History of Psychiatry

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Marxian analysis and mental illness

Gerald N. Grob
History of Psychiatry 1990; 1; 223
DOI: 10.1177/0957154X9000100205
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History of Psychsatry, i ( 1990),223223-232. Printed in England

Marxian analysis and mental illness

GERALD N. GROB*

Andrew

Scull, a sociologist who appreciates the significance of historical data,

has been a highly visible and active participant in the scholarly debating dealing
with the mentally ill, psychiatry, and public policy. His new book, Social Disorderl
Mental Disorder,1 brings together a number of his articles published during the
past fifteen years. The collection illuminates his own analyses and frequent
disagreements with those who do not share his views.
Underlying Sculls scholarship is his firm belief that sociology and history are
but two sides of the same coin, distinguishable yet inseparable. A sensitivity to
questions of evidence and inference must be combined with theoretical sophistication and vision.2Too often historians have ignored theory and emphasized
data in the mistaken belief that a narrative is self-explanatory (just as sociologists
have emphasized theory and misunderstood the nature of adequate data). Only
theory, grounded in data and utilizing a comparative framework, he insists, can
help scholars avoid an approach that legitimates the present and obscures alternatives.
Sculls commitment to a venerable intellectual tradition - historical sociology is in part related to his fealty to Marxism. His Marxism is neither crude nor
simplistic, but is based on wide research in primary sources. Nor does Scull
dismiss, at least outwardly, individual volition, although he approvingly quotes
Marxs famous dictum that while human beings make their own history, they do
not make it just as they please ... [or] under circumstances chosen by themselves.Broad social and economic forces, not individuals, shape historical
deveiopments and impart to institutional structures a tenacity not easily overcome. If pushed to an extreme, he would probably agree with what some contemporary philosophers have designated as soft determinism.
When Sculls historical sociology and Marxism are applied to mental illness, the
result is a coherent description and explanation of a problem that has been the
*
Institute for Health,
N.J. 08983, USA.

Health Care

Policy and Aging Research, Rutgers University, New Brunswick,

1
Social Order/Mental Disorder: Anglo-American Psychiatry m Historical Perspective (Berkeley, 1989).

2 5.
Ibid.,
Ibid., 263.
3

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224

of scholarly controversy for more than two decades. Unlike many critics of
psychiatry (including Thomas Szasz, R. D. Laing, Thomas Scheff, Erving
Goffman, and Michel Foucault), Scull does not deny the reality of madness.
Mental alienation, he insists, is not simply the product of arbitrary social labeling
or scapegoating, a social construction tout court, nor should psychiatry be dismissed as merely a malevolent or cynical enterprise. Indeed, denials of the reality
of madness have provided, often unwillingly, an intellectual figleaf with which to
4
camouflage a policy of malign neglect .4
If Scull does not challenge the reality of madness, he surely questions the ways
in which England and America responded to behaviour that was (and is)
genuinely problematic.5His basic goal, as a matter of fact, is to explain the origins
of the asylum, the medicalization of madness, and the creation of a psychiatric
monopoly. The institutionalization of the mentally ill, after all, was neither
inevitable nor was it the sole alternative. On the contrary, the asylum, like other
institutions, had its roots within a specific set of circumstances. Sculls basic
objective is to illuminate its origins and describe its evolution. In a series of articles
and in two other books6 he has presented a forceful explanation of the emergence
of the asylum and the ensuing consequences.
The origins of the asylum, according to Scull, lay in a series of historically
specific and closely interrelated changes in Britains political, economic and
social structure as well as a corresponding alteration in the intellectual and
cultural horizons of the English bourgeoisie.~Specifically, an authentic shift in
moral consciousness occurred. In the seventeenth century madness was equated
with bestiality and a suspension of all rational faculties. Consequently, external
discipline and compulsion were required to break the will of madmen and subjugate
them. By the early nineteenth century madness had in effect been domesticated.
Lunatics were no longer perceived as beasts who lacked moral understanding;
they were now perceived as possessing the same sensibilities as normal human
beings and hence were receptive to appeals to reason and self-esteem. Put another
way, there was a shift from external controls designed to enforce outward conformity toward an emphasis on the internalization of moral standards.
Such a change led unerringly to the creation of ubiquitous asylum and the rise
in the nineteenth century of what was known as moral treatment. This novel form
of therapy, insists Scull, was not the result of humanitarian sentiment even
though it involved a rejection of coercion and an emphasis on - to quote Samuel
Tuke of the famous York Retreat - a mild system of management. Moral
treatment sought to transform lunatics, to remodel them into something
approximating the bourgeois ideal of the rational individualLunatics would
source

