Minds In Crisis

Mental illness and the broken system to address it

by Kristi Rector

Among people experiencing housing insecurity, just over 21 percent have a serious mental health condition, according to an article in Forbes magazine. Very recently, in 2022, about one-third of U.S. adults experienced both a mental health condition and a substance abuse problem. That same year, approximately 5.2 million veterans experienced a behavioral health condition, the Substance Abuse and Mental Health Services Administration (SAMHSA) reported. And the National Institute of Mental Health states that in the U.S. young adults ages 18 to 25 have the highest rate of experiencing any mental health concerns (33.7 percent) and the highest rate of serious mental illness (11.4 percent).

Brandan Thomas — Citygate Network’s director of leadership, learning, and programs, and the son of a paranoid schizophrenic father — said, “Mental health concerns everyone; recent years have emphasized its importance in our daily lives.” The numbers are overwhelming. “We don’t just have a poverty crisis; we have a mental health crisis,” he said.

How did we get here?

The path to this mental health crisis began in 1945, when Dr. Robert Felix, director of the Public Health Services Division of Mental Hygiene, advocated for shifting funds from mental illness institutions to mental health services. Backed by political support from Senator John F. Kennedy and President Harry Truman, Felix shifted the focus to improving the nation’s mental health, mostly through prevention. This approach, along with a belief that institutions bred mental illness, led to the establishment of the National Institute of Mental Health (NIMH) in 1949.

Then Felix worked with President Kennedy to sponsor a bill that would profoundly change the mental health system. Kennedy was drawn to the cause of the mentally ill because of his own sister Rosemary’s story — she suffered from mental illness and had been given a lobotomy — and he signed into effect the revolutionary Community Mental Health Act (CMHA) in 1963. This act marked the beginning of the decline of large mental institutions, providing grants instead for community-based settings, which were to take up the slack. Thus began the move towards deinstitutionalization. But the funding didn’t hold up.

The introduction of Medicaid a few years later, with its IMD (Institutes for Mental Disease) exclusion, further strained the system because it prohibited Medicaid from funding care in facilities with more than 16 psychiatric beds. By treating mental health differently than other medical conditions, this rule contributed to the reduction of available psychiatric beds and the subsequent reliance on jails and prisons to house people with untreated mental illnesses.

“This is discriminatory because it treats diseases of the brain differently than other diseases. I believe this is why we see jails and prisons become warehouses for the mentally ill,” Brandan said. “It’s concerning that modern medical practices are not fully addressing mental illness, treating the brain — a critical organ like the liver or lungs — differently and often inadequately due to outdated laws. These laws, some over half a century old, contribute to a disparity in care for mental health conditions, not aligning with contemporary medical understanding.”

Later, in 1981, President Reagan signed the Omnibus Budget Reconciliation Act of 1981. This Act repealed most of the Mental Health Systems Act (which provided grants to community health centers and had been passed only the year before) and consolidated the Alcohol, Drug Abuse, and Mental Health Administration’s treatment and rehab services into a single block grant that enabled each state to administer allocated funds as they saw fit.

How big is the problem?

In most recent years, the number of anxiety and depressive disorders grew worldwide due to the COVID-19 pandemic, Forbes reported. Depressive symptoms grew a whopping 28 percent, from a base of about 193 million people affected worldwide to 246 million. Anxiety disorders grew about 25 percent, from about 298 million people affected to 374 million.

“One hundred percent of people deal with mental health [concerns]. The last two years have shown us that,” Brandan said. “An estimated 169,000 homeless individuals suffer from severe mental illness, a figure believed to be an underestimate.”

Eighteen percent of adults have a mental illness that is recognized in the Diagnostic and Statistical Manual of Mental Disorders, and 4 percent have “severe mental illness” or SMI — that’s 8.8 million adults with SMI. (These are pre-2020 numbers.) The most common SMIs are schizophrenia and/or bipolar disorder, and people with these diseases are at the greatest risk for criminal legal system involvement, homelessness, psychiatric hospitalization, and involuntary treatment. On top of that, approximately half of people with severe mental illness experience anosognosia, or lack of insight, that impairs their ability to understand their illness.

