The U.S. has never tried a comprehensive approach to mental health care

 The U.S. has never tried a comprehensive approach to mental health care

The pandemic worsened mental health problems, but solutions have long been elusive

More than 600,000 Americans are dead from covid-19. This incalculable loss of human life and the many other stressors imposed by the pandemic have left mental health as fragile as bodies and economic well-being — and just as deserving of robust care.

Yet, alarmingly, people are actually accessing mental health services less than in the pre-pandemic period. Some estimate that there has only been a 5 percent increase in new therapy patients, while the use of mental health services overall has dipped. In response, the Department of Health and Human Services has earmarked $3 billion for mental health services as part of the American Rescue Plan that President Biden signed in March.

This move isn’t surprising. In the wake of national crises over the past century, the U.S. government has periodically invested in mental health care, but such efforts have been brief and incomplete. The United States has never redressed a massive shortage of mental health-care providers, and no unified national infrastructure is in place to assist the most vulnerable would-be patients with navigating the difficult process of finding competent care and paying for it. Without addressing these problems, federal efforts to address the mental health crisis stemming from covid-19 are unlikely to succeed.

Consider the effort to care for the 16 million soldiers who served in the armed forces during World War II. Military leaders hoped to avoid a repeat of the failures of veteran reintegration at the close of World War I, an abandonment that haunted policymakers and military leaders. As soldiers returned to civilian life after World War II, many were eligible for the Servicemen’s Readjustment Act of 1944 (the GI Bill of Rights), which they learned about from short newsreels as they returned to the United States.

The GI Bill of Rights promised to provide services and benefits to returning soldiers, including housing, education and business loans. But racial, class and sexual politics were all deeply inscribed in the new law: By design, benefits were withheld from many returning Black veterans and out or outed gay veterans. And despite reassurances from the Army, for the more than 120,000 returning soldiers who were estimated to have psychological or neuropsychological conditions at war’s end, benefits alone were not sufficient.

Clinicians, alongside veterans and their families, protested for expansion of mental health care, and finally policymakers listened. Congressional hearings on the problems of providing mental health care in the United States resulted in the National Mental Health Act (NMHA). Passed in July 1946, the act had the stated goal of improving “the mental health of the people of the United States” and eventually provided the funding and auspices for the National Institute of Mental Health, founded three years later in 1949. Expert testimony from Army psychiatrists and sometimes even veterans helped drive the NMHA into law. But it envisioned helping all Americans in need of mental health treatment.

Unfortunately, those who had experienced success treating patients were mostly psychoanalytically oriented psychiatrists. However, this group was relatively small because psychoanalysis is an intensive, traditionally in-person, one-to-one treatment. Since medical training is also time intensive, the NMHA emphasized increasing the number of nonmedical therapists — which brought the category of the clinical psychologist (typically women) out from under the subordination of psychiatrists (typically men) and into the office for private practice.

With this emphasis on the expansion of psychological expertise, the NMHA specifically prioritized funding to increase education. As historian Ellen Herman writes, “Within one year, every state had designated a state mental health authority, 42 states had submitted comprehensive mental health plans to the federal government, 59 training and 32 research grants had been awarded, and 212 students were on their way to becoming clinical professionals thanks to federal stipends.”

But it wasn’t enough to meet Americans’ needs, and the gap between demand from patients and available clinicians persisted. As a result, short-term treatments (like cognitive behavioral therapy) and psychopharmacological drugs became more prevalent. Computer scientists and psychologists also turned to technology: programming therapy bots, automating diagnoses and mental health screening, for example. Activists, critiquing the profession for being out of touch and even violent, proposed other technological solutions, like suicide and crisis hotlines.

More funding poured into clinical psychology after passage of the Community Mental Health Act of 1963. Even so, many community mental health centers were left without viable funding. Although President Jimmy Carter signed new mental health legislation into law in 1980, which promised to systematize care networks and provide free mental health care to all, his successor, Ronald Reagan, repealed it just one year later, defunding the project.

The lesson? Partial and piecemeal remedies don’t address the entrenched problems tied to a lack of access to competent care in the United States. Neither will public relations campaigns by public officials and celebrities reminding us to take care of ourselves for Mental Health Awareness Month each May. Only a comprehensive approach to the issue will — and that means addressing insurance parity for mental health care, funding clinical training and ensuring access and continuity of care.

This article was originally published on The Washington Post on July 27, 2021.
Written by: Hannah Zeavin

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