4 8-9.
Ibid.,
Ibid., 9.
5
6

Museums of Madness: The Social Organization of Insanity in Nineteenth Century England (London, 1979)
and Decarceration: Community Treatment and the Deviant-A Radical View (Englewood Cliffs, N. J., 1977).
7
Scull, Social Order/Mental Disorder, 43.
Ibid., 89.
8

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225
thus become active participants in their own metamorphosis. Within such a
framework the dominance of the asylum becomes more understandable. It was a
place in which the internalization of self-control could be institutionalized in the
same way that a family domesticated its members. The result was a convenient
fiction; asylum care, by emphasizing kind and rational means of persuasion and
rejecting physical coercion, could assist lunatics in reclaiming their own powers of
self control.
What forces hastened this profound transformation in the perception and
treatment of lunacy? To Scull the answer to this intriguing question is to be found
in the rise of capitalism. In preindustrial society theological and supernatural
explanations of the physical and social environment were pervasive, for human
beings did not believe that they possessed either the capacity or knowledge to
transform themselves or their world. In modern capitalist society, on the other
hand, rationalization is forced by competition, and the result is a faith in the
capacity of humans to control and manipulate their environment and thus to
mould personality. During the nineteenth century this faith was expressed in a
variety of novel institutional forms, including schools, prisons and asylums, all of
which were founded on the presumption that controls could be internalized. In
Sculls words:
As the market made the individual responsible for his success or failure, so the
environment in the lunatic asylum was designed to create a synthetic link
between action and consequences, such that the madman could not escape the
recognition that he alone was responsible for the punishment he received. The
insane were to be restored to reason by a system of rewards and punishment not
essentially different from those used to teach a young child to obey the dictates
of civilized morality. Just as those who formed the new industrial work force
were to be taught the rational self-interest essential if the market system were to
work, the lunatics, too, were to be made over in the image of bourgeois rationality : defective human mechanisms were to be repaired so that they could once
more compete in the marketplace. And finally, just as hard work and selfdiscipline were the keys to the success of the urban bourgeoisie, from whose
ranks Tuke came, so his moral treatment propounded these same qualities as the
9
means of reclaiming the insane.9

The rise of the asylum was also accompanied by the medicalizing of insanity and
the emergence of the speciality of psychiatry. This development mirrored a larger
social trend whereby elites rationalized and legitimated their control over deviant
and troublesome groups by assigning them to the authority of experts. In his piece
on Medical Men as Moral Entrepreneurs Scull describes how physicians, with
elite sponsorship, gained control over asylums and thus medicalized responsibility
for the insane. Similarly, his portrait of John Conolly (whose reputation rested on
the dubious claim that he ended mechanical restraint) emphasizes his adoption by

