Junior English Project: Mental Health in America

s o c i e t y the

mental health issue

june 2019

STIGMa

OVERCOMING PREJUDICE AGAINST THOSE LIVING WITH MENTAL ILLNESSES

CARE

BUDGET

ALLOCATING RESOURCES TO PREVENT ADVERSE CONSEQUENCES

PROVIDING EQUAL COVERAGE TO EVERY CITIZEN

Fig. 1 Honaker, Edward. Looking For Help. Edward Honaker Photographer. Accessed 22 May 2019.

1

To the readers of SOCIETY,

As a young neophyte1, I never realized the true prevalence of mental illness in today’s society. I was taught that the worst people in society are insane, abetting my internalization of the negative commonly held societal attitudes towards people living with mental illnesses. Although I never would say it out loud, I didn’t really believe that mental illnesses were nearly as significant as physical ailments. This is simply because I didn’t know how truly universal mental illnesses are. I didn’t realize how many people are left untreated. I didn’t even think that mental illness was a problem in my own family.

It was not until the fall of 2018, when I had the honor of associate directing the Pulitzer-Prize winning musical Next to Normal, that I began my journey of finding the truth behind mental illness in today’s society. At first, I thought this would be just another musical with beautiful music, intriguing characters, and a wonderful story. However, this show turned out to be all that and much, much more. Depicting the life of a mother living with delusional bipolar disorder and showing how her illness affects the lives of her husband, daughter, and dead son (who is a part of her delusions, yet plays a greater role than one might intially think), Next to Normal vividly reflects the ideas of modern anti-psychiatry movement.

During our production, countless people from our community who saw the show were able to see themselves and their families up on that stage. What really touched me was the amount of people who opened up and talked about their experiences with mental illnesses. I was surprised by how ubiquitous these issues are: before, it seemed like no one really talked about them. Even my own family, which I had previously (and mistakenly) believed did not have any history of mental illness, began to communicate about our own experiences.

According to the National Alliance on Mental Illnesses, one in five people live with some mental illness ("Mental Health Facts in America"). However, as a society, we fail to acknowledge this prevalence. Although all families are likely to be affected in some manner, it is not normalized to talk about these experiences. Mostly, this is due to our attitude towards mental illness which is generally negative, characterized by gruesome depictions of people living with mental illnesses. Not only does this stigmatization have an adverse effect on our mental health literacy, it also has drastic real-life consequences. For example, many Americans fail to receive any sort of treatment for mental illness, exacerbating other exigent issues such as substance abuse, widespread criminalization, homelessness, gun violence, and increased suicide rates. As a society, we have a duty to overturn our beliefs and display our rectitude2 by reevaluating our approach to treatment.

In this issue, our team explores the wide range of perspectives surrounding mental health initiatives. We hope that come next election season, this will help you make an informed decision to support the initiatives that you find most important. Furthermore, we hope that this issue stimulates conversations in your families, schools, work environments, and communities so that we may begin the process of redefining our stereotypes, attitudes, and prejudices towards mental illness.

priya bhatt

Thank you,

Fig. 2 Bhatt, Shashi 2 Thanksgiving. 2017.

Priya Bhatt Editor-In-Chief

in this edition Fig. 3 Neural Network. Storyblocks Video. Accessed 17 May 2019.

from the editor

2 The state of our health LEARNING ABOUT HOW WE BROUGHT THIS IScare 28 SUE TO YOUR TABLE MEET THE TEAM

5

GETTING TO KNOW THE PEOPLE WHO BRING YOU SOCIETY EVERY MONTH

A HISTORY OF MENTAL HEALTH IN SOCIETY

8

MENTAL HEALTH TODAY

18

EXAMINING WHY AFFORDABLE CARE IS THE PANACEA4 OF THE MENTAL HEALTH CRISIS

testing your knowledge 30 REVIEWING VITAL MENTAL HEALTH TERMS

the parity problem

32

REVIEWING HOW THE MENTAL HEALTH CRISIS DETERMINING WHY MENTAL HEALTH CARE CAME TO BE TREATMENT REMAINS INACCESSIBLE TO MANY DISCLOSING OUR CURRENT MENTAL HEALTH SITUATION THROUGH STATISTICS & MORE

stigma in action: dr. stephen p. hinshaw 20

REVEALING HOW THE PREVIOUSLY DISSEMBLED3 STEREOTYPES SURROUNDING MENTAL HEALTH CAN AFFECT OUR PERSONAL LIVES

the affordable care act in action 35

EXPOSING THE TRUE NATURE OF THE SEEMINGLY ABSTRUSE5 NATIONAL HEALTH CARE SITUATION

Mental health misconceptions 40 DEBUNKING6 MENTAL HEALTH MYTHS

mental health sTIGMA: the silent killer 24 our federal budget

44

EXPLORING THE COMPOUNDED AFFECTS OF SCRUTINIZING OUR CURRENT ADMINISTRAMENTAL HEALTH STIGMA IN TODAY’S SOCIETY TION'S ECONOMIC GOALS

this is S O C I E T Y Our world is a place of beautiful connection with so many aspects to appreciate. However, our society is far from perfect: we have many matters that afflict us daily, sometimes to a degree that we can’t even begin to recognize. At times, these issues can seem absolutely overwhelming. With so much information (some of it false) spurring so many different perspectives, it is hard to know what can be done to alleviate our problems. However, we believe that people should not have to acquiesce7 to simply living with the situations that plague us. At SOCIETY, we aim to take the first step towards progress: we hope to inform our readers so that together we may develop a process that will move our civilization in a positive direction.

recent issues

progress. process.

4

2019 May: Climate Change April: Affirmative Action March: Immigration February: Media Bias January: The Government Shut Down 2018 December: Gun Violence November: Marijuana October: Health Care Innovation September: #MeToo August: Equal Education July: The Flint Water Crisis

positive development.

MEET THE TEAM It takes a team to achieve a vision. At SOCIETY, we have a vision of a world informed of our local, national, and global afflictions. We truly believe that such education may be the very key to combating such issues. Here are the people who work together to achieve this vision by bringing you a holistic view of the exigent topics of today.

Follow each of us on Twitter for the latest updates on what is catching our attention.

Feel free to @ us with questions, comments, or concerns!

Priya bhatt, editor-in-chief

@carpediem Ms. Bhatt, an experienced journalist, has had the chance to hone her talents in a multitude of avenues from scholastic achievement to artistic development. She cites the breadth of her experiences as the main reason as to why she aims to ensure that all sides of an issue are thoroughly considered so that the best course of action may be determined. With SOCIETY, she has a vision of transformation that will continue to push us to develop the best magazine we can create. She is excited to learn more about mental health and work to destigmatize mental health in her own life.

Fig. 4 Bhatt, Shashi. "Headshot." Jpeg file, Oct. 2018.

jennifer chung, artistic director

@cleanlines Ms. Chung, a graphic design master, has developed her eye for aesthetics through her years of freelance work for major news organizations such as The New York Times and The Wall Street Journal. Reflecting the high quality of her work, she truly understnads how visuals can powerfully convey information. For SOCIETY, she hopes to mold our visuals to best reflect the message we are trying to convey every step of the way throughout our issues. As she struggles with OCD herself, she is excited to inform readers about the truth of mental illness through this issue.

Fig. 5 Headshot. CEOportrait Headshots NYC. Accessed 18 May 2019.

ginger darcy, senior writer

@thegingerdarcy Mrs. Darcy, an adept8 writer, has been driven by her innate curiosity ever since her youth. A graduate of Northwestern University with a dual degree in Journalism and Communications, she has been trained to dig deep and get to the truth of different matters in everything she investigates. At SOCIETY, she hopes to satisfy her fascination with the exigent topics of today’s world by exploring different urgent issues, the potential consequences of leaving them as they are, and the possible outcomes if we take action. As she lost a close friend in high school to suicide and untreated depression, she believes this issue is so important for educating the public so that we may help people struggling with untreated mental illness who need it.

Fig. 6 Headshot. CEOportrait Headshots NYC. Accessed 18 May 2019. 5

MEET THE TEAM, contd. visit us at www.societymagazine.org

rosalind rale, business editor

@thebigROS Ms. Rale, a savvy businesswoman, has been tracking business trends throughout her career. Her main focus is on connections, or how individuals, communities, states, and nations can affect each other on both the macro and microscopic levels. For each of SOCIETY’s issues, she examines the economic aspects of the problems we face: how drastically they affect our economy, how much they could affect our economy if we leave them as they are, and the positive impact we could make if we develop a solution. Given the amount of stress in her field, she has seen many coworkers suffer with depression while remaining quiet, so she is grateful for how this issue normalizes mental illness and helps these people.

