Mental Health Care Is Sick Care in Crisis

After thirteen years as the National Institute of Mental Health Director, Tom Insel left his government job. Some might say he turned into a renegade, when Insel acknowledged that limited progress had been made to improve the lives of those with severe mental illness.

“We decided, in some odd way, that the care we provided for treating the serious mentally ill was based on a medical model as if we were treating an infectious disease — as long as we can get you the right antibiotics or vaccines you are good. These disorders are categorically different. They require a comprehensive approach that combines medical, social, and environmental factors.”

While other diseases such as cancer, diabetes, and heart disease made major strides during the last 50 years, mental illness fell drastically behind. By not treating a population with serious brain diseases, this demographic became homeless and incarcerated.

“We have failed to deliver in such an egregious way, we have more people with serious mental illness in the criminal justice system than the health-care system. That’s the piece that stands out,” Insel said.

After Insel left the government, he moved to California to help co-found several mental health startups. One with Google and several others focused on ways to integrate technology with improved mental health outcomes.

He also took on an advisory role at the request of California Gov. Gavin Newsom, who realized that homelessness and incarcerations had a common denominator — individuals with serious mental illness.

Insel traveled up and down the state only to discover that California’s 58 counties operated in mental health siloes. There was no cohesive mental health plan. California had no mental health department or central authority to set basic standards and goals to hold the counties accountable.

“There should be someone in the state that says this is what we are aiming for in mental health. This is the gold standard. These are the outcomes we are committed to,” Insel said.

A Sick System Built Around Crisis

Los Angeles County Jail is home to the largest population of individuals with serious mental illness in the country. It has become our ad hoc mental health hospital. California also has one of the largest homeless populations in the nation, with estimates of up to one-third of the homeless suffering from serious mental illness and substance use disorders. The numbers are in the thousands.

“It might mean reinventing an entire new system for mental health needs in the twenty-first century, Insel said. “We know a lot more than we did sixty years ago when we were trying to get out of the state system and build community support networks.”

The failure has been in the delivery. The country has operated in crisis mode. The result:

“We don’t have a health-care system. We have a sick care system all built around crisis, the most expensive, intensive care form of health care,” Insel said.

Those with serious mental illness need long-term recovery care. In addition to medication, recovery revolves around what’s been described as the 3Ps — people, place, and purpose. People with mental illness need support and a safe place, and as they recover they need to find purpose. It’s not a one-size-fits-all solution.

Mental Health Workforce Needs

Insel went looking for answers. Although he had been in the health-care sector for 50 years, he traveled extensively in the U.S. and overseas researching the mental health landscape. The work culminated in a book, Healing: Our Path from Mental Illness to Mental Health.

In the process, he uncovered an unexpected statistic about the U.S. behavioral health workforce. He had heard a lot about supply and demand and the shortage of U.S. workers in the behavioral health-care sector — psychiatrists, therapists, social workers, and clinicians. The numbers proved otherwise. He called the data “stunning.”

Recent 2020 data from the Substance Abuse and Mental Health Services Administration (SAMHSA) reported 780,000 people were employed in the mental health workforce compared to 200,000 in primary care.

So why were patients and families struggling to find care? Insel broke it down into four issues:

1. Most of this workforce does not service those with serious mental illness (SMI);

2. The workforce doesn’t have proper training to improve SMI outcomes;

3. Psychiatrists and therapists don’t take insurance and they charge high fees, causing a disparity in care; and

4. There are very few exceptions to the three previous issues, leaving the SMI community with limited to no options.

“We need to rethink our approach. We need to get over ourselves. Everyone doesn’t have to have an MD or PhD after their name. Everyone doesn’t need to be certified at the highest professional level,” he said.

Insel proposed to Gov. Newsom that the state create a behavioral health education program called Coach for California, similar to Teach for America. The mental health workforce would come from community colleges and represent the diversity of the state. The students would receive the training necessary to work in the schools, with the homeless, or child welfare. Folding in peer support and those with lived experience would also be part of the equation.

Discrimination Vs. Stigma

Our nation’s perception of the mentally ill required a serious rethink as well, according to Insel. For example, stigma is no longer part of Insel’s mental health vocabulary. Discrimination has replaced it.

“We are in the Jim Crow moment for mental health. People, especially those with serious mental illness, aren’t even in the back of the bus. They are left out altogether,” he said. “This is not just a health-care problem. It’s a social justice problem. It’s a form of discrimination.”

The life expectancy for someone with schizophrenia is 20 years less than the rest of the population.

“You need to call that out for what it is,” Insel said. “This is the kind of disparity we don’t see in any racial group or ethnic population in America. This is the most underserved population medically in the U.S. It’s the kind of discrimination that shouldn’t be tolerated.”

Which brings us back to the importance of people, place, and purpose. This is mandatory to changing the lens on helping the SMI population and committing to health care not sick care, Insel said.

The disease needs to be looked at like a “wily virus” that keeps mutating through each intervention, he said. Unlike a physical illness such as cancer or diabetes where an individual seeks out treatment and care, serious mental illness causes a loss of insight and brings on psychosis which prevents individuals from understanding the need for treatment. Engagement with mental illness differs from a physical illness. The clinician has to move into that SMI person’s space in a nonthreatening manner and not talk about symptoms and medications. How they intervene and engage are significantly different.

Mental Health Literacy

Even though the work ahead remains daunting, Insel is optimistic. The conversation about mental illness, which once lived exclusively within organizations such as NAMI, Mental Health America, and the Treatment Advocacy Center, has begun to push into our nation’s consciousness. These grassroots organizations want to leverage their strengths on a nationwide level.

Legislators need to be educated in mental health statistics, Insel said. If officials are asked about the number of suicides in their county, they come up blank. Yet they know homicide numbers, COVID numbers, and traffic fatalities. “That’s inexcusable,” Insel added. “We need a social movement to change that.”

Retired California State Sen. Jim Beall said that means we need a fourth P, “Political Activism.”

Insel couldn’t agree more. “Just the way we pushed the civil rights movement, marriage equality, and climate change into a national conversation. That’s what we need to do with mental health.”