Ibid., 94.
9

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226
the

English elite. Faced by the threat of Chartism and restiveness of a militant

working class on the one hand and the devastation wrought by industrial
capitalism on the other, elite groups could at least point to the generous and kind
treatment now accorded mad people. In celebrating Conollys accomplishment,
Scull observes, Victorians were thus simultaneously affirming the moral validity
of their social order. ,10
Asylums, of course, failed to live up to their promise and remained a convenient place to get rid of inconvenient people. Reformers only succeeded in
substituting for active cruelty what late nineteenth century critics called the
monstrous evils of idle monotony. What is remarkable, Scull observes in
caustic language, is the absence of change and the determination of those in charge
of the system to deflect attention away from the horrors of the present by
resurrecting the tales of the barbarities of the past. Indeed, historians of
psychiatry have simply manufactured reassurance by contrasting the inhumanities of earlier generations with our present (relative) state of grace and

enlightenment. 11
Sculls interpretation of developments in recent decades follows much the same
line of thought. Just as the mental hospital was a product of capitalism, so too was
deinstitutionalization (the policy that came into vogue during and after the 1950s).
This new policy measured its success by the decline in in-patient mental hospital
populations and length of stays. Its supporters idealized the care and treatment of
the mentally disordered in the community, a policy that would restore the independence and initiative of this disabled group. The reality of deinstitutionalization,
however, was quite different. A large part of the decline in hospital populations in
the United States (less so in England) was due to the transfer of aged mentally ill
patients from hospitals to nursing homes. The result was a new trade in lunacy
that proved a boon to speculators who have every incentive to warehouse their
charges as cheaply as possible, since the volume of profit is inversely proportional
to the amount expended on inmates. Moreover, those who promoted the community care approach ignored the reality of the increasingly segmented, isolated,
and atomized existence characteristic of late capitalist societies. The basic problem, Scull concludes, is our collective reluctance to undertake a serious and
sustained effort to provide a humane and caring environment for the mentally
disordered. Ideologically Americans have never accepted the concept that individuals have a right to a certain minimum standard of living. Instead they have
held fast to an ideology dominated by the myth of a benevolent market-place and
a corresponding amoral individualism. Indeed, the essays in Social OrderlMental
Disorder constitute a powerful indictment of the manner in which England and the
United States have treated their mentally ill citizens.2
The coherence and symmetry of Sculls provocative interpretation is alluring.
10

11
12

Ibid., 193.
Ibid., 231, 305, 307.
Ibid., 314, 322-23, 327.

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227

There are no inconsistencies; individual and collective behaviour are explainabie

in purely rational terms; human volition, chance and accident are largely absent;
and the merging of historical data with sociological insights create an allencompassing structure capable of comprehending all of the details that constitute
social reality. The entire universe is linked within a unitary system that can be
understood and explained by using familiar Marxian categories. Conversely, Scull
dismisses the work of other scholars because their flawed theories and hidden
assumptions lead them to act as apologists for the system.
Symmetry and comprehensiveness, however attractive, are not by themselves
evidence of the validity of an interpretation. All scholarly claims must be subjected
to rigorous scrutiny. How persuasive is the nature of the theoretical structure that
shapes the work? Are the data and structure linked in clear and coherent ways?
Are data missing that if present would introduce contradictions and inconsistencies ? Are there alternative interpretations that better explain more of the
historical record? Despite the obvious strengths of Sculls work, there are significant methodological and substantive difficulties that vitiate many of his assertions.
Indeed, a close examination suggests that the linkages between interpretation and
evidence are hardly as firm as he insists, and even the quality of his data leaves
something to be desired.
Let us turn first to Sculls assumptions and methodology. His work admits no
room for doubt; the historical record is clear and unambivalent. But what if one
rejects his ideological framework? The validity of his interpretation, after all, is
not self-evident, but rests upon a particular view of society and human behaviour.
Scull of course insists that those who reject his quasi-Marxian framework are
merely apologists for the system who permit hidden assumptions to shape their
analysis. The other side of the coin is clear; only his approach is capable of
comprehending the true nature of social reality. The very same argument, however, can be turned on him. Does not his own Marxist assumptions direct rather
than follow his choice of data and his interpretation, thereby giving rise to a
distorted understanding of reality? Not all scholars, after all, accept his assumptions and theoretical framework. This is not in any way to insist that economic
factors play no role in shaping society and behaviour. It is simply to assert that
other elements may enter the picture, and that material factors - admittedly of
major importance - are not alone in moulding the world in which we live. To put
it another way, there are alternative models of human behaviour and their application to historical data gives rise to very different explanations. Cognition may very
well reflect more than economic factors; passion, emotion, and a range of affective
elements may enter into individual and collective behaviour. My disagreement
with Scull is not that he argues from a particular ideological vantage point, but
rather because he does not apply to himself the standards that he uses to criticize
others.
Sculls ideological framework - his denials notwithstanding - assumes an
interrelated and deterministic universe. Within this system all phenomena are
linked in causal ways. Hence the care and treatment of the mentally ill are shaped

