is the idea that while social structures are themselves produced by men and women, at the same time these structures act as mediators to constrain and influence this very productive process. In the context of health and illness, Giddens (following Durkheim) argues that for a society to function effectively requires that people have a sense of order and continuity - the social rules that people draw upon in their social practices. The existence of this structural continuity within society requires that people find intellectual and emotional meaning within their own personal lives - what he terms 'ontological security'. However, when we assess the meanings of illness or death and dying, for example, we recognise that these essentially individual experiences cannot simply be denied or disregarded by social structures. Our mortality is something we all have to face individually, and this calls into question many of the assumptions we might hold about the structures that appear to shape our lives. Equally, our self-identity is not simply provided for us by the social system we live within: it is something we have to search for ourselves. 'Praxis' is the name Giddens gives to this link between practical consciousness which informs our actions and behaviours, and the social conditions in which this action takes place.

3.  The Sociology of health and illness: Defining the field

Sociology brings two distinct focuses of analysis to the study of health and illness:

• At one level it tries to 'make sense of illness', by applying sociological perspectives both to an analysis of the experience of illness, and to the social structuring of health and disease. At this level, sociology makes an important contribution to multi-disciplinary research into issues of interest to clinicians and other health professionals, the development of health policy, and epidemiological studies.
• At a second level, sociological enquiry can open doors to an understanding of the impact of wider social processes upon the health of individuals and social groups. Such processes include social inequalities, professional relationships, change and self-identity, knowledge and power, and consumption and risk.

See Glossary for Section 1

4.  Research paradigms

Research into human behaviour can be quantitative or qualitative . Quantitative research gathers or generates numerical data on what is measurable and classifiable. It quantifies information on characteristics, behaviours, attitudes and other variables and uses statistics to test for differences, examine trends and patters, and generalise findings from samples to populations. Qualitative research focuses on words and their meanings, using methods such as interviews and focus groups to gather rich information from participants. Qualitative data may be grouped or classified according to themes, either pre-determined or emerging from the data, but it is not described or tested statistically.

The main purpose of quantitative research is to test hypotheses, whereas qualitative research is mainly exploratory. Traditionally there was resistance to qualitative methods in scientific research on the basis that their findings do not tend to be reproducible, and a general perception that they lack scientific rigour. However, this perspective overlooked the limitations of quantitative or epidemiological approaches, which are less useful in answering questions about why observed trends and differences occur, or understanding people’s lived experiences, attitudes and choices. The benefits of qualitative research for gaining more in-depth understanding of human behaviour and its relationship to health are now more widely appreciated, challenging the view of quantitative methodologies as the dominant paradigm.

There is nevertheless some concern among qualitative researchers about the rise of qualitative studies that lack quality and methodological rigour, due to a lack of understanding about this methodology among both researchers and reviewers (see Pope & Mays, 1993; 2009). There are also limitations to interviews and focus groups as the most common methods of obtaining qualitative data, because what people say does not always reflect their behaviour (Pope & Mays, 2009). Ethnography, which is a methodology that involves the researcher integrating themselves into a setting and observing the behaviours of individuals and groups, is one way to overcome this barrier; however, it can be time-consuming and costly to conduct, and it can sometimes be difficult to obtain ethical approval and consent.

While both quantitative and qualitative methodologies have distinct strengths and limitations, it is unhelpful to polarise the debate by viewing them as opposing or rival paradigms. The causes of public health problems are complex and multi-faceted, and the most effective public health research will reflect this by using a range of methods (Baum, 1995). Mixed methods research is becoming increasingly common, with quantitative data and qualitative studies complementing one another in both hypothesis generation and analysis.

© I Crinson 2007, Lina Martino 2017

[1] British Psychological Society: http://www.bps.org.uk/

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Conceptual analysis article, the political economy of the mental health system: a marxist analysis.

• Division of Psychiatry, University College London, London, United Kingdom

The present paper analyses the functions of the mental health system in relation to the economic organisation of society, using concepts derived from Marx’s work on political economy and building on previous critiques. The analysis starts from the position that mental health problems are not equivalent to physical, medical conditions and are more fruitfully viewed as problems of communities or societies. Using the example of the United Kingdom, it traces how a public mental health system evolved alongside capitalism in order to manage the problems posed by people whose behaviour was too chaotic, disruptive or inefficient to participate in a labour market based on exploitation. The system provided a mixture of care and control, and under recent, Neoliberal regimes, these functions have been increasingly transferred to the private sector and provided in a capitalistic manner. Welfare payments are also part of the system and support those less seriously affected but unable to work productively enough to generate surplus value and profit. The increased intensity and precarity of work under Neoliberalism has driven up benefit claims at the same time as the Neoliberal state is trying to reduce them. These social responses are legitimised by the idea that mental disorders are medical conditions, and this idea also has a hegemonic function by construing the adverse consequences of social and economic structures as individual problems, an approach that has been particularly important during the rise of Neoliberalism. The concept of mental illness has a strategic role in modern societies, therefore, enabling certain contentious social activities by obscuring their political nature, and diverting attention from the failings of the underlying economic system. The analysis suggests the medical view is driven by political imperatives rather than science and reveals the need for a system that is more transparent and democratic. While the mental health system has some consistent functions across all modern societies, this account highlights one of the endemic contradictions of the capitalist system in the way that it marginalises large groups of people by narrowing the opportunities to make an economic contribution to society.

Introduction

The subject of mental health has perhaps never been more widely discussed than today, and mental health problems more widely accepted as “proper” medical conditions. There has been a huge escalation in the diagnosis and treatment of such problems across western societies in the past few decades. A quarter of the English population report that they have suffered from a mental illness at some point in their lives ( Health and Social Care Information Centre, 2015 ), and even larger numbers have been persuaded that many instances of unhappiness and discontent arise from biochemical abnormalities and require medical interventions ( Pilkington et al., 2013 ). This phenomenon has been referred to as “psychiatrization” ( Beeker et al., 2021 ), and also as widening medicalisation or “disease-mongering”, since psychiatric disorders are classified as a subset of medical disorders and often subject to medical-style interventions like pharmaceuticals ( Conrad and Potter, 2000 ; Moynihan et al., 2002 ). In the meantime, there has been a profound reorganisation of provision for the seriously mentally unwell, with care provided by large state institutions transferred to smaller facilities and organisations, many run by the private sector on a “for-profit” basis.

The works of Marx and Engels are recognised to provide important insights into the nature and workings of many contemporary institutions, and systems for addressing mental health problems, particularly psychiatry, are no exception. Several scholars within a broadly defined Marxist tradition have examined mental institutions and treatments, building on the analysis of social deviance, and focusing on the way psychiatric interventions serve as mechanisms of social control, developed to manage behaviour that threatens to destabilise the capitalist system ( Conrad, 1992 ; Scull, 1993 ; Cohen, 2016 ). Other authors have documented how, over recent decades, Neoliberal capitalism has coincided with the trend to medicalise and “commodify” more and more aspects of human feelings and behaviour, in the process turning them into a source of profit for the pharmaceutical and healthcare industries ( Fisher, 2009 ; Davies, 2017 ). The ideological consequences of reframing social problems as individual pathology have also been highlighted, in the way this process diverts attention from the structural inequality and injustice that make life difficult for people in the first place ( Fisher, 2009 ; Davies, 2011 ; Cohen, 2016 ).

Marxist analyses overlap with the “antipsychiatry” position, which argues that mental illness is a strategic, political concept, rather than a scientific one ( Szasz, 1970 ; Szasz, 1989 ). There is also a wealth of Marxist literature on the welfare state that is relevant to understanding the role and functions of the mental health system ( Gough, 1979 ; Higgs, 1993 ).

In the following article, I set out an analysis of how the mental health system relates to the economy, particularly a capitalist economy, making use of Marxist concepts such as use value, exchange value, exploitation, productive labour and ideology (see Table 1 ). I trace the evolution of the English system, revealing its social functions, which include social control, but also functions that have received little previous attention, such as the provision of care, and the way in which the biomedical ideology of psychiatry facilitates the capitalist welfare system, and promotes capitalist hegemony. I attempt to distinguish those aspects of the system that are specific to capitalism from those that are more general features of modern societies, and describe how understanding the mental health system in this way reveals some of the contradictions of capitalism. Since industrial capitalism is generally acknowledged to have started in England, the analysis provides a paradigmatic case of the relationship between economic development and social responses to mental disturbance in advanced capitalist economies, but it is not necessarily applicable to parts of the world where economic development has taken a different course.

TABLE 1 . Marxist concepts.

As a practising psychiatrist, I have experienced the situations that mental health services are required to address, and the frequent disjunction between the official diagnostic framework for explaining these situations, and the problems individuals, families and communities actually experience. Yet, I have also been socialised by the system, in particular by the language it employs. The terminology of “mental health,” “mental illness” and “mental disorder” is premised on the existence of a material entity or disease, located in the individual, a view that is challenged in this article. However, since there are no widely accepted alternative ways to describe the problems in question, I have used current terms.

The Nature of Mental Health Problems

In contrast to the mainstream position, I and other critics suggest that mental health problems are not equivalent to general medical conditions ( Valenstein, 1998 ; Szasz, 2000 ; Whitaker, 2002 ; Moncrieff, 2020 ). Although human beings are embodied creatures, and all human activity depends on biology, none of the situations we call mental disorders have been convincingly shown to arise from a biological disease, or, putting it another way, from a specific dysfunction of physiological or biochemical processes.

The abundance of research into the biological basis of mental disorders means it is difficult to challenge every new claim or theory, yet fundamental flaws have been identified in key areas of research. For example, genetic research with families and twins has overlooked important confounders and positive findings have been highlighted while negative ones have been buried ( Rose et al., 1984 ; Joseph, 2003 ). More recent genome wide studies produce negligible evidence for any relevant genetic effects ( Latham and Wilson, 2010 ; Moncrieff, 2014 ). The most consistent finding in biological psychiatry is that people diagnosed with schizophrenia have smaller brains and larger brain cavities than people without, and this has recently been shown to be due, at least in part, to the effects of antipsychotic treatment ( Fusar-Poli et al., 2013 ). Any remaining differences are likely accounted for by intellectual ability and other uncontrolled factors ( Moncrieff and Middleton, 2015 ). Biochemical research also fails to support widely held beliefs that mental disorders are caused by abnormalities of specific neurotransmitters ( Valenstein, 1998 ). The hypothesis that depression is caused by serotonin deficiency is not supported by evidence from any of the principle areas of research into depression and the serotonin system (Moncrieff et al.). Evidence on dopamine also fails to confirm the dopamine hypothesis of schizophrenia or psychosis, though dopamine is known to be involved in arousal mechanisms that are likely to be awry in someone who is acutely psychotic ( Moncrieff, 2009 ; Kendler and Schaffner, 2011 ).

Instead of viewing mental disorders as biological conditions that are inherent in individuals, I suggest we need to understand them as problems of communities or societies. If we do this, we will see from the following account of the evolution and functions of the mental health system, the principal problems we refer to as mental disorders consist, from a societal point of view, of dependency and disruptive behaviour. It is true that these problems can be caused by medical conditions. Occasionally, brain diseases, such as dementia and Huntingdon’s chorea produce behaviour that is aggressive or socially undesirable, and many physical diseases reduce people’s ability to maintain themselves. Indeed, for centuries, the institutions that developed to accommodate the mentally disturbed, also provided for people with neurological conditions, and sometimes still do ( Rehling and Moncrieff, 2020 ). Moreover, in most countries, people with dementia, a neurological disease, are treated by psychiatrists rather than neurologists.

However, in the situations we routinely refer to as “mental disorders”, no disease can reliably be found. It is in the nature of human beings to react to their environment in different ways. Some people behave in ways that are bizarre, difficult to understand and sometimes troublesome for others, and some people are more productive and efficient than others. Rather than representing these problems as the manifestations of as yet undiscovered brain diseases, I suggest that “mental illness” is simply the 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 ( Moncrieff, 2020 ).

In what follows I accept the view that many of our current mental troubles are consequences of the particular socio-economic conditions of late capitalism, and the way in which these consequences are construed ( Davies, 2011 ; Cohen, 2016 ; Davies, 2017 ). However, in contrast to the purely social constructionist view, I also assume that some are perennial features of human life and occur across different sorts of societies with varying economic bases.

Mental Health Problems From a Social and Economic Perspective

In line with this view, the mental health system can be viewed as a social response to the set of problems we refer to as “mental disorder” or “illness”. Some of these are problems for any modern society, whether capitalist, socialist or something else. Some are specific to capitalism. Though much debated, Marxist theory suggests that social institutions (the superstructure) reflect the need to support the prevailing economic system (the base) of each society and historical era ( Harman, 1986 ). Therefore, institutional functions need to be understood in the context of the economic system in which they are embedded.

One of the functions of mental health services is to provide support and care for people when they are unable to look after themselves. Just like people with a severe physical disability, learning difficulties or neurological disease, people who have a serious mental disorder that would nowadays be referred to as schizophrenia, bipolar disorder or severe depression, are sometimes unable to wash or dress themselves, to manage money, shop, cook or maintain their environment in a habitable condition. The disability may be temporary, and many recover or improve, but for some it is long-term.

