Mental Health Care in America.

“There is a particular kind of pain, elation, loneliness, and terror involved in this kind of madness. When you're high it's tremendous. The ideas and feelings are fast and frequent like shooting stars, and you follow them until you find better and brighter ones. Shyness goes, the right words and gestures are suddenly there, the power to captivate others a felt certainty. There are interests found in uninteresting people. Sensuality is pervasive and the desire to seduce and be seduced irresistible. Feelings of ease, intensity, power, well-being, financial omnipotence, and euphoria pervade one's marrow. But, somewhere, this changes. The fast ideas are far too fast, and there are far too many; overwhelming confusion replaces clarity. Memory goes. Humor and absorption on friends' faces are replaced by fear and concern. Everything previously moving with the grain is now against-- you are irritable, angry, frightened, uncontrollable, and enmeshed totally in the blackest caves of the mind. You never knew those caves were there. It will never end, for madness carves its own reality.” -An Unquiet Mind by Kay Redfield Jamison.

When a celebrity has a full blown meltdown the media circus shifts into high gear and supermarket tabloids exhaust themselves trying to capture every moment.

When a mass shooting occurs there’s a pretty standard playbook. The left denounces promiscuous gun culture and calls for background checks and weapons bans. The right goes all in on mental health. And the cycle continues.

A homeless individual has a mental break in a public arena and cell phones capture every second of a human tragedy.

When those afflicted with severe mental health issues suffer acute breakdowns they become public property. We stand at a distance and gawk at the spectacle and thank god it’s not happening to us. In reality, mental illness is something that touches all of our lives. It’s inescapable. The most severe public demonstrations merely serve to relieve us of any associated guilt or shame that comes from admitting this fact. To be precise, permit me to quote from the National Institute of Health:

“It is estimated that more than one in five U.S. adults live with a mental illness (57.8 million in 2021). Mental illnesses include many different conditions that vary in degree of severity, ranging from mild to moderate to severe. Two broad categories can be used to describe these conditions: Any Mental Illness (AMI) and Serious Mental Illness (SMI). AMI encompasses all recognized mental illnesses. SMI is a smaller and more severe subset of AMI.”

Before one can have a productive and informed conversation about mental illness, it’s important to agree upon language and definitions. But here’s the thing, the mind remains as unexplored and misunderstood as the ocean or the galaxy. There is more we don’t know than can be claimed as a certainty. So to be clear, I’m going to take a very careful and topical approach to this subject and stay within some pretty clear margins when speaking to conditions and care. For us, this is a story about the failures of capitalism. Hard stop. But to make this case, we have to wade through some complicated language and circumstances to understand why I make such a statement.

To our international audience, I’m writing specifically about conditions and care in the United States specifically. While some of the history we review includes references to asylum care in the UK and there are strong correlations between diagnoses and treatments in other parts of the world, the underlying thesis pertains strictly to the U.S.

Rosemary

Noted Portuguese doctor António Moriz won the Nobel Prize in Physiology or Medicine in 1949 for developing a surgical technique that became known as the frontal lobotomy. Inspired by behavioral improvements in chimpanzees that had their frontal lobes removed, Moriz initially experimented with alcohol to dissolve parts of the brain. Later he developed a wire loop instrument that traveled through holes cut in the skull that literally scraped matter fibers in the brain.

There were early signs of success that some claim Moriz oversold without revealing detrimental side effects. But the success was enough for the industry to proclaim his procedure somewhat of a miracle and it was added to the arsenal of physical and invasive treatments for a host of psychological disorders. For nearly two decades, the lobotomy procedure was practiced all over the world, often with disastrous results. Perhaps the most famous instance that impacted the trajectory of the mental health field in ways that are still felt to this day is that of Rosemary Kennedy, sister to the soon-to-be President of the United States, John F. Kennedy.