Fig. 7 Blazer, Slava. Professional Headshot. Slava Blazer Photography. Accessed 18 May 2019.

george ren, culture editor

@talktome Mr. Ren, an adroit9 journalist, has spent the past few years working as a producer at CNN. Most fascinated by how news stories truly affect the people who read or see them, he has recently begun delving more deeply into the social aspects of journalism. For SOCIETY, he analyzes the social impact of each issue on individuals, cultures, and society as a whole, and explains how our readers should rethink their actions after being informed about the issues at hand. He is excited to see how this issue will aid the process of destigmatization in our culture.

Fig. 8 Headshot. CEOportrait Headshots NYC. Accessed 18 May 2019.

anne baker, policy expert

6

@theannebaker Ms. Baker, a political scientist, had been writing for the Atlantic’s political column for the past few years before coming to SOCIETY. Examining each of the dense government-related document that confound1⁰ us all while simultaneously following the major news outlets’ commentary on these actions, she has been closely following the political arena for the past decade. For SOCIETY, she hopes to decipher abstruse documents in order to make them trenchant11 so that everyone may understand what is going on in our government’s back rooms. Furthermore, she hopes that this issue prompts people to encourage their representatives to enact legislation to support mental health care reform.

Fig. 9 Headshot. CEOportrait Headshots NYC. Accessed 18 May 2019.

willis casa, m.d., health expert

@williscasaMD Dr. Casa, a medical professor venerated12 for her work at the Johns Hopkins Medical School, has been an avid reader of SOCIETY for years. Always staying current on the latest news in medicine, she enjoys educating people from her medical school students to the general public on medicinal topics. SOCIETY consults with Dr. Casabianca to ensure that our understanding of the health topics we explore is anatomically correct and as up to date as possible. At Hopkins, she sees trauma patients from all over Maryland who have been accidents that have resulted from untreated mental illness, so she understands the extent of the mental health crisis and the necessity of this issue.

Fig. 10 Blazer, Slava. Professional Headshot. Slava Blazer Photography.

Accessed 18 May 2019.

lee brown, historian

@oldsoul Mr. Brown, a historical research expert, has always been fascinated by the events that led to our current societal situations. After working at the Field Museum of History in New York, he decided to apply his historical skills to a more practical, cultural avenue. In each issue of SOCIETY, he finds the most pertinent historical facts to bring our readers up to speed on that topic, clearly displaying the exigence in the process. As mental health is a topic that has recently been receiving a lot of attention, he finds it interesting that mental health issues can be traced far back in our history. He hopes that by learning about the history of this issue, we may better be able to solve it.

Fig. 11 Headshot. CEOportrait Headshots NYC. Accessed 18 May 2019.

shaun marsh, head technician

@helloworld Mr. Marsh, a software engineer and technological genius, has been immersed in technological innovation for many years in the Silicon Valley.

A reader of SOCIETY himself, he has recently become involved by developing our online presence through our website and social media platforms. He also guides our SOCIETY writers through the process of creating, maintaining, and properly utilizing their Twitter accounts, which we believe is of great importance for proper discourse with our readers. As his wife is living with schizophrenia, he is glad for what this issue will do to help families like his own.

Fig. 12 Headshot. CEOportrait Headshots NYC. Accessed 18 May 2019.

Fig. 15 Twitter Icon. Twitter.

Accessed 19 May 2019.

Fig. 14 Facebook Icon. Flaticon.

Accessed 18 May 2019.

@societyofficial

SOCIETY Magazine, Inc.

@societymag

Fig. 13 Instagram Icon. Flaticon.

Accessed 18 May 2019.

CONNECT WITH US

7

Fig. 15 Mental Icon. Free Icons Library, 2018. Accessed 25 Feb. 2019.

a history of mental health in society

What the intersection of pop culture, preventative health care, politics, and progress has looked like through time

By Lee Brown

moral treatment

Fig. 16 Medical Inquiries. Their Own Words, 17 July 2003. Accessed 25 Feb. 2019.

1790s-1900s humane care through moral intervention (schwartz 3)

8

1812

The first textbook on mental health in the U.S., Medical Inquiries and Observations upon the Diseases of the Mind was published. Author Benjamin Rush developed the field of modern psychiatry by advocating for insane asylums and involuntary psychiatric treatment while also developing the idea of addiction as a disease (Shwartz 5). Revolutionizing the medical field by establishing as a disease what had previously been regarded as erratic behavior, Rush allowed society to take the first steps towards treatment of individuals living with mental illnesses.

1854

1926

President Franklin Pierce vetoes the Indigent Insane Bill, which would have provided land for the insane and an opportunity to live in “moral treatment” centers (Schwartz 8-9). By restricting aid, President Pearce began to further the idea that people living with mental illnesses should be met with some form of confinement.

Exploring the idea that mental illness is “otherworldly,” the Japanese silent film A Page of Madness creatively used masks and dream sequences to show the relationship between a married couple in an asylum (Haider para. 9).

Subconciously, audiences would gain idea that the mentally ill are fundamentally different.

1896

Fig. 17 A Page of Madness Still. Hope Lies at 24 Frames per Second, Wordpress. Accessed 20 May 2019.

1927

Becoming the first state to implement such policies, Connecticut prohibited marriage for the mentally ill (Larson para. 27). This inadvertently set a precedent for other states and forwarded explicit stigmatization of mental illnesses in legislation.

Fig. 18 Insulin Shock Therapy. Rebel Circus. Accessed 27 May 2019.

Austrian therapist Manfred Sakel developed the experimental insulin shock therapy that attempted to cure cases of schizophrenia (Larson para.

33). Experimental treatments such as these often harmed patients more than help them.

era of the asylum

1850s-1950s EXPLORATION OF eugenics leading to the development of misled treatmenTS (Schwartz 11)

1907

Promoting ideas of eugenics, Connecticut mandated that if a board of experts recommended it, certain individuals (meaning the mentally ill) must be sterilized (Larson para. 27). The promotion of the idea that people living with mental illnesses should not be present in society further inflamed stigmatization.

1937

One of the first managed care organizations (MCOs), the Group Health Association (GHA) was created with the intention to regulate medical expenses in order to reduce the number of mortgage defaults.

The GHA, like many other MCOs of the time, faced opposition from its local medical society who threatened expulsion for their physician members who chose to participate in the GHA (Fox and Kongstvedt 3). Health care was starting to develop in its earliest stages.

1913

As their patient population of the mentally ill had more than quadrupled since its opening, Oregon had to open a second state hospital (Larson para. 19). Along with an increase in stigmatization, the nation was witnessing an increase in institutionalization and abusive treatment.

Fig. 19 Eastern Oregon State Mental Hospital 1913. Oregon State Hospital Museum of Mental Health, Oregon State Hospital of Mental Health. Accessed 26 May 2019.

9

1942

Imposing wage and price controls on businesses in response to inflation and a tight labor supply during World War II, the Stabilization Act led to a great increase in the number of employed individuals who had health benefits, which were not constrained by wage controls (Fox and Kongstvedt 5-6). Individuals became more dependent on provided health care.

1946

1945

The McCarran-Ferguson Act led to the regulation of insurance companies at the state level rather than the federal level, which further resulted in variability between government oversight of insurance companies throughout the nation (Fox and Kongstvedt 6). As opposed to being standardized, health care was becoming more fragmented throughout the nation.

Indicating a shift towards greater government intervention in mental health and in ideologies towards the treatment of mental illness, the National Mental Health Act was signed (Larson para. 43).

Previous recognition of poor mental health treatment led to the increase in popularity of humane mental health laws.

deinstitutionalization

1940s-1950s journalistic exposés LEADING to the development of attitudes that asylums were inhumane, psychopharmacological revolution (Schwartz 15)

1946

A Life Magazine Expose on the Bedlam Institution is released, developing public attitudes towards the institutions that characterized mental health treatment over the past century. According to Robert Whitaker, author of “Mad in America,” “all of a sudden America sees these photos that look like concentration camp photos. You see people huddled naked along walls, strapped to benches… and it really is this descent into this shameful moment” (Shwartz 16). People began to recognize the brutality of treatment towards the mentally ill.