Serious mental disorder can also involve people behaving in ways that are disruptive or dangerous to the lives of others. Managing this behaviour to ensure social harmony is something societies have endeavoured to address long before the advent of capitalism, and is one of the principle functions of the mental health system. As legal scholar (and subsequently notorious lawyer), Alan Dershowitz, commented: “it is a fairly constant phenomenon in most societies that dangerous and bothersome people will be isolated by one means or another” ( Dershowitz, 1974 ) (P 58). English history records how local, informal procedures aimed at managing dangerous and disruptive behaviour evolved to address lacunae in the criminal law, which included the difficulty of convicting people who were too confused, distracted or deluded to understand the justice system or respond to punishment. These informal procedures were gradually codified into formal law regarding the care and control of the “insane” ( Dershowitz, 1974 ).

Disturbed and disruptive behaviour is not just a social nuisance, however, it potentially affects the processes of production that form the basis of modern societies. The individual who is acutely paranoid or severely depressed, for example, is unlikely to be able to work, or at least to work efficiently, and family members, too, may be prevented from working because of the disruption caused to their lives. Moreover, someone who is severely mentally disturbed may frighten and upset those around them, preventing people from feeling secure and motivated enough to satisfy the requirements of labour, and potentially jeopardising the whole system of modern production.

The more common, yet less visible social consequence of mental health problems that is specific to capitalist societies is not being able to support oneself financially. Capitalism depends on the majority of people earning their living through wage labour, and to be of use to capitalists, workers have to generate more wealth or value than they earn–what is known as “surplus value”. If an individual falls below a certain level of productivity, it is no longer worth the expense of employing them. However, people who are unable to participate in productive labour that generates “exchange value” may nevertheless be able to engage in other useful activities and create “use value”. They are not incapable of work, just incapable of doing the sort of work that is available in an advanced capitalist economy. Some of these people are part of the “industrial reserve army”, who are recruited into work at times of labour shortage, and who help capitalists to keep wages down to maximise profit, but others, whom Marx referred to as the “demoralised, the ragged”; are unable to perform capitalist work on any terms ( Marx, 1990 ) (p. 797).

The inability to earn associated with mental health problems may be temporary, lasting for the few weeks or months that the episode of madness, depression or stress endures, or it may be longer-lasting. Even if it is temporary, it may be recurrent, and the occurrence and duration of episodes is highly individual and unpredictable, making it difficult for those without highly supportive employers to sustain employment. There is no mechanism integral to capitalism to provide for people who are not employed, but capitalist economies have developed systems of welfare through the course of the last century, including the provision of financial support to the those who are classified as medically sick or disabled ( Matthews, 2018 ).

The Mental Health System and the Welfare State

The mental health system, along with physical health services, education and the criminal justice system, fulfil certain social needs and thereby produce “use values” in the Marxist sense. If these services are provided capitalistically, that is by private firms that generate and accumulate capital through the extraction of surplus value, they also produce “exchange value”. In modern capitalist societies of all political hues, a large part of these services are funded and coordinated by the state, both because a significant section of the population cannot afford them, and because of the level of organisation required. They may be provided by state enterprises or by private firms or charitable organisations, and they are often referred to collectively as the Welfare State.

Marxist commentators on the Welfare State highlight how it contributes to the social reproduction of the capitalist system by ensuring that there is a supply of healthy, educated and disciplined workers ( Gough, 1979 ; O'Connor, 1973 ). These activities indirectly facilitate productive labour and the process of capital accumulation. The welfare state also ensures social harmony, by providing for the old and sick and sustaining those who will never enter the workforce, for example. These expenses are what Marx referred to as the “ faux frais [incidental expenses] of capitalist production” ( Marx, 1990 ) (p. 797). They are not associated with capitalist production per se , but can be viewed as a means of legitimation of the system, since, by preventing people from dying on the streets, they ensure the continuation of capitalist relations of exploitation and domination through hegemony rather than force ( Higgs, 1993 ). Other Marxists highlight how the welfare state resulted from class struggle, and represents a concession to the working class inspired by the threat of revolution ( Ferguson et al., 2002 ; Matthews, 2018 ), and others have pointed out how many functions of the welfare state are necessary for social reproduction in any modern economic system, and are not specific to capitalism ( Cowling, 1985 ).

Most welfare state spending is not directly productive as it is provided either by public enterprises, which do not generate surplus value, or, if provided by the private sector, capital accumulation is constrained by the limits of public funding and taxation. Welfare services embody a contradiction, therefore, and represent both a pre-requisite for the continued existence of capitalism, and, at the same time, a drain on the surplus; “both a condition of capital accumulation and a subtraction from it” ( Pierson, 1996 ) (p. 581) ( O'Connor, 1973 ). This has led some to argue that the welfare state potentially undermines capitalism in the long-run ( Gough, 1979 ; Bennett et al., 2009 ).

The philosophy behind the creation of the welfare state in the mid 20th century, as espoused by Keynes and the social democratic regimes that took up his ideas, was that it was the duty of the state to intervene and alleviate problems such as poverty and unemployment. It was the state’s responsibility to ensure there were employment opportunities, education, housing and healthcare available to all ( Higgs, 1993 ). During the 1970s, however, the welfare state came to be seen as contributing to or even causing the economic crisis of capitalism, and regimes all over the world started to bring in measures to reduce its costs. This commonly involved the privatisation of state services, since the private sector could employ people at lowers costs due to longer hours, worse pay and conditions. It also involved a reorientation of the philosophy behind the welfare state, which involved shifting responsibility from the government to the individual. Relatively generous and automatic unemployment or social security benefits were phased out, for example, and in their place individuals had to prove their entitlement, which involved demonstrating either a willingness to work, or an incapacity for work ( Higgs, 1993 ).

Much of the mental health system predates the creation of the welfare state; indeed it prefigures other aspects of the welfare state in its role in producing a social environment conducive to the accumulation of capital. However, as a state-subsidised enterprise, it can usefully be considered as part of the welfare state, and as with other sectors, the provision of services for the seriously mentally ill has been increasingly transferred from the state to the private sector over recent decades.

The functions of the mental health system

Maintaining order and providing care.

The mental health system in England evolved out of the Poor Laws that were enacted from the Tudor period in order to manage the problems created by the expropriation of the agricultural population, which was the first step necessary to provide the labour needed for capitalism, as depicted by Marx in Das Capital ( Marx, 1990 ). The Poor Laws provided material and financial assistance or “relief”, raised through local taxes, to families who could not provide for themselves, including in those instances in which a member of the family was mentally incapacitated. Poor Law officials also helped to keep the community safe and secure, and could use the money at their disposal to pay for the confinement of local people felt to be dangerous in various settings, such as a neighbouring household or, if necessary, a prison or prison-like establishment such as a “House of Correction” ( Fessler, 1956 ; Rushton, 1988 ).

Public mental institutions, known as “asylums”, arose in the context of an austerity drive in the early 19th century. This was intended to reduce the welfare burden by ending the system of “outdoor relief” that supported people in their own homes, and making state support contingent on entering the forbidding and highly stigmatised Workhouse, a policy encapsulated in the 1834 Poor Law Amendment Act [although some local authorities continued to pay “outdoor relief” ( Forsythe et al., 1996 )]. With the rise of the Workhouse, the “deserving” poor, who could not work by dint of mental derangement or impairment among other causes, needed to be separated from the “undeserving” poor - those deemed capable of work. The former were diverted to the new system of public asylums for treatment and cure that were constructed all over England during the middle of the 19th century, while the latter were made to do hard labour in exchange for their upkeep in the Workhouse ( Scull, 1993 ).

The system was publicly funded because the costs of care and confinement were way beyond the majority of families, and because, as historian, Andrew Scull, suggests, building on the work of Michel Foucault, it was part of the means of establishing a disciplined workforce that had the requisite motivation to be put to work as wage labourers in the service of Capital ( Foucault, 1965 ; Scull, 1993 ). Asylums provided a secluded place where people whose behaviour was socially disruptive but not obviously criminal could be contained, but they also provided care and sustenance for those who were too confused, chaotic or apathetic to be put to work in the Workhouse or driven out to scrape a living together in the harsh world of Victorian England. Despite widespread myths to the contrary, people who were simply eccentric or socially deviant (e.g. unmarried mothers) were not routinely admitted to the public asylums unless their behaviour posed significant problems ( Rehling and Moncrieff, 2020 ).

The need for the State to provide care and containment arose partly because the capitalist system of wage labour meant there was little spare capacity within the family or community to look after someone who could not look after themselves ( Wright, 1997 ). All modern societies that rely on industrial production and a large workforce have similar requirements and allowing the disturbed and confused to roam the streets or rot away due to lack of care would quickly undermine the legitimacy of any system. Persuading people to work in a capitalist manner towards the enrichment of others arguably requires greater motivation and discipline, however, especially if, as was the case at the beginning of the capitalist era, people are not used to doing so. Early capitalism, therefore, produced a particular imperative for the management of the seriously mentally ill, which is manifested in the vast amount of public resources expended on the asylum system in the 19th century.

Although the roots of this system are political and social - “moral” according to Foucault - since the 19th century it has presented itself as a medical endeavour directed at medical problems. Foucault suggested that the medical framework was superimposed onto the system in order to give it the legitimacy associated with science. He referred to psychiatry as a “moral enterprise overlaid by the myths of positivism” ( Foucault, 1965 ) (p. 276). In a modern liberal society where the rights of the individual are pre-eminent, psychiatry can only fulfil its functions by presenting itself as a technical activity that is immune to political considerations. The medical nature of psychiatric terminology and knowledge obscures the values and judgements that are embedded in its practical execution ( Ingelby, 1981 ). It enables interventions that are designed to curb or control unwanted behaviour to be conceptualized as medical treatments intended to benefit the recipient rather than the people who are disturbed by the individual’s behaviour. It also extends the prerogative of the sick role, with its entitlement to care, to those who are unable to care for themselves, but where no obvious physical disease can account for their incapacity, and where the entitlement might, therefore, be questioned.

Modern Developments

The large public asylums were scaled down and finally closed from the 1980s onwards, and the official story declares that this process of deinstitutionalisation, as it was known, demonstrates the efficacy of modern drug treatments and confirms the validity of the medical view of mental disorder ( Cookson et al., 2005 ). A Marxist analysis, on the other hand, suggests that the institutions were closed because of the desire to reduce public spending ( Scull, 1977 ). It is now apparent that although the new drugs may render some people more subdued, they rarely enable people to become fully independent. A study published in 2005, for example, found that in 1998, more people were dependent on state and private services due to mental health problems than in 1898 ( Healy et al., 2005 ). Instead, long-term psychiatric patients are now placed in other institutions - smaller, privately-run but state funded residential and nursing homes, for example, as well as private psychiatric hospitals, secure units and prisons, and many rely on the care and support of family members or paid carers ( Priebe et al., 2005 ). Many subsist on financial support from the state, the new version of “outdoor relief”.

Deinstitutionalisation was, therefore, partly an exercise in transferring provision for the long-term mentally disabled from the state to the private sector. The income still largely derives from the state, but the organisation of these services into private companies has enabled them to become a potential source of capital accumulation through the exploitation of employees.

The vast majority of people who are currently diagnosed with a mental disorder cause no trouble for other people and have no difficulty looking after themselves on a day-to-day basis but are not able to work and so rely on financial support provided through the state welfare system. Welfare payments have become an important part of the mental health system and illustrate how conceptualising certain problems as mental illness or disorder disguises the flaws of the capitalist system, thus helping to suppress resistance to it.

Marxist analysts of disability have pointed out how capitalism constructs disability or dependency as a social problem. In pre-capitalist societies, the distinction between the dependent and independent was not clear-cut. Most people could produce “use value”, contributing to the maintenance of the family and community in some fashion. In a capitalist society, in contrast, people are either fit to be exploited or they are unemployable ( Finkelstein et al., 1981 ; Oliver, 1999 ; Slorach, 2011 ; Bengtsson, 2017 ). One of the major roles of the welfare state is the provision of financial or material support for those who cannot work intensively and productively enough to generate surplus value.

Sickness and disability payments were introduced in most western countries in the middle of the 20th century and have been rising rapidly since the 1980s, despite efforts to curb them ( Kemp et al., 2006 ; Niemietz, 2016 ). Much of this rise is accounted for by the increase in people claiming benefits for mental health problems, particularly those classified as depression or anxiety ( Waddell and Aylward, 2005 ; Kemp et al., 2006 ; Brown et al., 2009 ; Danziger et al., 2009 ). In the United Kingdom in 2008, it was estimated that the total cost of sickness and disability-related worklessness among the working age population was more than the cost of the whole of the National Health Service ( Black, 2008 ). By 2014, almost half of United Kingdom claimants were classified as having a mental disorder as the reason for their claim, which was by far the largest category of causal medical conditions. Claims made due to a mental disorder doubled between 1995 and 2014, while claims made for most other types of medical conditions fell. These claims were predominantly long-term ( Viola and Moncrieff, 2016 ). Similarly in the United States, claims for disability payments due to mental health problems have increased at a faster rate than claims for other medical conditions, and by 2005 they accounted for around a third of claims made to the major disability benefit schemes ( Danziger et al., 2009 ). Again, once on disability benefits, people rarely go off them ( Joffe-Walt, 2013 ).

The rise in disability payments to people with common mental disorders like anxiety and depression is paralleled by the phenomenal rise in antidepressant prescribing that has occurred since the early 1990s throughout the world. Consumption of antidepressants more than doubled in the United Kingdom between 1998 and 2010, for example ( Ilyas and Moncrieff, 2012 ), having previously risen by more than three times from 1988 to 1998 ( Middleton et al., 2001 ). There have been similar rises in many OECD countries ( Organisation for Economic Development, 2020 ). Over the past few decades, an increasing proportion of people have been prescribed these drugs on a long-term basis ( Mars et al., 2017 ; Taylor et al., 2019 ).