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228

by capitalism and its commitment to productivity and internalization of controls.

To be sure, Scull insists, at least in theory, that human beings possess volition and
the ability to make choices that are not necessarily dependent on antecedents. Yet
his work suggests the opposite - a system in which individuals are pawns whose
destiny is shaped by impersonal and materialistic determinants. Because the
rhetoric is clothed with the language of the social sciences, he does not have to
concede that his own theoretical (i.e., ideological) commitments represent a
personal choice or act of faith; somehow he knows that Marxism is true and all
competing ideologies false.
Accompanying Sculls emphasis on theoretical sophistication and vision,
oddly enough, are a series of moral imperatives. Throughout the book are expressions of indignation at the cruelty of mental hospitalization as well as statements
that one of the marks of a civilized society is its determination to provide as of right
certain minimum standards of living for all its citizens..13 Although I do not
necessarily disagree, I fail to see how Sculls insistence on the primacy of
materialistic forces meshes with his moral indignation. The former assumes that
impersonal forces shape our existence; moral systems assume a degree of freedom.
It is inconsistent to insist on the primacy of impersonal forces and yet condemn
the results as immoral. As things stand, Scull comes close to merging Marxism
with classic natural law theory - an unlikely and improbable pot-pourri.
Some years ago J. H. Plumb, an eminent English scholar, drew a sharp
distinction between the past and history. History, he insisted, is not the past, even
though there are common elements to both. History represents an effort to see
things as they actually were, and from this study to formulate processes of social
change which are acceptable on historical grounds and none other. The past, on
the other hand, has always been a created ideology with a
designed to
purpose,
control individuals, or motivate societies, or inspire classes.
Plumbs distinction
is particularly applicable to Scull, whose work represents a clarion call to action. It
is not an analysis designed only to enlighten, but is rather intended to rationalize
the need for presumably fundamental change in the economic and social system.
The result is a scholarship that is partly distorted because of its didactic qualities.
Nor is Social OrderlMental Disorder devoid of substantive problems. Lest the
following comments to be misunderstood, let me note that Scull is a sociologist
who understands and appreciates historical data. He does not rely solely on the
work of others. On the contrary, he is willing to undertake the arduous and
time-consuming task of sitting in libraries and archives examining the musty
records - manuscript and printed - from the past. It is therefore entirely appropriate
to judge his work in the same ways that we judge the work of those who write
within the discipline of history.
Most of Sculls research, at least for the nineteenth century, is based on the
writings of medical and other elite groups, contemporary observers and govern., 5, 327.
Ibid
13

