Saturday, January 22, 2011

On Mental Health Issues -- Cont'd

I don't want to make it seem like the mental health care system in this country in the '50's and '60's was all violets and rosewater. It wasn't. Care of the mentally ill was essentially custodial, treatment was largely based on ignorance. In operation, it could occasionally be extremely cruel.

The point I make is that there was a system of mental health care in place that did not rely on theories of punishment and neglect. There is no such system now. By design and by policy decision.

For all the faults of the system when time was, progress was being made in correcting elements that didn't serve the interests of patients, on eliminating abuses, and on improving custodial conditions. Still, there were huge numbers of patients in the system at any given time, about twice the number now held in America's domestic jails and prisons, but at the time, the ratio between the number of mental health care patients and prisoners was astronomical, many millions vs a few hundred thousand.

An obvious question arises: why were so many people "in the system" back in the day? And why are so relatively few in it today?

The answer isn't quite so obvious, but I'll give it a shot.

One of the chief organizing social values in the United States -- at least from the '20's onward -- was conformity. Americans were obsessed with being like one another, knowing and adhering to custom, deviating as little as possible from the expectations of family, friends and neighbors, submitting to authority, and on and on. As the catastrophes of the 20th Century mounted, first the Depression, then WWII, the need to belong and to conform became almost overwhelming for most people. Eccentricity was not encouraged, often it wasn't tolerated at all. "Alternative lifestyles" were impossible for most people. During the '50's and up to the early '60's "conformity" was practically an absolute demand.

There were very limited "non-conformist" outlets (Beaniks, artist communities and so forth), but they, too, were internally very conformist.

Mentally ill individuals, by definition, didn't and most often couldn't "conform" to more and more rigid social standards. What to do?

That was the question. Because people believed at the time in common social responsibility and that the government, as the agent of the common will, had the authority to act on that responsibility, the result was an extensive public mental health care system. Many people used it -- voluntarily and involuntarily -- which was the point of having it in the first place. This would seem to be an obvious concept, but strangely it is not.

Many of those who utilized the system (voluntarily or involuntarily) did so because they either wanted to conform or their social context required that they do so.

We can opine as we will on the need for conformity in those days. I myself saw how destructive it could be, but it was possible to see the social value in conformity, too. It seemed that people could be designated "mentally ill" on the basis of little more than an eccentricity or two, and that could be very abusive. On the other hand, it didn't happen that often, not nearly as often as one might believe.

Nevertheless, the social pressure to conform was intense, and the level of stress on the people who had difficulty doing so, for whatever reason, was just as intense. For some of them, utilizing the mental health care system was a way to cope.

All that said, because treatment was based on so much ignorance -- ignorance that's still a real problem in the field -- results of treatment were not necessarily desirable or benign. Suffering people continued to suffer. On the other hand, there was treatment or at least care available, which simply isn't the case now, at least not on the scale and level of access there once was.

I'm not inclined to go all the way back to the system as it was, but it's long past time for the recognition that the current underfunded and balkanized non-system that is extremely difficult to access and maintain any sort of consistency of care within is not in the public interest.

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