Studies of employment have also shown that receiving treatment for a mental health problem is associated with people taking more time off and being less likely to return to work than people who do not receive treatment ( Dewa et al., 2003 ). It appears, therefore, that in many high income countries, including the United Kingdom and US, large numbers of people become economically inactive and are classified as being long-term mentally ill. They receive financial benefits and prescriptions for psychiatric drugs, and some may receive psychological therapy.

These recent trends illustrate the relationship between welfare and capital accumulation. During the period of Neoliberalism the ruling class has pushed back against the concessions that workers won during the mid 20th century in order to increase or maintain profit margins ( Harvey, 2005 ; Glynn, 2006 ; Boltanski and Chiapello, 2018 ). This has been achieved by relocating many manual industries to countries where labour costs are cheaper, and by increasing the intensity or productivity of the work that remains ( Office for National Statistics, 2018 ).

People have to work harder than they did in the past, their output and performance is constantly scrutinsed, and there is the constant threat of losing one’s jobaltogether, especially for the increasing number of people employed on a casual or “self-employed” basis. The work environment requires workers to be more and more robust, efficient and compliant ( Dardot and Laval, 2017 ). This applies to the public sector too, which has been remodelled on the private sector since the 1990s ( Ironside and Seifert, 2004 ). Whereas previously there may have been a niche for the less productive in state enterprises, such as the UK’s National Health Service (NHS), these now engage in intense performance monitoring and take a more disciplinarian approach to the workforce, resulting in a culture of “fear and blame” and a “demotivated workforce with low morale” ( Stevenson and Moore, 2019 ) (p. 1). It is not surprising, therefore, that increasing numbers find they cannot tolerate the demands of work as it is currently organised.

Neoliberal capitalism increases the need or demand for disability benefits, therefore, but at the same time it attempts to restrain those benefits, which represent a drain on the overall surplus. In the United Kingdom, for example, the government has introduced more stringent criteria for qualifying as sick or disabled, abolished certain allowances, capped others, and set benefit rises below inflation ( UNISON, 2013 ). Such measures are in constant tension with the fact that the alternative of working on the open market is less achievable for many, and hence attempts to restrain spending are barely successful ( Office for Budget responsibility, 2019 ).

Capitalism creates redundant workers out of those people who can work, but are not productive enough to produce the desired amount of surplus value due to physical or mental disability ( Finkelstein et al., 1981 ; Oliver and Flynn RJL, 1999 ). State-funded sickness and disability benefits disguise this structural unemployment–unemployment that is inherent to the current stage of capitalism ( Beatty et al., 2000 ; Roberts and Taylor, 2019 ). In the US, this activity has become a new industry, with states paying businesses to help move people from state-funded social security to federally funded disability programmes ( Joffe-Walt, 2013 ).

This process of exclusion from the productive workforce deprives people of a feeling of connection with and investment in their community, thus contributing to people becoming marginalised and demoralised, which is then labelled as mental illness. In this way, unemployment and low productivity are constructed as the fault of the individual (albeit a biological rather than a moral fault), rather than a systemic problem that reflects the prioritisation of profit over participation ( Davies, 2017 ). The welfare system also solidifies people’s identity as “spoiled” or damaged; as being incapable. Like the asylums of the 19th century, it keeps the non-working population quiet and secluded so the rest can be effectively exploited.

The Promotion of Hegemony

Underpinning the previously described functions of the mental health system is the idea that the situations concerned are medical conditions, with the implication that they originate in the body and thus absolve individuals of responsibility for their behaviour, and justify the forcible modification of that behaviour by others ( Moncrieff, 2020 ). Although we have seen that this position is not supported by scientific evidence, it is widely embraced and its acceptance helps to legitimise the social and political status quo.

Construing life difficulties as an illness in what Nikolas Rose has called “the psychiatric re-shaping of discontent” ( Rose, 2006 ) (p. 479) has long been recognised as a political strategy that silences protest and inhibits change. This was pointed out in the 1960s and 1970s by social scientists who explored the creeping medicalisation of society ( Zola, 1972 ; Illich, 1976 ; Conrad and Schneider, 1980 ), along with “antipsychiatry” thinkers ( Laing, 1967 ) and has been explored more recently by critics of neoliberalism ( Fisher, 2009 ; Cohen, 2016 ; Davies, 2017 ). This strategy has been employed in socialist as well as capitalist countries. As William Davies points out, unhappiness has “political and sociological qualities that lend it critical potential” ( Davies, 2011 ). To construe it as an illness, to label it as “clinical depression” as it is in neoliberal, western societies, as anxiety as it was for much of the 20th century ( Healy, 2004 ), or neurasthaenia as it was in the Soviet bloc and communist China ( Kleinman, 1982 ; Skultans, 2003 ), is to declare that it is not reasonable, to see it as something to be eradicated, rather than understood. Viewing worry, distress and misery as a medical condition isolates the individual as a patient who needs to be cured of their internal flaws. It cuts them off from understanding the social implications of their feelings, and it prevents society from understanding epidemics of mental health problems as “commentaries on social life” ( Davies, 2017 ) (P 205).

As already noted, there has been a huge expansion in the numbers of people receiving mental health diagnoses and treatments in high income countries over recent decades with dramatic increases in the use of antidepressants, in particular, but also of stimulants (commonly prescribed for a diagnosis of ADHD), new anti-anxiety agents and drugs usually associated with the treatment of more severe disorders, such as antipsychotics ( Ilyas and Moncrieff, 2012 ). Seventeen per cent of the population of England are now prescribed an antidepressant alone ( Taylor et al., 2019 ).

There are some obvious drivers of this trend, such as the pharmaceutical industry, whose marketing activities have been facilitated both by the arrival of the Internet, and by political deregulation, including the repeal of the prohibition on advertising to consumers in the US and some other countries in the 1990s ( Davies, 2017 ). Despite the fact that there is no evidence of an imbalance or abnormality of brain chemicals or any other biological abnormality in people with depression ( Kennis et al., 2020 ; Moncrieff et al., 2021 ), the industry, aided and abetted by professional organisations such as the American Psychiatric Organisation and the UK’s Royal College of Psychiatrists ( APA, 2018 ; Royal College of Psychiat, 2009 ), has succeeded in persuading the general public that unhappiness and discontent arise from a faulty brain. Surveys conducted in the US and Australia in the 2000s, for example, showed that 85 and 88% of respondents respectively endorsed the idea that depression is caused by a chemical imbalance ( France et al., 2007 ; Pilkington et al., 2013 ).

Political institutions have also embraced the idea that human reactions to difficult circumstances can be understood as mental health problems. The United Kingdom government’s initiative on “transforming children and young people’s mental health” for example ( NHS, 2021 ), is premised on the idea that the source of stress, anxiety and behaviour problems among the young is not the conditions they grow up in or the highly competitive nature of the modern educational system, but individual flaws or weaknesses that can be addressed through treatment designed to help the individual to adjust and assimilate. Mental health support teams have been introduced into schools to “provide early intervention on some mental health and emotional wellbeing issues, such as mild to moderate anxiety” and referrals to NHS services for more severe problems. Inevitably, this will lead to increasing numbers of pupils being given a potentially stigmatising diagnostic label and pharmaceutical treatments, which are unlikely to have net benefits for most of them but certainly have risks and dangers ( Kazda et al., 2021 ).

Capitalism requires a certain level of dissatisfaction in order to operate smoothly and maintain consumption. People need to be persuaded that their lives are lacking in some way, and neoliberalism, with its rolling back of state responsibilities, has exaggerated this tendency ( Davies, 2011 ). The “privatisation of public troubles and the requirement to make competitive choices at every turn” ( Hall et al., 2013 ) (p. 12) breed perpetual feelings of insecurity and inadequacy that establish the demand necessary to stoke capital accumulation. The construction of the ideal neoliberal subject as an informed and intelligent consumer, who is fully responsible for their own wellbeing, both creates the conditions for increasing personal stress, in what has been called a “malady of responsibility” ( Dardot and Laval, 2017 ) (P 292), and encourages people to look for solutions in the consumption of pharmaceuticals and other easily marketable products, such as short-term therapy ( Davies, 2017 ).

Competition, the basis of the capitalist system, creates winners and losers. Fear of failure is therefore a constant source of anxiety for the modern individual, and failure itself so often the precipitant of the demoralisation and hopelessness that is called depression ( Ehrenberg, 2010 ; Dardot and Laval, 2017 ). “Depression is the shadow side of entrepreneurial culture,” said Marxist author Mark Fisher, “what happens when magical voluntarism confronts limited opportunities” ( Fisher, 2012 ).

Presenting this situation as individual deficiencies rather than a systemic by-product helps obscure its political and economic origins. The language of mental health and mental illness or disorder can be thought of, therefore, as an “ideology”, in the Marxist sense that these concepts help to obscure real underlying tensions and conflicts, and render the population amenable to viewing them as relatively simple, technical problems that should be left to experts. As Bruce Cohen points out, “biomedical ideology has become the dominant “solution’’ to what are social and economic conditions of late capitalism’’ ( Cohen, 2016 ) (p. 91). Authors who have described this phenomenon as “psychiatrization” highlight how it leads to numerous personal and social consequences from the creation of individual dependency to the diversion of needed resources from other areas of health and social services ( Beeker et al., 2021 ), but most importantly, from the Marxist point of view, it disguises “failed policies” ( Conrad, 1992 ) (p. 7).

The current “mental health movement”, with its encouragement to conceive of our understandable reactions to an increasing array of social problems, including unemployment, school failure, child abuse, domestic violence and loneliness as individual pathology requiring expert, professional treatment, promotes an ideology that helps legitimise existing social and economic relations by diverting attention from the problems themselves. In this way, it acts as a hegemonic tool for the capitalist system that now dominates most of the globe. It has been successful in moulding public attitudes and gaining political support, despite efforts of some mental health campaigners, professionals and academics to expose its political implications and to present other ways of understanding the difficulties we currently refer to as mental disorders ( Johnstone et al., 2018 ; Guy et al., 2019 ).

Social Responses to Mental Health Problems

As this analysis illustrates, how society responds to the problems posed by dependency and troublesome behaviour is potentially contentious. For Foucault, and medical sociologists, such as Peter Conrad, one of the important consequences of the medicalisation of such problems is to render them morally and politically neutral ( Foucault, 1965 ; Conrad, 1992 ). The concept of mental illness provides a justification for using force against people whose behaviour is antisocial or dangerous, but who are too confused or irrational to be appropriate for the criminal justice system. It also authorises support for people who do not qualify for care or welfare by virtue of being old or physically sick or disabled. Presenting these responses as medical activities that are the rightful and exclusive terrain of qualified, medical specialists shields them from being questioned or challenged. As the psychiatrist and critic, Thomas Szasz pointed out, the psychiatric system performs its functions “in a manner that pleases and pacifies the consciences of politicians, professionals and the majority of the people” ( Szasz, 1994 ) (p. 200). It also has a wider hegemonic role in the maintenance of capitalism, along with other socio-economic systems, by locating the sources of individuals’ unhappiness and discontent within their own brains, rather than in their external circumstances, individualising “what might otherwise be seen as collective social problems” and thereby letting the political and economic system off the hook ( Conrad, 1992 ) (p. 224).

On the other hand, some left-wing analysts, notably Peter Sedgewick, point out that this position enables capitalist governments to cut disability benefits and reduce other resources available for people affected by mental health problems ( Sedgewick, 1982 ). While this may be theoretically possible, it depends on Sedgewick accepting the view that mental disorders are essentially equivalent to neurological diseases.

Apart from the lack of evidence that this is the case, it is difficult to accept that all dependency and disruptive behaviour is caused by a physical disease. If it is not, ( Moncrieff, 2020 )? then surely we need a more transparent system of control and care, that acknowledges the ethical and political dilemmas involved and is based on widespread democratic debate informed particularly by the voice of the system’s recipients. Such a system would have to balance the need to restrict people’s behaviour when it becomes a nuisance or danger to other people, with the individual’s legitimate interests to live in the way they want to live (19). We also need an alternative to the sick role in order to fairly and transparently distribute resources and care to people who are unable to be financially or practically independent, without having to deem them as being biologically flawed ( Cresswell and Spandler, 2009 ).

Reflections on Capitalism

This analysis suggests that the mental health system can be understood as part of a wider system of social reproduction through which modern societies produce a fit, capable and amenable workforce and ensure social harmony. The particular means of social reproduction depend on the economic and social form that each society takes. Some aspects of the mental health system are an enduring response to perennial social problems that cut across different epochs, political systems and cultures. These have not been fundamentally changed by the introduction of modern medical perspectives and interventions. For hundreds of years, English Poor Law officials grappled with how to help a family whose breadwinner had become mentally incapable, or how to protect the community from someone who was behaving irrationally and unpredictably ( Rushton, 1988 ). Supporting the chronically dependent and controlling chaotic and disruptive behaviour remain the main functions of the modern mental health system.

On the other hand, some trends are distinctive of capitalism in general and neoliberal capitalism in particular. The modern welfare state emerged, in part, to compensate those who cannot work intensively and productively enough to earn a living through wage labour. The concept of mental illness enables a system that is justified by the nature of physical sickness and disability to incorporate people who are disorganised, demoralised, slow, antisocial, chaotic or unmotivated–factors whose significance clearly varies according to the nature of the work that is available. Some of these people may be recruited into the work force during an economic boom, and in the mid 20th century, when conditions for labour were more favourable, even those people diagnosed with severe mental conditions such as ‘schizophrenia’ had a reasonable chance of employment ( Warner, 2004 ).

