As Marxists, our understanding of mental illness must oppose the disease model of mental illness—while not rejecting the possibility of biological causes in specific individual cases—and instead focus on contextualizing the development of poor mental well-being within society. Mental illness is profoundly a materialistic phenomenon, greatly determined by the interaction between the material conditions of society and corresponding economic organization, and the position of an individual within society. A social understanding of mental health is required, like that of the social model of disability. During the 1970s, British socialist and Marxist-inspired disability activists, such as the Union of the Physically Impaired Against Segregation, rejected biological interpretations of disability and strenuously advocated the understanding of disability as a social identity conferred on individuals, reflecting their oppression and exploitation. While potentially experiencing a physical or cognitive impairment, this was not the same as disability as a social category, which reflected their social status of exploitation and oppression as a consequence of capitalist society being organized and operating in a way to exclude individuals with certain impairments. Capitalism thus created disability, especially through its exclusion of individuals with impairments from the labor force.15David Matthews, “Disability and Welfare Under Monopoly Capitalism,” Monthly Review 72, no. 8 (2021).
Mental Illness and Economic Growth
The prevalence of the explanation of mental illness as a biological phenomenon also mirrors neoliberal values, particularly that of individualism and the dominance of the self. Not only that, but acceptance of biology as the root cause of mental illness offered a very lucrative basis for the expansion of commercial medical and pharmacological enterprises.
Capitalism, Karl Marx asserted, could be defined by its inherent need for economic expansion. “Accumulate, accumulate! That is Moses and the prophets,” he proclaimed. To remain competitively viable, all capitalist enterprises must continually expand, increasing their financial returns after investment. Yet, since the decline of the postwar boom, advanced capitalism has been characterized by stagnation, as reflected by the economies of North America, Western Europe, Australia, New Zealand, and Japan. Opportunities for investment are less than the quantity of investment capital available. Investment subsequently declines and existing output, produced from previous rounds of investment, is underutilized, resulting in the growth of surplus capital, goods, and productive capacity, including labor. The existence of surplus limits the incentive for new investment, as the potential to identify demand for future output is considered restricted if what has already been produced has not been absorbed by the market. Within this context, the recent history of advanced capitalism has been one of gradual stagnation, with capitalist enterprises engaged in an urgent quest for new outlets for investment. In this context, commercial medical operations have worked over the last four decades to identify a key new means of accumulation.16Joel Lexchin, “The Pharmaceutical Industry in the Context of Contemporary Capitalism,” in Health Care under the Knife: Moving Beyond Capitalism for our Health, ed. Howard Waitzkin (New York: Monthly Review Press, 2018).
As a method of stimulating economic growth, the disease model of mental illness has been very attractive, given its role in expanding the pharmaceutical market since the 1970s. As such, the industry has actively encouraged its own development and solidification. The last four decades have witnessed the pharmaceutical industry invest in the development not only of new products but, importantly, in a knowledge base that supports the disease model. It has been significantly involved in conducting research and financing, managing, and analyzing drug trials, including withholding negative results, as part of wider efforts to create favorable data. Additionally, the industry has influenced how its products are presented, employing industry individuals to write positive reviews and encouraging academics, often using financial incentives, to put their name to this work.17Lexchin, “The Pharmaceutical Industry in the Context of Contemporary Capitalism.” In this vein, the pharmaceutical industry has even supported the expansion of many academic departments. Overall, as James Davies proclaims, in the last forty years pharmaceutical corporations have been able “to literally create an evidence base…to legitimize their products.”
In addition to such efforts, the pharmaceutical industry has expanded its markets by broadening the medical basis on which mental illness is evaluated. In coalition with psychiatry, the industry has occupied a powerful position by being able to define “normality,” exponentially shrinking what constitutes “normal.” During the past forty years, more and more cognitive and subjective experiences have been reconceptualized as opportunities for medical intervention. As an increasingly narrower definition of “normal” has prevailed, there has been a reliance on drugs to return an individual to a perceived state of normality. Rather than reflecting the growth of objectively existing mental health issues, medicalization reflects the manipulation of knowledge for the purpose of economic growth. The direct link between the pharmaceutical industry and the expansion of the disease model significantly reflects the industry’s role in commodifying subjectivity, identifying experiences of the psyche as opportunities for accumulation and attaching value to them.
Not all scientific inquiry reflects the needs of capital, but capitalism does provide a framework within which scientific knowledge is pursued, influencing the construction of scientific knowledge. As Stephen Jay Gould asserted, there exists the significant possibility, conscious or unconscious, of a ruling class bias embedded in scientific investigations for the purpose of social control. The disease model exemplifies many of the ways capitalism infuses science, using it for both ideological purposes and commodity production.18Richard York and Brett Clark, The Science and Humanism of Stephen Jay Gould (New York: Monthly Review Press, 2011), 114. As Richard Lewontin has argued, science is “directed by those forces in the world that have control over money…as a consequence the dominant social and economic forces in society determine to a large extent what science does and how it does it.”19Richard C. Lewontin, Biology as Ideology: The Doctrine of DNA (New York: Harper Perennial, 1992).