14

J. H. Plumb, The Death of the Past (Boston, 1970), 13, 17.

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229
documents. He uses such sources to illuminate the origins and development
institutional complex, its relationship to the larger social and economic
system, and the new perceptions of insanity that rationalized incarceration in
dehumanizing hospitals. The result is a generalized portrait of institutional
excesses and failures that were inherent in the system. Thus he writes about the
mental hospital as though differences were of no consequence whatsoever. His
generalizations, by virtue of their clarity and simplicity, are inherently appealing.
Unfortunately, reality is far more complex than Scull would have us believe.
Aggregate data, as we know too well, conceal even more than they reveal. Were all
mental hospitals similar or identical? Scull presents the statements of isolated
observers to prove his case - a technique that is hardly persuasive. An examination
of other kinds of sources would probably suggest that variation was quite common, that mental hospitals often differed in fundamental respects. One has only
to look at the history of the Wisconsin and New York systems during the past
century to understand how different they were. If historians of American higher
education were to write a history of the college and university, they would
immediately come under sharp criticism for their failure to distinguish between
very different types of institutions. Why then should we accept a one-dimensional
view of mental hospitals that ignores significant variations?
More importantly, Scull provides virtually no data on patient populations. In
this sense his work is curiously old-fashioned and somewhat dated. Since the
1960s new social historians have called attention to the important role played by
inarticulate, minority, female and lower-class groups in shaping culture and
institutions. Their findings have effectively destroyed the myth that these groups
were passive and that their destiny was shaped by elites. By ignoring patients,
Scull fails to recognize their importance. Patient populations, after all, were not
unchanging in character, and their impact on the character of hospitals was
profound. Sculls strategy of treating patients as passive victims - while serving
his larger ideological purpose - misses a real opportunity to expand our knowledge
of how mental hospitals actually functioned. More important, he completely
ignores major substantive issues about the role of mental hospitals. Because such
institutions are the creation of a malevolent capitalism, it follows logically that
their basic function was to reinforce the economic system. Unfortunately, logic is
not necessarily synonymous with reality, nor can ideology serve as a replacement
for evidence.
Although Scull avoids grappling with hospitals and patients, it is not because of
lack of data. There are abundant sources that illuminate patient populations and
institutional functions. American data since the nineteenth century are a case in
point. Before 1880 the proportion of chronic patients (Sculls description notwithstanding) was relatively low. Most patients were admitted and discharged
within four to six months, and only a small minority remained for as much as a
year or longer. Other data suggests that many patients who were discharged were
never again admitted. One of the only follow-up studies done before 1900 found
that 58 percent of nearly a thousand patients discharged as recovered in the

ment

of

an

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230

mid-nineteenth century were never again readmitted, suggesting the possibility

that hospitalization was not altogether void of benefits.
To be sure, after 1890 there was a rapid increase (because of changing demographic patterns and funding policies) in the admission of patients aged sixty-five
and older and others suffering from somatic disorders with accompanying
behavioural signs. As a result, the custodial functions of hospitals were magnified
in importance, a development that altered their character in fundamental respects.
Even here, however, Sculls arguments are not persuasive. Many aged patients
required total care; the same was true for males with tertiary syphilis or paresis, a
group that constituted 20 percent of all male first admissions. In the terminal stage
of this disease - which can last from six months to several years - individuals
manifest bizarre behaviour and dramatic neurological symptoms, including loss
of control over bodily functions and general paralysis. Such data offers little
support for Sculls allegation that incarceration was intended to penalize idleness
or nonproductivity or to inculcate traits conducive to a capitalist society; aged and
paretic patients for the most part required custodial and general medical care.
This is not to argue that mental hospitals embodied goodness and virtue. It is only
to insist that certain forms of dependency may mandate total care systems irrespective of the setting in which such care is provided. In the absence of alternatives,
the mental hospital assumed the function of providing care for certain dependent
populations. Admittedly, Scull does not deny the reality of mental illness.
Nevertheless, his ide fixe about hospitals renders him all but incapable of dealing
with patient needs and institutional functions.
Sculls analysis of the last half of the twentieth century represents by far the
weakest part of his scholarship. His treatment of the nineteenth century was based
largely on primary sources. His discussion of the post-World War II era in both
Social OrderlMental Disorder as well as Decarceration rests on a largely superficial
examination of a very small number of sources. In this sense his description of the
last four decades bears little resemblance to his original strictures about the need
for a historically-grounded sociological analysis. His discussion of the community
mental health movement is a case in point. He provides no historical data about its
origins. The movement simply appears out of a social vacuum, although its
champions, according to Scull, ignore the reality of the increasingly segmented,
isolated and atomized existence characteristic of late capitalist societies and
invoke millennial claims not very different from those that accompanied its
predecessors in the history of psychiatric reform.15There is virtually no mention
of the fact that the community mental health movement grew out of a combination
of World War II experiences, psychodynamic (or psychoanalytic) psychiatry, an
intellectual shift that posited an unbroken continuum from mental health at one
end to mental disease at the other (thus justifying claims that treatment in
non-institutional settings could prevent the onset of more serious mental illnesses),