During the decades of neoliberal capitalism, however, as labour entitlements have been rolled back and work has become more competitive and exploitative, increasing numbers of people have become economically inactive for long periods. It is patently absurd to imagine that the quarter of the population who have been diagnosed with a mental illness ( Health and Social Care Information Centre, 2015 ), or the fifth who take antidepressants ( Taylor et al., 2019 ) have an as yet unidentified brain disease. Instead, this situation reflects the changing structure of contemporary capitalism. Disability support disguises the way in which capitalism narrows the opportunities for people to contribute to the productive efforts of society, thereby relegating large numbers of people into a surplus population that has no investment in its own community. The transformation of post-industrial populations into mental patients represents the economic and social marginalisation of a large segment of society. Rejecting the medicalisation of so-called mental health problems is a necessary step in revealing some of the fundamental contradictions of capitalism and laying the groundwork for political change.

Author Contributions

The author confirms being the sole contributor of this work and has approved it for publication.

Conflict of Interest

The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Acknowledgments

I would like to thank Graham Scambler, Paul Higgs, Bruce Cohen and Paul Blackledge for providing helpful comments on the manuscript and suggestions for further reading.

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Keywords: Marxism, mental disorder, history of psychiatry, neoliberalism, political economy

Citation: Moncrieff J (2022) The Political Economy of the Mental Health System: A Marxist Analysis. Front. Sociol. 6:771875. doi: 10.3389/fsoc.2021.771875

Received: 07 September 2021; Accepted: 14 December 2021; Published: 17 January 2022.

Reviewed by:

Copyright © 2022 Moncrieff. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Joanna Moncrieff, [email protected]

This article is part of the Research Topic

Psychiatrization of Society

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2 Explaining Health, Illness, and Society: Theoretical Approaches

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The first part of this chapter is about emergence of SOHM and the second part engages in details with four major sociological theories postulating the relations between society, health and medicine. We would be able to understand the significance of sociological theories of medicine and health, only if we know why SOHM emerged and what its proposed role and its initial concerns were. Accordingly the first part of the chapter outlines the conditions under which SOHM emerged in various parts of the world and what kind of relation it had with systems of medicine of the times. The latter part offers a detailed account of four theories, namely, Functionalism, Marxism, Feminism and Pluralism with examples and case studies for each.

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19.2: Sociological Perspectives on Health and Illness

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• Page ID 57132

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The Functionalist Perspective

In the functionalist model, Parsons argued that illness is a form of deviance that disturbs the social function of a society.

Learning Objectives

Discuss the functionalist perspective on illness in society, specifically the role the sick play in a specific society and how that role affects others

• Functionalism addresses society as a whole in terms of the function of its constituent elements (namely norms, customs, traditions, and institutions ), much like the interacting organs within the human body.
• Prominent functionalist theorists include Auguste Comte, Herbert Spencer, Talcott Parsons, Kingsley Davis and Wilbert E. Moore, Robert Merton, and Gabriel Almond and Bingham Powell.
• Functionalism is a framework that sees society as a complex system whose parts work together to promote solidarity and stability.
• Functionalists argue that a sick individual is not a productive member of society; therefore this deviance needs to be policed. This is the role of the medical profession.
• Structural functionalism reached the peak of its influence in the 1940s and 1950s, and by the 1960s was in rapid decline, replaced by conflict-oriented approaches in Europe and more recently by structuralism.
• deviance : Actions or behaviors that violate formal and informal cultural norms, such as laws or the norm that discourages public nose-picking.
• structuralism : A theory of sociology that views elements of society as part of a cohesive, self-supporting structure.

Structural functionalism, or simply functionalism, is a framework for building theory that sees society as a complex system whose parts work together to promote solidarity and stability. This approach looks at society through a macro-level orientation, which is a broad focus on the social structures that shape society as a whole. This approach looks at both social structure and social functions. Prominent functionalist theorists include Auguste Comte, Herbert Spencer, Talcott Parsons, Kingsley Davis and Wilbert E. Moore, Robert Merton, and Gabriel Almond and Bingham Powell.

Functionalism addresses society as a whole in terms of the function of its constituent elements; namely norms, customs, traditions, and institutions. A common analogy, popularized by Herbert Spencer, presents these parts of society as “organs” that work toward the proper functioning of the “body” as a whole. For Talcott Parsons (1902–1979), an American sociologist, “structural-functionalism” came to describe a particular stage in the methodological development of social science, rather than a specific school of thought.

The Sick Role

Sick role is a term used in medical sociology regarding sickness and the rights and obligations of the affected. It is a concept created by the American sociologist Talcott Parsons in 1951. Parsons was a functionalist sociologist who argued that being sick means that the sufferer enters a role of “sanctioned deviance”. This is because, from a functionalist perspective, a sick individual is not a productive member of society. Therefore this deviance needs to be policed, which is the role of the medical profession.

In the functionalist model, Parsons argued that the best way to understand illness sociologically is to view it as a form of deviance that disturbs the social function of the society. The general idea is that the individual who has fallen ill is not only physically sick, but now adheres to the specifically patterned social role of being sick. “Being Sick” is not simply a “condition”; it contains within itself customary rights and obligations based on the social norms that surround it.

The theory outlined two rights of a sick person and two obligations. The sick person’s rights are twofold: the first one is being exempt from normal social roles; the second one is not being responsible for their condition. Conversely, the sick person’s obligations included trying to get well and cooperating with the medical professionals. Parsons concluded that there are three versions of the sick role: conditional, unconditional legitimate, and illegitimate (a condition stigmatized by others).

Critics of the Functionalist Perspective

Critics of Parsons and the functionalist perspective point to different flaws they see with his argument. The model assumes that the individual voluntarily accepts the sick role. It also assumes that the individual may not comply with expectations of the sick role, may not give up social obligations, may resist dependency, and may avoid the public sick role if their illness is stigmatized. The model also blames the sick, where “rights” do not always apply.

Structural functionalism reached the peak of its influence in the 1940s and 1950s, and by the 1960s was in rapid decline. By the 1980s, its place was taken in Europe by more conflict-oriented approaches, and more recently by “structuralism”. While some of the critical approaches also gained popularity in the United States, the mainstream of the discipline has instead shifted to a myriad of empirically-oriented middle-range theories with no overarching theoretical orientation. To most sociologists, functionalism is now obsolete.

The Conflict Perspective

Conflict theory argues that the economic and political structures of a society create social divisions, inequalities, and conflicts.

Examine the differing views on conflict theory from various sociologists, such as Karl Marx and C. Wright Mills

• Conflict theories are perspectives in social science that emphasize the social, political, or material inequality of a social group.
• Of the classical founders of social science, conflict theory is most commonly associated with Karl Marx, who posited that capitalism would inevitably produce internal tensions leading to its own destruction.
• Marx advocated for the rejection of false consciousness (explanations of social problems as the shortcomings of individuals rather than the flaws of society ) and the claiming of class consciousness (workers’ recognition of themselves as a class unified in opposition to the capitalist system).
• The Polish-Austrian sociologist Ludwig Gumplowicz and the American sociologist Lester F. Ward approached conflict from a comprehensive anthropological and evolutionary point-of-view.
• C. Wright Mills has been called the founder of modern conflict theory. In Mills’s view, social structures are created through conflict between people with differing interests and resources.
• Conflict theory is most often associated with Marxism, but may also be associated with other perspectives such as critical theory, feminist theory, postmodern theory, queer theory, and race -conflict theory.
• functionalism : Structural functionalism, or simply functionalism, is a framework for building theory that sees society as a complex system whose parts work together to promote solidarity and stability.
• military-industrial complex : The armed forces of a nation together with the industries that supply their weapons and materiel.
• capitalism : A socio-economic system based on private property rights, including the private ownership of resources or capital, with economic decisions made largely through the operation of a market unregulated by the state.

Conflict theories are perspectives in social science that emphasize the social, political, or material inequality of a social group, that critique the broad socio-political system, or that otherwise detract from structural functionalism and ideological conservatism. Sociologists in the tradition of conflict theory argue that the economic and political structures of a society create social divisions, classes, hierarchies, antagonisms and conflicts that produce and reproduce inequalities. Certain conflict theories set out to highlight the ideological aspects inherent in traditional thought. While many of these perspectives hold parallels, conflict theory does not refer to a unified school of thought, and should not be confused with, for instance, peace and conflict studies.

Of the classical founders of social science, conflict theory is most commonly associated with Karl Marx (1818–1883). Based on a dialectical materialist account of history, Marxism posited that capitalism, like previous socioeconomic systems, would inevitably produce internal tensions leading to its own destruction. Marx ushered in radical change, advocating proletarian revolution and freedom from the ruling classes. At the same time, Karl Marx was aware that most of the people living in capitalist societies did not see how the system shaped the entire operation of society. Just like how we see private property, or the right to pass that property onto our children as natural, many of members in capitalistic societies see the rich as having earned their wealth through hard work and education, while seeing the poor as lacking in skill and initiative. Marx rejected this type of thinking and termed it false consciousness, which involves explanations of social problems as the shortcomings of individuals rather than the flaws of society. Marx wanted to replace this kind of thinking with something Engels termed class consciousness, which is when workers recognize themselves as a class unified in opposition to capitalists and ultimately to the capitalist system itself. In general, Marx wanted the working class to rise up against the capitalists and overthrow the capitalist system.

Two early conflict theorists were the Polish-Austrian sociologist and political theorist Ludwig Gumplowicz (1838–1909) and the American sociologist and paleontologist Lester F. Ward (1841–1913). Although Ward and Gumplowicz developed their theories independently, they had much in common and approached conflict from a comprehensive anthropological and evolutionary point-of-view as opposed to Marx’s rather exclusive focus on economic factors.

C. Wright Mills has been called the founder of modern conflict theory. In Mills’s view, social structures are created through conflict between people with differing interests and resources. Individuals and resources, in turn, are influenced by these structures and by the “unequal distribution of power and resources in the society. ” Mills argued that the interests of the power elite of American society (for example, the military-industrial complex) were opposed to those of the people. He theorized that the policies of the power elite would result in the “increased escalation of conflict, production of weapons of mass destruction, and possibly the annihilation of the human race. ”

Conflict theory is most commonly associated with Marxism, but as a reaction to functionalism and the positivist method, it may also be associated with a number of other perspectives, including critical theory, feminist theory, postmodern theory, post-structural theory, postcolonial theory, queer theory, world systems theory, and race-conflict theory.

The Interactionist Perspective

According to theorists working in the symbolic interactionist perspective, health and illness are socially constructed.

Explain and give examples of social constructions of health according to the symbolic interactionist perspective

• Symbolic interactionist researchers investigate how people create meaning during social interaction, how they present and construct the self, and how they define situations of co-presence with others.
• Constructivist grounded theory emphasizes the development of an interactive relationship and mutual construction of knowledge between researcher and participants.
• Medicalization of deviance refers to the process that changes “bad” behavior into “sick” behavior.
• Demedicalization refers to the process when “sick” behavior is normalized again.
• medicalization of deviance : The medicalization of deviance refers to the process that changes “bad” behavior into “sick” behavior.
• demedicalization : Demedicalization refers to the process when “sick” behavior is normalized again.
• symbolic interactionist : Symbolic interactionist researchers investigate how people create meaning during social interaction, how they present and construct the self, and how they define situations of co-presence with others.

According to theorists working in the symbolic interactionist perspective, health and illness are socially constructed. Symbolic interactionist researchers investigate how people create meaning during social interaction, how they present and construct the self (or “identity”), and how they define situations of co-presence with others. One of the perspective’s central ideas is that people act as they do because of how they define situations.

Constructivist grounded theory emphasizes the development of an interactive relationship and mutual construction of knowledge between researcher and participants. Symbolic interactionists believe that objects have meaning only through people’s interactions with them in the environment, that the meanings people have for things develops through social interaction and that those meanings are handled and modified by a constant and ongoing interpretive process by individuals.

An example of the social construction of health the the Rate of Perceived Exertion, or RPE. This scale measures the intensity of a person’s workout on a scale of 0 to 10. This scale was developed by Gunnar Borg, and it is used by medical professionals to assess a person’s health in a variety of ways.

In essence, interactionists focus on the specific meanings and causes people attribute to illness. The term “medicalization” of deviance” refers to the process that changes “bad” behavior into “sick” behavior. A related process is “demedicalization”, in which “sick” behavior is normalized again. Medicalization and demedicalization affect who responds to the patient, how people respond to the patient, and how people view the personal responsibility of the patient.

An example of medicalization is illustrated by the history of how our society views alcohol and alcoholism. During the 19 th century, people who drank too much were considered “bad, lazy people. ” They were called drunks, and it was not uncommon for them to be arrested or run out of a town. Drunks were not treated in a sympathetic way because, at that time, it was thought that it was their own fault that they could not stop drinking. During the latter half of the 20 th century, however, people who drank too much were increasingly defined as people with a disease or a genetic predisposition to addiction. With alcoholism defined as a disease and not a personal choice, alcoholics came to be viewed with more compassion and understanding. Thus, “badness” was transformed into “sickness”.

While interactionism does acknowledge the subjective nature of diagnosis, it is important to remember who benefits the most when a behavior becomes defined as illness. Pharmaceutical companies make billions of dollars treating illnesses such as fatigue, insomnia, and hyperactivity that may not actually be illnesses in need of treatment, but opportunities for companies to make more money.

The Labeling Approach

The labeling approach to health and illness claims that mental illness is manifested solely as a result of societal influence.