Individualizing Mental Illness
A significant consequence of the medical science framework of understanding mental health is the construction of mental illness as an individual issue. Biology’s dominance reflects neoliberalism’s concern with the self, with both causes of and solutions to mental illness centering around the individual. The rise in popularity of cognitive behavior therapy—the principles of which are to modify how individuals think about issues in order to change their behavior—in this century can be seen as another illustration of the individualization of mental illness. The ideological consequence, as Joanna Moncrieff argues, is that “locating the source of problems in individual biology—blaming the brain—impedes exploration of social and political issues.”20Joanna Moncrieff, “Psychiatric Drug Promotion and the Politics of Neoliberalism,” British Journal of Psychiatry (2006): 188, 301–2.
Diagnoses and explorations of the cause of mental illness under capitalism start and end with the individual who needs correction to integrate into society. It is viewed in medical terms, with the cause located in the biological and chemical composition of the individual, and as such is something that individuals and wider society have little control over. This obscures the significance of social and economic factors in the experience of mental health and distribution of mental illness. The disease model and the process of medicalization privatize social problems when, in fact, radical social and economic changes is what is needed to alleviate and prevent distress. Capitalism and its values must be understood as integral to determining the development and nature of mental health.
The Misery of Capitalist Life
Instead of reducing mental health solely to biology, attention must be given to the social and economic determinants of mental illness. Capitalism, and the conditions of oppression and exploitation inherent to it, are the biggest determinants of mental illness. Throughout the works of Marx and Frederick Engels, sporadic reference is made to matters commonly understood today as mental health issues. Marx made a vital contribution with his concept of alienation, yet it was Engels who focused on the relationship between everyday capitalist society and its impact for mental well-being. Living under conditions of severe exploitation, oppression, and poverty, Engels argued, brings a pervasive desperate misery to working-class life. For large swaths of the labor force, life oscillated dramatically between fear and hope, constantly facing economic insecurity, which denied them contentment and stability, and resulted in the inability “to attain peace of mind and quiet enjoyment of life.”21Frederick Engels, The Condition of the Working Class in England (Oxford: Oxford University Press, 2009), 108–9.
For Engels, unemployment and destitution was always one accident, or death, away, while the whims of a laissez-faire system determined whether an individual would be able to eat an evening meal or left to the precariousness of the market, without protection or assurances. Conditions of acute uncertainty of existence had dramatic consequences for the mental state of many working-class people. Indeed, the extent to which the impermanence and misery of life blighted mental well-being was such that Engels noted how suicide had “become fashionable among the English workers, and numbers of the poor kill themselves to avoid the misery from which they see no other means of escape.” Alcohol abuse, which today is considered a mental health issue, was also common. Drunkenness, as Engels referred to it, remained one of the few sources of enjoyment available to the working class, many of whom indulged excessively to obscure the misery of existence. Such behavior, Engels emphatically argued, was directly the result of an exploitative existence: “They who have degraded the working man to a mere object have the responsibility to bear.”22Engels, The Condition of the Working Class in England, 114, 127.
Overall, Engels presents a picture of a working class riddled with despair, anxiety, and hopelessness. The uncertainty of economic life, not knowing if, and for how long, they would have a job or if they would be able to feed themselves and their family, placed a severe mental strain on many. In response, many working-class people sought sensory pleasures, as they were the few sources of pleasure available to them.23Engels, The Condition of the Working Class in England, 139.
Marxist Psychology and Mental Health
The analysis presented by Engels provides an essential basis on which to build a Marxist understanding of mental health, situating the emergence of poor mental well-being within the framework of capitalism and the social relations of exploitation and oppression. Though we must reject biological determinism, biology does influence mental health. But biology does not operate in isolation from social context. Mental health under capitalism evolves from a dialectical relationship between, on the one hand, the material conditions of capitalism and, on the other hand, the corporeal, and hence material, nature of the individual. Mental health is the product of continuous interaction between broader society and biological and psychological wants, needs, instincts, and desires, which have an intrinsic corporeal existence. Although Marx did not formulate a coherent psychological theory, and despite efforts to impose on him a kind of psychological relativism, he nonetheless contended that “we must first deal with human nature in general and then with human nature as modified in each historical epoch.”24Karl Marx, Capital, vol. 1 (London: Lawrence and Wishart, 1977), 571. Marx was acutely aware of certain elements as innate to the human experience: drives and needs, such as hunger and sex, on the one hand, and what Erich Fromm referred to as “passions” on the other, such as an individual’s need to express creativity and demonstrate and experience relatedness to others and nature.25Erich Fromm, The Crisis of Psychoanalysis: Essays on Freud, Marx and Social Psychology (London: Jonathan Cape, 1971), 65. For Marx, human nature had dual qualities, ones that are definitive and grounded in the corporeal existence of individuals, and ones that are the product of social existence. Together, they make up a truly materialist understanding of mental health.
