Have We Reached a Tipping Point for Mental Health in America?
“That is the paradox of the epidemic: that in order to create one contagious movement, you often have to create many small movements first.”
Malcolm Gladwell, The Tipping Point How Little Things Could Make a Big Difference
There are many examples of cultural tipping points in mental health which ushered in a collective consciousness, where urgent change is needed. In terms of mental health and criminal justice, one example is court innovation and the establishment of Broward County’s Mental Health Court.
When the court began in 1997, the media and public response was immediate and intense, as the community delegations, representing a wide range of mental health policy organziations, court delegations and mental health and psychology experts wanted to know what Broward County’s specialized Mental Health Court was. This to counter the trend known as the criminalization of persons with serious mental illnes and co-ocurring disorders — and how we were doing it.
The national movement to proliferate mental health courts, as a criminal justice strategy to offer treatment over punishment was deemed a human rights statgety. At the time, no one considered whether this type of problem-solving court had or had not been in existance. Our community had reached a point where we knew action was necessary and we needed to “do something.” With no money or grants, a specialzied court dedicated to diversion and the promotion of access to community-based mental health care, and psycho-social services would have to be enough — for now.
According to the focus of Malcolm Gladwell’s book relates to the drivers of social change, and ‘how little things can make a difference” That based on social trends, and perhaps desperation for innovation, a new idea turns into a movement. I went for the desperation principle. That what families with loved ones with mental illness were suffering. In Broward County in the early to mid-90’s when I served as Director, of the Office of Public Guardian, family members would arrive at my office pleading for help on behalf of thier mother with Schizophrenia, or brother with Bipolar Disorder. As I immersed myself into the mental health system as a young lawyer for what is now known as Disability Rights Florida, I witnessed more than my share of suffering.
I have believe that Broward County’s mental health is a case study, where a series of related problems over time, led to actions which ultimately ignited a tipping point for court innovation.
The conditions in 1994 which led to court innovation came in the form of five precipitating problems, these included: 1) jail overcrowding, 2) an over-representation of persons arrested with serious mental illness, 3) several suicides in the jail, 4) the high-profile case of Aaron Wynn, and 5) A Grand Jury investigation of Broward County’s mental health system.[i]
For our community, change was driven through a series of pivotal events. This included, the release of a scathing 1994 Broward County Grand Jury Report, finding Broward County’s mental health system to be chronically underfunded and “deplorable”,[ii] the establishment of an Ad Hoc Broward County Criminal Justice Mental Health Task Force, and the launch of Broward County’s specialized Mental Health Court.[iii]
The Mental Health Court, the first in the nation, was an outgrowth of the Grand Jury Report. The consensus of the Task Force; that a specialized Court was needed to disrupt the trend known as the criminalization of persons with serious mental illness, was described at the time as, “a leap of faith.” The court’s goals and objectives to marshal scarce community-based mental health resources and implement diversionary strategies to move persons out of jail, with linkages to individualized mental health care, holistic services, and housing. [iv]
The tipping point would come with a call from former Ohio Governor, (then Congressman) Ted Strickland’s office, (approximately 18 months after the launch of the court) asking whether I had any objection to the introduction of federal legislation to pilot mental health courts, to promote jail diversion for persons with mental illnesses. [v] The America’s Law Enforcement and Mental Health Project was unanimously passed by congress and signed into law by President Bill Clinton in December 2000.
Disparities in Mental Health Care for Racial and Ethnic Communities
In 2001, former U.S. Surgeon General, Dr. David Satcher, M.D., Ph.D., published “Mental Health: Culture, Race, and Ethnicity — A Supplement to the U.S. Surgeon General’s landmark (1999) Report on Mental Health. [vi] In these critical times for mental health based upon the COVID-19 pandemic, and racial tensions, I thought it relevant to go back to the Supplement for guidance and perspective.
I was not surprised, key research findings and recommendations in the Mental Health: Culture, Race, and Ethnicity remained relevant. For example, research showed that even though prevalence of mental disorders for racial and ethnic minorities in the United States is like that of whites; “striking disparities persist.” [vii] A review of current data still supports the 2001, findings, (See. NAMI “You are Not Alone Fact Sheet”) and the prevalence of adults experiencing any mental illness during a 12-month period finds:
· 19 % of adults experienced mental illness in 2019. (47.6 million people). This represents 1:5 adults.