Analyze the pros and cons of labeling theory, especially the implications it has for the “mentally ill” and HIV/AIDS patients

• Developed by sociologists during the 1960s, labeling theory holds that deviance is not inherent to an act. The theory focuses on the tendency of majorities to negatively label minorities or those seen as deviant from standard cultural norms.
• The social construction of deviant behavior plays an important role in the labeling process that occurs in society.
• Labeling theory was first applied to the term “mentally ill” in 1966 when Thomas J. Scheff published Being Mentally Ill . Scheff challenged common perceptions of mental illness by claiming that mental illness is manifested solely as a result of societal influence.
• Hard labeling refers to those who argue that mental illness does not exist. They note the slight deviance from the norms of society that cause people to believe in mental illness.
• Soft labeling refers to people who believe that mental illnesses do, in fact, exist. Unlike the supporters of hard labeling, soft labeling supporters believe that mental illnesses are not entirely socially constructed.
• self-fulfilling prophecy : a prediction that, by being voiced, causes itself to come true
• social construction : A concept or practice that is the construct (or artifact) of a particular group, meaning that the concept or practice is understood differently by various groups and institutions.

Labeling Theory on Health and Illness

Labeling theory is closely related to social-construction and symbolic-interaction analysis. Developed by sociologists during the 1960s, labeling theory holds that deviance is not inherent to an act. The theory focuses on the tendency of majorities to negatively label minorities or those seen as deviant from standard cultural norms. The theory is concerned with how the self-identity and behavior of individuals may be determined or influenced by the terms used to describe or classify them. It is associated with the concepts of self-fulfilling prophecy and stereotyping.

The social construction of deviant behavior plays an important role in the labeling process that occurs in society. This process involves not only the labeling of criminally deviant behavior—behavior that does not fit socially constructed norms—but also labeling that reflects stereotyped or stigmatized behavior of the “mentally ill.” Hard labeling refers to those who argue that mental illness does not exist; it is merely deviance from the norms of society that cause people to believe in mental illness. Mental illnesses are socially constructed illnesses and psychotic disorders do not exist. Soft labeling refers to people who believe that mental illnesses do, in fact, exist, and are not entirely socially constructed.

Labeling theory was first applied to the term “mentally ill” in 1966 when Thomas J. Scheff published Being Mentally Ill . Scheff challenged common perceptions of mental illness by claiming that mental illness is manifested solely as a result of societal influence. He argued that society views certain actions as deviant. In order to come to terms with and understand these actions, society often places the label of mental illness on those who exhibit them. Certain expectations are placed on these individuals and, over time, they unconsciously change their behavior to fulfill them. Criteria for different mental illnesses, he believed, are not consistently fulfilled by those who are diagnosed with them because all of these people suffer from the same disorder. Criteria are simply fulfilled because the “mentally ill” believe they are supposed to act a certain way—over time, they come to do so.

Another issue involving labeling was the rise of HIV/AIDS cases among gay men in the 1980s. HIV/AIDS was labeled a disease of the homosexual and further pushed people into believing homosexuality was deviant. Even today, some people believe contracting HIV/AIDS is punishment for deviant and inappropriate sexual behaviors.

Labels, while they can be stigmatizing, can also lead those who bear them down the road to proper treatment and recovery. The label of “mentally ill” may help a person seek help, such as psychotherapy or medication. If one believes that being “mentally ill” is more than just believing one should fulfill a set of diagnostic criteria, then one would probably also agree that there are some who are labeled “mentally ill” who need help. It has been claimed that this could not happen if society did not have a way to categorize them, although there are actually plenty of approaches to these phenomena that don’t use categorical classifications and diagnostic terms (for example, spectrum or continuum models). Here, people vary along different dimensions, and everyone falls at different points on each dimension.

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• Sick role. ( CC BY-SA ; Wikipedia via en.Wikipedia.org/wiki/Sick_role)
• Functionalist perspective. ( CC BY-SA ; Wikipedia via en.Wikipedia.org/wiki/Functionalist_perspective)
• structuralism. ( CC BY-SA ; Wiktionary via en.wiktionary.org/wiki/structuralism)
• deviance. ( CC BY-SA ; Wiktionary via en.wiktionary.org/wiki/deviance)
• Herbert Spencer. ( Public Domain ; Wikipedia via en.Wikipedia.org/wiki/File:Herbert_Spencer.jpg)
• BMC Health Services Research | Full text | Employment status and differences in the one-year coverage of physician visits: different needs or unequal access to services?. ( CC BY ; BioMed Central via http://www.biomedcentral.com/1472-6963/6/123 )
• Healthcare in the united states. ( CC BY-SA ; Wikipedia via en.Wikipedia.org/wiki/Healthcare_in_the_united_states)
• Sociology of health and illness. ( CC BY-SA ; Wikipedia via en.Wikipedia.org/wiki/Sociology_of_health_and_illness)
• Conflict perspective. ( CC BY-SA ; Wikipedia via en.Wikipedia.org/wiki/Conflict_perspective)
• capitalism. ( CC BY-SA ; Wiktionary via en.wiktionary.org/wiki/capitalism)
• functionalism. ( CC BY-SA ; Wikipedia via en.Wikipedia.org/wiki/functionalism)
• military-industrial complex. ( CC BY-SA ; Wiktionary via en.wiktionary.org/wiki/military-industrial_complex)
• Health care reform supporter 2 at town hall meeting in West Hartford, Connecticut, 2009-09-02. ( CC BY ; Wikimedia via commons.wikimedia.org/wiki/File:Health_care_reform_supporter_2_at_town_hall_meeting_in_West_Hartford,_Connecticut,_2009-09-02.jpg)
• ( CC BY ; Rice University via bread.cnx.rice.edu:9680/content/m10414/1.5/)
• BMC Women's Health | Full text | Becoming the best mom that I can: women's experiences of managing depression during pregnancy - a qualitative study. ( CC BY ; BioMed Central via http://www.biomedcentral.com/1472-6874/7/13 )
• User:Ceplm/Symbolic Interactionism. ( CC BY-SA ; Wikipedia via en.Wikipedia.org/wiki/User:Ceplm/Symbolic_Interactionism)
• Boundless. ( CC BY-SA ; Boundless Learning via www.boundless.com//sociology/definition/medicalization-of-deviance)
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• Boundless. ( CC BY-SA ; Boundless Learning via www.boundless.com//sociology/definition/demedicalization)
• Labeling theory. ( CC BY-SA ; Wikipedia via en.Wikipedia.org/wiki/Labeling_theory%23The_.22mentally_ill.22)
• social construction. ( CC BY-SA ; Wikipedia via en.Wikipedia.org/wiki/social%20construction)
• self-fulfilling prophecy. ( CC BY-SA ; Wiktionary via en.wiktionary.org/wiki/self-fulfilling_prophecy)
• Mental disorder. ( Public Domain ; Wikipedia via en.Wikipedia.org/wiki/Mental_disorder)

Chronic Illness

"spoon theory" can change the way you view mental health, spoons aren't just cutlery. they're an invaluable form of metaphorical currency..

Posted May 14, 2024 | Reviewed by Michelle Quirk

• What Is a Chronic Illness?
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• Many people can easily go to work, run errands, meet friends, and still have energy left over.
• People with chronic illnesses, disabilities, or mental health conditions may wake up with fewer "spoons."
• People with fewer "spoons" must carefully manage their day.

For many people, day-to-day life is a series of relatively easy errands, appointments, and to-do’s. For others, however, keeping up with daily routines can be a monumental effort. And on hard days, even the bare minimum can seem like an impossible feat. It’s not uncommon for struggling individuals to be left wondering how those around them manage to thrive so easily—let alone get out of bed.

Many of us may know this feeling all too well; others may not. This fact alone can be frustrating for those familiar with the experience. However, we now know that this phenomenon can be understood with what is referred to as “spoon theory.”

What Is “The Spoon Theory”?

The term was conceptualized by Christine Miserandino in her essay titled "The Spoon Theory," which follows her response to the question of what it’s like to live with chronic illness . She explained the difficulty in finding the words to describe such a constant yet inexplicable experience but also acknowledged the importance of doing so.

This prompted the creation of the theory: “I quickly grabbed every spoon on the table; hell, I grabbed spoons off of the other tables. I looked at her in the eyes and said ‘Here you go, you have Lupus.’” And with actual spoons, she created a thought experiment that served to describe the indescribable.

Imagine that every day, you wake up with a set amount of spoons in your possession. Each spoon represents a unit of energy you have to use throughout the day. Just like currency, these spoons are finite—you can only spend what you have, and there’s no getting more once you’ve used them all. As you go about your day, every action you take costs you one or more spoons. The more demanding the task, the more spoons it requires.

For many people, these tasks are manageable within their daily allowance of spoons. They can easily go to work, run errands, meet friends, and still have energy left over for hobbies or other activities. However, people with chronic illnesses, disabilities, or mental health conditions will wake up with fewer spoons. For them, simple tasks like getting dressed, making breakfast, or taking a shower can be costly; addressing their basic physiological needs can leave them with few spoons left for the rest of their day.

Given this limited supply of energy, people with fewer spoons must carefully manage their day. They may need to prioritize essential tasks over social activities, work commitments, or exercise. They may need to plan rest breaks and pace themselves to avoid running out of spoons too early. If they exhaust their spoons, they might not have the energy to do anything else.

You may notice that people with chronic conditions appear to have less stamina or to be more cautious in their choices. This is not because they lack motivation or willpower but because their energy resources are limited. With a lower allowance of spoons, they must use them wisely.

Since Miserandino’s essay, the theory has served as a poignant metaphor that illustrates the limited energy resources available to individuals with compromised physical and mental well-being. As for the use of spoons, she explained, “I wanted something for her to actually hold, for me to then take away, since most people who get sick feel a ‘loss’ of a life they once knew. If I was in control of taking away the spoons, then she would know what it feels like to have someone or something else, in this case Lupus, being in control.”

The Implications of the Spoon Theory

Research further exemplifies how spoon theory has become an incredibly effective way for people with illness, disability, or mental health issues to communicate the fluctuating nature of their experiences. The metaphor resonates because it simplifies a complex reality into a tangible concept. It allows people to describe their daily challenges in a way that others can understand.

With spoon theory, a person can explain that they may have good days when they have more energy, and bad days when they have far less. This framework makes it easier to talk about conditions that are often invisible, helping others comprehend why they might need extra support or flexibility. The theory’s simplicity also serves as a bittersweet prompt for everyone—those who have ample energy and those who do not—to reflect.

For those with limited spoons, the theory is a crucial reminder to slow down and listen to their bodies. It can be difficult and disheartening to realize that you need to pace yourself while others don’t. But, it’s important to remember that there is no race to the finish line of a day; the goal is to complete what’s necessary without burning through your energy reserves.

Taking breaks, saying no to unnecessary tasks, and asking for help are all valid strategies to preserve spoons. While it can feel defeating to have to count every spoon, it’s better than burning out and finding yourself unable to do the things that truly matter. It’s OK to prioritize your health and well-being over external expectations.

For people who need not count their spoons, the theory prompts a consideration of how they might take their energy for granted. It’s easy to waste spoons on trivial things without much thought. This is a privilege not everyone has, and recognizing it can lead to a greater sense of gratitude and responsibility. If you have friends or family members with limited spoons, consider asking them what you can do to help them save theirs. Whether it’s offering a ride, picking up groceries on your way home, or taking on a task they can’t manage—even a small gesture could make a significant difference.

Finally, know that if you are close to someone with few spoons, your relationship is cherished. As Miserandino professed to her friend, “I don’t have room for wasted time, or wasted ‘spoons,’ and I chose to spend this time with you.”

A version of this post also appears on Forbes.com.

Mark Travers, Ph.D., is an American psychologist with degrees from Cornell University and the University of Colorado Boulder.

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About Vibrio Infection

• Vibrio are bacteria that naturally live in coastal waters.
• About a dozen kinds of Vibrio can cause people to get an infection called vibriosis.
• People can get vibriosis after swallowing Vibrio or getting it in a wound.
• Vibrio infection can be serious. Know when to seek medical care.

What are Vibrio ?

Vibrio are bacteria that naturally live in certain coastal waters. They are found in higher numbers in May through October, when water temperatures are warmer.

Coastal waters include salt water and brackish water. Brackish water is a mixture of salt water and fresh water. It is often found where rivers meet the ocean.

What is vibriosis?

About a dozen species (kinds) of Vibrio can cause a human illness called vibriosis. The most common species causing human illness in the United States are

• Vibrio parahaemolyticus
• Vibrio vulnificus
• Vibrio alginolyticus

Keep in mind‎

How do people get vibriosis.

Most people get vibriosis by eating raw or undercooked shellfish, particularly oysters .

Some people get vibriosis after an open wound comes in contact with coastal waters.

How common is vibriosis?

CDC estimates that:

• 80,000 cases of vibriosis happen each year in the United States.
• 52,000 cases of vibriosis are the result of eating contaminated food.

Common signs and symptoms of Vibrio infection

• Watery diarrhea
• Stomach cramps

Signs and symptoms of Vibrio bloodstream infection

• Dangerously low blood pressure
• Blistering skin lesions

Signs and symptoms of Vibrio wound infection

• Discoloration (turning a color other than normal)
• Discharge (leaking fluids)

Complications

Some Vibrio species, such as Vibrio vulnificus , can cause severe and life-threatening infections.

Some Vibrio infections lead to necrotizing fasciitis , a severe infection in which the flesh around an open wound dies. Some media reports call Vibrio vulnificus "flesh-eating bacteria." However, public health experts believe group A Streptococcus are the most common cause of necrotizing fasciitis in the United States.