As Marxist psychoanalyst Otto Fenichel wrote, “A materialistic psychology acknowledges the existence of the psychic as a particular realm of nature.” It “explains the special forms in which the psychic appears as derived from the material reality in which the bearer of this psyche exists (his body as well as the concrete environment which affect him by their stimulations).”26Otto Fenichel, “Psychoanalysis as the Nucleus of a Future Dialectical—Materialistic Psychology,” American Imago 24, no. 4 (1967): 292.
Capitalism and the Social Character
Marxist-inspired psychoanalysts like Erich Fromm and Wilhelm Reich contended that individuals are characterized by physiological, and for Fromm in his later works, psychological, instincts and internal drives intrinsic to humans. For Fromm, it was indefensible to assume that “man’s mental constitution is a blank piece of paper, on which society and culture write their text, and which has no intrinsic quality of its own.… The real problem is to infer the core common to the whole human race from the innumerable manifestations of human nature.” Early in his career, Fromm recognized the importance of biological instincts such as hunger, sleep, and sexual desires that required satisfaction “rooted in the inner chemistry of the body.”27Erich Fromm, The Sane Society (London: Routledge, 2002), 18, 65; Erich Fromm, Beyond the Chains of Illusion: My Encounter with Freud and Marx (London: Continuum, 2009), 27. He accepted the primacy of libidinal instincts as a fundamental biological impulse yet contended that, as humans evolved and their biological needs could be more easily met, the evolutionary process developed humans’ more complex intellectual and emotional capacities. As Fromm argued, humans “have their own basic needs, which they share with all the human race; they need to relate to others; they need to feel rooted in a world they consider their own; they need to transcend their feelings to be a creature either by creating or by destroying; they must have their own sense of identity that allows them to say ‘I’ and to have a frame of orientation that gives some meaning to the world they live in.”28Erich Fromm, “The Influence of Social Factors in Child Development,” marxists.org, 1958. Thus, many of the most significant human drives and instincts go beyond biology.29Fromm, The Sane Society, 27. In a similar vein, Reich emphatically emphasized the centrality of the libido and sexual instincts as paramount, even governing the nature of all individuals.30Wilhelm Reich, Character Analysis, 3rd edition (New York: Farrar, Straus, and Giroux, 1972).
Social systems greatly determine how instinctual needs and drives are fulfilled and the direction in which instinctual energy is channeled. Both Fromm and Reich posited that individuals must adapt their needs and instincts to society, and that most needs have a degree of plasticity that allow for this. This is what makes individuals capable of existing under, and within, various social conditions, as history illustrates. As Fromm underscored, “while the instinctual drives do develop on the basis of biologically determined instincts, their quantity and content are greatly affected by the individual’s socioeconomic situation or class.”31Fromm, The Crisis of Psychoanalysis, 155. And Reich argued that ”social conditions must first have impinged upon and changed human needs before these transformed drives and needs could begin to have an effect on historical factors.”32Reich, Character Analysis, xxii. Herbert Marcuse asserted this too, writing that “the reality which shapes the instincts as well as their needs and satisfaction is a socio-historical world.”33Herbert Marcuse, Eros and Civilization: A Philosophical Inquiry into Freud (Abingdon: Routledge, 1998), 14.
One consequence of the instinctual adaptation to capitalism is the emergence of what we can call a character structure, broadly shared by many individuals within society. The character structure reflects the sociohistorical ways in which the instincts of most people in society have been shaped, fulfilled, and adapted to the needs of capitalism at the time they are living. For Fromm, “every society has a libidinal structure,” a result of “the influence of socio-economic conditions on human drives.”34Fromm, The Crisis of Psychoanalysis, 161. Later in his life, Fromm referred to this as the social character: the ”essential nucleus…of most members of a group which has developed as the result of the basic experiences and mode of life common to that group.”35Erich Fromm, The Fear of Freedom (London: Routledge, 2001), 239. The social character reflects the broad similarities among members of society, in terms of attitudes and behavior—that is, “the sum total of character traits to be found in the majority of people in a given culture.”36Fromm, Beyond the Chains of Illusion, 62.
The purpose of the social character is to “mold and channel human energy within a given society for the purpose of the continued functioning of this society.” Without ignoring the multitude of unique individual characteristics, many people, Fromm argued, share a broad range of behavioral traits required and encouraged by capitalism for its preservation and reproduction.37Fromm, The Sane Society, 106–7. Similarly, Reich asserted that “every social order creates those character forms which it needs for its preservation…the formation of a psychic structure which corresponds to the existing social order.” For Reich, the shared character structure reflected the social relations of production, with the instinctual drives of the majority having to adapt to capitalism.38Reich, Character Analysis, xxii–xxiii