Dr. Martin Luther King once said, “Of all the forms of inequality, injustice in health is the most shocking.” I thought of his words as I pondered this conundrum: Why, with more people getting treated and better treatments available, are we in the middle of a mental health crisis? Why, with so much progress in neuroscience and psychological science, are we still sending people with mental illness to jail?
To figure out how we could solve these seemingly intractable problems, I had to leave the worlds of government and academia to connect with people and providers, from tent cities and jails to remote rural clinics and mental health clubhouses (mutual support organizations that provide connections and assistance for people in recovery). Clearly our healthcare system has broken down. The lack of capacity, low engagement, poor quality, and absence of accountability preclude good outcomes, especially for people with the most serious forms of mental illness. But I realized the problem was not just the broken care system: Outcomes are worse because of the world outside of healthcare. It’s our housing crisis, our poverty crisis, our racial justice crisis, our increasing social disparities that weigh heaviest on those with the greatest needs. As the late epidemiologist Paul Farmer of Partners in Health has said, “This growing outcome gap is related to the growing income gap.”
People with mental illness are more likely to be incarcerated, homeless, and destitute, because they are the most vulnerable in a world that no longer has a social safety net. It may be tempting to point fingers at clinicians or to blame those who toil in the trenches. But they are more like the field biologists reporting on the effects of climate change. They grapple with the results, but they are not the cause of the problem.
To resolve that conundrum, we need to redefine mental healthcare to include prevention and recovery. As President Biden has said of COVID-19, mental health has become a measure of the soul of our nation. The most visible signs that this soul was ailing — homelessness, mass incarceration, deaths of despair – were evident before the pandemic.
To understand the root of the causes, one need look no further than how this nation fails to support families and children. The United States, with the most expensive healthcare system in the world, ranks first in maternal mortality rates among wealthy nations. In UNICEF’s annual report card on 38 OECD and European Union countries, the U.S. ranks near the bottom in terms of the well-being of its children. The United States is the only industrialized nation to fail to offer paid parental leave. And the U.S. alone has failed to ratify the UN’s Convention on the Rights of the Child, the most widely adopted human rights document in history that has now been ratified by 195 nations.
A focus on recovery does not mean abandoning the medical model. We need health care – or more accurately, sick care – as an initial response for anyone in crisis. Sick care requires a comprehensive approach, combining medication and psychotherapy with a provider fully trained in evidence-based treatments. Crisis response would mean a mental health mobile van with a nurse, a social worker, and peer support personnel – not a medical-surgical ambulance or a police cruiser. Acute needs that could not be addressed at home would be treated in a psychiatric emergency room and then, potentially, a crisis residential facility.
Equally important, mental health care is about finding connection. Recovery requires ongoing care that focuses on the 3 P’s – people, place, and purpose. Care should include support for housing, education, employment and other basic needs, as well as social connection through peer support. If this sounds unrealistic or prohibitively expensive, remember that clubhouses provide these services everyday, at a small fraction of the cost of our jails and prisons. Online communities are beginning to provide social support for recovery. And during the pandemic, innovative social practitioners have found ways to offer supportive housing and employment.
Getting the government to support these services is critical – and it has been critically difficult. There are massive political lobbies for pharmaceuticals and hospitals and prisons but historically no comparable group for mental health. People with mental illness are struggling to get acute care and their families are usually too overwhelmed and sometimes too ashamed to speak out. There are advocacy groups, like NAMI and Mental Health America, but their focus is understandably on acute care, including parity enforcement. Until recently, there was no one to fight for prevention and recovery services, but without those services, we will never get ahead of the crisis.
The good news is that we have already started down this path. But realistically, it’s going to take more than a piece of legislation or extra funding to create a recovery- and healing-focused care system. As with the fight for civil rights or climate change, it’s going to take a movement, with families at the core of that effort. Movements begin with education and building awareness. We need to recognize that we are deep in a crisis of care, made worse by a pandemic of loss and by the social inequities that have increased during the pandemic. We need to reframe this crisis as more than a medical challenge: It is an issue of social justice. The increasing deaths of despair and the mass incarceration and disenfranchisement of people with mental illness demonstrate that we are in the Jim Crow phase of America’s embrace of mental health – separate and unequal.
Our grandchildren will no doubt wonder how, in the presence of good treatments, we banished people with brain disorders to jails and homeless shelters or the street. Paul Hawken, who has advocated for environmental justice, put this argument clearly in his book Blessed Unrest. “Our house is literally burning, and it is only natural that the environmentalists expect the social justice movement to get on the environmental bus. But it is the other way around, the only way we are going to put out the fire is to get on the social justice bus and heal our wounds, because, in the end, there is only one bus.”
Demanding government action is part of the movement. But the solutions are not all policies and Beltway leadership. What matters is not only what they do in Washington but what we do at home. America as a nation of “I” needs again to become a nation of “we.” As parents, teachers, neighbors, employers, citizens, we each can play a part to rebuild community, to ensure that those who struggle can find a hand. This means getting past the shame and blame that have kept families struggling with mental illness quiet and isolated. This means schools committing to mental fitness the way they have committed to physical fitness. And it means investing in social services.
This is the moral test of our nation. To be great, we need to build a community of compassion and connection, where one need not get ill to get care.
When I started this journey to resolve the mental health crisis, I believed that technology and science would provide the answers we need. A new drug, a killer app, a breakthrough would make the difference. But the years I spent listening to families and touring homeless shelters, clinics and hospitals left me convinced that the problems are more complex and the solutions far simpler than most of us realize. We must summon the will to enact them, because we have for too long asked individuals and families to bear this crisis of care alone.
From them I have learned some of the greatest lessons of all. From families who have lost children to mental illness, I learned the soul-destroying power of these illnesses. From those who were struggling with depression or psychosis, I learned the importance of patience and courage. From those who had recovered, I learned the power of love and purpose.
I end this journey with hope. The problems are indeed complex, but we have solutions that are effective. President John Kennedy had a vision in 1963 that people with mental illness would “no longer be alien to our affections.” They need be alien no longer. We know how to help them recover. Recovery is, after all, not just an outcome for those with an illness. Recovery is a measure of who we are. And the path to recovery is how we heal the soul of our nation.
About the author: Thomas Insel, a psychiatrist and neuroscientist, served as director of the National Institute for Mental Health from 2002 to 2015. He is the author of Healing: The Path from Mental Illness to Mental Health (2022), from which this excerpt is adapted, and a co-founder, donor and advisory board chair of MindSite News.