Many people with Vibrio vulnificus infection can get seriously ill and need intensive care or limb amputation. About 1 in 5 people with this infection die, sometimes within a day or two of becoming ill.

When to seek emergency care‎

People at risk.

Anyone can get a Vibrio infection.

Some medical conditions and treatments can increase your risk for infection and severe complications. They include:

• Having liver disease, cancer, diabetes, HIV, or thalassemia
• Receiving immune-suppressing therapy for the treatment of disease
• Taking medicine to decrease stomach acid levels
• Having had recent stomach surgery

Some behaviors also can increase your risk of infection. These include:

• Eating raw seafood, particularly oysters
• Exposing an open wound to coastal waters
• Exposing an open wound to raw seafood or its drippings

Diagnosis and testing

Infection is diagnosed when Vibrio are found in the wound, blood, or stool (poop) of an ill person.

If you have signs and symptoms of infection, be sure to tell your healthcare provider if

• You recently ate raw or undercooked seafood, especially oysters
• Coastal water, including sale water or brackish water
• Raw or undercooked seafood or its drippings

Antibiotics are not recommended to treat mild Vibrio infections. People with diarrhea or vomiting should drink plenty of liquids to prevent dehydration. Dehydration is not having enough fluids in the body.

Antibiotics can be used to treat severe or prolonged Vibrio infections.

Vibrio wound infection is treated with antibiotics and surgery to remove dead or infected tissue. Surgery might include amputation.

Vibrio Infection

Some kinds of Vibrio cause an illness called vibriosis. Most people become infected by eating raw or undercooked shellfish, particularly oysters.

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Marxist Theory and Mental Illness: A Critique of Political Economy

• First Online: 25 November 2016

Cite this chapter

• Bruce M. Z. Cohen 2  

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“If sociologists of medicine are truly serious about accurately researching issues of health and illness,” argues Bruce Cohen, “then there is an urgent need to contextualise our work in a set of historical and contemporary power relations.” The sociologist of mental health sets about doing just this through a Marxist analysis of the modern mental health system, from Pinel’s unchaining of the “mad” in the eighteenth century to the “drugs revolution” of the twentieth century. Applying Marx’s theory of historical materialism, Cohen demonstrates how health philosophies such as moral treatment, mental disorders including “masturbatory insanity,” and “treatments” like electroshock therapy can all be understood as fulfilling specific economic and ideological prerogatives of industrial capitalism for compliant and productive workers.

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Cohen, B.M.Z. (2016). Marxist Theory and Mental Illness: A Critique of Political Economy. In: Psychiatric Hegemony. Palgrave Macmillan, London. https://doi.org/10.1057/978-1-137-46051-6_2

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The Political Economy of the Mental Health System: A Marxist Analysis

Samuel Lézé , Université de Lyon, France

The present paper analyses the functions of the mental health system in relation to the economic organisation of society, using concepts derived from Marx’s work on political economy and building on previous critiques. The analysis starts from the position that mental health problems are not equivalent to physical, medical conditions and are more fruitfully viewed as problems of communities or societies. Using the example of the United Kingdom, it traces how a public mental health system evolved alongside capitalism in order to manage the problems posed by people whose behaviour was too chaotic, disruptive or inefficient to participate in a labour market based on exploitation. The system provided a mixture of care and control, and under recent, Neoliberal regimes, these functions have been increasingly transferred to the private sector and provided in a capitalistic manner. Welfare payments are also part of the system and support those less seriously affected but unable to work productively enough to generate surplus value and profit. The increased intensity and precarity of work under Neoliberalism has driven up benefit claims at the same time as the Neoliberal state is trying to reduce them. These social responses are legitimised by the idea that mental disorders are medical conditions, and this idea also has a hegemonic function by construing the adverse consequences of social and economic structures as individual problems, an approach that has been particularly important during the rise of Neoliberalism. The concept of mental illness has a strategic role in modern societies, therefore, enabling certain contentious social activities by obscuring their political nature, and diverting attention from the failings of the underlying economic system. The analysis suggests the medical view is driven by political imperatives rather than science and reveals the need for a system that is more transparent and democratic. While the mental health system has some consistent functions across all modern societies, this account highlights one of the endemic contradictions of the capitalist system in the way that it marginalises large groups of people by narrowing the opportunities to make an economic contribution to society.

Introduction

The subject of mental health has perhaps never been more widely discussed than today, and mental health problems more widely accepted as “proper” medical conditions. There has been a huge escalation in the diagnosis and treatment of such problems across western societies in the past few decades. A quarter of the English population report that they have suffered from a mental illness at some point in their lives ( Health and Social Care Information Centre, 2015 ), and even larger numbers have been persuaded that many instances of unhappiness and discontent arise from biochemical abnormalities and require medical interventions ( Pilkington et al., 2013 ). This phenomenon has been referred to as “psychiatrization” ( Beeker et al., 2021 ), and also as widening medicalisation or “disease-mongering”, since psychiatric disorders are classified as a subset of medical disorders and often subject to medical-style interventions like pharmaceuticals ( Conrad and Potter, 2000 ; Moynihan et al., 2002 ). In the meantime, there has been a profound reorganisation of provision for the seriously mentally unwell, with care provided by large state institutions transferred to smaller facilities and organisations, many run by the private sector on a “for-profit” basis.

The works of Marx and Engels are recognised to provide important insights into the nature and workings of many contemporary institutions, and systems for addressing mental health problems, particularly psychiatry, are no exception. Several scholars within a broadly defined Marxist tradition have examined mental institutions and treatments, building on the analysis of social deviance, and focusing on the way psychiatric interventions serve as mechanisms of social control, developed to manage behaviour that threatens to destabilise the capitalist system ( Conrad, 1992 ; Scull, 1993 ; Cohen, 2016 ). Other authors have documented how, over recent decades, Neoliberal capitalism has coincided with the trend to medicalise and “commodify” more and more aspects of human feelings and behaviour, in the process turning them into a source of profit for the pharmaceutical and healthcare industries ( Fisher, 2009 ; Davies, 2017 ). The ideological consequences of reframing social problems as individual pathology have also been highlighted, in the way this process diverts attention from the structural inequality and injustice that make life difficult for people in the first place ( Fisher, 2009 ; Davies, 2011 ; Cohen, 2016 ).

Marxist analyses overlap with the “antipsychiatry” position, which argues that mental illness is a strategic, political concept, rather than a scientific one ( Szasz, 1970 ; Szasz, 1989 ). There is also a wealth of Marxist literature on the welfare state that is relevant to understanding the role and functions of the mental health system ( Gough, 1979 ; Higgs, 1993 ).

In the following article, I set out an analysis of how the mental health system relates to the economy, particularly a capitalist economy, making use of Marxist concepts such as use value, exchange value, exploitation, productive labour and ideology (see Table 1 ). I trace the evolution of the English system, revealing its social functions, which include social control, but also functions that have received little previous attention, such as the provision of care, and the way in which the biomedical ideology of psychiatry facilitates the capitalist welfare system, and promotes capitalist hegemony. I attempt to distinguish those aspects of the system that are specific to capitalism from those that are more general features of modern societies, and describe how understanding the mental health system in this way reveals some of the contradictions of capitalism. Since industrial capitalism is generally acknowledged to have started in England, the analysis provides a paradigmatic case of the relationship between economic development and social responses to mental disturbance in advanced capitalist economies, but it is not necessarily applicable to parts of the world where economic development has taken a different course.

Marxist concepts.

As a practising psychiatrist, I have experienced the situations that mental health services are required to address, and the frequent disjunction between the official diagnostic framework for explaining these situations, and the problems individuals, families and communities actually experience. Yet, I have also been socialised by the system, in particular by the language it employs. The terminology of “mental health,” “mental illness” and “mental disorder” is premised on the existence of a material entity or disease, located in the individual, a view that is challenged in this article. However, since there are no widely accepted alternative ways to describe the problems in question, I have used current terms.

The Nature of Mental Health Problems

In contrast to the mainstream position, I and other critics suggest that mental health problems are not equivalent to general medical conditions ( Valenstein, 1998 ; Szasz, 2000 ; Whitaker, 2002 ; Moncrieff, 2020 ). Although human beings are embodied creatures, and all human activity depends on biology, none of the situations we call mental disorders have been convincingly shown to arise from a biological disease, or, putting it another way, from a specific dysfunction of physiological or biochemical processes.

The abundance of research into the biological basis of mental disorders means it is difficult to challenge every new claim or theory, yet fundamental flaws have been identified in key areas of research. For example, genetic research with families and twins has overlooked important confounders and positive findings have been highlighted while negative ones have been buried ( Rose et al., 1984 ; Joseph, 2003 ). More recent genome wide studies produce negligible evidence for any relevant genetic effects ( Latham and Wilson, 2010 ; Moncrieff, 2014 ). The most consistent finding in biological psychiatry is that people diagnosed with schizophrenia have smaller brains and larger brain cavities than people without, and this has recently been shown to be due, at least in part, to the effects of antipsychotic treatment ( Fusar-Poli et al., 2013 ). Any remaining differences are likely accounted for by intellectual ability and other uncontrolled factors ( Moncrieff and Middleton, 2015 ). Biochemical research also fails to support widely held beliefs that mental disorders are caused by abnormalities of specific neurotransmitters ( Valenstein, 1998 ). The hypothesis that depression is caused by serotonin deficiency is not supported by evidence from any of the principle areas of research into depression and the serotonin system (Moncrieff et al.). Evidence on dopamine also fails to confirm the dopamine hypothesis of schizophrenia or psychosis, though dopamine is known to be involved in arousal mechanisms that are likely to be awry in someone who is acutely psychotic ( Moncrieff, 2009 ; Kendler and Schaffner, 2011 ).

Instead of viewing mental disorders as biological conditions that are inherent in individuals, I suggest we need to understand them as problems of communities or societies. If we do this, we will see from the following account of the evolution and functions of the mental health system, the principal problems we refer to as mental disorders consist, from a societal point of view, of dependency and disruptive behaviour. It is true that these problems can be caused by medical conditions. Occasionally, brain diseases, such as dementia and Huntingdon’s chorea produce behaviour that is aggressive or socially undesirable, and many physical diseases reduce people’s ability to maintain themselves. Indeed, for centuries, the institutions that developed to accommodate the mentally disturbed, also provided for people with neurological conditions, and sometimes still do ( Rehling and Moncrieff, 2020 ). Moreover, in most countries, people with dementia, a neurological disease, are treated by psychiatrists rather than neurologists.

However, in the situations we routinely refer to as “mental disorders”, no disease can reliably be found. It is in the nature of human beings to react to their environment in different ways. Some people behave in ways that are bizarre, difficult to understand and sometimes troublesome for others, and some people are more productive and efficient than others. Rather than representing these problems as the manifestations of as yet undiscovered brain diseases, I suggest that “mental illness” is simply the 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 ( Moncrieff, 2020 ).

In what follows I accept the view that many of our current mental troubles are consequences of the particular socio-economic conditions of late capitalism, and the way in which these consequences are construed ( Davies, 2011 ; Cohen, 2016 ; Davies, 2017 ). However, in contrast to the purely social constructionist view, I also assume that some are perennial features of human life and occur across different sorts of societies with varying economic bases.

Mental Health Problems From a Social and Economic Perspective

In line with this view, the mental health system can be viewed as a social response to the set of problems we refer to as “mental disorder” or “illness”. Some of these are problems for any modern society, whether capitalist, socialist or something else. Some are specific to capitalism. Though much debated, Marxist theory suggests that social institutions (the superstructure) reflect the need to support the prevailing economic system (the base) of each society and historical era ( Harman, 1986 ). Therefore, institutional functions need to be understood in the context of the economic system in which they are embedded.

One of the functions of mental health services is to provide support and care for people when they are unable to look after themselves. Just like people with a severe physical disability, learning difficulties or neurological disease, people who have a serious mental disorder that would nowadays be referred to as schizophrenia, bipolar disorder or severe depression, are sometimes unable to wash or dress themselves, to manage money, shop, cook or maintain their environment in a habitable condition. The disability may be temporary, and many recover or improve, but for some it is long-term.

Serious mental disorder can also involve people behaving in ways that are disruptive or dangerous to the lives of others. Managing this behaviour to ensure social harmony is something societies have endeavoured to address long before the advent of capitalism, and is one of the principle functions of the mental health system. As legal scholar (and subsequently notorious lawyer), Alan Dershowitz, commented: “it is a fairly constant phenomenon in most societies that dangerous and bothersome people will be isolated by one means or another” ( Dershowitz, 1974 ) (P 58). English history records how local, informal procedures aimed at managing dangerous and disruptive behaviour evolved to address lacunae in the criminal law, which included the difficulty of convicting people who were too confused, distracted or deluded to understand the justice system or respond to punishment. These informal procedures were gradually codified into formal law regarding the care and control of the “insane” ( Dershowitz, 1974 ).

Disturbed and disruptive behaviour is not just a social nuisance, however, it potentially affects the processes of production that form the basis of modern societies. The individual who is acutely paranoid or severely depressed, for example, is unlikely to be able to work, or at least to work efficiently, and family members, too, may be prevented from working because of the disruption caused to their lives. Moreover, someone who is severely mentally disturbed may frighten and upset those around them, preventing people from feeling secure and motivated enough to satisfy the requirements of labour, and potentially jeopardising the whole system of modern production.

