Is the Mental Health System “Broken”?
The oft-repeated phrase is seldom questioned.
Posted Oct 11, 2018
“The mental health system is broken.” This phrase is now used with great regularity by the popular media, politicians, “advocacy” organizations, and even governments themselves responsible for delivering mental health services (a Google search of the phrase in quotes turned up over 51,000 search results). Related to endorsement of this statement are beliefs that mental health service providers fail in their responsibility to prevent mass shootings (endorsed by nearly half of Americans), that homelessness is caused by deinstutionalization, and that community mental health systems abandon people released from psychiatric hospitals with no aftercare follow-up. The New York Times, speaking from its editorial page platform this past June, went so far as to proclaim that no one disagrees that the current community-based mental health system is a “colossal failure” (with the recommendation that more people with mental illnesses need to be permanently confined in institutions).
When phrases are repeated so frequently, they can become part of the “conventional wisdom,” defined as “generally accepted belief, opinion, judgment, or prediction about a particular matter.” The conventional wisdom is a potentially powerful tool for influencing social behavior, and can thus be a force for good or ill, depending on how closely it aligns with scientific evidence. Researcher and sociologist Bruce Link has discussed the need for researchers to communicate scientific findings in order to turn “social misunderstanding” in the general public into “social understanding.” As an example, he discussed how the conventional wisdom in the United States used to be that smoking cigarettes posed no health risks, despite evidence to the contrary (in 1954, only roughly 40% of persons with a high school education believed that smoking caused lung cancer); however, as a steady stream of evidence from the research community began to reach the public’s awareness, this gradually changed, such that, by 1999 over 90% of US residents with a high school education endorsed that smoking causes lung cancer (greater than the proportion believing that the Earth revolves around the Sun!). Link pointed out that the transformation of the “conventional wisdom” in this regard has been associated with corresponding dramatic reductions in smoking behavior and increases in life expectancy in the US general public.
Is the conventional wisdom that “the mental health system is broken” accurate and helpful? Taking a closer look at the phrase, implicit in it is the assumption that the mental health system was once whole. Essentially, this represents a yearning for the pre-deinstitutionalization system in which public-sector services consisted almost completely of state hospitals which confined people with serious mental disorders for indefinite periods (usually life). This represents the belief that indefinite confinement in hospitals is the best way for society to care for people with serious mental disorders.
While the lives of people who lived in these institutions are generally shrouded in mystery, an impressive study was recently conducted which reviewed the abandoned suitcases of people who resided at one state institution in New York State which closed in 1995. Through an examination of letters and case notes, this study found that many individuals who lived in these settings (often symptom-free, according to case files), sometimes left behind promising lives in the community, and desperately wanted to leave but were not allowed to.
Whether one considers a system that is based on indefinite confinement in hospitals to be ideal or not depends on one’s values and what one sees as the purpose of the mental health service system. As I and others have argued elsewhere, if we believe that the purpose of the mental health system to help people diagnosed with mental disorders to live the best lives possible, then it is clear that such a system is inappropriate; however, it may be appropriate if one believes that the protection of community members from people with mental illness is the primary purpose of the system. However, this is far from the consensus within the mental health field (even as promoted by President George W. Bush’s “New Freedom Commission”), which views recovery and community participation to be the primary purpose of the mental health service system.
How well does our current community-based system of care perform in its mission of facilitating recovery? It is clear that it falls short in many ways. For those of us who work in the system, an almost universal frustration is the lack of an adequate supply of subsidized housing which can allow people with mental disorders to live safely and participate in community life. Such housing is needed because social safety-net income supports (such as Supplemental Security Income [SSI] and Social Security Disability Income) are not high enough to allow people to rent unsubsidized units (e.g., in New York State, SSI payments are approximately $800 per month- not enough to afford a market-rate apartment). This leads many people to become homeless or live in substandard settings. Risk of incarceration also increases with homelessness. Subsidized housing has been demonstrated to lead to improvements in community participation, decreases in hospitalization and emergency use, and to be less costly than shelters, hospitals or jails, but communities seem to lack the political will to appropriately invest in them.
Other aspects of the service system are ones that there is reason to be proud of, although they need to be expanded. Supported Employment services have been demonstrated to more than double employment rates among people with mental disorders, but need to be more widely available. Flexible service models which reduce barriers to treatment engagement, such as Assertive Community Treatment (which I work in) and targeted services for people who have experienced a first psychotic episode, have repeatedly shown success in improving outcomes, but are still not available to all that would benefit from them. Person-centered models such as peer support help a great number of people as well but are also not as widely available as they should be.
The mental health system is not broken because it was never whole. It is a deeply flawed system, but a much better one than existed previously. As the late Dr. Fred Frese, a psychologist who had been diagnosed with schizophrenia, who passed away this year, stated “there's never been a better time to be a person with serious mental illness. There's more hope than ever before.'' However, he also noted that stigma continues to pose a major barrier to community integration. There is a desperate need for more investment in affordable housing and an expansion of evidence-based services. People who care about improving the lives of people diagnosed with mental illnesses should join together to advocate for these investments. But blaming the community-based system of care for social problems like mass incarceration, homelessness and gun violence is unlikely to lead to such improvements. Instead, doing so can contribute to support for coercive interventions and the endorsement of negative stereotypes that can make people's lives worse.