Fig. 20 May 1946 LIFE Magazine Article on Mental Hospitals. Stevenson High School. Accessed 20 May 2019.

10

Fig. 21 The Snake Pit. DirecTV, AT&T Intellectual Property. Accessed 27 May 2019.

1948

Written by journalist Albert Deutsch, The Shame of the States highlighted the various abuses he witnessed in mental institutions. In the same year, these abuses were also depicted in the movie The Snake Pit (Larson para. 39-40). Collective feelings against the brutal treatment of the mentally ill were further excacerbated.

1954

By supporting outpatient clinics through the Community Mental Health Act, New York became one of the first states to reform its mental health care system (Larson para. 45). Prompted by popular disdain for current mental health treatment, his indicates a willingness to improve mental health treatments.

1955

Congress passed the Mental Health Study Act, initiating a study on the humanity of mental health institutions to take place over the next few years. (Schwartz 21). This shows a demonstrated interest in fully understanding the atrocity of mental health treatment.

1954

Signaling the rise of psychopharmacological medications, Thorazine began making its way into the U.S. market in 1954 (Larson para. 44). This signals the beginning of the development of treatments similar to those available today.

However, ads would employ extreme negative stereotypes of the mentally ill, promoting stigmatization.

1954

Fig. 22 Thorazine Ad. blahpolar, Wordpress.

Accessed 20 May 2019.

Serving as a model for modern independent practice associations (IPAs), the San Joaquin Medical Foundation paid contracted physicians regular salaries with money from their consumers’ monthly premiums. They also benefited their consumers by hearing their complaints and regulating their overall quality of care (Fox and Kongstvedt 6). This would encourage more doctors to participate in health care networks and encourage more consumers to buy into plans, increasing the overall popularity of health insurance.

11

1965

Medicare for the elderly and Medicaid for selected low-income populations were established in the Social Security Act. Providing separate benefits, Medicare Part A paid for hospitalization using taxes on earned income and Medicare Part B paid for physician services paid by general revenues and enrollee premiums (Fox and Kongstvedt 7). This was a major turning point in increasing the accessibility of health care for everyone.

1961

Issued as the final report resulting from the study done as according to the Mental Health Study Act, the Action for Mental Health by the Joint Commission on Mental Health and Illness finds that immediate mental health care should be made availbale in community settings, full-staffed mental health clinics should be accessible to all people in the U.S., and community based aftercare and rehab should be provided to patients (Schwartz 21). This indicates a recognition of the pressing need for mental health care reform.

1973

The HMO Act was passed, developing “health maintenance organizations� as federally qualified prepaid health care providers as opposed to third-party providers (Fox and Kongstvedt 9). This would increase the validity of health insurance, presenting it as an even more viable payment option.

community health movement

1960s-1980s commitment to the growth of mental health treatment (Schwartz 24)

1960

Featuring the eerie Norman Bates and a sinister score by Bernard Herrmann, Alfred Hitchcock’s Psycho is released (Haider para. 7). The use of the mentally ill for "thrill factor" would also propogate negative stereotypes and stigmatization.

1972

In order to encourage people to live independently as opposed to in institutions, Social Security was changed to allow payments to individuals who did not live in hospitals (Larson para. 55). This would allow more people to take advantage of Social Security benefits while also preventing them from having to suffer the disadvantages of stigma.

1963 Norman Bates in Psycho. MSN, Micro12 Fig. 23soft News. Accessed 20 May 2019.

The Mental Retardation Facilities and CMHC Construction Act was signed, providing grants to community mental health centers (CMHCs) so that they could better provide treatment to all individuals (Schwartz 25). The government was increasing spending on mental health care, impproving the quality of treatment for all citizens.

Because of the Supreme Court case O’Connor v. Donaldson, people could not be committed involuntarily unless they were deemed a threat to themselves. This led to a transition towards more reactionary mental hospitals housing those associated with crime (Larson para. 60). Because those who were being "treated" were the most dangerous in our nation, popular opinion developed that mental illness equates danger.

Fig. 25 Movie Poster A Nightmare on Elm Street. Amazon. Accessed 20 May 2019.

1975

1982

1980

In The Shining, Jack Nicholson depicted insanity as a murderous showman (Haider para. 7). This furthered the idea of the mentally ill as unreliable, extremely fractious13, and dangerous.

1975

Ken Kesey’s movie One Flew Over the Cuckoo’s Nest was released, depicting the story of a convict who fakes a mental illness to escape prison labor, leading to his subsequent subjection to the horrors of various mental illness treatments such as ECT (Haider para. 6). This exposed some of the more harmful experimental treatments of the time.

1984

Like many iconic slasher movies, A Nightmare on Elm Street depicts madness as malicious. Usually, writers chose to exacerbate15 the extremity of their portrayals of mental illness for shock effect (Haider para.

7), unwittingly increasing stigma.

Most states were supported by the National Institute of Health’s Community Support Programs, meant to provide services such as rehabilitation for the mentally ill (Schwartz 39). This would allow supportive mental health care to become more accessible.

1981

The Omnibus Budget Reconciliation Act annulled14 the National Mental Health Systems Act, slashing domestic programs and decreasing the overall quality of care (Larson para. 11).

This shows a marked turning point in the government's approach to mental health treatment.

1980

1987

In Fatal Attraction, the eminent16 actress Glenn Close portrays a career woman who descends into madness (Haider para. 11), furthering mental health stereotypes.

1982

Jessica Lange stars as Frances Farmer, an actress who was subjected to involuntary commitment to a psychiatric institution during the 1930s (Haider para. 13), reflecting opposition to in humane treatment.

13

The National Mental Health Systems Act was passed in order to reinvigorate the CMHC program to treat those with chronic mental illness (Schwartz 41), showing further commitment to mental treatment improvement.

Fig. 24 Vintage Photo of Jessica Lange and Frances Farmer. Amazon. Accessed 27 May 2019.

1996

Fig. 26 Eccles, Andrew. Time Magazine Cover - What Your Doctor Can't Tell You. 22 Jan. 1996. Time. Accessed 21 May 2019.

Embodying general negative feelings towards managed health care systems, Time magazine ran this cover story in their January 22d issue (Fox and Kongstvedt 23-24). This reflects the general indignant spirit towards rising rates of treatment coupled with an increasing difficulty of receiving quality treatment.

1994

Modeling the national trend, the Blue Cross Shield Association voted to allow its member plans to convert from not-for profit to for-profit organizations (Fox and Kongstvedt 15), making the new purpose of most companies to earn money as opposed to provide care.

1997

Backlash against the managed health care system led to an investigation by the Government Accountability Office (GAO) who found that of 1150 physician contracts from 529 HMOs there were no instances of a gag clause, or a part of the contract that would prohibit physicians from informing their patients about their best medical options (Fox and Kongstvedt 23). This strengtehend the idea that MCOs are accountable.

managed care & recovery era

1990s-2010s health care services paid for by third-parties such as the government with a commitment to improve the quality of care (Schwartz 54-56)

1993

The Health Security Act would have established health care, including mental health care, for all Americans, but was defeated by intense lobbying (Schwartz 52).

This indicates a lack of support for centralized mental health, and exasperating17 advocates who recognized a lack of treatment.

14

1996

The Mental Health Parity Act was passed in an attempt to ensure equality of traditional and mental health care, however, it had many loopholes (Schwartz 60). Although well-intentioned, this legislation did not achieve its goals of achieving equality of mental and physical treatment.

1996

Limiting health plans’ ability to deny coverage to individuals based on health status, the Health Insurance Portability and Accountability Act (HIPAA) was enacted (Fox and Kongstvedt 20). People with chronic ailments could finally receive stable treatment, signalling a positive move towards providing care for everyone.

1999

Multistate health care firms such as Kaiser Permanente represented three-fourths of U.S. enrollment in managed care plans, a result of the consolidation of many managed care organizations over the course of several decades (Fox and Kongstvedt 14).

MCOs were becoming bigger and bigger, with greater monopolizing power.

2008

By establishing the Mental Health Parity and Addiction Equity Act, the Obama Administration continued working on ensuring equality of care (Schwartz 61).

Although this showed progress in equity of care, there were many looopholes to be adressed.

2003

Established by the Bush Administration, the President’s New Freedom Commission on Mental Health began to study mental health treatment and make recommendations for improvement.

