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.

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.

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.

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, 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.

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).

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.