Without consulting his family members, including his wife, Kennedy patriarch Joseph Kennedy enlisted Dr. Walter Freeman to perform the nascent procedure on his daughter Rosemary. Rosemary was by all accounts a vivacious and engaging young woman with full control of her mental faculties. But as she grew out of adolescence she began to exhibit signs of mental instability and volatility. This was too much for the image conscious Joe Kennedy to endure and so he had her lobotomized.

Rosemary was awake during the procedure and speaking to the doctor and attending nurses. Until she wasn’t. Freeman had gone too far and the botched procedure left her incapable of speaking and barely able to move. Horrified by this turn of events, the Kennedy parents locked their daughter away in an institution. They didn’t visit her for two decades. Eventually, Rosemary was reunited with her family and placed in residential care in a Wisconsin facility where she remained until her death at the age of 86.

Rosemary’s tragic life inspired her brother to reform the mental health care system when he became president. The Kennedy family shame prompted a slew of legislation introduced under Kennedy with the most important objective passed just shortly before his assassination: to reform the system of asylums.

Kennedy was determined to end the practice of forced institutionalization. He recognized the importance of community based care and the failure of institutions to do much more than warehouse mentally ill people and keep them away from the rest of society.

Bedlam

The origin of the word ‘bedlam’ is the most infamous mental hospital in history in Bethlem, which was established in 1247. The Bethlem hospital housed the so-called criminally insane and was a rather small institution for hundreds of years until the beginning of the industrial revolution. As author Micha Frazer-Carroll writes in her book Mad World, “Firstly, the industrial revolution meant that Mad and disabled people could no longer work or be cared for in the home.” Centralizing factories and industrial production meant people were moving from feudal community-based agriculture and trades to centralized urban centers with long hours, thus destroying the home and community balance humans had known throughout recorded history.

But industrialization did more than just drive families apart. The work itself caused enormous stress that manifested in physical and mental issues. Poverty wages, poor working conditions, community bonds being fractured—everything we knew about life on the earth abruptly changed and so did our body and mind chemistry. The industrial revolution also ushered in tremendous population growth. And with the growth of the population came the need to accommodate the growing percentage of sick people. As Carroll writes:

“As more asylums were built, more people would fill them—when they continued to expand to accommodate for this, they would once again become overrun. By the end of the nineteenth century, there were more than 100,000 people living in county pauper asylums, all of which were ‘compulsory’ patients detained by the state, and were less likely to be released than prisoners.”

In order to cover the expense of these growing facilities, many of them—Bethlem included—opened up the facilities as attractions and would charge visitors to gawk at the inmates. Behind closed doors, the treatments these wards of the state were subjected to were often horrific and barbaric. It wasn’t until the Quakers began experimenting with “humane” care that the psychiatric industry started moving away from torture and restraint. But the population growth was too much to make this sustainable in all parts of the world and so many asylums fell into disrepair and became overcrowded. Even the best intentions couldn’t cover for the sheer volume of care that was required from an increasingly sick population.

Before the advent of pharmaceuticals and other breakthroughs in treatments and understanding of disorders in the 20th Century, asylums remained the primary mode of treatment for patients with mental illnesses. Depending upon resources and population density, the level of care varied dramatically as there was little continuity in approach to care and many resembled little more than prisons.

President Kennedy envisioned a two-pronged approach to changing the nature of care. Importantly, his administration’s proposals followed on the heels of breakthroughs in pharmacology, which helped advance the psychiatric profession beyond the theoretical realm of figures like Freud and the brutality of asylum care. Many of the drugs that were released in the ‘50s held great promise for mitigating some of the most severe conditions. In a short period of time a great sense of optimism came over the profession, which allowed the political class to rethink compulsory incarceration of those suffering from mental illness.

The first part of the concept was to shutter the large institutions that house the most severe inpatient cases. The second part of the plan, to occur simultaneously, was to replace the centralized facilities with community based centers that could provide a balance of drug therapies with inpatient and outpatient care that allowed families to stay closer to loved ones as they pursued treatment.