The Medicare Prescription Drug Improvement and Modernization Act was also implemented to provide drug benefits to Medicare recipients (Schwartz 58). These acts show governmental recognition of the lack of proper mental health treatment.

1999

Winona Ryder and Angelina Jolie star in Girl, Interrupted, a story adapted from Susanna Kaysen’s chronicle of her time spent in a youth psychiatric institution (Haider para. 13). This embodies continued disdain for mistreatment of the mentally ill, especially youths.

2008

Fig. 27 Girl, Interrupted. Prezi. Accessed 21 May 2019.

Hospital consolidation over the past few decades gave provider organizations greater negotiating power over commercial health plans, leading to an increase in hospital prices to private payers by 20% between 1994 and 2001 and 42% between 2001 and 2008 (Fox and Kongstvedt 16).

Clearly, individual health care costs were skyrocketing, and health insurance was becoming the only feasible way to pay for health care.

15

Fig. 28 Bhatt, Priya. National Health Expenditures 1999. Plotly. Accessed 21 May 2019.

2012

2009

From 14% in 1999, the number of Americans living without health insurance rose to 17% in 2009 (Fox and Kongstvedt 26). Health care costs were rising, which meant that health insurance costs would rise too. Uninsured Americans most likely lived without treatment, or went bankrupt.

From 55.9% in 1960, the percentage of all healthcare costs paid by patients themselves declined to 11-12% (Fox and Kongstvedt 7). This shows how the third party system of payment caused great inflation of health care costs, causing less people to buy into them. Meanwhile, national health expenditures as a percentage of the gross domestic product (GDP) grew from 5.2% in 1960 to 5.8% in 1965 (the year before Medicare was implemented) to 7.4% in 1970 and finally to 17.2% in 2012 (Fox and Kongstvedt 7), showing an increase in dependence on government-provided health care.

2012

The Patient Protection and Affordable Care Act (ACA, or “Obamacare�) brought sweeping changes to managed care, including mandating that health insurance cannot deny coverage or vary premiums based on health status, that all Americans purchase health insurance or pay a penalty, and that Medicare would be expanded to cover a greater number of individuals (Fox and Kongstvedt 28). This is a major turning point for accessible care: many Americans were now able to experience their first doctor's visits, take their first perscription medicines, and for the first time, feel security of health.

16

Fig. 29 Silver Linings Playbook. Hollywood Reporter. Accessed 21 May 2019.

2010

Starring Jennifer Lawrence and Bradley Cooper, the romantic comedy Silver Linings Playbook depicts the story of a man living with bipolar disorder and woman living with depression who have an inexplicable affinity18 for one another and come together in their process of rehabilitation (Haider para. 17).

This signals the popular move towards the recognition and normalization of mental illnesses, providing a model for people to follow in the future.

NOW

Proposed by Cassidy-Murphy, the Mental Health Reform Act is meant to integrate physical and mental health and establish other reforms (Schwartz 63), signalling the potential for positive development in our government.

Fig. 30 Maniac. Netflix. Accessed 21 May 2019.

Symbolizing the modern anti-psychiatry movement, the upcoming Netflix series Maniac tells the story of two people who participate in a drug trial that promises to cure all traces of mental illness (Haider para. 3). People are beginning to recognize that psychopharmacological treatments aren't one-size-fits-all, prompting new types of treatment to be developed.

LOOKING BACK AND LOOKING AHEAD

With a long and arduous history, it is clear that there are many factors affecting our current situation of treating individuals living with mental illnesses. Our societal attitudes towards mental illness, reflected in our movies and other means of pop culture, definitely affected how legislators approached mental health throughout the past century. For example, although many health insurance plans were available, mental health was not always included within these plans until it was mandated in the Mental Health Parity Act of 1996. As a country, we have shown great growth in treating individuals living with mental illnesses, but we still have a long way to go. What is our current situation regarding mental health?

Now, with the ever-growing federal deficit, conservatives in Congress are seeking to slash government spending on healthcare, the costliest expenditure in our budget. In doing so, the Trump Administration intends to provide Americans with greater freedom to choose individual health care options. To further bridge the deficit, Trump has proposed several budget cuts in mental health initiatives. Although enacting these changes, President Trump has displayed how sanctimonious19 he is by assuring the nation of his commitment to mental health, emphasizing the importance of institutionalization and preemptive measures. However, his frugal plan may be costlier to Americans than we first perceive. Individual health care plans are extremely expensive, and many Americans have opted out of health insurance altogether. With the increase in price of healthcare and the loss of individual mandate, will the average person prioritize their physical or mental health? As of 2018, over half of Americans still fail to receive mental health treatment, leading to skyrocketing incarceration and suicide rates. The government has a responsibility to alleviate these problems before they arise, but how? We must focus on their root cause: mental illness, or lack of care.

In order to move past hypocritical empty promises and get people the help they need, we must focus on destigmatizing the cultural influence behind self-diagnosis, providing basic health coverage to every American, and instating legislation to make mental health parity a reality.

17

What the mental health crisis looks like today

By Ginger Darcy

one in five

Americans live with some mental illness

one in twenty-five Fig. 31 Elliott, Tim. Person Icon. 18 July 2018. Founders Kitchen and Bath. Accessed 21 Mar. 2019.

Americans live with serious mental illnesses (“Mental Illness” para. 5)

More prevalent than most people believe, mental illnesses are some of the most common ailments in our nation. Many of these people choose not to disclose20 their conditions due to accompanying stigma that would prevent them from living their best lives socially and professionally and leave them despondent21. Unbeknownst to us, our family members, co workers, and friends live with mental illnesses.

however, nearly

60%

of Americans living with mental illnesses do not receive mental health services (“Mental Illness” para. 6)

Even though mental health is so prevalent, over HALF of these people do not receive treatment. A lack of treatment leads to problems even more severe than stigmatization (and, to some degree, contribute to the severity of stigma) such as substance abuse, homelessness, gun violence, and unemployment.

18

26%

of people living in homeless shelters also live with serious mental illnesses (“Mental Health Facts In America”)

Because people living with serious mental illnesses face greater adversity when trying to find jobs, they are more likely to not be able to support themselves and therefore become homeless. A lack of suitable treatment, which can be extremely expensive, further forestalls22 these people from getting back on their feet.

27%

of adults living with serious mental illnesses are covered by Medicaid (“Taking Away” para. 1), but President Trump is calling for a

$1.4

trillion

reduction in Medicaid spending (Howard para. 8)

Because President Trump is reducing accessibility of health care by reducing spending on Medicaid, he is taking away support for many people living with serious mental illnesses. He rationalizes this by saying that people can purchase their own insurance off of the individual market. However, insurance premiums on the individual market are so expensive that this would lead to an even greater treatment gap.

24%

of state prisoners have a recent history of mental illnesses (“Mental Health Facts In America”)

Without treatment, people living with mental illnesses can act out in ways they wouldn’t if they were healthy.

In some cases, this erratic behavior can land them into prisons as opposed to hospitals, where they could receive the treatment they need.

10.2 million

American adults live with co-occurring mental illnesses and substance abuse disorders (“Mental Health Facts In America”) People without treatment for mental illnesses may turn to alcohol and other stimulants/depressants to distract from their situations. This unintended consequence of the mental health crisis leads to an exacerbation of the substance abuse crisis.

suicide 10th 90% is the

leading cause of death in the United States, and

of people who died by suicide lived with some mental illlness ("Mental Health Facts In America").

Suicide, a cause of death that is intentionally self-inflicted, is one of the leading causes of death in the nation.

This could and should be prevented.

$193.2

billion

dollars worth of earnings are lost due to serious mental illness (“Mental Health Facts In America”) The vast number of people living with mental illnesses who are unable to receive treatment and therefore are unable to work indicate a loss of productivity. Furthermore, the staggering cost of supporting prisons, substance abuse programs, and homelessness programs can be ascribed23 to the negligence we display towards people liv19 ing with mental illnesses.

Stigma in action:

STEPHEN P. HINSHAW Interview By George Ren

Fig. 32 Stephen Hinshaw. Bring Change to Mind.

Accessed 4 Mar. 2019.

Dr. Stephen Hinshaw is an internationally renowned psychologist and author whose accolades24 include the many awards he has received for his powerfully written memoir Another Kind of Madness. Recently, his work became the winner of Best Book Award, Autobiography/Memoir at the American Book Fest (2018) and a finalist for the Best Book Award, Psychology/Mental Health at the American Book Fest (2018) (Hinshaw, "Mental Health Stigma JEP"), showing the power of his experiences. In this book, Dr. Hinshaw explores his deep personal experiences that embody the concept of mental health stigma. Here, we talk to him about these experiences and how they affected his development and outlook on the mental health crisis.

