Five Improvements We Should Make to Mental Health Care

February 27, 2018 | By June Gruber and Darby Saxbe

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.