Disorder

A few things happened after Kennedy’s assassination that unraveled the plan over time. Funding for community centers stalled even though the first part of the plan to decommission centralized asylums began in earnest. Then, Kennedy’s successor Lyndon Johnson amended the Social Security Act to exclude hospital care for mental health patients in an effort to incentivize the dismantlement of the asylum system. So while the unraveling of centralized care was accelerated, the community health system remained in limbo, thus creating a gap in care and crisis for families left with few options to manage difficult and extreme cases.

As a Time Magazine article points out, “The miracle drugs, introduced in the fifties, proved less miraculous than first hoped. Less than half of the community centers Kennedy envisioned were ever built, though 90% of patient beds in large state mental health hospitals were eliminated.”

The United States would linger in this treatment purgatory with experimental drugs and procedures, a declining number of beds and general confusion throughout the ‘60s and ‘70s. At the very end of the Carter administration, the Carter team attempted to address what had developed into a full blown crisis by signing the Mental Health Systems Act, which was essentially an attempt to actualize Kennedy’s original vision of expanding community-based care. A feature in Salon chronicles the fate of the bill:

“Consistent with the report of the Carter Commission, the act also included a provision for federal grants ‘for projects for the prevention of mental illness and the promotion of positive mental health,’ an indication of how little learning had taken place among the Carter Commission members and professionals at [National Institute of Mental Health] NIMH. With President Reagan and the Republicans taking over, the Mental Health Systems Act was discarded before the ink had dried and the CMHC [Community Mental Health Centers] funds were simply block granted to the states. The CMHC program had not only died but been buried as well.”

The article makes two critical points. Despite Carter’s attempts to reinvigorate community care the political class largely misunderstood the nature of mental illness and the type of research and funding required to build modes of care and experimental drug therapies. The other part is the Reagan connection.

Most of the time when I dig into a topic, I start by addressing my own biases and work backwards from there. In this instance, I had a long held assumption that somehow Ronald Reagan was responsible for destroying the mental health care industry and threw mentally ill citizens into the streets. This is partially true but as usual, there’s so much more to the story.

Despite the fact that Ronald Reagan was nearly assassinated by a mentally ill person, he had remarkably little interest in understanding mental illness. But that’s an aside. What Reagan did was convert the funding proposed by Carter for community centers specifically into block grants for the states. Block grants are notorious for misappropriation because the standards for accepting and implementing them are typically pretty low. Meaning the funds are often misallocated and misaligned from their intended purpose. They also come with strings. Federal block grants are great for projects that don’t require ongoing funding and maintenance. Infrastructure block grants, for example, are far more popular and easy for state legislators to digest because they're more one and done than a healthcare facility.

So even though the funding was available, not all the states were interested in it. Moreover, there was little consistency in the direction and application of the funding so of those that were implemented, the outcomes were wide ranging and inconsistent. As Dr. Kenneth Paul Rosenberg writes in his book Bedlam:

“Of the two thousand community mental health centers proposed to replace the demolished asylums, only half wound up being built and those were only partly funded…by the 1980s, fewer than one hundred of the outpatient community mental health centers that were built to solve America’s mental illness crisis remained.”

The list of disorders listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM), including the most recent version DSM-5 is voluminous:

• Neurodevelopmental Disorders
• Schizophrenia Spectrum and Other Psychotic Disorders
• Bipolar and Related Disorders
• Depressive Disorders
• Anxiety Disorders
• Obsessive-Compulsive and Related Disorders
• Trauma- and Stressor-Related Disorders
• Dissociative Disorders
• Somatic Symptom Disorders
• Feeding and Eating Disorders
• Elimination Disorders
• Sleep-Wake Disorders
• Sexual Dysfunctions
• Gender Dysphoria
• Disruptive, Impulse Control and Conduct Disorders
• Substance Use and Addictive Disorders
• Neurocognitive Disorders
• Personality Disorders
• Paraphilic Disorders

The DSM is the psychiatric industry bible. It’s updated every few years to incorporate new concepts and covers all types of disorders. And it will likely be updated further in years to come as we begin to grapple with the long-term effects of COVID. As the World Health Organization reported, “In the first year of the COVID-19 pandemic, global prevalence of anxiety and depression increased by a massive 25%, according to a scientific brief released by the World Health Organization (WHO).”

