Mental Illness and Social Justice
Mental illness has a history in the United States since colonial times, possibly even before. The first hospital specializing in mental health opened in 1773 in the United States. Prior to 1773, individuals were left to care for themselves or be cared for by family members or they were placed in jail for criminal behavior.
In the mid-1800s, Dorothea Dix noticed the inhumane treatment of prisoners and the mentally ill in prisons and institutions. Patients were often living in deplorable conditions of filth. They were naked. They were beaten and abused by guards. She advocated for better treatment of mentally ill patients. Miss Dix traveled in England gathering ideas for improvements to be made in America. She lobbied governments to make these improvements. Her advocacy was ground breaking.
At the beginning of the 20th century, Clifford Beers, a recent Yale graduate and Wall Street financier had his first episode of bipolar disorder. He tried to commit suicide which prompted his hospitalization in private and public institutions in Connecticut for three years. He experienced firsthand the cruel atrocities in these facilities. Upon his release, he planned to expose the brutality he suffered. He published his autobiography, A Mind That Found Itself in 1908.
In 1909, Mr. Beers, philosopher William James, and psychiatrist Adolf Meyer created the National Committee for Mental Hygiene. It later became the National Mental Health Association and today is Mental Health America (MHA). “The organization set forth the following goals:
- to improve attitudes toward mental illness and the mentally ill;
- to improve services for people with mental illness; and
- to work for the prevention of mental illnesses and the promotion of mental health” (Our History, n.d.).
William White in 1930 built on Beers efforts to improve standards of care. In his article, The Origin, Growth and Significance of the Mental Hygiene Movement he explains that advances in the field of psychiatry at the beginning of the mental hygiene movement helped to precipitate change. Psychiatry moved toward a search for causes, explanation of meanings, developed methods of analyzing, and separated tendencies to better understand different illnesses. They began to treat the person as a whole unit instead of individual systems. The methods they employed were therapeutic control of stimulus in the environment, psychotherapy to change the individual from within, and preventive medicine before the years of incubation (White, 1930, p. 79-80).
The mental health field experienced some huge strides after World War II. The National Mental Health Act of 1946 was the first major mental health legislation in the United States. It provided federally supported training and research to further prevention and treatment programs. In 1949, the National Institute of Mental Health (NIMH) was created.
By the mid-1950s, most psychiatrists could be found practicing in inpatient wards of state mental hospitals both public and private. The majority (77%) of psychiatric episodes were inpatient. Very few outpatient or community programs existed.
Sociological work on normal versus pathological can be traced to Emile Durkheim in 1895 (Busfield, 2000). His analysis in the understanding of mental disorders focused on behavior. What was acceptable within society and what deviated. American sociologists, Talcott Parsons and Thomas Scheff both expanded on the idea of mental illness as deviance during the 1950s & 60s. Anti-psychiatrist, Thomas Szasz “viewed mental illness as the breaking of social, political and ethical norms” (Busfield, 2000, p. 545). Michel Foucault in 1967, on the other hand, viewed mental disorder as unreason and irrationality. He was concerned about the intelligence of thought, emotion and behavior. He focused on mental processes rather than behavior. Both schools of thought emphasize “the social and cultural relativity of categories of mental disorder” (Busfield, 2000, p. 546).
The 1960s saw the deinstitutionalization of many mentally ill people with the Community Mental Health Act of 1963. It was a move to outpatient treatment, short hospital stays, and supervised group homes in the community. In California in 1967, a controversary between Governor Ronald Reagan and the psychiatric profession over budget cuts and the view of mental health raged. Reagan proposed to cut the previous budget from $128.2 million to $111.1 million and reduce the Department of Mental Health staff by approximately 3700 positions, one sixth of the department (Boffey, 1968). At that time, the extreme “right wing” viewed mental health as a “Communist plot to brainwash Americans” (Boffey, 1968, p. 1329).
The United States was unprepared for the mass exodus of mental health patients from institutional care. Community mental health programs were slow to gain acceptance in the early 1970s. Program directors and supporters had to provide persuasive arguments when educating communities as to why community mental health was better than previous or current ideas.
Mental health beliefs of the 1970s were that schizophrenia had no treatment and could only be handled as inpatient and organic dementia was incurable and, also, required inpatient treatment. Syphilis was the “most predominant affliction of mental hospital patients” before the discovery of penicillin (Hanley, 1973, p. 1184). These beliefs likely contributed to the rise in mentally ill patients being shifted from one institution to another. By 1977, 668 000 mental health patients were residing in nursing homes. “Nursing homes never intended to house mentally ill persons but did so as a result of a lack of poor planning, flawed policy and entrepreneurship. Mental Health planners failed to create sufficient alternative care facilities to provide choice rather than the nursing home” (Brown & Cooksey, 1989, p. 1131).
Nursing homes were highly profitable due to low quality of care, understaffing or non-professional staffing, and use and abuse of psychoactive drugs. The annual cost of a patient in a nursing home was $10 000 per year less than in a hospital (Brown & Cooksey, 1989, p. 1131).
The deinstitutionalization of the mentally ill precipitated a shift from the public sector of the first half of the 20th century to the private sector. By the mid-1980s, a variety of private psychiatric and non-psychiatric facilities grew to the point of replacing or augmenting public facilities. Treatment was paid for through public funds or private insurance. Public funds were shifted from the state to federally funded programs. The advent of Medicare and Medicaid and private insurance paying for psychiatric care promoted the growth of the private sector to provide inpatient care.
The Omnibus Budget Reconciliation Act (OBRA) of 1981 repealed the 1963 and 1965 Community Mental Health Acts and their amendments and the 1980 Mental Health Systems Act. It provided block grants that replaced categorical funding and reduced the alcohol, drug abuse and mental health funding by 21% in 1982 (Brown & Cooksey, 1989, p. 1133).
Many individuals suffering from mental illness do not know how to access the system to seek treatment or are unaware that they need treatment. Often, they are pushed into treatment by family or friends, the legal system or courts, or by institutional agents (police, teachers). Individuals are less likely to be open to care if they are forced to into it. Negative outcomes are produced affecting attitudes that are carried into the community. This in turn affects how and what they recommend to others suffering from mental illness (Pescosolido & Lubell, 1998).