The Incurable

A materialist genealogy of homelessness

Pilgrim State Hospital, Brentwood, N.Y., 1938

Last week, I wrote about the cultural factors behind untreated mental illness and homelessness in the United States. Briefly, I argued that two radically different conceptions of human freedom — the Yankee authoritarian philosophy of “ordered liberty” and the Scots-Irish libertarian spirit of Greater Appalachia — contributed, respectively, to the emergence of the mental asylum, and then to its dismantling.

A different explanation, however, is articulated by many on the political left: homelessness is the by-product of capitalism. It’s a predictable line, but it’s not wrong. There’s a Marxian, materialist reading of the phenomenon with which the cultural explanation is not only compatible; it’s incomplete without it.

I’m going to do my best to make that case here.

It’s easy to dismiss the connection between capitalist relations of production and homelessness, as the forces at work are invisible. The closing of the asylums is a much more obvious and tangible cause of the appearance of severely mentally ill people on American city streets. Much less apparent are the abstract economic forces that created the problem that the asylum was invented to address in the first place.

But that problem can be traced precisely to the emergence of modern capitalism in eighteenth-century England when rural paupers suddenly began to appear all over the English countryside. The forces behind their appearance were even more mysterious then than the ones behind urban homelessness are today. Some attributed the problem to people having too many dogs; others blamed the effects of tea on workers’ health. It wasn’t obvious until years later that pauperism was the consequence of the mass eviction of peasants from common lands by enclosure laws, which began in the seventeenth century. This was a necessary precondition of capitalism. Though it followed nobody’s conscious design, the “driving of the peasants from their land,” in Marx’s words, was necessary to catalyze the emergence of a market economy. By depriving them of the means to feed themselves in any way other than by trading their labor for wages, the policy transformed the peasantry into an industrial working class.

It wasn’t until the nineteenth century, however, that the process was completed. For several decades, England had a public subsidy scheme for both the employed and the unemployed known as the Speedhamland System, which was something like a Universal Basic Income program. There was little incentive under this system to work for a wage that was guaranteed to you anyway. That meant that there was no mechanism by which employers could increase or even sustain the productivity of their workers. Along with the drop in productivity, there was a relentless downward pressure on wages, as the government was, in effect, subsidizing employers to pay less. As wages plummeted, more and more workers were forced out of their jobs and onto “the rates.” Pauperism exploded.

The Poor Law Amendment Act of 1834 abolished that dysfunctional system. Under the new economic order, those who were unable or unwilling to work in the factories, including the sick, the orphaned, the disabled, and the elderly, no longer received government welfare, but were instead herded into ghastly Victorian workhouses like the one in the Dickens novel Oliver Twist. Through this measure, English employers finally imposed upon workers the work-or-starve conditions necessary for a competitive labor market to materialize, and capitalism could, at long last, gallop out of the starting gate.

Much the same occurred in the United States. There were no enclosure laws in America, but as the growth of wage labor eroded the artisan economy of the colonial era, nascent capitalism nonetheless begat a surplus population that could be absorbed by neither farm nor factory. As the workplace separated from the home, and as urbanization and the development of a national labor market encouraged the geographical dispersal of family members, many of the traditional roles and duties of the family and the community eroded. The structures of village and kin were stripped bare by market forces, leaving them unable to continue to perform the welfare functions that had been their unquestioned responsibility for centuries, in both the New and the Old Worlds.

The state took their place. Instead of being attended to, however well or poorly, by their neighbors and relatives, people surviving at the margins were shepherded into government-financed almshouses and early “hospitals,” which were essentially almshouses by another name. The insane, meanwhile, were sequestered in newly constructed mental asylums.

This was what Marx meant when he wrote of the incessant innovation of capitalism and the social disruption it creates: “All fixed, fast-frozen relations, with their train of ancient and venerable prejudices and opinions, are swept away, all new-formed ones become antiquated before they can ossify. All that is solid melts into air, all that is holy is profaned, and man is at last compelled to face with sober senses, his real conditions of life, and his relations with his kind.” Under the capitalist mode of production, the elderly, the chronically infirm, and the insane, having no economic value that can be traded in the marketplace, are shorn of their roles as fathers, mothers, brothers, sisters, and friends, and made into an undifferentiated mass of superfluous humanity to be warehoused at public expense until they die.

But this explanation begs the question: If the almshouses and asylums performed the indispensable role for capitalism of overseeing a population that the market was unable to absorb, why did they disappear?

I’ll leave the question of almshouses, which I have not investigated, for another day. But I can attempt a materialist explanation for the closure of the asylum.