The more common, yet less visible social consequence of mental health problems that is specific to capitalist societies is not being able to support oneself financially. Capitalism depends on the majority of people earning their living through wage labour, and to be of use to capitalists, workers have to generate more wealth or value than they earn–what is known as “surplus value”. If an individual falls below a certain level of productivity, it is no longer worth the expense of employing them. However, people who are unable to participate in productive labour that generates “exchange value” may nevertheless be able to engage in other useful activities and create “use value”. They are not incapable of work, just incapable of doing the sort of work that is available in an advanced capitalist economy. Some of these people are part of the “industrial reserve army”, who are recruited into work at times of labour shortage, and who help capitalists to keep wages down to maximise profit, but others, whom Marx referred to as the “demoralised, the ragged”; are unable to perform capitalist work on any terms ( Marx, 1990 ) (p. 797).

The inability to earn associated with mental health problems may be temporary, lasting for the few weeks or months that the episode of madness, depression or stress endures, or it may be longer-lasting. Even if it is temporary, it may be recurrent, and the occurrence and duration of episodes is highly individual and unpredictable, making it difficult for those without highly supportive employers to sustain employment. There is no mechanism integral to capitalism to provide for people who are not employed, but capitalist economies have developed systems of welfare through the course of the last century, including the provision of financial support to the those who are classified as medically sick or disabled ( Matthews, 2018 ).

The Mental Health System and the Welfare State

The mental health system, along with physical health services, education and the criminal justice system, fulfil certain social needs and thereby produce “use values” in the Marxist sense. If these services are provided capitalistically, that is by private firms that generate and accumulate capital through the extraction of surplus value, they also produce “exchange value”. In modern capitalist societies of all political hues, a large part of these services are funded and coordinated by the state, both because a significant section of the population cannot afford them, and because of the level of organisation required. They may be provided by state enterprises or by private firms or charitable organisations, and they are often referred to collectively as the Welfare State.

Marxist commentators on the Welfare State highlight how it contributes to the social reproduction of the capitalist system by ensuring that there is a supply of healthy, educated and disciplined workers ( Gough, 1979 ; O'Connor, 1973 ). These activities indirectly facilitate productive labour and the process of capital accumulation. The welfare state also ensures social harmony, by providing for the old and sick and sustaining those who will never enter the workforce, for example. These expenses are what Marx referred to as the “ faux frais [incidental expenses] of capitalist production” ( Marx, 1990 ) (p. 797). They are not associated with capitalist production per se , but can be viewed as a means of legitimation of the system, since, by preventing people from dying on the streets, they ensure the continuation of capitalist relations of exploitation and domination through hegemony rather than force ( Higgs, 1993 ). Other Marxists highlight how the welfare state resulted from class struggle, and represents a concession to the working class inspired by the threat of revolution ( Ferguson et al., 2002 ; Matthews, 2018 ), and others have pointed out how many functions of the welfare state are necessary for social reproduction in any modern economic system, and are not specific to capitalism ( Cowling, 1985 ).

Most welfare state spending is not directly productive as it is provided either by public enterprises, which do not generate surplus value, or, if provided by the private sector, capital accumulation is constrained by the limits of public funding and taxation. Welfare services embody a contradiction, therefore, and represent both a pre-requisite for the continued existence of capitalism, and, at the same time, a drain on the surplus; “both a condition of capital accumulation and a subtraction from it” ( Pierson, 1996 ) (p. 581) ( O'Connor, 1973 ). This has led some to argue that the welfare state potentially undermines capitalism in the long-run ( Gough, 1979 ; Bennett et al., 2009 ).

The philosophy behind the creation of the welfare state in the mid 20th century, as espoused by Keynes and the social democratic regimes that took up his ideas, was that it was the duty of the state to intervene and alleviate problems such as poverty and unemployment. It was the state’s responsibility to ensure there were employment opportunities, education, housing and healthcare available to all ( Higgs, 1993 ). During the 1970s, however, the welfare state came to be seen as contributing to or even causing the economic crisis of capitalism, and regimes all over the world started to bring in measures to reduce its costs. This commonly involved the privatisation of state services, since the private sector could employ people at lowers costs due to longer hours, worse pay and conditions. It also involved a reorientation of the philosophy behind the welfare state, which involved shifting responsibility from the government to the individual. Relatively generous and automatic unemployment or social security benefits were phased out, for example, and in their place individuals had to prove their entitlement, which involved demonstrating either a willingness to work, or an incapacity for work ( Higgs, 1993 ).

Much of the mental health system predates the creation of the welfare state; indeed it prefigures other aspects of the welfare state in its role in producing a social environment conducive to the accumulation of capital. However, as a state-subsidised enterprise, it can usefully be considered as part of the welfare state, and as with other sectors, the provision of services for the seriously mentally ill has been increasingly transferred from the state to the private sector over recent decades.

The functions of the mental health system

Maintaining order and providing care.

The mental health system in England evolved out of the Poor Laws that were enacted from the Tudor period in order to manage the problems created by the expropriation of the agricultural population, which was the first step necessary to provide the labour needed for capitalism, as depicted by Marx in Das Capital ( Marx, 1990 ). The Poor Laws provided material and financial assistance or “relief”, raised through local taxes, to families who could not provide for themselves, including in those instances in which a member of the family was mentally incapacitated. Poor Law officials also helped to keep the community safe and secure, and could use the money at their disposal to pay for the confinement of local people felt to be dangerous in various settings, such as a neighbouring household or, if necessary, a prison or prison-like establishment such as a “House of Correction” ( Fessler, 1956 ; Rushton, 1988 ).

Public mental institutions, known as “asylums”, arose in the context of an austerity drive in the early 19th century. This was intended to reduce the welfare burden by ending the system of “outdoor relief” that supported people in their own homes, and making state support contingent on entering the forbidding and highly stigmatised Workhouse, a policy encapsulated in the 1834 Poor Law Amendment Act [although some local authorities continued to pay “outdoor relief” ( Forsythe et al., 1996 )]. With the rise of the Workhouse, the “deserving” poor, who could not work by dint of mental derangement or impairment among other causes, needed to be separated from the “undeserving” poor - those deemed capable of work. The former were diverted to the new system of public asylums for treatment and cure that were constructed all over England during the middle of the 19th century, while the latter were made to do hard labour in exchange for their upkeep in the Workhouse ( Scull, 1993 ).

The system was publicly funded because the costs of care and confinement were way beyond the majority of families, and because, as historian, Andrew Scull, suggests, building on the work of Michel Foucault, it was part of the means of establishing a disciplined workforce that had the requisite motivation to be put to work as wage labourers in the service of Capital ( Foucault, 1965 ; Scull, 1993 ). Asylums provided a secluded place where people whose behaviour was socially disruptive but not obviously criminal could be contained, but they also provided care and sustenance for those who were too confused, chaotic or apathetic to be put to work in the Workhouse or driven out to scrape a living together in the harsh world of Victorian England. Despite widespread myths to the contrary, people who were simply eccentric or socially deviant (e.g. unmarried mothers) were not routinely admitted to the public asylums unless their behaviour posed significant problems ( Rehling and Moncrieff, 2020 ).

The need for the State to provide care and containment arose partly because the capitalist system of wage labour meant there was little spare capacity within the family or community to look after someone who could not look after themselves ( Wright, 1997 ). All modern societies that rely on industrial production and a large workforce have similar requirements and allowing the disturbed and confused to roam the streets or rot away due to lack of care would quickly undermine the legitimacy of any system. Persuading people to work in a capitalist manner towards the enrichment of others arguably requires greater motivation and discipline, however, especially if, as was the case at the beginning of the capitalist era, people are not used to doing so. Early capitalism, therefore, produced a particular imperative for the management of the seriously mentally ill, which is manifested in the vast amount of public resources expended on the asylum system in the 19th century.

Although the roots of this system are political and social - “moral” according to Foucault - since the 19th century it has presented itself as a medical endeavour directed at medical problems. Foucault suggested that the medical framework was superimposed onto the system in order to give it the legitimacy associated with science. He referred to psychiatry as a “moral enterprise overlaid by the myths of positivism” ( Foucault, 1965 ) (p. 276). In a modern liberal society where the rights of the individual are pre-eminent, psychiatry can only fulfil its functions by presenting itself as a technical activity that is immune to political considerations. The medical nature of psychiatric terminology and knowledge obscures the values and judgements that are embedded in its practical execution ( Ingelby, 1981 ). It enables interventions that are designed to curb or control unwanted behaviour to be conceptualized as medical treatments intended to benefit the recipient rather than the people who are disturbed by the individual’s behaviour. It also extends the prerogative of the sick role, with its entitlement to care, to those who are unable to care for themselves, but where no obvious physical disease can account for their incapacity, and where the entitlement might, therefore, be questioned.

Modern Developments

The large public asylums were scaled down and finally closed from the 1980s onwards, and the official story declares that this process of deinstitutionalisation, as it was known, demonstrates the efficacy of modern drug treatments and confirms the validity of the medical view of mental disorder ( Cookson et al., 2005 ). A Marxist analysis, on the other hand, suggests that the institutions were closed because of the desire to reduce public spending ( Scull, 1977 ). It is now apparent that although the new drugs may render some people more subdued, they rarely enable people to become fully independent. A study published in 2005, for example, found that in 1998, more people were dependent on state and private services due to mental health problems than in 1898 ( Healy et al., 2005 ). Instead, long-term psychiatric patients are now placed in other institutions - smaller, privately-run but state funded residential and nursing homes, for example, as well as private psychiatric hospitals, secure units and prisons, and many rely on the care and support of family members or paid carers ( Priebe et al., 2005 ). Many subsist on financial support from the state, the new version of “outdoor relief”.

Deinstitutionalisation was, therefore, partly an exercise in transferring provision for the long-term mentally disabled from the state to the private sector. The income still largely derives from the state, but the organisation of these services into private companies has enabled them to become a potential source of capital accumulation through the exploitation of employees.

The vast majority of people who are currently diagnosed with a mental disorder cause no trouble for other people and have no difficulty looking after themselves on a day-to-day basis but are not able to work and so rely on financial support provided through the state welfare system. Welfare payments have become an important part of the mental health system and illustrate how conceptualising certain problems as mental illness or disorder disguises the flaws of the capitalist system, thus helping to suppress resistance to it.

Marxist analysts of disability have pointed out how capitalism constructs disability or dependency as a social problem. In pre-capitalist societies, the distinction between the dependent and independent was not clear-cut. Most people could produce “use value”, contributing to the maintenance of the family and community in some fashion. In a capitalist society, in contrast, people are either fit to be exploited or they are unemployable ( Finkelstein et al., 1981 ; Oliver, 1999 ; Slorach, 2011 ; Bengtsson, 2017 ). One of the major roles of the welfare state is the provision of financial or material support for those who cannot work intensively and productively enough to generate surplus value.

Sickness and disability payments were introduced in most western countries in the middle of the 20th century and have been rising rapidly since the 1980s, despite efforts to curb them ( Kemp et al., 2006 ; Niemietz, 2016 ). Much of this rise is accounted for by the increase in people claiming benefits for mental health problems, particularly those classified as depression or anxiety ( Waddell and Aylward, 2005 ; Kemp et al., 2006 ; Brown et al., 2009 ; Danziger et al., 2009 ). In the United Kingdom in 2008, it was estimated that the total cost of sickness and disability-related worklessness among the working age population was more than the cost of the whole of the National Health Service ( Black, 2008 ). By 2014, almost half of United Kingdom claimants were classified as having a mental disorder as the reason for their claim, which was by far the largest category of causal medical conditions. Claims made due to a mental disorder doubled between 1995 and 2014, while claims made for most other types of medical conditions fell. These claims were predominantly long-term ( Viola and Moncrieff, 2016 ). Similarly in the United States, claims for disability payments due to mental health problems have increased at a faster rate than claims for other medical conditions, and by 2005 they accounted for around a third of claims made to the major disability benefit schemes ( Danziger et al., 2009 ). Again, once on disability benefits, people rarely go off them ( Joffe-Walt, 2013 ).

The rise in disability payments to people with common mental disorders like anxiety and depression is paralleled by the phenomenal rise in antidepressant prescribing that has occurred since the early 1990s throughout the world. Consumption of antidepressants more than doubled in the United Kingdom between 1998 and 2010, for example ( Ilyas and Moncrieff, 2012 ), having previously risen by more than three times from 1988 to 1998 ( Middleton et al., 2001 ). There have been similar rises in many OECD countries ( Organisation for Economic Development, 2020 ). Over the past few decades, an increasing proportion of people have been prescribed these drugs on a long-term basis ( Mars et al., 2017 ; Taylor et al., 2019 ).

Studies of employment have also shown that receiving treatment for a mental health problem is associated with people taking more time off and being less likely to return to work than people who do not receive treatment ( Dewa et al., 2003 ). It appears, therefore, that in many high income countries, including the United Kingdom and US, large numbers of people become economically inactive and are classified as being long-term mentally ill. They receive financial benefits and prescriptions for psychiatric drugs, and some may receive psychological therapy.

These recent trends illustrate the relationship between welfare and capital accumulation. During the period of Neoliberalism the ruling class has pushed back against the concessions that workers won during the mid 20th century in order to increase or maintain profit margins ( Harvey, 2005 ; Glynn, 2006 ; Boltanski and Chiapello, 2018 ). This has been achieved by relocating many manual industries to countries where labour costs are cheaper, and by increasing the intensity or productivity of the work that remains ( Office for National Statistics, 2018 ).