15

Scull, Social Order/Mental Disorder, 314.

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231
and a generalized belief that environment shaped personality and culture. That
the community mental health movement was less than successful is true. Many of
the justifications offered by its proponents were expressions of rhetoric rather
than descriptions of reality. Yet rhetoric - Sculls disdain to the contrary - ought
not to be so easily dismissed. Rhetoric, after all, shapes agendas and debates; it
creates expectations that in turn mould policies; and it informs socialization,
training and education of those in professional occupations. Indeed, what is
intriguing about the postwar psychiatric rhetoric was the extent to which it
permeated not only the thinking of a broad public, but intellectual elites as well.
Nor is Sculls use of statistical data impressive. He includes a number of tables
detailing the decline in the resident populations of state and county mental
hospitals, but ignores other data that reveals that the decline in the resident
population was matched by an increase in the number of admissions. Between
1955 and 1970, for example, the aggregate resident population declined from
559,000 to 338,000. During this same period admissions increased from 178,000
to 385,000. Such data suggests a change in the functions of state hospitals. Before
1965 hospitals dealt with a chronic population. When the number of aged residents fell after 1965, hospitals - for a variety of reasons - began to change in
character and provide short-term care and treatment for severely mentally ill
persons. Indeed, some evidence suggests that public mental hospitals treat the
most seriously mentally ill who may be unsuitable candidates for alternative
reatment in community environments.
Similarly, other generalizations about the post-World War II era lack any basis
in fact. Since policy is a function of an impersonal economic system, Scull feels no
obligation to deal with specifics or to describe the role of differing political
structures in both America and England. The result is a profoundly ahistorical
treatment despite the fact that manuscript and primary printed sources for these
decades are overwhelming in quantity. Few of his descriptions of events after
1945 can be sustained when compared with existing documentation. There is no
awareness of the multiple sources of policymaking, and analysis of the process of
change is absent; policy is always an inevitable consequence of an ubiquitous
capitalism. Moreover, his discussion assumes a rationality in behaviour that is
quite at variance with the facts. Human beings in his eyes have the ability and
knowledge to control their destiny, and negative or undesirable outcomes must be
ipso facto the deliberate end product of a calculating behaviour.
Although Sculls work suffers from a number of weaknesses, it also offers many
strengths. The essay on the career of John Conolly is first rate, and the discussion
of the ways in which psychiatrists asserted jurisdiction over mental disorders,
although one-sided, is illuminating. In addition, Sculls insistence that any
analysis of public policy and mental illness must take broad structural elements
into account is refreshing, and his call for work that is truly cross-disciplinary
should be heeded. These and other strengths, however laudable, do not compensate for his unsuccessful, if not depressing, effort to impose a rigid Marxian
framework on a very messy reality. In the end Sculls ideological commitments

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232
detract from his ability to deal with the empirical data that constitutes the
foundation of historical scholarship. The result is an extensive corpus of work that
is deficient on two counts. First, it fails to deal adequately with a complex and
changing past. Secondly, its rigid Marxian foundation mandates continuance of
the status quo; presumably the fate of the mentally ill will have to await a
fundamental revolution in economic relations.

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