While I’m not qualified to delve much further into the actual world of mental health and the nature of mental illness—this is a story about capitalism and politics—I want to share a passage from Mad World that helps illustrate the difficulty of even attempting to classify disorders and ascribe therapies and treatments.

“Mental health awareness places responsibility for ‘fixing’ Madness/Mental Illness on individuals, by suggesting that if people have the correct knowledge about symptoms and how to address them, we can then solve this crisis among ourselves. The knowledge we are given to name and describe our struggles is usually psychiatric knowledge…Meanwhile, cure is framed as a clear and steady path, as long as we are willing to try going to health services, taking our medication, paying for therapy, practising self-care, taking up mindfulness, eating better, getting regular exercise, having an active social life—or anything on the expanding list of practices that are promised to help us recover. While many of these things may make people feel better, an exclusive focus on these individual actions overlooks the fact that they don’t work for everything; and the road to ‘recovery’ is rocky, complex or even impossible for many of us in our current conditions. It frames ongoing distress as a personal failure to self-discipline or seek out appropriate services, rather than acknowledging the structural conditions that also dictate our lives. This approach aligns perfectly with neoliberal ideology, which emphasises free-market competition, decreased state spending, and increased personal responsibility.”

I’ll cap this with a profound statement from Dr. Rosenberg who said, “Mental illness doesn’t just happen in a vacuum. There’s a progression of illness, exacerbated by life’s stresses, during which the smoldering brain erupts into an all-out five-alarm fire.”

In speaking in these terms you can begin to appreciate the difficulty in tackling mental illness as a society. Is it biological? Something in our DNA? Is it environmental, in both ways—meaning exposure to neurotoxins as well as daily work and life stresses? Is it folly to search for a cure? Where do the rights of patients begin and where do they end? Is it okay to strip someone of their civil liberties if they pose a danger to themselves? Or to others?

The recent rise in homelessness and violent crime following COVID prompted states like New York and California to assume antiquated and draconian postures toward the unhoused. Plainly speaking, the public outcry left officials feeling as though they had no choice but to detain people involuntarily. Of course, without beds and facilities and protocols for care, that simply meant that people were deposited into the carceral system, which only serves to exacerbate the stresses that likely placed them in a precarious life position in the first place.

That’s why Carroll’s words resonate with me. The first step to developing a coordinated system of care that can be replicated successfully and iterated upon when new breakthroughs occur is recognizing that mental illness is not something to be cured. It’s something to be treated. To be cared for. This simple sentiment elucidates the protocol moving forward: holistic systems of care that reduce environmental stresses with prescribed combinations of therapies to achieve a balance that allows a patient to function then hopefully thrive. As Rosenberg states, this looks like:

“Consistent and comprehensive care provided by a team of doctors, nurses, public defenders, case workers, licensed counselors, and the judge—an approach that’s called wraparound care… Whether we like it or not, jails, judges, and law enforcement are already intimately involved in overseeing and managing mental health care, and it is critical to know how to leverage the law for treatment, not punishment.”

Wraparound Care

Okay, so understanding that wraparound care rather than searching for a cure is paramount to crafting solutions, we can more clearly see how our capitalist structure poses an enormous barrier.

First off there’s the inexorable link between the pressure a capitalist system places on its citizens. Again, Carroll:

“Our mental health cannot be disentangled from the intertwined systems of white supremacy, ableism, gendered oppression, imperialism and capitalism. All forms of what we call ‘illness’ or suffering interact with the political world—a world that is particularly deadly for certain bodyminds.”

