The Long-Standing Call for Stronger Mental Health Systems

The process of caring for those suffering from mental health issues — ranging from depression and anxiety to post-traumatic stress and schizophrenia — has been a long-standing challenge in the U.S. that typically has not been done well.

During a November virtual conference hosted by the National Alliance on Mental Illness (NAMI) Minnesota, “Mental Health in Challenging Times,” Dr. Patrice Harris — the first Black woman elected president of the American Medical Association — advised that we need to work collaboratively, in partnerships, as well as center ourselves at the beginning of each day.

Harris’s presentation was titled “Collaborative Leadership: The Path Forward for an Equitable Mental System.” She says as a whole we need a systems change in caregiving networks, support for integrated care models, and an expansion of tele-psychiatry. She noted that California offers a good model of improved parity between mental and physical healthcare.

Harris asked the question: “Who creates health?” Her answer: “The whole community,” which includes employers, educators, housing developers, nutritionists, physical and behavioral health resources, transportation, social services, and criminal justice systems. She specifically noted that drug addiction requires mental health treatment, not incarceration.

[Our ongoing “Transforming Justice” series will examine this topic further.]

Harris also stressed the need for more conversation about Adverse Childhood Experiences (ACEs). The pandemic, plus existing racial and ethnic inequities, create trauma in children’s lives. “We need to keep an eye on our children in years to come, and provide trained support staff in schools, because childhood trauma often leads to serious consequences in adult life and, by extension, to society.”

Another presenter, Dr. Thomas Insel, stressed the 3 Ps of people (social connections), place (safe housing), and purpose for the prevention of and recovery from mental illness. Insel indicated that 40 percent of our health is dependent on society and the economy, with 10 percent each a factor of genetics, physical environment, clinical care, and the remainder impacted by our behaviors. Since mental illness takes place in the brain, it is a medical problem — but a large portion of the solution is social. Treatment needs to become patient-centered, rather than centered on the needs of the provider and the insurance payer. He said Phoenix offers a good model for integrated response to mental health crisis through its call center, psychological emergency room, and short-term institutional stays for stabilization. Most of the U.S. offers fragmented, rather than integrated, care, and separates families from the care process.

Insel, former director of the National Institute of Mental Health, said the U.S. is well behind other countries in providing compassionate, patient-centered care. “We used to do community care better, but the quality has decreased since the 1980s.

Minnesota’s History Around Mental Health Care

According to Susan Foote’s book, “The Crusade for Forgotten Souls,” in 1946 there were 11,000 inmates in Minnesota’s mental health hospitals, including those we might now considered to be suffering from dementia, people who were unconventional, and those suffering from poverty. “They were isolated from the world, inadequately clothed and fed, restrained and untreated, out of sight and out of mind.” There also were 3,500 children and adults labeled “mentally deficient” in the State School for Feeble-Minded at Faribault (built in 1879) and the State Colony for Epileptics in Cambridge (1925).

There was a lot of shame and silence about the level of care in these institutions. Institutional treatment had become the preference. Overwhelmed towns previously dealt with individuals by putting them in jails, workhouses, and poorhouses.

After Minnesota became a state in 1858, the growing population included those who were challenged, Foote wrote, by “eking out a living in a new land and coping with dislocation, poverty, homesickness, and despair.” The Minnesota Hospital for the Insane was established in St. Peter in 1866. Facilities were developed in Rochester in 1879 and Fergus Falls in 1899 and could not keep up with demand. “With little scientific knowledge, mental imbalance during this time was associated with such ‘disorders’ as immorality, intemperance, poverty, epilepsy, or religious excitement.”

With overcrowding in all facilities, additional institutions were constructed in Anoka (1900), Hastings (1901), and Willmar (1912) for those who were deemed incurable. The Willmar facility originally housed alcoholics. “Essentially the asylums became dumping grounds for chronic cases to save the state money by providing only bare minimum custodial care,” Foote explains.

In May 1948, Minneapolis Tribune reporter Geri Hoffner stayed several days in each institution, along with a photographer, to showcase the dismal conditions in an 11-part series. She wrote about the inadequate food, overcrowding, excessive use of restraints, understaffing, and overworked and underpaid attendants.

Minnesota’s governor at the time, Luther Youngdahl, previously had made mental health reform a moral crusade, and quickly announced a Citizens Mental Health Committee to mobilize public opinion and support needed changes.

Although steps had been taken to remove restraints and improve food and training, reform faltered in Minnesota after political leadership changed. There were longer-lasting improvements, however. Mental health advocacy by the state’s Unitarian congregations, Governor Youngdahl, and the Minneapolis Tribune coverage led to the country’s first statewide reforms to improve patients’ rights to dignity and comprehensive care.

By the 1970s, advocates for the developmentally disabled worked to ensure that individuals qualified for benefits under the new Medicaid (low-income) and Medicare (elderly) programs. Accommodations also enabled nursing homes to be developed to care for the elderly. However, physical and mental health benefits were treated differently, even though mental health issues are a function of the physical brain. It was Minnesota’s U.S. Senator Paul Wellstone who worked with colleagues from 1995 until his death in 2002 to change that. Under Minnesota’s U.S. representative Jim Ramstad the Mental Health Parity and Addiction Equity Act was finally passed in 2008.

The Affordable Care Act of 2010 significantly expanded mental health and substance abuse coverage, though each state is required to build the system that can tend to the needs.

In Minnesota, Foote quotes Sue Abderholden, of the National Alliance on Mental Illness (NAMI) Minnesota, as saying: “The system isn’t broken; we just haven’t built it.”

The Minnesota Mental Health Action Group has joined advocates, providers, hospitals, and health plans, along with the Minnesota Departments of Human Services and Health, to develop in 2005 a “Road Map for Mental Health System Reform in Minnesota,” with a vision, guiding principles, and desired outcomes. However, Minnesota received a grade of C from NAMI’s 2009 national report card, citing urgent needs for strengthened workforce, housing and employment programs, and attention to increasing criminalization of mental illness.

In 2015, the state approved $46 million in new funding for state mental health initiatives, including crisis training programs, and an additional $48 million in 2016. However, institutions in St. Peter and Anoka continue to suffer from neglect.

As Foote concluded in her book, “Health care has become a battle of ideologies, with huge industries — insurance, pharmaceuticals, hospitals, and big business — all working to protect their own interests, and often drowning out the voices of citizen advocates. Public policy making must be, in the end, for the people and by the people. … The crusaders learned a painful lesson in 1951 and 1953, when the legislature began to dismantle the program they had worked so hard to create. But they left a legacy — a vision of the right to treatment in a comprehensive and responsive system of care.”