Mental Health Care: How to Make a Utopia Our Reality
One small Italian city could be the answer to solving our crippling mental health care system.
The World Health Organization outlines access to quality health care as a human right, and that includes mental health care.
During the COVID-19 pandemic, we have seen how important having a robust public health system is to keep society functioning, but we have also seen how social isolation takes a toll on everybody’s mental health. Now we are faced with the overwhelming transmission of the Omicron variant, which makes me ask myself sometimes: is “when COVID is over” just a fantasy?
These past two years continue to highlight the American government’s glaring lack of resources to support the growing number of residents who struggle with mental illness. Especially within underserved populations, mental health disparities among youth, communities of color, low-income communities and rural communities are more apparent and need to be addressed to save lives. Beyond the systemic issues, the stigma around mental health has persisted for generations, severely hampering people’s efforts to seek help.
Before the Community Mental Health Act of 1963 was passed, institutionalization, which is largely considered inhumane by today’s standards, was the main method of treating mentally ill patients. The act shifted patient treatment to community health centers, which they could pursue while living at home. However, in the 1980s, President Reagan’s budget bill cut community mental health services by 25 percent, leaving the most vulnerable with few resources. Many people who lost medical support from closing clinics turned to drugs, because finding a drug dealer was far easier than finding a psychiatrist. Many of these individuals were later arrested for drug possession. Today, the largest mental health care provider in the United States is Cook County Jail in Chicago, Illinois. Some journalists estimate that about a third of all the inmates at Cook County Jail have a diagnosed mental illness, with many of them arriving after the state of Illinois substantially cut mental health funding in 2012. The sheriff’s department has tried to cope with the influx of these inmates by spending time and money training jail staff on how to approach mental health treatment. Yet the criminal justice system’s attempt to treat individuals’ mental health while they are incarcerated is not only dehumanizing but also costly, taking funds from state taxes.
Two million people who struggle with mental illness are incarcerated each year in the United States. Jails are not meant to be mental health treatment centers, because they are not conducive to treating and healing trauma. Thus, they are inherently ineffective in treating inmates, leaving them without the care they so desperately need. Inmates facing mental illness are more likely to stay in jail longer and become victims of abuse. Once they are released from jail, they are given little support and find it difficult to gain employment; therefore, many end up in cycles of homelessness and incarceration.
While the American media commonly stereotypes those who live with a mental illness as violent and dangerous, in reality these individuals are much more likely to be victims rather than perpetrators of violent crime. Living with a mental illness is often manageable, especially with early intervention. However, when untreated, it can lead to chronic concerns like unemployment, dysfunctional relationships, inadequate housing, and a lack of social connections. There are multiple ways to dismantle the stigma surrounding mental health, such as altering how news outlets portray mental illness or eliminating the invalidating language we use to speak about mental illness in our daily lives. The stigma causes a cyclical problem, as the fear of discrimination leads to worsening mental health symptoms without treatment. Just like any health problem, prevention and early intervention is crucial. We all recognize that, however, the difficulty lies in finding where people can get help.
While it is easy for us to say that we need to change our cultural viewpoint on mental illness, there is one other powerful entity that needs to go: the American health insurance system. According to The British Journal of Psychiatry, there is clear evidence that socioeconomic status plays a central role in someone’s ability to receive mental health treatment, and those that are uninsured or underinsured are among those who need mental health care the most. The incongruent healthcare system in the United States is grossly under-regulated, leading insurance companies to put profits over people. Mental illnesses are less visible than physical illnesses, but can ultimately have similar or more devastating consequences.
Congress has passed several laws in the past decade to repair the disparity between how health insurance companies cover mental versus physical illnesses, most notably the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). MHPAEA aimed to have health insurance plans to treat coverage for mental healthcare the same as physical health care. However, due to the so-called subjective nature of mental illness, insurance companies still leave those struggling with mental illness underinsured. They deem mental health treatment as “medically unnecessary,” even in extreme cases when the patient’s life is at risk.