20

So let’s get to it. Why don’t you tell our readers a little bit about yourself?

Well, I grew up in Columbus, Ohio with my father, a reputable25 philosopher, my mother, an English professor, and my younger sister Sally. After high school, I attended Harvard University. During the spring term of my freshman year, I had a life-changing conversation with my father that spurred my interest in psychology.

After earning my B.A., I spent a few years directing dayschool programs and summer camps for students with developmental disabilities. I then earned my doctorate in clinical psychology from UCLA. Now, I’m a professor of Psychology at UC Berkeley.

What was this “life-changing” conversation with your father?

That was the first time my father opened up to me about living with mental illness. He described to me a bout of serious erratic behavior he had when he was a teenager during World War II. One summer day, he jumped from the roof of his house because he believed he could fly and that his flight would send a signal to the Fascists that they must surrender. Subsequently, he spent time at the Norwalk County Hospital, a public mental facility, where he realized that unfortunately, he perhaps had found his true peers amongst the clinically insane. After this stay, he was diagnosed with schizophrenia. This misdiagnosis would persist for the majority of his lifetime.

That must have been a jarring conversation.

In that moment, did you feel surprised?

At the time, I was so shocked. In a way, however, his confession cleared up so many questions and fears I had during my childhood. My father was a loving man, but many times over the years he would lash out unexpectedly or cause family altercations26, disappear for weeks or even months at a time, and then come back and be a loving father again as if nothing had ever happened.

Through conversations with my father later in life, I realized that during these prolonged disappearances, he was actually spending time at different mental institutions.

When your father would leave, how did you feel?

When he left, it was almost like a part of me left too.

Our lives were never as full as they were when my father was around. It was hard to stay resilient27 without him there, as there was an undiscussed expectation that ev-

erything must proceed as normal. Although it wore her down over the years, my mother had ideas ingrained in her by society that mental illnesses were taboo. I didn’t find this out until much later, but the doctors strictly advised my father and mother to not talk about his illness with anyone, including their own children. As a result, my father continually had to leave without the support of his family, my mother was left alone to bear the burden of covering for him during each disappearance, and my sister and I had to live in a state of inexorable28 confusion and uneasiness. That was probably the worst part about the whole situation for us: although he left many times over the course of our childhood, my sister and I never knew why he left. Together to have to continue our lives in relatively blissful yet still tormented ignorance.

“

we had to uphold the image of being the PERFECT FAMILY

“

It’s an honor to meet you in person, Dr. Hinshaw.

The pleasure is all mine!

Wow. Were these stays at least beneficial to your father’s health?

Like I said, after his stays, he would come home and resume his normal loving disposition, almost as if he never left and as if nothing bad had even happened. However, I know that these stays and some of the extreme treatments he received were not really beneficial: the doctors had his diagnosis wrong for decades, and he continued to have major episodes. How can you treat someone for an illness if you don’t even really know what the problem is? He struggled for so long with no hope that his illness would get better, and it was hard for him to remain intrepid29 with the threat of him acting out and hurting someone he loved looming over his head. It wasn’t until I developed the idea that he truly was living with bipolar disorder as opposed to his previous diagnosis of schizophrenia that I pushed his doctors to consider an alternative course of treatment. My father finally was started on lithium, and after a year, he told me that 21

he never had felt such assurance that he wouldn’t have another manic episode.

How did your father’s misdiagnosis and hospitalizations affect the rest of your family?

More than anything, I think we felt the consequences of the stigma surrounding mental health. Feeling the pressures associated with a major figure in our lives routinely disappearing, we had to uphold the image of being the “perfect family.” My mother would make up excuses to friends, explaining that that he was on a work trip, or that he was visiting family on an unplanned visit. We knew not to ask where he was, and there would be a heavy silence over us for the duration of his stays. When he would come back, he would never talk about where he was: everything would always just return to normal.

Our family would throw parties or we would go out together, doing all the things "normal" families would do while ignoring the very thing that made us so, so abnormal. This lack of communication definitely excarcerbated the pain we felt during his episodes, and allowed that pain to continue without any deep relief. At that time, we could never be open about his illness without tarnishing our family’s image, and we were even deterred30 from talking about it within the confines of our own household.

Fig. 33 Getty Images. Lithium. Verywell Mind, About. Accessed 22 May 2019.

A lithium treatment similar to the one that Dr. Hinshaw's father would have transferred to when his diagnosis changed to bipolar disorder.

This all sounds pretty unimaginable.

What makes this even more shocking is that I don’t think my family was alone. Many people who lived with mental illnesses during the time and their families must have felt similar burdens, but didn’t feel as if they could talk about the problems that they faced.

How do you think stigma has changed over the years?

As our society becomes more aware of stigma and 22 how it affects the livelihood of so many people, I

think stigma is still very pronounced, but has become less apparent. Seeing that people do not have as pronounced stereotypes, attitudes, and discriminatory behaviors as they used to, there is a veneer31 of awareness of stigma surrounding mental illnesses. However, these prejudices are definitely still present, and these subtle yet strong and deeply-rooted discriminatory tendencies can be extremely hard to change. According to Wulf Rössler, who did a study called “The Stigma of Mental Disorders: A Millennia-Long History of Social Exclusions and Prejudices,” in a survey of respondents from 27 countries, almost 50% of people with schizophrenia reported discrimination in their personal relationships. Up to ⅔ of these people anticipated discrimination when faced with job applications (para. 10). Clearly, even though we would like to believe that we are improving stigma by talking about mental illnesses, we must do more to dispel the negative consequences of stigma. Education is not enough to dispel stereotypes: we must aid people in making the connection between the truth of mental illnesses and the people who actually have them to support the idea that these people are not necessarily unreliable or dangerous and that they should be treated the same as anyone else.

On top of being unfair, these discriminatory experiences can prove noxious32 to the mentalities of those living with mental illnesses. Self-stigma, defined as stigma against oneself resulting from the internalization of public stigma, can prevent people from seeking proper treatment for their illnesses. In my book Another Kind of Madness, I noted that without treatment, people with serious mental illnesses will witness a decrease in life expectancy by 10 to 25 years (Hinshaw 261). This is a significant reduction: it can be from 1/10 to 1/4 of a person's lifetime lost due to mistreatment of a disease.

Not only are these people prevented from having stable health and leading normal social lives, their lives aren't as full. Furthermore, they are ascribed with stereotypes that will prevent them from finding the treatment they need. Stigma is far-reaching, pervasive, and if it’s ignored, it will lead to drastic consequences.

What can be done?

It is hard to adjust deeply rooted beliefs. Historically, our nation has shown progress in such initiatives through government policies. I hearken back to the civil rights movement in the sixties: after the Civil Rights Act of 1964, our nation began to develop towards renouncing the long-held prejudices against African-Americans.

However, there was a prominent need for that movement at that time that took hold of the entire nation. To-

day, many are unaware of the severity of mental health stigma and lack of treatment for mental illnesses, and as such, any movement seeking reform will not see success.

Until the entire nation is gripped by the reality of the mental health crisis, we will not see significant progress.

Fig. 34 Another Kind of Madness Cover. MacMillan. Accessed 22 May 2019.

Besides nationwide reform, everyone can stand to be further informed about mental illness and mental health. According to Allison Crowe et al., becoming literate about mental health can actually allow a decrease in self-stigma (2). Working to erase this stigma on a personal level will allow us all to begin erasing stigma on a larger scale. There are great resources out there: the National Alliance on Mental Illness has tons of basic fact sheets about mental illnesses, my book The Mark of Shame: Stigma of Mental Illness and an Agenda for Change provides a detailed history about mental health stigma, and countless other publications are available on the internet just a few clicks away. These easily accessible resources make it easy to become more informed and to promote a general better understanding of mental health and the mental health crisis. Doing so would improve the general mental health situation across the nation and would definitely lead to positive progress.

Thank you so much for giving us your time and telling your story.

