Medical Examiner

Five Improvements We Should Make to Mental Health Care

Even if they won’t prevent gun deaths.

A hand unfurling someone's messy thoughts.
Photo illustration by Slate. Photo by Thinkstock.

As two clinical psychologists, we ought to be thrilled when public conversations draw attention to mental health. After all, mental health problems tend to be under-researched, undertreated, and overstigmatized. So when President Donald Trump promises, as he did last week, to “tackle the difficult issue of mental health,” it should be music to our ears.

We’ve had a hard time feeling positive about this new attention to our field, though, because far from an honest investment in health care, these suggestions are simply an obvious deflection from talking about guns. And what’s more, there’s a clear downside to putting mental health in the limelight on the heels of tragic school shootings: It suggests a strong link between violence and serious mental illness that simply doesn’t exist. It also detracts from the real and pressing issues facing mental health care in our society.

If politicians were serious about preventing and treating mental health, they would be tending to our broken mental health care system. What should politicians actually talk about when they talk about mental health? We compiled a list of priorities—and, spoiler alert, bringing back mental institutions did not make the cut.

1. Invest Early to Protect Kids and Families

The child welfare system is the first line of defense for kids who are neglected, abandoned or abused—kids who may be most vulnerable to mental health problems in the future. But this system is too often overwhelmed and underfunded. For example, Sam Brownback’s dramatic tax cuts in Kansas resulted in budget shortfalls that devastated the state’s mental health system, particularly its child welfare system. With 222 fewer psychiatric beds today than in 2013 and record-setting numbers of kids in the system, troubled foster kids in Kansas have been sleeping on couches in contractors’ offices because there is nowhere else for them to go. Kansas is not alone: In the wake of the opioid epidemic, caseloads have ballooned around the country, and funding has often not caught up.

Children in foster care may need enriched mental health services, like multidimensional treatment foster care (MTFC), a wraparound approach that combines family- and youth-focused therapy. A 2011 study in Washington state concluded that every dollar spent on MTFC saved the government $5.28 in reduced juvenile delinquency costs. An Oregon study of preschoolers found that by reducing foster care–placement instability, MTFC saved the state thousands of dollars per case. Despite this evidence that MTFC is incredibly cost-effective, a 2017 report found that less than 5 percent of foster children with serious mental health problems participated in evidence-based treatment programs like MTFC. A 2016 bill to revamp the foster system and emphasize family reunification unanimously passed the House but was lobbied out of existence in the Senate.

We could also make investments that could try to get ahead of some of the problems that cause kids to end up in foster care in the first place. As the only industrialized nation without any guaranteed paid parental leave, the U.S. fails to give families a break when they need it most. The lack of family leave hurts poor families the hardest; many low-income women go back to work within a few weeks of delivering an infant. Giving families proper support from the get-go might have benefits for parents and kids.

2. Focus on Treatment Over Punishment

The U.S. incarcerates more of its citizens than any other developed nation. Many of those citizens suffer from serious mental illness. A 2016 report found that in every U.S. county with both a jail and a psychiatric facility, a greater number of mentally ill adults could be found in the jail than the hospital.

Few jails and prisons offer comprehensive psychiatric services. Even when psychiatric treatment is recommended by judges, inmates may experience prolonged delays for services due to lack of funding. Take one example: Tyler Haire, a 16-year-old boy with seven different mental health diagnoses who stabbed his father’s girlfriend, was placed in jail awaiting a court-ordered psychiatric evaluation—and ended up spending 1,266 days in jail while he remained on the waitlist for one of the 15 beds in the state hospital forensic unit. Ultimately, he never saw a psychiatrist, received any therapy, or took psychiatric medication. Instead, he was frequently placed in solitary confinement, a practice that is known to worsen symptoms but is still used with mentally ill inmates. It is not only counterproductive but often more expensive to jail mentally ill inmates than to treat them in the community. We need to offer alternatives to incarceration for the mentally ill.