The number of denied insurance claims and out-of-pocket cost for mental healthcare treatment has skyrocketed in recent years. Difficulty accessing care, often due to economic barriers, is the leading cause of people not seeking necessary mental health treatment. In 2018, the Cohen Veterans Network found that 53 million Americans wanted to seek help from a mental health professional but were unable to do so due to “reasons outside of their control.” Another heartbreaking statistic is that one in four Americans had to choose between mental healthcare and basic necessities. Due to how convoluted the American healthcare system is, with thousands of healthcare plans, MHPAEA is incredibly difficult to enforce. The systems used to enforce mental health parity, from individual states’ department of insurance to the national Department of Health and Human Services (HHS) and Department of Labor, are just patchworked together. According to Kaiser Health, there have been relatively few complaints of violations by insurance companies issued to HHS and the Department of Labor, but these numbers only reflect violations that people reported. Anyone who has called an insurance company before can understand why someone already struggling with their health would be discouraged to jump through the hoops of filing a report. A survey from the National Alliance of Mental Illness found that patients were twice as likely to have mental health claims denied than other medical claims. New York and California have taken legal action against companies for violating state mental health parity laws. A New York investigation into Excellus Blue Cross Blue Shield found that the insurance company issued 64 percent more denials for claims related to mental health treatment than any other treatment type, since rules applied to mental health treatment were far more strict than those for physical treatment. The investigation also found that Excellus applied “fail first,” a controversial policy that requires the patient to seek the cheapest option for therapy first even if their provider disagrees with the treatment option. These ridiculous protocols save a little bit of money at the expense of real people’s lives.
The statistical evidence only bolsters anecdotal experiences: Too many people have personal stories of failing to receive adequate mental healthcare in their time of need. Elena Kilgore, a mental health advocate and founder of the non-profit “Other People Fund,” spoke candidly about her experience with mental health inequity and her nonprofit’s important work in selling t-shirts to cover mental health services for people who cannot afford them. She started the nonprofit because she was frustrated with the lack of access to mental health service for herself, as well as specifically for one of her close friends who could not access treatment due to financial constraints. After she turned to TikTok to promote sales, her initiative went viral. Soon, she had more than enough for her friend’s care and to officially turn the “Other People Fund” into a nonprofit. We both related to the struggle that so many people with mental illness face: Not only do you have to find a therapist and psychiatrist that you can reasonably afford, but also one that you can be vulnerable with. Ms. Kilgore brought up an analogy.
She asked me to “think about how hard it is to make a friend as an adult, but this is a professional person you pay and you need to tell them all the worst parts of yourself… and respect what they say back to you. The chances of that happening… is like harder than finding a significant other.”
In other words, financial constraints are not the only barrier to adequate mental health care; liking and trusting your mental health care provider also matters. And while these barriers are an issue for everyone seeking mental health services, college students especially get stuck with the burden of affordability and access.
Prior to the COVID-19 pandemic, many students experienced problems with affording private therapy and accessing psychological services on campus that were already stretched far too thin. The pandemic greatly exacerbated these existing problems. Some students were on campus and hadn’t seen their families in months. Other students had been at home since the pandemic started and haven’t seen their friends in over a year. The transition to online classes has been difficult, especially when professors had to first change their curriculum to an online format. Students who were already struggling academically felt, and still feel, as though the floor has sunk beneath them. They also face canceled graduations, postponed study abroad programs, lost job opportunities, and growing anxiety surrounding their loved ones’ health. Since vaccinations have become routine for many, there have been times with a semblance of normalcy. But it is hard to ignore the veil of trauma and uncertainty that persists, especially recently as skyrocketing case numbers bring us back to remote learning.
