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Changing Our Response to Behavioral Health

Written by Jennie M. Simpson

Robin Williams's death has saddened and shocked many of us, and as the many displays of mourning through social media indicate, Williams's death has deeply touched so many and brought to the fore much needed conversations about mental illness. Through his diverse work and career, we came to care deeply for Robin Williams, and so it is with such sadness that we reflect on the loss of his life. As an anthropologist whose work has focused on the intersections of mental health and criminal justice amongst homeless individuals, I find this may be an opportune time to examine how we as a country might generate broader social support for the prevention and treatment of mental illness and addiction for all Americans, as right now, our behavioral health care system is failing to reach far too many people.

Mental illness and addictive disorders -- referred together as behavioral health -- are health concerns that impact millions of people in the United States every year. But behavioral health also has profound social dimensions, with access to services and health outcomes particularly tied to socioeconomic status and inequality. As noted anthropologist Tanya Luhrman in her book,Of Two Minds: An Anthropologists Looks at American Psychiatry, reminds us of mental illnesses, "The way we understand these illnesses affects not only the way they are treated but the way they are experienced, their outcomes, and our sense of responsibility toward those who suffer" (2000: 20). Additionally, the role of stigma and the required public and political will to address our underfunded behavioral health system are social and cultural factors that vastly impact how people experience and recover from mental illness and addiction. Harnessing the concern and conversation around behavioral health that Williams's death has generated, it would benefit us as country to take this time to reflect on the relevant health and social policy dimensions of behavioral health care. As many Americans struggle to access and/or pay for behavioral health services and overcome stigma within their communities, I argue this conversation should start with those most marginalized within our communities.

The Intersections of Behavioral Health and Criminal Justice

In a 2006 Bureau of Justice Statistics report, 45 percent of federal prisoners, 56 percent of state prisoners and 64 percent local or county jail inmates were found to have mental health problems. In the United States today, the three largest providers of mental health services are county jails. This has not occurred by chance, but is the result of policy decisions that have been made over the past 50 years. While the closing of state mental institutions in the 1960s and 1970s held the promise that people in need of behavioral health services would be served in the community, the reality was that the necessary funding needed to ensure comprehensive public behavioral health services was not forthcoming. Anthropologists Sue Estroff and Kim Hopper, in their work in the 1970s and 1980s, both chronicled the coming crisis that was occurring as people with behavioral health needs were unable to secure services, affordable housing and employment.

Without access to behavioral health services, housing and/or a family or community support system, the United States began to see an increasing number of people with behavioral health issues in the prisons and jails beginning in the 1980s, as their contacts with law enforcement channeled them into the criminal justice system. Today, there are a number of federal agencies and organizations that are working to stem this trend through diversion programs, including specialized police-based responses, treatment courts and continuity of care from prisons and jails into the community.

Strengthening and innovating our criminal justice system to treat and connect people with behavioral health needs is important. However, the goal of providing services through a robust and comprehensive behavioral health service system should not be forgotten in these efforts. If we reflect on the lessons learned from the absence of community-based services in the 1970s and 1980s, it can be argued that the way forward in reducing the number of people with behavioral health disorders in the criminal justice system is to fund and prioritize a comprehensive public behavioral health system.

Reducing Stigma and Harnessing Public Will to Address Behavioral Health Needs

Research has long indicated that social and demographic disparities and inequalities impact health outcomes. In part, this is due to stigma around mental illness and addiction disorders, the availability and location of behavioral health resources, and how communities embrace people with behavioral health disorders. With federal, state and local leadership, as well as public support, these things can be changed.

The stigma of mental illness and addiction disorders stands as one of the most challenging barriers that must be overcome, as it affects whether people seek services, how people with behavioral health disorders are treated and the level of importance placed on funding and providing services in a robust behavioral health system. This is especially critical as veterans from wars in Afghanistan and Iraq, as well as veterans of previous wars and conflicts, return to our communities and confront profound behavioral health needs. Anthropologist Erin Finlay at the Department of Veterans Affairs argued in her book, Fields of Combat: Understanding PTSD among Veterans of Iraq and Afghanistan that, "the myriad ways in which combat PTSD is understood in American life have a profound effect on how veterans with PTSD understand their own symptoms, feel about their diagnosis, and make what may be life-changing decisions about coping and care seeking." (2011:9)

It is imperative, then, that as society we begin to understand mental illness and addiction disorders as health issues and integrate services in primary healthcare settings. Primary health care professionals can the first line in communicating this message in communities and with patients. Every primary care professional should have the ability to conduct behavioral health screenings and refer patients to behavioral health specialists and resources. This will take training, continued education and the support of health care professionals to make sure their door is not closed when a patient is in need of behavioral health services.

Finally, we must embrace people with mental illness and addiction disorders in our communities. Efforts to restrict where services are provided or where people with behavioral health needs may reside are rooted in stigma and inequality. Anthropologist Vincent Lyon-Callo has documented community resistance to service providers and supported living accommodations -- the Not In My Backyard (NIMBY) response to community integration of people with behavioral health disorders. Changing how we perceive people with mental illness and addiction disorders, particularly those most marginalized by poverty and inequality, and how we envision our responsibilities for their care, housing and employment as a society are critical matters.

Addressing the significant number of people with behavioral health disorders in the criminal justice system, reducing stigma through integrating health and behavioral health care, and changing our responses to people with mental illness and addiction in our families and communities are strategies that are possible. They respond to systemic problems within our health care system, to the realities of inequality within our country, and the social stigma of mental illness and addictive disorders that harms anyone struggling with these health issues. As sociocultural phenomena, they are not fixed, but can be transformed with political and public will. As individuals, we can change how we respond to people with behavioral health disorders, and we can demand that the necessary funding be provided for a comprehensive behavioral health system. In communities, health care professionals should have the training necessary to integrate behavioral health screenings into primary care and connect individuals with the appropriate resources and services. The U.S. Department of Health and Human Services is working towards transforming behavioral health care, particularly through the Affordable Care Act, but it takes public will to ensure that behavioral health care receives the funding and attention that is needed to support all Americans in need of behavioral health care. We have not been a nation that is renowned for our behavioral health care and treatment of people with behavioral health disorders. Perhaps, it's time to change this.

Jennie M. Simpson received her PhD in cultural anthropology from American University in 2011 with a concentration in Race, Gender and Social Justice. Her work focuses on the policing, mental health, homelessness, and the intersections of criminal justice and mental health systems. As an applied anthropologist, she has worked with police agencies across the United States on specialized police-based responses to people with mental illnesses, as well as in public mental health care.

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