3. Make Mental Health Treatment Affordable and Accessible

The good news is that we have made remarkable progress in developing research-backed psychological interventions that work to treat chronic and serious mental illnesses, ranging from depression and anxiety to substance abuse and psychosis. The bad news is that only a small fraction of people who need these services actually receive them. One estimate by the Epidemiologic Catchment Area Survey reported that 40 percent of adults with severe mental illness did not receive any psychiatric care within a one-year period. Many individuals will continue to suffer from serious mental illness until we can reduce barriers to treatment access.

Why is it so hard to get effective treatments to the public? One reason is that mental health treatments remain largely unaffordable to many, especially those from lower socio-economic or disadvantaged groups. Mental health parity laws, which mandate insurer reimbursement for mental health treatment, have been in place for more than a decade—but enforcement of these laws can be stymied by, among other things, a lack of treatment providers. In 2016, Congress passed the 21st Century Cures Act, which includes a number of mental health parity provisions, but budget delays have slowed the distribution of funds, and funding for some programs—such as a community mental health block grant—have already been cut.

Recent cuts to Medicaid may worsen the problem; an estimated 40 percent of recipients of Medicaid expansion under the Affordable Care Act, for example, have mental health issues. Changes to the ACA have also allowed insurance policies free of essential health benefits to again be sold, creating concerns that the mentally ill would return to using emergency rooms for basic mental health treatment.

There’s additional work we can do to bridge the gap for those who cannot easily find treatment. This includes addressing structural barriers, including limited access to transportation, language and cultural barriers, and unstable living conditions. This includes taking advantage of recent technological advances such as online clinical interventions and support groups, phone-based psychotherapy, and flexible administration of treatments by nontraditional and lay mental health providers, including peer-support and peer-to-peer health care approaches.

4. Support and Fund Mental Health Research

If we want to offer the most effective mental health treatments, we need cutting-edge research to test those treatments and understand how they work. The National Institutes of Mental Health (NIMH), the nation’s largest funder of mental health research, has seen flat budgets since 2003, and currently funds less than 20 percent of the proposals it receives. This tight funding environment discourages new researchers from entering the mental health arena and slows research progress.

Over the past decade, NIMH has moved away from funding clinical trials and mental health–services research in favor of neuroscience research that examines the underpinnings of mental illness. This shift has produced incredibly valuable research but has also left a vacuum in terms of studies focused on the dissemination and implementation of treatments in the community.

The National Science Foundation, another science-funding agency, has repeatedly weathered proposed cuts to its budget, including proposals to entirely cut its Directorate for Social, Behavioral, and Economic Sciences (SBE), which includes psychology. SBE has been a frequent target in Congress, and several lawmakers have called for social science funding to take a back seat to disciplines such as math and computer science. Without social science research, we cannot make progress in understanding mental health.

5. Combat Unwarranted Stigma

There is well-documented stigma against those who suffer from psychiatric illness, and our reaction to shootings is a clear example. According to a new ABC News poll, “Americans by a 2-to-1 margin blame mass shootings mainly on problems identifying and treating people with mental health problems, rather than on inadequate gun control laws.” Contrary to the stereotype that mental illness leads to violence, research actually suggests that those with mental illness may, in fact, be more likely to suffer as victims of violence than as perpetrators. One study found that gender and ethnicity were much stronger predictors of a person’s potential to be violent than mental illness. In cases where violence is connected to mental illness, substance use is typically involved.

Inaccurate conceptions of dangerousness and violence also cause harm to both society at large and to individuals with psychological disorders. People may be reluctant to seek treatment if they fear judgment or stigma by a society that views mental illness as synonymous with violence. And research suggests that this is particularly true for underrepresented minorities.

We could all take action to combat this stigma by reorienting conversations—in our own lives and lobbying to politicians to do the same—away from sensationalized and unsupported links between mental illness and violence and toward mental health parity, integration with physical health care, and better funding and access to mental health screening and services. And we should address mental health care not because it will “stop shootings” (because it is orthogonal to that issue) but because it is a necessary ingredient for any society that values the well-being of its citizens.

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