You are welcome. It is my pleasure. I hope that from hearing what I went through, indicative of what many people of my time might have experienced in their lifetimes, people can see the importance of destigmatization in today’s society.

this is

S O C I E T Y

The cover of Hinshaw's memoir explaining his childhood experiences with stigma. The picture in the background is one of Hinshaw with his father in the eighties, during Hinshaw's first year of college at Harvard.

name: address: City: State:

Order your subscription of SOCIETY today! monthly: $15.99 yearly: $129.99 (a 33% discount) Mail to: society magazine

2550 clearwater rd.

ann arbor, mi 49284

zip code: phone number: email address:

monthly yearly

Fig. 35 Honaker, Edward. Looking For Help. Edward Honaker Photographer. Accessed 22 May 2019.

mental health

STIGMA 24

How the stigmatization of mental health is demonstrated in our society

By George Ren

Imagine it’s February 26, 2018, a couple weeks after the horrific massacre that took place at Marjory Stoneman Douglas High. You are watching the news, where President Donald Trump is promulgating33 his opinion on mental illness, or the presumed cause of the shooter’s actions. You hear him declare, “We have to confront the issue and we have to discuss mental health and we have to do something about it” (Trump on Mental 00:24), showing his belated34 support for mental health inititiatives.

No kidding. Mental illness is more common than we might think: approximately 1 in 5 Americans live with some mental illness, and approximately 1 in 25 Americans live with serious mental illnesses such as schizophrenia, major depression, and severe bipolar disorder. However, of these people, over half do not receive any treatment for their illnesses (“Mental Illness” para. 4-7). With drastic consequences such as increased suicide rates, gun violence, homelessness, and substance abuse problems, lack of mental health treatment has been causing a “mental health crisis” that is shocking the nation.

What is the cause of such disparity of mental health treatment? The most obvious reason is accessibility of care: even though everyone should have some sort

psychiatrist, rigth?), but it is a much more nuanced issue than one might perceive. Each individual internalizes instances - big or small - of public discrimination against the mentally ill, leaving these individuals to form their own unshakeable fears of what might happen to them if they seek treatment.

Stigma on a micro-level is simply the beginning of our problem: it is also prevalent throughout our entire society, impeding any progress towards improving the mental health crisis. In general, our society has developed certain stereotypes, attitudes, and discriminatory behaviors against those living with mental illnesses apparent in our media every day. Causing intense feelings of inferiority, these ideas and connotations belittle those from living with mental illnesses and saturate every aspect of their lives.

Many would argue that stigma has substantially improved throughout the past few decades. Even though mental health stigma is no longer obvious, it is still there - and it may even be worse. By thoroughly examining our society’s common ideas, we can see how our fundamental beliefs clearly influence our behaviors and continue to uphold the concept of stigma, even if it may be quietly. In the movies, you see stereotypical “crazy people” depicted as villains who ravage the world. In the

perceptions people

Fig. 36 Paint Brush PNG Transparent. SCCPRE. Accessed 27 May 2019.

of health insurance plan, not all plans equally cover physical/surgical and mental health services. However, another major hidden factor that may be harder to ameliorate is self-stigma. According to Allison Crowe et. al, self-stigma is defined as beliefs about oneself resulting from the internalization of public stereotypes surrounding mental health (1). Quite often, this stigma, deeply rooted and hard to change or remove, can prevent a person from seeking treatment because there may be an inability to recognize symptoms in oneself due to lack of knowledge, internal denial of any problem, or simply fear of judgement from others. This self-prevention from receiving treatment seems like it should be an easy fix (all it takes is to tell the person that they need to go see a

press, real-life tragedies caused by a few people living with mental illnesses perpetuate ideas that everyone living with mental illnesses is prone to such erratic behaviors. In the actions of the leaders our society, we can see constant suggestions that people living with mental illnesses are unreliable, unpredictable, or even unable to live on their own.

Of course, such instances of blatant discrimination have decreased over time. In fact, a general awareness of the truth of mental health has risen: now we see movies about people living with mental illness who live normal lives and celebrities and advocates speak up for mental health awareness. By educating the public, these 25

people have been able to dispel some discriminatory behaviors, but in other ways, this has made our deeply rooted discrimination against people living with mental illnesses more obvious. Employers still see mental illness as an uncontrollable, variable disability, families don't understand how to help their relatives, and people still react to the mentally ill according to their deeply ingrained beliefs about mental illness.

You can even see the concept of stigma in our colloquial language. For example, it is normal to hear someone call another person a “psycho.” Here, people unwittingly ascribe the quality of violent, nonsensical unreliability to other people. Unfortunately, they do so by calling upon the public image of “crazy people” as people who do and say things that “normal” people would absolutely never do. These images are upheld because we have conditioned over time to think of "crazy people" as the homeless unable to find jobs, as the alcoholics who constantly act out, and as the criminals who fill up our jails. When we think of “crazy people”, why don’t we think of our friends and family members who live with mental illnesses? Typically, people who have access to treatment and can afford it are able to “hide” their mental illnesses.

Because they are treated for their disease (much like how any other physical disease would be treated), they do not display the symptoms that more vilified “crazy people” exhibit and refute35 the imagery commonly associated with mental illnesses. Most people who receive treatment choose not to publicly acknowledge their illnesses due to public stigma and the negative feedback they would probably receive. Conversely, the characteristically “crazy people” who we consider the worst of the people in our society, would probably not display such erratic behavior if they could access treatment.

Simple displays of stigma in our everyday language clearly show the inherent view that people living with mental illnesses as a threat to society. Even President Trump, the most important representative of our nation, displays how negligent36 he is: he claimed that because the mentally unstable can’t really be locked up, they must be institutionalized so that they may receive some help (Trump on Mental 00:40-00:48). Although Trump is simply trying to find a solution to the mental health crisis in the face of shocking events revealing the breadth of the consequences due to lack of successful treatments, his comments exhibit common discriminatory beliefs.

By suggesting that the only solution is some form of isolation (with an emphasis that institutionalization is less advantageous than incarceration), Trump 26 implies that people living with mental illnesses

Fig. 37 White Paint Brush Stroke (PNG). OnlyGFX. Accessed 28 May 2019.

Shevchenko, Yuri. serious. Pinterest. Accessed 28 May 2019.

cannot and should not live on their own and that allowing them to live on their own is threatening to society. Instead of indicating that an improvement of our understanding of their illnesses is necessary, Trump suggests that we should shove these people into facilities that will prevent them from acting out. Shouldn't we be looking for preemptive supportive measures that would ensure something horrible wouldn't happen in the first place? Shouldn’t they be treated as if they haven’t innately done anything wrong? Shouldn’t we focus on finding better sources of treatment instead of looking to institutionalize?

are being explored further. This way, when people living with mental illnesses find their symptoms persisting even when they use traditional treatment methods, they will be able to turn to alternative methods that may improve their quality of life and ease their deserved integration into society.

The biomedicalization of mental illnesses justifies the idea that people living with mental illnesses are unable to control their symptoms and therefore not to be discriminated against. Therefore, it would make sense that if people had greater mental health literacy and understood the uncontrollable medical nature of How would you perceive someone if they told you these diseases, mental health stigma would decrease. they have hypertension or diabetes? How would that In several meta-analyses, Kvaale et. al support this by perception change if this person instead had depression, showing that biogenetic explanations cause a decrease schizophrenia, or bipolar disorder? Many fundamentally in blaming people for their diseases. However, they believe that people with mental illnesses are unreliable also show that with this decrease in blame, there is and prone to erratic behavior, and therefore should be also an increase in pessimism towards mental illnesses.