· 15% of Asian adults
· 16% of Black adults
· 17% of Hispanic or Latinx adults
· 20% of white adults
· 22% of American Indian or Alaska Native adults
· 27% of adults who report mixed/multiracial (Note the “Supplement” was limited to four most recognized racial and ethnic groups according to Federal Classifications.) [viii]
According to Dr Satcher, disparities in mental health care for racial and ethnic communities were profound due to barriers; which included a lack of access and availability of care, poorer quality of care, a greater burden of disability, a lack of diversity, and an under-representation in mental health research. [ix] While All Americans endured “a constellation of barriers” i.e. prejudice and stigma, fragmentation of services, and lack of a finance structure. The Supplement Report included additional barriers for racial and ethnic communities, which included, “mistrust and fear of treatment, racism, discrimination, and differences in language and communication.” [x]
In terms of disparities, research revealed that “The Nation’s most vulnerable populations, which have the higher rates of mental health disorders also experienced greater disability burden due to unmet mental health needs. Which led to collateral social and economic consequences; which include the inability to equitably share in the “hope of scientific advances and opportunities of our society.”[xi] This dynamic he warns, “include the potential for greater exposure to racism, discrimination, violence, and poverty. “All which takes a toll on mental health.” [xii]
The State of Mental Health — Have We Reached a Tipping Point
As we face the prospect of emergent mental health crisis due to the impact of COVID-19, the evidence on the toll on U.S. and global mental health is mounting. According to many public health experts, Social isolation, the stress of financial and social impact of Covid-19 pandemic and rising mental health issues surrounding disparities due to discrimination and racial trauma, has led to a third wave of the pandemic[xiii].
This past week the World Health Organization, United for Global Mental Health and the World Federation for Mental Health released a joint statement in preparation for World Mental Health day, October 10th, 2020. [xiv] The joint press release describes a global mental health emergency, and needs of billions of people around the world, who have been impacted by the COVID — 19 pandemic, 75% who lack access to mental health and substance use treatment; where a person dies every 40 seconds of suicide.[xv] In a dire warning, by Dr. Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization, states: “Unless we make serious commitments to scale up investment in mental health right now, the health, social and economic consequences will be far reaching.” [xvi]
With that call to action — I wonder will this be the tipping-point moment?
— — — — — — — — — — — — — — — — — — — — — — — — — — — — — -
[i] John S.Goldkamp and Cheryl Irons-Guynn, “Emerging Judicial Strategies for the Mentally Ill in the Criminal Caseload: Mental Health Courts in Fort Lauderdale, Seattle, San Bernardino, and Anchorage” Bureau of Justice Assistance. April 2000. https://www.ncjrs.gov/pdffiles1/bja/182504.pdf
[ii] Trevor Jensen, Mental Health System Deplorable, Report Says,” Sun- Sentinel, November 10, 1994. https://www.sun-sentinel.com/news/fl-xpm-1994-11-10-9411100049-story.html
[iii] Administrative Order No. VI-I-1A “In re Creation of a Mental Health Court Subdivision Within the County Criminal Division, 17th Judicial Cir., Ct., Broward., Fla.
[iv] Lerner-Wren, “A Court of Refuge: Stories From the Bench of America’s First Mental Health Court”, Beacon Press, 2018.
[v] FRONTLINE, A Case of Insanity, “In Congress: Mental Health Courts” uploaded 2000 https://www.pbs.org/wgbh/pages/frontline/shows/crime/trial/mhcourts.html
[vi] U.S. Department of Health and Human Services. (2001). Mental Health: Culture, Race, and Ethnicity — A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services. https://www.ncbi.nlm.nih.gov/books/NBK44243/
[vii] U.S. Department of Health and Human Services. (2001). Mental Health: Culture, Race, and Ethnicity — A Supplement to Mental Health: A Report of the Surgeon General. Executive Summary. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services. P 12.
[viii] NAMI “you are NOT ALONE Factsheet and Resources, Last Updated, September 2019. https://www.nami.org/NAMI/media/NAMI-Media/Infographics/NAMI-You-Are-Not-Alone-FINAL.pdf
[ix] [ix] U.S. Department of Health and Human Services. (2001). Mental Health: Culture, Race, and Ethnicity — A Supplement to Mental Health: A Report of the Surgeon General. Executive Summary. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services. P 13.
[x] Ibid. at 13.
[xi] Ibid. 13.
[xii] Ibid at 13.
[xiv] News Release, Geneva, “World Mental Health Day: an Opportunity to Kick-start a Massive Scale-Up in Investment in Mental Health”, Joint Release by the World Health Organization and the World Federation for Mental Health, August 27, 2020.https://www.who.int/news-room/detail/27-08-2020-world-mental-health-day-an-opportunity-to-kick-start-a-massive-scale-up-in-investment-in-mental-health
[xv] Ibid.
[xvi] Ibid.
