Do we need to shift mental health policy in this time of economic crisis? I think we do. I think we need to worry about the impact of economic decline on people with serious, long-term mental illness, and I think we need to build concern about the emotional well-being of the American people into the economic rescue plans now underway.
For the past 50 years we have pursued an incremental community mental health policy in the United States and in New York State. We have established the expectation that people with serious, long-term mental illnesses will live freely in the community, and we have gradually been making it possible for more and more people to lead secure and satisfying lives by incrementally increasing the services and supports that are available to them. Life is better for some, perhaps even many; but we have a very long way to go to meet the needs of people with serious mental illness. We need more supportive housing. We need more services oriented towards rehabilitation and recovery. We need more integrated mental health and substance abuse services. We need to increase the quality as well as the quantity of outpatient treatment. We need to assure that inpatient care is available and of high quality when people need it and that outpatient and community-based alternatives are available for those who are in hospitals because there are too few decent alternatives. We need far more attention to meeting the physical health needs of people with serious mental illness, who die much younger than the general population in large part because of poor health and poor health care. Over the years we have chipped away at these needs—some years more than others, but the basic expectation has been that each year we address more of the unmet needs.
Now we are confronted with an economic crisis unlike anything we have experienced in 80 years. Fortunately in this, the first year of the crisis, funding cuts for mental health services in New York are to projected, rather than to current, spending. That is, improvements promised in prior years have been put on hold, hopefully only temporarily. New housing for people with serious mental illness will be delayed, despite the fact that stable housing is the single most important precondition of recovery. Cost of living adjustments that do not come close to making up for the erosion of base funding that took place during the 1990s and early in the current decade have also been put on hold despite the fact that the mental health workforce has been strained in the extreme because of low wages and poor benefits.
All this is not good, but it is probably tolerable—for a year. What will happen next year and the year after and the year after that if the economy does not recover rapidly? We know what has happened in the past. Depressions in the 19th and 20th centuries contributed mightily to the dreadful conditions that came to exist in state asylums and hospitals in the years after the Civil War and again in the 1930s. We need to be on guard, it seems to me, that this does not happen to our hospitals again, that the squeeze to get through a tough year does not become tolerance for terrible care and treatment in either state or general hospitals.
We also need to be on guard now against vast decay of outpatient and community-based services. These services are not adequate now. There are too many people with serious mental illness on the streets, in jails and prisons, in squalid housing, in institutions such as adult homes and nursing homes where care is uneven—to put it delicately. What happens if the economic crisis persists? We need to worry about this. We need to have a fallback plan that is built on a premise other than a rapid return to incremental improvement year after year. We need to contemplate the possibility that our state and our nation are entering a period in which life will get worse for all of us, and, if history is any guide, worse still for people with serious mental illness.
This brings me to my second thought about mental health policy in a time of economic crisis. What is the impact of the crisis on the emotional well-being of average Americans? My guess is that all of us have reacted with considerable emotional turmoil. Losing a job, a home, a pension, a sense of security about the future—these take their emotional toll. Should we expect our government—our public mental health system—to respond to this in some way or is it just a private matter?
This is debatable to be sure, but in the aftermath of the terrorist acts of 9/11/2001, our nation and our state mounted a considerable effort to help people to manage emotionally. I think we should consider a similar response to the economic crisis.
I understand that the two events are not identical. Disasters or acts of terrorism happen and are over. Reactions unfold in fairly predictable stages, and over time most people are able to regain lives that were disrupted by the disaster, even when they have lost someone whom they loved, even when their sources of livelihood have been ended, and even when their homes have been destroyed. This economic crisis is not an event of that kind. It does not happen and end in a brief period that is followed by a period of recovery. This economic crisis has already gone on for months, and it may go on for years. Job losses, foreclosures, retirements no longer possible—all will continue to happen for a totally unpredictable period of time. I cringe to think of it.
What can the public mental health system do? First, it can acknowledge that the economic crisis does contribute to emotional turmoil that can be quite destructive to individuals, families, productivity at work, and more. Second, it can bring together the best thinkers about mental health systems in much the same way that President Obama has brought together the best economic minds in the country. Third, it can devise a responsible policy built on what we know about helping people deal psychologically with crises based in real, uncontrollable events.
Frankly, I am not sure what policy would emerge from such a process. But I’d guess that, like the response to disasters, it would emphasize providing emotional support in the context of people trying to hang on to their houses, get jobs, and devise retirement plans based on what they have left. It would emphasize education about what we can do to manage our emotions ourselves. It would emphasize the value of joining with others in our communities to face new realities together. It would emphasize suicide prevention. And it would include helping those people who would benefit from treatment to get access to it, without expecting that there will be a huge increase in need for formal treatment.
I am just speculating, of course. But don’t you think it would be useful to get good thinkers together to develop a mental health policy and a plan related to those of us who are taking big economic hits with hard consequences for us and our families?
I hope, of course, that this would all prove to be a waste of time, that the economic recovery is more rapid than a planning process would be. I hope that we will get back to what we regard as normal in the United States and the rest of the industrialized world. But I am now clear that we have no right to assume the best. And it only makes sense to me to prepare ourselves for the worst and to prepare too for how we as a society will protect people with serious, long-term mental illnesses if the economy does not bounce back soon. Economic recovery plans without regard for the most vulnerable among us are just not good enough in a nation that wants to reclaim moral, as well as economic, leadership in the world.
Michael Friedman is The Director of The Center for Policy, Advocacy, and Education of the Mental Health Association of New York City. He is also Adjunct Associate Professor at Columbia University’s schools of social work and of public health. The opinions expressed in this essay are his own and do not necessarily represent the views of the organizations for which he works. Mr. Friedman can be reached at center@mhaofnyc.org.
