How to Fix the American Mental Healthcare System for Good

January 21, 2019

It’s January in Colorado and a short man in his fifties is dancing under a streetlight outside a homeless shelter, yelling expletives to the sky, a backpack tossed in the snow next to him. I watch him through the glass door of the shelter from which he has just been ejected. He wasn’t able to follow the code of conduct tonight, and he’s overwhelmed and losing control. He drains the last of a fifth of vodka and gleefully throws the bottle as he dances. It shatters on the icy pavement in front of him, as the shelter manager calls the police.

Meet Paul. He is one of approximately 30 percent of individuals experiencing homelessness who live with serious mental illness. He will be spending the night in jail, even though the shelter manager recognizes that he needs treatment, not punishment. His story is not unique. In four years doing homeless outreach in Denver, I met countless people who live with severe mental illness and struggle every day to meet their basic needs and stay safe on the streets.

How did we get here?

Mental illness used to be treated in institutions, closed inpatient facilities that inspired films like One Flew Over the Cuckoo’s Nest. But in the '50s and '60s, Americans lobbied for the closure of these facilities, which were both ineffective and inhumane. Instead, experts proposed a system of “community-based care,” where individuals with mental illness could live with their families or in group homes while receiving outpatient treatment and participating in day programs.

The thing is, this was a two-step process where the second step was forgotten. The institutions closed, but the replacement system was never built. Instead, many of the people living in these facilities ended up homeless.

The intervening decades have shown that mental health care is not a problem that can be solved by ignoring it and hoping it will go away. When we don’t provide services and housing for those who live with mental illness, those people don’t disappear. They end up on the streets, and increasingly, in jails and prisons, which are some of the largest providers of mental health care in the country.

That’s a big problem. In seeking to liberate people with severe mental illness from institutions, we created a new system of institutionalization with a different name.

The good news is, we can fix this. We can start by building the promised system of community-based care. This begins with creating small group homes in communities across the country where individuals with mental illness can live indefinitely for an affordable price. Unlike the institutions of the past, group homes house only around a dozen people each and are staffed with social workers who run them like family homes, not hospitals. We also must ensure that there are a sufficient number of outpatient clinics that are geographically and financially accessible, as well as hospitals equipped to deal with psychiatric emergencies in each community.

But this solution is not just about high-level policy decisions; it involves all Americans. We need communities across the country to step up and say “Yes, we will host a group home for people living with mental illness in our community.” There is no room for Not In My Backyard rhetoric here. The man sleeping on the sidewalk over whom you step on your way to the subway is already in your hypothetical backyard.

Some will say that a plan like this is too expensive. But what they do not see is how expensive it is to maintain the mangled system we already have.

The cost of doing nothing is huge: it’s the $2 billion of annual federal funding to community nonprofits helping the homeless across the nation, and it’s the $168,000 a year per person that it costs the state of New York to keep someone imprisoned. It’s also the untraceable millions that individual citizens and churches give to people who ask for help and the cost of treating an uninsured person who turns up in the emergency room having a mental health crisis. By redistributing these funds wasted on maintaining the status quo, we will spend no more and the results will be substantially more sensible and humane.

There is no reason to keep waiting, watching the so-called “revolving door” of people with mental illness cycling through homelessness, jails, and hospitals. With an initial investment in housing and a commitment from communities to finally provide the community-based care we promised 70 years ago, we can create real change in the lives of the 9.8 million Americans who experience severe mental illness. It should be an easy decision: continue throwing away billions of dollars on a broken system or use those funds to create a lasting solution to take care of vulnerable Americans. Which would you choose?

Christina Kay is a first-year MPH student in Population and Family Health.

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