According to the U.S. Department of Housing and Urban Development (HUD) 2016 Annual Homeless Assessment Report, more than half of adults living in permanent supportive housing either had a mental disorder or co-occurring mental and substance use disorder. In addition, “Data show that adults aged 65 and older who are homeless also have a higher prevalence of unmet needs for substance use and mental disorder treatment compared with their younger adult counterparts,” SAMHSA reports. To complicate matters, problems with substance abuse and mental disorders can often exacerbate each other, for example, drug withdrawal symptoms can appear to be SMI symptoms, and vice versa.

A system in shadows

Since 1955 there has been a 97 percent decrease in state hospital beds, and half of the remaining beds are forensic beds. Because of this, law enforcement has had to become our shadow mental health system. More than 20 percent of total law enforcement time is dedicated to responding to and transporting the untreated mentally ill. In 2017 10 percent of police budgets was spent transporting the mentally ill.

“If we’re doing our work well, we’ll be working closely with law enforcement because oftentimes law enforcement becomes the people who work most closely with men and women in mental health crisis because our mental health system is so broken,” Brandan said. “In the absence of needed treatment and care, individuals in acute or chronic disabling psychiatric crisis increasingly gravitate to hospital emergency departments, jails, and prisons. These systems experience significant negative impacts as a result.”

Nationally, on any given day approximately 400,000 mentally ill people are incarcerated and another 750,000 are on parole. The untreated mentally ill are 10 times more likely to end up in jail than in a hospital. Hospital emergency departments are so overcrowded that some acutely ill patients wait days or even weeks for a psychiatric bed to open so they can be admitted; some eventually are released to the streets without treatment.

Law enforcement agencies say that service calls, transportation, and hospital security for people in acute psychiatric crisis create significant, growing demands on their officers and strain public safety resources. Jails and prisons are increasingly populated by individuals with untreated mental illness, with some facilities reporting that one-third or more of their inmates are severely mentally ill. And in some communities, officials have reported as many as two-thirds of their homeless population are mentally ill.

What should our role be?

“I believe it’s time for missions to become mental health providers because many of us already are,” Brandan said. “We just need to bring it to the light and put better systems around it. We can’t wait for a better system to come to us; we must build it.”

Of course, that’s no small task. People who are experiencing both mental illness and homelessness have unique treatment challenges because both housing and treatment need to be addressed at the same time in order for treatment to be most effective, according to SAMHSA. “Relapse prevention and recovery management present unique challenges for providers, as clients with mental and/or substance use disorders are at a higher risk of relapse … and subsequent loss of housing.”

Adding more complexity, the U.S. Interagency Council on Homelessness claims that nationwide, 78 percent of unsheltered homeless have mental health issues, 84 percent have other health issues, 75 percent have addiction, and 50 percent have tri-morbidity. Because of this, “as ministries focus on recovery, we may miss a significant part of what may be driving substance use,” said Ta’Mella Pierce, the senior director of clinical and residential programs at Phoenix Rescue Mission’s Changing Lives Center.

Rescue missions are in a unique position to help people with mental illness. “What rescue missions do well is to share the hope of Jesus through relationships as we meet physical needs. We also do recovery well, which often needs tough love with accountability. This approach needs to be modified with those who have mental health issues, especially for those with undiagnosed needs who have no understanding that they are in crisis,” said Eric Burger, executive director of Shelter KC: A Kansas City Rescue Mission.

Ministries’ biblical approach is actually well suited to address the challenges that people with mental illness face. “The church has had a history of following Jesus and running in to work with folks who are not easy to work with.… The good Samaritan took the beaten man to an inn (professional help).… If we want to be credible in our communities, this is how we as Christ-followers become credible: We provide a service to our community that no one wants to do. We see the value of every individual and we build services to address their greatest needs,” Brandan said.

“It’s time for missions to step into the role of mental health providers — a role many of us are already fulfilling informally,” he adds. “In our efforts to be credible and compassionate community members, we must remember the examples set by historical and biblical figures who reached out to those society had rejected.”

Kristi is the former managing editor of Instigate and a freelance writer. She also owns KnotSense, a small business she started to provide calming support for people with sensory needs. Kristi and her family live in Colorado.

To read more articles like this from our bi-monthly members-only magazine Instigate email Aly Zadurowicz about membership today.