Does "Rugged Individualism" Undermine Mental Health?
Exploring the post-World War II idea that "society" was the "patient."
Posted Sep 19, 2018
After the Second World War, there was a pronounced shift in mental health thinking towards seeing society, rather than the individual, as the focus of psychiatric efforts, especially those aimed at preventing mental illness. As the title of a 1950 collection of essays by American social scientist and Rockefeller administrator, Lawrence K. Frank—Society as Patient—indicates, many mental health professionals and academics believed that focusing only on the individual was not only inefficient and costly, but also disregarded broader truths about the nature of mental illness itself.
Although psychoanalysis (which was in its pomp at his period) and biological psychiatry (which was beginning to gain significant influence) were both individualistic in their approach to mental illness, a more community-based approach was advocated by the emergent, interdisciplinary field of social psychiatry. By the 1960s, this community-based approach would be put into action via the Community Mental Health Acts, which led to the deinstitutionalization of mental health care (effectively, the shutting down of mental hospitals in favor of community care). Whereas approximately 600,000 Americans found themselves in mental hospitals in 1955, by 1990, there were only 115,000 Americans being treated in psychiatric institutions.
Deinstitutionalization has had a mixed legacy: on the plus side, it ushered in the idea that the mentally ill had rights and should be treated humanely. Rather than being segregated from the rest of community, people with mental health problems should remain part of the community whenever possible. But, in reality, many patients ended up in other institutions (ranging from nursing homes to prisons) or, worse, homeless. Putting the role of numerous political and economic factors to one side, it's possible that community care was a little too idealistic or was ushered in too aggressively.
But perhaps that is missing the point when it comes to what social psychiatrists really meant about community care and "society as patient." When you read what people like Lawrence Frank and others were saying about community mental health, a much more profound idea emerges. Specifically, many post-war social psychiatrists believed that if Americans wanted to reverse the apparently rapid rise in mental illness, the balance between the individual and the community had to shift to the latter. As Frank argued, Americans would have “to give up … time-honored beliefs in human volition and responsibility” and “replace them with a larger and humanly more valuable belief in cultural self-determination, social volition, and group responsibility.”
During the 1950s, a decade of economic prosperity, free market capitalism and McCarthyism, such views were controversial. After all, the "rugged individualism" of Herbert Hoover was believed by many to be the key factor in "American exceptionalism"; it was what made America "great." But the communitarian idea persisted in mental health circles, lingering somewhere at the edges of the community mental health movement. In many core social psychiatry texts, this idea in a shift from the individual to the community could be detected, even if one had to read between the lines. By the time of the "me decade" of the 1970s and Reagan's rise in the 1980s, such ideas were dismissed, as funding for community mental health centers disappeared and political interest in preventive psychiatry abated. But that doesn't mean that such ideas are not worth reconsidering today, as we continue to experience escalating rates of mental illness.
The past decade has seen a return to debates about the individual and society, even if the terminology has changed. In the UK, individualism fueled the victory for Brexiteers, as 52 percent of Britons rejected membership in the European community of nations (Scotland, where I live, voted 62 percent in favor of staying in the EU). Similar debates are being held throughout Europe—not least because of recent refugee crises. And in the US, individualism was one of the key pillars in Donald Trump's rise to power. Tax cuts, economic isolationism, and the reverse of a whole series of environmental protections are but a few examples of the return to "rugged individualism" in the US.
At the same time, however, we've seen the resurgence of left wing parties (fueled largely by the youth vote), renewed interest in egalitarian economic policies, such as universal basic income (UBI), and (despite Trump) concerted efforts by most countries to work together to combat climate change. If we are serious about combating mental illness and, crucially, preventing it, we should start to revisit the debates of the post-war period. As I have argued elsewhere, establishing a UBI would be a bold step in not only reducing inequality, but also reducing mental illness, as it would both reduce the stresses associated with poverty and allow people more control over their lives. In this way, UBI provides a more positive individualism, whereby one individual's success does not have to come at the expense of another's.
As with many of the world's biggest problems, tackling mental illness requires nuance, sophisticated, and creative thinking. Only by thinking of mental illness as both a societal and an individual problem can we combat it effectively.
Matthew Smith, "A fine balance: individualism, society and the prevention of mental illness in the United States, 1945–1968," Palgrave Communications (2016), https://www.nature.com/articles/palcomms201624