by Andy Hyatt
While the state of the healthcare system in the United States is poor all around, our mental health system is its own particular brand of horrible. Even in a city like Boston, a supposed healthcare mecca where we have more therapists and psychiatrists per capita than almost anywhere in the country, it can be almost impossible to find a clinician you can afford, who takes your insurance, or with whom you feel comfortable (let alone all three at once); people are often paying hundreds of dollars out of pocket to see a psychiatrist to refill their depression or anxiety meds four times a year or waiting months to see a therapist who takes Medicaid. The situation is even more grim in smaller cities and rural areas, where there is even less access than in cities. This all comes at a time of veritable mental health emergency, as the toll from opioid overdose, suicide, and other “deaths of despair” continue to rise, and overall life expectancy is falling for the first time in nearly one hundred years. In short, mental health services are poorly planned, underfunded, inaccessible, and unaffordable for many people in our communities at a time where need has never been higher.
How did we get here?
In order to understand how to fix the shambles we’re in, it’s important to understand how this mess came to be in the first place. With the advent of industrialization and urbanization, persons with mental illness often lost support they would traditionally get from extended kin or village networks, and could be locked up in poorhouses or sent to live on the street. Even today, rates of mental health distress and disability are higher in industrialized areas compared to more rural or agrarian societies.
Modern efforts to improve the treatment of people with mental illnesses began in the 19th century, sparked by horrific conditions at hails, poorhouses, alhouses, and other institutions of social control that incarcerated people with mental illness and disabilities1. Middle class reformers focused on treating people struggling with mental illness with dignity by founding asylums and publicly funded state hospitals to treat individuals away from unsanitary 19th century cities, and advocated for treatment of people with mental illness by medical staff in hospitals as opposed to untrained police, prison guards, and other non-clinical personnel. Unfortunately, these efforts largely ended in failure due to underfunding, overcrowding, and usage of mental health infrastructure by elites to marginalize and control deviant populations without a focus on rehabilitation or support. Psychiatric hospitals became custodial holding environments where individuals were afforded shelter, food, and other basic necessities, but not dignity or support in efforts to live meaningful lives.
The 1950s and 1960s saw the rise of the community mental health movement, which despite its shortcomings, showed glimmers of what a just mental health system could look like. It emphasized treatment in the community in a person’s existing social context rather than removal from society, and its greatest victory was the 1963 Community Mental Health Center Act, which envisioned a publicly funded, universally accessible community mental health center in every community in the country. A local example of this was the Cambridge/Somerville Community Mental Health Center (CMHC), which met individuals for treatment wherever they were most comfortable, offered opportunities for socializing and forming meaningful relationships, and helped with job placements. The CMHC even owned its own cooperative apartments for people receiving its services. All of this coincided with a steady decrease in state hospital populations, and it was hoped that instead of locking people up for their entire lives, comprehensive social support would allow individuals to live meaningful, fulfilled lives in the community.
All this is not to idealize the community mental health movement, which had several flaws. Most importantly, clinicians and health systems could be overly paternalistic, often substituting what they thought of as “best” for individuals without truly consulting with the communities affected. These biases were challenged by the recovery and consumer movements, which emphasized individuals’ understandings of their own experiences and their own desires for purpose and meaning over biomedical concepts like “symptoms” and “illnesses.” By giving individuals agency over their own recovery, the consumer movement sought to place the concerns and values of mental health service users first, and let them direct the course of their own lives and their own recovery. Unfortunately, given that the consumer movement arose in the 1980s and 90s, in significant ways it reflected the neoliberal turn of that era, and its vital emphasis on individual dignity and autonomy also prefigured a greater capitalist turn in mental health care.
The ascension of Ronald Reagan and the brutal regime of austerity that we are still living with today gutted continued funding for mental health services and halted federal spending on new community mental health centers. Laying the groundwork used for welfare reform in the 90s, Reagan cut and block granted funds meant for mental health and turned them over to the states to use as they saw fit. States (including Massachusetts) privatized vast swaths of the mental health treatment system, turning it over to a hodgepodge of private organizations and cut the community mental health centers off from their communities. Individuals now had more “choice” in which providers they could see (if they could afford to see anyone) while centers that served the community were starved of funding and became slowly more like other players in our corporate healthcare system
There have been some recent positive developments, although the scale of the crisis remains vast. The Affordable Care Act (ACA), especially through its Medicaid expansion, helped many people with mental health needs get access to health insurance for the first time. Unfortunately, large deductibles and copayments limit the utility of many insurance plans and people on Medicaid have an extremely difficult time getting access to adequate psychiatric treatment due to extremely low reimbursement of providers. The other positive development was the passage of federal mental health parity legislation in the late 2000s. This prohibited formal discrimination against people using mental health services, but unsurprisingly corporations still found ways around regulations to discriminate against mental health and increase their own profits. Recent reporting has shown how insurance and managed care companies are flouting mental health parity laws and preventing their beneficiaries from accessing treatment.