By introducing related structural ills such as racism, Carroll demonstrates just how layered and complicated the discussion can be. We’ve talked about this before when speaking about the concept of weathering, coined by Dr. Arline Geronimus at the University of Michigan in the ‘90s. Weathering describes the phenomenon of premature aging due to repeated exposure to stressful social factors.

Carroll offers an example from a UK study that found Black Caribbean people are nine times more likely to be diagnosed as schizophrenic than white people in the UK. “Notably, this extremely high rate of diagnosis in the UK has not been replicated in the Caribbean—suggesting that these rates are more to do with the social and political experiences of Black British people.”

In purely economic terms Carroll writes about workers in what she describes as ‘precarious’ fields:

“Hospitality workers experience the highest reported levels of workplace stress out of any industry; and those who rely on tips are at a particularly high risk of depression and sleep problems. These occupational hazards are exacerbated by ‘emotional labour’—the process of having to control, mask and split off certain emotions when faced with customer hostility or even sexual harassment—which disproportionately affects women in the service industries.”

For my critics who suggested that I spent too much time talking about socialist theory, there’s a construct for this: Marx’s theory of alienation. But I digress…

So it’s in these structural ways that capitalism contributes to the inputs of mental disorder. On the flip side it only deepens the crisis by failing to compensate for the outputs, or care.

In following the neoliberal belief system that markets will cure all, we have privatized care in this country and allowed for-profit organizations to step into the role of government. As a result some aspects of care have developed in counterintuitive ways to how we even think about capitalist structures. For example, in allowing the free market to develop drug therapies, we have destroyed and disincentivized competition.

In Bedlam, Dr. Rosenberg quotes Richard Friedman, MD, director of psychopharmacology at the Payne Whitney Psychiatric Clinic, who says:

“The risk-averse pharmaceutical industry takes a known compound with a known mechanism of action and modifies it just slightly to get a ‘new drug.’ So you have lots and lots of what we call ‘me-too’ drugs that are new, they’re patented but they work on exactly the same targets as the old drugs.’ As Dr. Friedman explains, we have decided to leave most of the research, development and testing of medications to the for-profit pharmaceutical industry, rather than to NIMH or other government agencies.”

Then, of course, we have the personal financial part of the equation. Most people in need of wraparound care simply can’t afford to avail themselves of such services even in parts of the country where it is available. Attempts to ameliorate this circumstance have proven effective, however, and offer a glimmer of hope. Both the Affordable Care Act and the Mental Health Parity and Addiction Equity Act of 2010 have promoted coverage for individuals for basic psychosis services and to prevent discrimination by insurance companies against mental health patients respectively. But it’s a drop in the bucket of what’s required if we don’t backstop this with community facilities, wider long-term coverage and research and development into new therapies and modalities of care.

The free market approach to mental health care is as disastrous as letting citizens go without basic care for physical and more obvious health issues. But because mental illness isn’t as visible unless it is on full display in the form of a violent homeless person in the streets, we fool ourselves into believing it’s not as prevalent. Or as destructive.

It’s why we fight for greater equity. This is an all-of-us problem, not a some-of-us problem. There are aspects of society that cannot be cured by the free market and in many cases the free market is perhaps the root of the problem or gasoline on the fire of the mind. It’s also a stark reminder that what we have today isn’t even a capitalist society as Adam Smith would have envisioned. Recall that the tenets of Smith’s capitalism were to release the forces of markets to enrich society and to pay for that which the market cannot provide such as welfare, art, music and education. The success of a society should not be judged by how well it performs for those in the upper echelon of the economic stratosphere, but how well it compensates for those who exist in all other levels.

A healthy society starts with an understanding of the distinction between markets and governance and where the responsibilities between and among them truly lie. If we can begin to reconcile these concepts perhaps we can take the first step in realizing the unfulfilled promise of Rose Kennedy’s tragedy and rewrite the American story; a story that doesn’t strive for a happy ending but a fulfilling and healthy journey as that may be all that’s possible in the complicated world of mental health. After all, a nation is only as strong as its people.

Here endeth the lesson.