With every school shooting, celebrity suicide, and aggressive police encounter, we hear the common cry, “Get them to mental health!” While there is good reason to worry about the mental illness of our nation as the country becomes more fragmented and polarized, in the cost-driven marketplace of 2018, the public mental health system has collapsed. What happened? How did it disappear?
“Community mental health” refers to a system of care in which the community, not a specific facility such as a hospital, is the primary provider of care for people with a mental illness. The idea holds a long history that emphasizes access to high-quality care for all Americans through allocation of a variety of professional medical and social service resources to treatment. While substantive research demonstrates that specialized psychiatric, psychological, and social services lessen social exclusion and reduce the potential for neglect and violation of human rights, they are nearly invisible in our contemporary social fabric. Available resources are inaccessible. Community mental health centers, psychoeducational classes, local primary care assessment, crisis intervention, school counseling, and in-patient and partial hospitalizations are now the exception, rather than the rule, in mental health care.
Fundamentally, the commoditization of health care has led to the current scarcity. As a result of cost-cutting measures, supported by insurers and politicians, mental health care now emphasizes less access and diminished levels of care, provided by non-licensed professionals, as a way of saving money. Mental health care has become consolidated, limited, and restricted. Clinical treatment options for those Americans needing psychological help with mental illness, addiction, stress, and life transitions is at its breaking point as a domestic community service.
Six essential services are historically defined under the umbrella of community mental health: inpatient hospitalization, outpatient counseling and psychotherapy, medication management, day treatment, emergency services, and educational consultation. The limits to all areas of service are alarmingly evident, particularly when another community tragedy underlines the social disenfranchisement of instigators and perpetrators. Any number of issues bedevil mental health practice. Availability of high-quality professionals is limited as practice demands rise. Insurance benefits paying for outpatient services are limited by managed care. Practitioners now add a horrid ethical question to their triage and diagnostic considerations: “Is inadequate treatment better than none?” Mental health care is increasingly considered by policymakers as non-essential and excluded from third-party reimbursement; the current political administration’s push for discriminatory insurance coverage will only deepen the obstacle of proper care provision to the success of community-based approaches. Regrettably, mental health care has been paired with gun control, an issue too complex and controversial to be resolved by a dismissive sound bite.
Community mental health has an overarching goal to offer treatment and rehabilitation for all individuals of all ages with all types of illness. For this to work, assistance and care must continue from the moment the need is recognized until the problem is acceptably resolved. The loss of access and availability of scarce resources keeps professional providers and family members awake at night. As a functional result of the loss of community mental health service, people who are personally troubled but can marginally function — from the disenfranchised high school senior who finally discharges his isolation by killing his classmates, to the depressed persons who die by their own hands — are now the lowest priority for receiving mental health service.
Community mental health is social-action oriented. At best, it is sensitive to individual need in context and perspective of the larger populace’s strengths and deficits. As the moral compass of the nation devolves and loss of the “common good” becomes more evident, the impact of the failure of community mental health becomes real as a public health disaster. As of this day, there simply is no monetary, social, or communal value to address the issue of people who are not in treatment, who resist treatment, or who have become debilitated and destitute. “Send them to mental health!” is a knee-jerk response that has no weight.
It is not an overstatement to say that the United States is in a mental health crisis requiring pragmatic solutions. The gun debate has been co-opted as a means for discussing mental health legislation related to who can own a gun, even though research shows that the vast majority of people with mental health problems are no more likely to be violent than anyone else. Rather, we should address mental health care because it is a necessary ingredient that values the well-being of its citizens.
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