Where to go from here?
For any reader that has made it this far through a detailed history of community mental health in America, I am grateful for your fortitude! While we cannot simplistically pine for an overly idealized past (as we on the US Left are tempted to do when remembering the New Deal or Great Society), I do believe that in studying past movements we can discover the seeds of a better future. In my opinion, recovering the best elements of both the community mental health and recovery movements can shed light on what a socialist mental health and wellness system should strive for. In learning from the community mental health movement, we can aspire to easily accessible medical and psychological services, embedded in the communities where people live, with a vision of care incorporating social needs like housing and employment. From the recovery movement, we learn the vital importance of giving mental health service users both agency in their individual recovery and a central role in leading the development of comprehensive freely accessible services for all.
Concretely, the fight for mental health justice is broad, and intersects with many of our other struggles in the Left. Ahead of the 2020 election, grassroots groups like the National Alliance on Mental Illness and other advocacy groups are forming coalitions to press candidates on forthrightly addressing suicide, substance use, and other aspects of the mental health crisis. Thus far they have not suggested any concrete policy goals, but the following could be a good start. Most obviously, mental health services should be de-commodified and made free for everyone at the point of use. A good first step would be a true single payer, Medicare for All system, which would eliminate onerous deductibles, co-pays, and other unjust forms of cost sharing that discourage use of needed medical care. As a part of this, it is essential that as many providers as possible be brought into the government health insurance system, as the current glut of exorbitant cash-only practices places services out of reach of all but the wealthy. Equalizing wages for clinicians who work with low and high income patients will alleviate some of this, as will a dramatic reduction in the infuriating regulatory and paperwork burdens many clinicians face today. Moving forward, given the complex service needs of some mental health service users as well as the vital importance of coordinating healthcare with other social services, there is a strong argument to be made that the Left should be arguing for a true national community mental health service along the lines of the UK or Sweden. This must include true leadership by both front line service workers and by mental health service users, with the end goal of a truly democratically run health services. As the rallying cry from the disability rights and recovery communities goes, “nothing about us without us.”
While improving, decommodifying, and democratizing healthcare systems is a necessary first step to improving mental health, I don’t want my clinician biases to blind me to the vastly greater importance that structural factors have on the health of communities. Fundamentally, societal improvements in mental well-being have to stem from the lived conditions of communities and the restructuring of our societies to place human needs above market ones. While improving the mental health of communities intersects with nearly every area of our activism, I want to point out a few particularly important areas we should be mindful of. Firstly, we must fight against displacement and for truly affordable homes for all people, through rent control, community land trusts, and social housing. Not living in constant fear of displacement is of course good for one’s mental well-being on its own, but it also helps build the supportive fabric of communities and starts to reverse the incredible fragmentation of our society. We must also fight against all forms of oppression and the violence society inflicts to impose its forms of domination on the basis of race, gender identity/expression, sexuality, country of origin, religion, and more. These forms of domination cannot exist without the widespread traumatization of oppressed communities, and no amount of counseling will fully heal a depressed young girl who spent a year in a border concentration camp waiting for asylum or a person of color traumatized by police brutality and murder. Finally, the fight for a livable climate and a just transition to a decarbonized economy must be central to our organizing, as there can be no mental health without hope for survival and a livable future.
Locally, Boston DSA’s healthcare working group is base building for healthcare justice by working with low-income communities saddled by medical debt with City Life/Vida Urbana. This Saturday (June 15), we’ll be canvassing in the North End to get conservative Democrat Steven Lynch to sign on to the federal Medicare for All bill (which would fully cover mental health care without any cost sharing). If you’ve been looking for a way to get involved, we’d love to have you join us!
Andy Hyatt is a member of the Boston DSA Healthcare Working Group and a psychiatry resident at a local hospital.
- The following several paragraphs on history are drawn from several sources, and owe the most to the following article and books: Morrissey and Goldman, “Cycles of reform in the care of the chronically mentally ill.” Psychiatric Services, 1984; Foley and Sharfstein. Madness and Government: Who Cares for the Mentally Ill?. American Psychiatric Press, 1983; Dorwart and Epstein. Privatization and Mental Health Care. Auburn House, 1993.