Lucas Taylor, president of “My State of Mind”, a student-led mental health advocacy group at University of California, Davis, explained how the campus community has been supportive of mental health services and awareness in his own experience. Another club member, Katrina Zara, agreed. However, going forward, especially following the pandemic’s mental health implications, they said better education of mental illness could help people identify its symptoms within themselves and others, with less stigma. For example, everyone knows depression makes you sad, but not everybody with depression necessarily sits in bed all day; some people instead fill their day with activities because they can’t be left alone with their thoughts. Everyone’s response to their own mental illness is different but equally valid.
In 1978, Italy passed impressive reforms to deinstitutionalize its then dehumanizing mental health care system, which had allowed overcrowded facilities, patients in cages and other extreme restrictions within asylums. Typically, once someone was sent to the asylum for mental illness, they were effectively ousted from society and subject to cruel treatment at the hands of the state for the remainder of their life. One Italian city, Trieste, has received international praise, especially from the World Health Organization, for its particular mental health model. Trieste has a population of around 200,000 and three community mental health centers which resemble recreational centers rather than hospitals. The centers are social places where patients can come and go, and it is difficult to distinguish their staff members from patients. When psychiatric emergencies occur in Trieste, the police are not dispatched. Rather, a team from one of the community health centers will be sent to the person in crisis. The returning patient would also have a team of familiar nurses to handle their treatment. Even beyond Trieste, the country’s universal healthcare system has ensured Italians do not have to worry about how to pay for such treatment. And while the United States has also seen a decline in mental hospital admissions in recent years, this change is largely driven by mental health care responsibility being shifted to the prison system rather than positive reforms like in Italy.
Italy’s holistic and community-based system could be implemented in the United States by coupling comprehensive reforms to end institutionalization with well-funded community mental health centers. The push for a universal healthcare system in the United States, as every other industrialized nation has already driven, is key to ensuring equal access to mental health treatment. Yet, while a universal system is essential in reforming mental health care, it is not a cure-all for the structural issues we face in our healthcare system. Canada, for instance, has universal healthcare but only dedicates 7.2 percent of its health care budget to mental health, although mental illness accounts for 23 percent of the total disease burden among Canadians. And despite Canada touting itself as a county with so-called “free” healthcare, 30 percent of its annual counseling services costs are paid out of pocket by Canadians. Clearly, reforming mental health care in the United States entails having our government make improving access to treatment a priority. Trieste’s model suggests that would work. By reforming the mental health care system, the Italian government not only made treatment more accessible, but also humanized those struggling with mental illness, integrating them into the community and substantially reducing the stigma towards mental health.
Trieste’s model is definitely one we should strive to emulate, but I think we can dream even bigger. In a utopian society, everyone would have government-paid, single-payer healthcare. Mental health services such as therapy, psychiatry, and rehabilitation would be even more accessible than physical health care is today. In my conversation with Ms. Kilgore we covered how, ideally, therapists and psychiatrists would be plentiful and affordable to patients. People in the United States are generally encouraged to have annual physicals and semi-annual dental cleanings. With more accessible care, everyone would also be recommended to schedule annual mental health appointments. Some people would be fine, which is great, but those who need help would have it readily available. As a preventative measure, Mr. Taylor and Ms. Zara suggested educational reforms to normalize mental health treatment, such as introducing key concepts as early as kindergarten and continuing that education through college. Each of these policy changes would go a long way in combating the mental illness crisis. Another non-radical adjustment is shifting the responsibility of mental health care from the criminal justice system to community social workers, as they do in Trieste.
American culture should give mental health professionals and social workers the same credence that other critical members of the community, such as doctors and nurses, are given. Ideally, like in Trieste, social workers, therapists and psychiatrists would be well-known members of the community that handle peers’ mental health challenges. Our healthcare system would prioritize rehabilitation overall, so that the global treatment of individuals with mental illness can be more drastically improved and made equitable for everyone.
Please note: The original version of this article appeared in Davis Political Review’s 2021 annual print publication and can be found here.