People have to work harder than they did in the past, their output and performance is constantly scrutinsed, and there is the constant threat of losing one’s jobaltogether, especially for the increasing number of people employed on a casual or “self-employed” basis. The work environment requires workers to be more and more robust, efficient and compliant ( Dardot and Laval, 2017 ). This applies to the public sector too, which has been remodelled on the private sector since the 1990s ( Ironside and Seifert, 2004 ). Whereas previously there may have been a niche for the less productive in state enterprises, such as the UK’s National Health Service (NHS), these now engage in intense performance monitoring and take a more disciplinarian approach to the workforce, resulting in a culture of “fear and blame” and a “demotivated workforce with low morale” ( Stevenson and Moore, 2019 ) (p. 1). It is not surprising, therefore, that increasing numbers find they cannot tolerate the demands of work as it is currently organised.

Neoliberal capitalism increases the need or demand for disability benefits, therefore, but at the same time it attempts to restrain those benefits, which represent a drain on the overall surplus. In the United Kingdom, for example, the government has introduced more stringent criteria for qualifying as sick or disabled, abolished certain allowances, capped others, and set benefit rises below inflation ( UNISON, 2013 ). Such measures are in constant tension with the fact that the alternative of working on the open market is less achievable for many, and hence attempts to restrain spending are barely successful ( Office for Budget responsibility, 2019 ).

Capitalism creates redundant workers out of those people who can work, but are not productive enough to produce the desired amount of surplus value due to physical or mental disability ( Finkelstein et al., 1981 ; Oliver and Flynn RJL, 1999 ). State-funded sickness and disability benefits disguise this structural unemployment–unemployment that is inherent to the current stage of capitalism ( Beatty et al., 2000 ; Roberts and Taylor, 2019 ). In the US, this activity has become a new industry, with states paying businesses to help move people from state-funded social security to federally funded disability programmes ( Joffe-Walt, 2013 ).

This process of exclusion from the productive workforce deprives people of a feeling of connection with and investment in their community, thus contributing to people becoming marginalised and demoralised, which is then labelled as mental illness. In this way, unemployment and low productivity are constructed as the fault of the individual (albeit a biological rather than a moral fault), rather than a systemic problem that reflects the prioritisation of profit over participation ( Davies, 2017 ). The welfare system also solidifies people’s identity as “spoiled” or damaged; as being incapable. Like the asylums of the 19th century, it keeps the non-working population quiet and secluded so the rest can be effectively exploited.

The Promotion of Hegemony

Underpinning the previously described functions of the mental health system is the idea that the situations concerned are medical conditions, with the implication that they originate in the body and thus absolve individuals of responsibility for their behaviour, and justify the forcible modification of that behaviour by others ( Moncrieff, 2020 ). Although we have seen that this position is not supported by scientific evidence, it is widely embraced and its acceptance helps to legitimise the social and political status quo.

Construing life difficulties as an illness in what Nikolas Rose has called “the psychiatric re-shaping of discontent” ( Rose, 2006 ) (p. 479) has long been recognised as a political strategy that silences protest and inhibits change. This was pointed out in the 1960s and 1970s by social scientists who explored the creeping medicalisation of society ( Zola, 1972 ; Illich, 1976 ; Conrad and Schneider, 1980 ), along with “antipsychiatry” thinkers ( Laing, 1967 ) and has been explored more recently by critics of neoliberalism ( Fisher, 2009 ; Cohen, 2016 ; Davies, 2017 ). This strategy has been employed in socialist as well as capitalist countries. As William Davies points out, unhappiness has “political and sociological qualities that lend it critical potential” ( Davies, 2011 ). To construe it as an illness, to label it as “clinical depression” as it is in neoliberal, western societies, as anxiety as it was for much of the 20th century ( Healy, 2004 ), or neurasthaenia as it was in the Soviet bloc and communist China ( Kleinman, 1982 ; Skultans, 2003 ), is to declare that it is not reasonable, to see it as something to be eradicated, rather than understood. Viewing worry, distress and misery as a medical condition isolates the individual as a patient who needs to be cured of their internal flaws. It cuts them off from understanding the social implications of their feelings, and it prevents society from understanding epidemics of mental health problems as “commentaries on social life” ( Davies, 2017 ) (P 205).

As already noted, there has been a huge expansion in the numbers of people receiving mental health diagnoses and treatments in high income countries over recent decades with dramatic increases in the use of antidepressants, in particular, but also of stimulants (commonly prescribed for a diagnosis of ADHD), new anti-anxiety agents and drugs usually associated with the treatment of more severe disorders, such as antipsychotics ( Ilyas and Moncrieff, 2012 ). Seventeen per cent of the population of England are now prescribed an antidepressant alone ( Taylor et al., 2019 ).

There are some obvious drivers of this trend, such as the pharmaceutical industry, whose marketing activities have been facilitated both by the arrival of the Internet, and by political deregulation, including the repeal of the prohibition on advertising to consumers in the US and some other countries in the 1990s ( Davies, 2017 ). Despite the fact that there is no evidence of an imbalance or abnormality of brain chemicals or any other biological abnormality in people with depression ( Kennis et al., 2020 ; Moncrieff et al., 2021 ), the industry, aided and abetted by professional organisations such as the American Psychiatric Organisation and the UK’s Royal College of Psychiatrists ( APA, 2018 ; Royal College of Psychiat, 2009 ), has succeeded in persuading the general public that unhappiness and discontent arise from a faulty brain. Surveys conducted in the US and Australia in the 2000s, for example, showed that 85 and 88% of respondents respectively endorsed the idea that depression is caused by a chemical imbalance ( France et al., 2007 ; Pilkington et al., 2013 ).

Political institutions have also embraced the idea that human reactions to difficult circumstances can be understood as mental health problems. The United Kingdom government’s initiative on “transforming children and young people’s mental health” for example ( NHS, 2021 ), is premised on the idea that the source of stress, anxiety and behaviour problems among the young is not the conditions they grow up in or the highly competitive nature of the modern educational system, but individual flaws or weaknesses that can be addressed through treatment designed to help the individual to adjust and assimilate. Mental health support teams have been introduced into schools to “provide early intervention on some mental health and emotional wellbeing issues, such as mild to moderate anxiety” and referrals to NHS services for more severe problems. Inevitably, this will lead to increasing numbers of pupils being given a potentially stigmatising diagnostic label and pharmaceutical treatments, which are unlikely to have net benefits for most of them but certainly have risks and dangers ( Kazda et al., 2021 ).

Capitalism requires a certain level of dissatisfaction in order to operate smoothly and maintain consumption. People need to be persuaded that their lives are lacking in some way, and neoliberalism, with its rolling back of state responsibilities, has exaggerated this tendency ( Davies, 2011 ). The “privatisation of public troubles and the requirement to make competitive choices at every turn” ( Hall et al., 2013 ) (p. 12) breed perpetual feelings of insecurity and inadequacy that establish the demand necessary to stoke capital accumulation. The construction of the ideal neoliberal subject as an informed and intelligent consumer, who is fully responsible for their own wellbeing, both creates the conditions for increasing personal stress, in what has been called a “malady of responsibility” ( Dardot and Laval, 2017 ) (P 292), and encourages people to look for solutions in the consumption of pharmaceuticals and other easily marketable products, such as short-term therapy ( Davies, 2017 ).

Competition, the basis of the capitalist system, creates winners and losers. Fear of failure is therefore a constant source of anxiety for the modern individual, and failure itself so often the precipitant of the demoralisation and hopelessness that is called depression ( Ehrenberg, 2010 ; Dardot and Laval, 2017 ). “Depression is the shadow side of entrepreneurial culture,” said Marxist author Mark Fisher, “what happens when magical voluntarism confronts limited opportunities” ( Fisher, 2012 ).

Presenting this situation as individual deficiencies rather than a systemic by-product helps obscure its political and economic origins. The language of mental health and mental illness or disorder can be thought of, therefore, as an “ideology”, in the Marxist sense that these concepts help to obscure real underlying tensions and conflicts, and render the population amenable to viewing them as relatively simple, technical problems that should be left to experts. As Bruce Cohen points out, “biomedical ideology has become the dominant “solution’’ to what are social and economic conditions of late capitalism’’ ( Cohen, 2016 ) (p. 91). Authors who have described this phenomenon as “psychiatrization” highlight how it leads to numerous personal and social consequences from the creation of individual dependency to the diversion of needed resources from other areas of health and social services ( Beeker et al., 2021 ), but most importantly, from the Marxist point of view, it disguises “failed policies” ( Conrad, 1992 ) (p. 7).

The current “mental health movement”, with its encouragement to conceive of our understandable reactions to an increasing array of social problems, including unemployment, school failure, child abuse, domestic violence and loneliness as individual pathology requiring expert, professional treatment, promotes an ideology that helps legitimise existing social and economic relations by diverting attention from the problems themselves. In this way, it acts as a hegemonic tool for the capitalist system that now dominates most of the globe. It has been successful in moulding public attitudes and gaining political support, despite efforts of some mental health campaigners, professionals and academics to expose its political implications and to present other ways of understanding the difficulties we currently refer to as mental disorders ( Johnstone et al., 2018 ; Guy et al., 2019 ).

Social Responses to Mental Health Problems

As this analysis illustrates, how society responds to the problems posed by dependency and troublesome behaviour is potentially contentious. For Foucault, and medical sociologists, such as Peter Conrad, one of the important consequences of the medicalisation of such problems is to render them morally and politically neutral ( Foucault, 1965 ; Conrad, 1992 ). The concept of mental illness provides a justification for using force against people whose behaviour is antisocial or dangerous, but who are too confused or irrational to be appropriate for the criminal justice system. It also authorises support for people who do not qualify for care or welfare by virtue of being old or physically sick or disabled. Presenting these responses as medical activities that are the rightful and exclusive terrain of qualified, medical specialists shields them from being questioned or challenged. As the psychiatrist and critic, Thomas Szasz pointed out, the psychiatric system performs its functions “in a manner that pleases and pacifies the consciences of politicians, professionals and the majority of the people” ( Szasz, 1994 ) (p. 200). It also has a wider hegemonic role in the maintenance of capitalism, along with other socio-economic systems, by locating the sources of individuals’ unhappiness and discontent within their own brains, rather than in their external circumstances, individualising “what might otherwise be seen as collective social problems” and thereby letting the political and economic system off the hook ( Conrad, 1992 ) (p. 224).

On the other hand, some left-wing analysts, notably Peter Sedgewick, point out that this position enables capitalist governments to cut disability benefits and reduce other resources available for people affected by mental health problems ( Sedgewick, 1982 ). While this may be theoretically possible, it depends on Sedgewick accepting the view that mental disorders are essentially equivalent to neurological diseases.

Apart from the lack of evidence that this is the case, it is difficult to accept that all dependency and disruptive behaviour is caused by a physical disease. If it is not, ( Moncrieff, 2020 )? then surely we need a more transparent system of control and care, that acknowledges the ethical and political dilemmas involved and is based on widespread democratic debate informed particularly by the voice of the system’s recipients. Such a system would have to balance the need to restrict people’s behaviour when it becomes a nuisance or danger to other people, with the individual’s legitimate interests to live in the way they want to live (19). We also need an alternative to the sick role in order to fairly and transparently distribute resources and care to people who are unable to be financially or practically independent, without having to deem them as being biologically flawed ( Cresswell and Spandler, 2009 ).

Reflections on Capitalism

This analysis suggests that the mental health system can be understood as part of a wider system of social reproduction through which modern societies produce a fit, capable and amenable workforce and ensure social harmony. The particular means of social reproduction depend on the economic and social form that each society takes. Some aspects of the mental health system are an enduring response to perennial social problems that cut across different epochs, political systems and cultures. These have not been fundamentally changed by the introduction of modern medical perspectives and interventions. For hundreds of years, English Poor Law officials grappled with how to help a family whose breadwinner had become mentally incapable, or how to protect the community from someone who was behaving irrationally and unpredictably ( Rushton, 1988 ). Supporting the chronically dependent and controlling chaotic and disruptive behaviour remain the main functions of the modern mental health system.

On the other hand, some trends are distinctive of capitalism in general and neoliberal capitalism in particular. The modern welfare state emerged, in part, to compensate those who cannot work intensively and productively enough to earn a living through wage labour. The concept of mental illness enables a system that is justified by the nature of physical sickness and disability to incorporate people who are disorganised, demoralised, slow, antisocial, chaotic or unmotivated–factors whose significance clearly varies according to the nature of the work that is available. Some of these people may be recruited into the work force during an economic boom, and in the mid 20th century, when conditions for labour were more favourable, even those people diagnosed with severe mental conditions such as ‘schizophrenia’ had a reasonable chance of employment ( Warner, 2004 ).

During the decades of neoliberal capitalism, however, as labour entitlements have been rolled back and work has become more competitive and exploitative, increasing numbers of people have become economically inactive for long periods. It is patently absurd to imagine that the quarter of the population who have been diagnosed with a mental illness ( Health and Social Care Information Centre, 2015 ), or the fifth who take antidepressants ( Taylor et al., 2019 ) have an as yet unidentified brain disease. Instead, this situation reflects the changing structure of contemporary capitalism. Disability support disguises the way in which capitalism narrows the opportunities for people to contribute to the productive efforts of society, thereby relegating large numbers of people into a surplus population that has no investment in its own community. The transformation of post-industrial populations into mental patients represents the economic and social marginalisation of a large segment of society. Rejecting the medicalisation of so-called mental health problems is a necessary step in revealing some of the fundamental contradictions of capitalism and laying the groundwork for political change.

Acknowledgments

I would like to thank Graham Scambler, Paul Higgs, Bruce Cohen and Paul Blackledge for providing helpful comments on the manuscript and suggestions for further reading.

Author Contributions

The author confirms being the sole contributor of this work and has approved it for publication.

Conflict of Interest

The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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