Additionally, they found that biogenetic explanations "she's a psycho" "so unreliable" "unsafe" perpetuate stereotypes that "they need to be locked up" people living with mental "weird" "he can't think properly" "can't be helped" illnesses are dangerous to "absolutely crazy" society (782). This shows Fig. 38 that indefinable blue. Pinterest. Accessed 28 May 2019. that educating people about prevented from taking leadership roles in society or that the truth of mental illnesses improves some aspects of these people might be avoided in general. These common stigma but also comes with a detrimental promotion of attitudes and perceptions certainly affect the livelihoods other stigmatized beliefs. This explains why the work of people living with mental illnesses. Unable to their that has been done over the past few years to educate conditions because of fear of losing a job, weakening and raise awareness about mental illness has led to some a relationship, or distancing a friend, these people live improvements yet also allowed other problems to persist. in constant fear and insecurity. To me, it seems unfair that these people should have to go through their lives Educating people about the true nature of mental illness constantly feeling as if they are inferior to others simply is necessary for accurate self-diagnoses and for a better because of a state of their mind. understanding of what our friends, colleagues, and family members are going through. However, because These people are not choosing to be unreliable or violent: mental health literacy may in reality propagate38 stigma, there is a proven biological change in their physiology we must try even harder to dispel the stereotypes that that causes them to be unable to function, much like impede the proper inclusion of people living with any other traditional chronic physical disease. However, mental illnesses in our society. In order to do so, we psychiatrists and psychologists have struggled to find must increase mental health literacy, encourage mental successful treatment methods because of the individual health advocates to exemplify destigmatized ideals, and nature of mental illness. Traditionally, people have address stigma at its core to help people realize the issue believed mental illness to be either completely biological and begin the process of destigmatizing their mindsets. or completely psychosocial. However, current research These steps are necessary to rethink the way we think shows that a combination of biological and psycho-social about mental illnesses and ultimately improve the lives factors can create a situation of mental illness, of which of people living with mental illnesses who have long been each individual has a unique manifestation. With the facing prejudice. It may be hard to abjure39 our long expansion of genetic research, which is becoming much held notions about mental illnesses, but it is absolutely more accessible37 with the increase in computational necessary to show any progress towards improving 27 power, individualized treatments for mental illnesses the mental health crisis.

ou r of

the state

Why affordable, accessible health care is vital for improving the mental health crisis

By Anne Baker

In our nation, it is a fundamental belief that each citizen is entitled to life, liberty, and the pursuit of happiness. How is it, then, that some of our citizens are not guaranteed these rights? Unlike in other countries around the globe, where welfare programs provide many necessities to every citizen, basic health care is not assured for all American citizens. This lack of protection of life, one of the accepted natural rights, also greatly impacts the current mental health crisis.

According to the Substance Abuse and Mental Health Administration, the leading reason why people are not receiving mental health treatment is that they are unable to afford health care (“Slides Based on the 2017 NSDUH Annual National Report� 76). This lack of accessible care clearly leads to an exacerbation of the mental health crisis as people are unable to purchase the mental health care they need in order to ensure some stability in their lives. This crisis leads to an increase of stigmatization that prevents people living with mental illnesses from living full lives while also causing a variety of problems that affect everyone in the nation such as increased gun violence, substance abuse disorders, and homelessness. In order to improve the current lack of health care, the clear solution is to ensure affordable, accessible health care for everyone in our country.

In the United States, the cost of health care itself has traditionally been extremely high. Simply going to the doctor's office for a routine checkup can incur a high cost, and the cost of an accidental trip to the Emergency Room is a root cause of many, many headaches. One of the only ways to alleviate the stress of paying health care costs out of pocket is to pay for health insurance, or plans intended to bring down the cost per service for consumers. On the individual market, or when health care is sold by private companies and not through the government, health insurance can be extremely expensive.

28

Fig. 39 Heart Beat PNG HD. PlusPNG.com. Accessed 28 May 2019.

health care

Before President Obama was elected, the government only offered affordable, accessible health care plans to people living far under poverty line through the Medicaid program. If people did not live close to the poverty line, they would have to purchase expensive individual market plans, causing some people to avoid purchasing insurance altogether, trying their luck and hoping that they wouldn't incur any medical costs. However, the people who neglected to purchase health insurance may have found themselves stuck in a rut if they ran into unplanned medical costs. This situation would become even more detrimental if these bills added up and people were unable to pay. In the early 21st century, it was estimated that more than half of all personal bankruptcies resulted from medical debt (Fox and Kongstvedt 26). These incurred expenses absolutely overwhelmed people financially, leaving no room for other necessities and worsening the economy through lost productivity and a lack of consumerism. Years of living with this vexing40, unconnected health care system inured41 some to its detriments. However, many others who were disillusioned with the health care situation chided42 our government for their lack of intervention, stimulating debate over how the government could improve this health care system that was undermining basic stability in the lives of our citizens.

what changed?

In 2008, the Obama Administration sought to answer this question through their Affordable Care Act (also known as Obamacare, pictured right). This was an ingenious43, comprehensive law that completely overhauled our health care system of the time. Among many reforms, perhaps the most outstanding was the individual mandate, which stated that every citizen must purchase some form of health insurance. Some people could continue to purchase their plans off the individual market, but the government also began to offer less comprehensive yet more affordable plans. As not everyone could afford even these less expensive plans, the ACA also expanded the programs of Medicare and Medicaid to provide care for both the elderly and for those living under the poverty line. Although some people were outraged that they were being forced to pay into the health care system with little flexibility, others were finally able to purchase insurance for the first time, allowing greater accessibility of treatment.

Because of Obamacare, many people who were previously uninsured are now able to get the treatment they need to live stable lives. In fact, the number of Americans living without health insurance is the lowest on record (Johnson, “What ACA Repeal Could Mean� para. 8), showing how Obamacare is making a clear positive impact by increasing accessibility of affordable health care to the American people. With more people on health care plans, the more agencies can pay for treatments.

Furthermore, the likelihood of medically-related bankruptcies will decrease. Previously, when our government assumed a laissez-faire attitude towards health insurance and health care by allowing citizens to purchase their own insurance off the private market, it was clear that this would lead to insufficient health care coverage for our people. This shows that the individual mandate and

Fig. 40 Doctor Symbol Cadeceus. FreePNGImg. Accessed 28 May 2019.

government regulated insurance are necessary for people to be able to afford care and gain security of health.

The strides we have made in improving accessibility and affordability of health care have been especially helpful in improving the mental health crisis: through the expansion of Medicaid and Medicare, we have in turn expanded accessibility of mental health care. Because Medicaid and Medicare are the largest payers of mental health services (Howard para. 7), they are vital to providing treatment to the poorest sectors of our citizenry who live with mental illnesses. Expansion of Medicaid and Medicare in Obamacare, therefore, led to a connected increase in mental health treatment for those who truly needed it. In turn, this treatment could allow these people the stability to start improving other aspects of their lives. For example, a person recently able to afford insurance and get medication for their bipolar disorder would be able to go to school or dive into the workforce, allowing them to realize their previously untapped working potential and improving the economy by increasing our national productivity.

The number of people living without health insurance may be the lowest on record, but we still have to protect the strides we have made in providing health care for all citizens and even work to further bridge that gap and continue to strive to provide basic health insurance to everyone. People who are unable to afford health care deserve the security of life through good health that insurance could provide. We must do what we can to provide affordable, accessible health care to everyone by covering the basic health necessities that everyone requires.

Without this security, people could drown in medical debt, preventing our entire nation from fulfilling 29 our greatest potentional in all other walks of life.

10

14

3

6

5

4

2

11

13

9

12

7

1

8

By Jennifer Chung Think you know mental illness?

Find out here‌

testing your knowledge

30

across

down

ONE: This is a researcher who, along with her colleagues, found that with an increase in mental health literacy there is a corresponding decrease in self-stigma (Crowe et al. 6).

ONE: This is a type of stigma that results from the transference of stigma from an already stigmatized people to the people who they share professional or familial relationships with (Rössler para. 20).

FOUR: This is the equality of treatment of traditional physical illnesses and mental illnesses (Schwartz 60).

TWO: One in this many Americans lived with some mental illness in 2016 (“Mental Illness” para. 5).

SEVEN: This is the president who advocated for comprehensive community mental health care treatment in the sixties (Schwartz 24).

THREE: Through bad health habits, risky behaviors, an increased pronesses to physical diseases, low access to health care, and self-destruction, serious mental illness can reduce life expectancy by up to this many years (Hinshaw, "Another Kind of Madness" 261).

9. Arkansas

8. decade

6. self stigma

5. five hundred

4. Parkland

3. twenty five

2. five

1. courtesy

NINE: The first state to implement a policy that takes away Medicaid from people not working a specified amount of hours each week, even if they are unable to prove their inability to function (“Taking Away” para. 3).

DOWN

10. mental health literacy

4. parity

1. Crowe

ANSWERS:

ACROSS

How did you do?

7. Kennedy

FOURTEEN: As of right now, 27% of adults living with serious mental illnesses are covered by this service, making it the nation’s largest payer of mental health services (“Taking Away” para. 1).

EIGHT: This is the amount of time it takes people who display symptoms of serious mental illnesses to seek treatment, mostly due to stigma surrounding the topic (Hinshaw, "Another Kind of Madness" 261).

14. Medicaid

THIRTEEN: This is the president who worked to enact the affordable care act, which provided greater access of health care for many Americans and includes mandating the benefits of mental illness and substance abuse treatment (Johnson, "What ACA Repeal" 1).