At this point, however, we have to depart somewhat from what a doctrinaire Marxist analysis would accept as “a materialist explanation.” One of the fundamental shortcomings of Marxism is its refusal to account for the history-shaping nature of the intermediate social classes, by which I mean those that are neither owners nor workers, but somewhere in between. The crudest of Marxists hand wave away artisans, bureaucrats, owner-proprietors, and professionals who neither exploit the labor of others nor are themselves exploited by profit-seeking owners as members of a doomed “petty bourgeoisie.” The interests, choices, and actions of the members of this class are, at best, “superstructural phenomena” that are incidental to the great, tectonic struggle between the proletariat and the bourgeoisie.

Capitalism, however, did not evolve as Marx believed it would. Marx expected that the ever-increasing concentration of capital would squeeze the petty bourgeoisie, driving the successful among them into the haute bourgeoisie and the unsuccessful into the proletariat. Instead, the opposite happened: in the postwar years of the twentieth century, the middle class expanded into the majority class in advanced capitalist countries, while the professional class has become, in the twenty-first century, the new ruling class.

The class interests of professionals are now the most determinative of all class interests in the shaping of the post-industrial world. These interests are distinct from those of the workers or the capitalists. In the Marxist reading, capitalists have an objective interest in milking their workers of as much surplus labor as possible, as this is where profits come from. Workers, meanwhile, have an objective interest in retaining as much of that value for themselves as they can. This, to Marx, is the basis of their collective resistance to, and, eventually, revolutionary action against their exploiters.

The professional, however, has neither of these interests. The lawyer, the scientist, the surgeon, the creative director, the accountant, and the architect don’t profit by extracting surplus labor from their workers, nor do they produce surplus labor that their employers extract from them. They are outside of that binary relationship of economic exploitation. They aren’t fundamentally oriented around profits and wages at all. They are driven, rather, by status.

Professionals compete with one another over status within their industry. But they also compete collectively, within an industry, to enhance the status of their profession as against other professions. The principal way they do this is through status group closure: restricting the pool of entrants into the profession to make membership within it a more rarified commodity. Once upon a time, the only prerequisite for being a lawyer was a high school degree. Then practicing lawyers made it a rule that you had to graduate from college to enter their guild. Then law school. Then passing the Bar exam. As the credential requirements increased, so too did the status of the legal profession.

The field of psychiatry emerged out of the asylum, which was regarded, at its inception, as a healing institution. In an age of technocratic optimism, the assumption prevailed that mental illness was a condition that, given time and resources, could be cured by medical specialists. And often, it was. Contemporary correspondence between ex-patients and their former psychiatrists attests to the therapeutic successes of the asylums. These successes redounded to nineteenth-century psychiatry’s vaunted position within the general field of medicine.

But there was a stubborn fraction of the patient population that, it soon became clear, would never be cured. For those severe, chronic, intractable psychiatric cases, the asylum’s duty shifted from medical treatment to custodial care. As those cases accrued in the back wards, custodial care became the primary function of the asylum.

To make matters worse, by the turn of the century, asylums began filling up with elderly patients. Declines in mortality as a result of medical advancements meant that the number of people over the age of 60 in the United States had exploded over a few generations, from 1.3 million just before the Civil War to 13.7 million by 1940. At the same time, almshouses were disappearing. Families without the means to support their dependent elderly relatives began pushing them into state psychiatric hospitals. By 1958, almost a third of asylum patients in the U.S. were over the age of 65.

As asylums became overcrowded with incurable cases of chronic mental illness and with elderly people whose only “condition” was the inevitable mental decline of old age, the public began to see them less as houses of healing than as warehouses of the doomed. Stories and images of abuse and negligence appeared in popular magazines and newspapers. Psychiatrists came to be regarded as managerial professionals rather than medical ones, and were associated with the despair and misery of the dismal institutions that birthed the profession.

Grasping for its lost stature, the profession of psychiatry, little by little, distanced itself from the asylum system. Many new entrants into the field established private practices, which were all but unknown before World War II. Others moved into the novel and ostensibly preventative sub-discipline of “mental hygiene.” Their clientele changed along with their institutional settings. Psychiatry’s new patient population became the “worried well” — largely functional people with anxiety issues attached to ordinary but challenging life events, like divorce or the death of a loved one. By the postwar years, one could spend an entire career as a psychiatrist without ever stepping foot in an asylum and without ever treating anyone with a severe and chronic mental illness.

This was one of the several fundamental variables that led to the closure of the asylums (the others being the development of the antipsychotic drug Thorazine, and a larger cultural turn against institutions that climaxed in the 1960s). Today, we are no closer to a cure for severe, chronic psychiatric disorders than we were in the days of the asylum, but now, we are deprived not only of traditional family and community structures but of institutional ones as well. Instead of being relegated to locked wards, capitalism’s surplus population of the mentally ill is dumped on the streets to sleep in doorways and live in tents under freeway overpasses. They are the paupers of the twenty-first century and, like their eighteenth-century counterparts, they are the refuse of an indifferent economic order.