SIX: Resulting from the internalization of public stigma surrounding mental health, this is the stigma against oneself that leads to a lack of self-confidence or prevents one from seeking help (Crowe et al. 1).

13. Obama

TWELVE: As the champion of the anti-psychiatry movement, this psychiatrist argued that mental illnesses are not real (Poulsen para. 3).

FIVE: Trump’s 2019 fiscal year budget reduces funding for Medicare by this many billion dollars (Howard para.

6).

12. Szasz

ELEVEN: This is the president who promised to reduce government spending, leading to major cuts to domestic programs including mental health initiatives such as the National Institute of Mental Health and Community Mental Health Centers (Schwartz 42).

FOUR: The place at which nikolas cruz, who suffered from mental illness, initiated a mass shooting that has sparked conversations surrounding our broken mental health system (Larson para. 2).

11. Raegan

TEN: This is the knowledge of mental disorders that can aid proper management of illnesses which leads to better health outcomes, lower costs, less disparity between groups being treated, and an overall decreased mortality rate of the older population (Crowe et al. 2).

31

problem

Fig. 41 Healthcare Balance of Scales. IconArchive. Accessed 23 May 2019.

the How health care reform is necessary for the treatment of mental health

By Willis Casa

The prevalence of mental health in our nation is greater than many perceive it to be, yet somehow, many people living with mental illnesses do not receive adequate treatment. In 2017, the Substance Abuse and Mental Health Services Administration (SAMHSA) issued their report of the state of our nation, finding that 46.6 million adults, or 18.9% of all American adults, were living with some mental illnesses (SAMHSA 47).

However, of these people, over 40% had a “perceived unmet need for mental health services” (SAMHSA 5).

This shows how our nation is in the middle of a mental health crisis: even though almost one fifth of our nation lives with mental illnesses, we fail to treat a sizeable portion of this population. These people are unable to go to work, unable to interact with friends, and unable to lead normal lives without succumbing to the symptoms of their untreated diseases. Something must be done to alleviate this problem, but what? In order to understand what we can do to improve, we must first examine the whole nature of the issue of lack of care itself.

Many believe that a lack of accessibility to health 32 care is the main reason for this wide treatment gap.

However, because of the Affordable Care Act of 2010, every American should have access to coverage that would allow them to meet their mental health treatment needs. As it is indicative of a lack of sucess of the ACA, the current statistics that display the prevalence of mental illnesses and the persisting lack of treatment cause many people to accuse the ACA of being useless, inconvenient, and unnecessary. However, according to Steven Ross Johnson, a mental health advocate and journalist, the number of people with health care insurance is the lowest on record (“What ACA Repeal Could Mean” para. 8), showing that a lack of health care is actually not the root cause of a lack of mental health treatment. If the majority of people in our nation are insured, shouldn’t they therefore have access to the mental health services that they need? Why does the treatment gap persist?

Besides the provision of health insurance, where can we look to discover inequity of care?

To answer these questions, we must look beyond the idea of whether or not people have health care to the actual provision of health care itself. Many health care plans do not provide equal coverage for mental and physical

health. In 2008, the Mental Health Parity and Addiction Equity Act sought to ameliorate this problem by requiring plans to uphold the concept of parity, or equal treatment. Even though a decade has passed, however, many health care plans continue to violate parity requirements with few checks. National enforcement is difficult as states are allowed to address enforcement of parity independently, yielding a disparity of the upholding of the concept of parity.

Because each state has a different ambiguous definition of parity, health insurance agencies are not always required to uphold a specific standard of parity. Although many have implemented some reforms within their companies to yield to parity laws, these companies face internal issues that prevent them from providing treatment. For example, there are “differences in how health plans enact utilization management and how they define medical necessity, separate deductibles and co-pays for mental and medical healthcare, limited behavioral healthcare services offered within their provider networks, and lower reimbursement for behavioral healthcare providers” (Johnson, “Mental Health Parity Remains a Challenge” para. 9). This variety of issues undermines health insurance agencies' ability to provide equal treatment of mental and physical illnesses. Each of these issues represents a hurdle to be faced in the journey to achieve mental health parity. Let’s examine each of these issues in depth:

SEPARATE DEDUCTIBLES AND COPAYS Health care providers have long considered medical and mental health care to be separate entities. This is perhaps most evident when examining the most fundamental interaction between patient and provider: the payment of deductibles and co-pays.

Most health insurance providers separate the payment of mental health and traditional health care, exhibiting the generally held idea that the two types of health care should be separate and allowing people to continue their belief that mental health care is less necessary than traditional health care.

UTILIZATION MANAGEMENT / MEDICAL NECESSITY In order to reduce “unnecessary” costs, many health care providers have guidelines in place that allow them to assess the medical necessity of treatments and guide patient’s decision-making based off of these evaluations. This process is called utilization management: providers are managing the utilization of their services. For more traditional physical treatments, these guidelines have been developed over a long period and are generally standardized from provider to provider. However, because mental health treatment is not fully understood and has a highly individualized nature, guidelines for utilization management in this sector of healthcare are more ambiguous and vary from provider to provider.

LIMITED BEHAVIORAL HEALTHCARE Health insurance agencies contract medical services through health care providers, LOWER REIMBURSEMENT FOR who typically provide limited behavioral BEHAVIORAL HEALTHCARE SERVICES healthcare services. By switching providers, Because many health insurance these agencies could search for hospitals plans provide lower reimbursement and other providers that would provide for behavioral healthcare services, a greater variety of behavioral health providers tend to offer limited services. However, this does not make sense f r o m behavioral healthcare services. Without a business standpoint: health insurance companies compensation similar to traditional have established long-standing relationships with the treatments, health care providers have less incentive providers who serve their customers. In this regard, the to provide a greater amount of behavioral healthcare health care providers themselves must reform the types services for the general population. of health care they provide to their patients.

Why have these problems arisen despite national parity laws? Clearly, a lack of regulation and standardization has caused major differences between health care agencies across the nation. The idea of true parity has been lost.

Because allowing states to enforce parity laws as they see fit has not brought an equality of mental and traditional health care, we must standardize mental health care standards for health insurance providers across the nation and provide sufficient enforcement to hold these agencies accountable. Without it, problems associated with a lack of mental health parity will continue to persist: agencies will continue to provide unequal treatment due to precedent, and people will continue to lack the health care they need.

33

Fig. 42 Honaker, Edward. Looking For Help. Edward Honaker Photographer. Accessed 22 May 2019.

"i'm just tired." stop the stigma.

learn what illness looks like, and help your loved ones get better. (crowe 2) visit stopthestigma.org for more information

THE

O F F A

E L B A RD

E AC

CA R

T

in action

Fig. 43 Crowd PNG. Pixabay. Accessed 28 May 2019.

Round Table Moderated By Anne Baker How repealing Obamacare could affect mental health in America

35

allison crowe, ph.d.

Associate Professor and Counselor Education Program Coordinator

Mental Health America Advocacy Manager

Public Health Journalist

Fig. 48 Bruce Poulsen. Twitter. Accessed 14 Apr. 2019.

Fig. 47 Steven Ross Johnson. Modern Healthcare, Crain Communications. Accessed 14 Apr. 2019.

Fig. 46 Caren Howard. Mental Health America. Accessed 14 Apr. 2019.

caren howard

steven ross johnson

bruce poulsen, ph.d.

Teacher at the University of Utah School of Medicine

stephen p. hinshaw, ph.d.

Psychologist specializing in Devleopmental Psychology

36

Fig. 45 Allison Crowe. VIVO, East Carolina University. Accessed 14 Apr. 2019.

Representative of the Heritage Foundation

Fig. 49 Stephen Hinshaw. Bring Change to Mind. Accessed 4 Mar. 2019.

Fig. 44 Tamara Thompson. Tamara Thompson. Accessed 14 Apr. 2019.

tamara thompson

Baker Good morning. Thank you all for being here. Today, I would like to explore the topic of mental health care, specifically in the context of “Obamacare”. Nine years ago, the Affordable Care Act was enacted with the most comprehensive reforms to the American healthcare system since Medicaid and Medicare were first implemented.

Today, these reforms have significantly improved health care accessibility, yet there are still many problems that must be addressed. For example, many Americans continue to fail to receive mental health care services, causing a “mental health crisis” that is quaking the nation.

Ms. Howard, your job as a mental health advocate has allowed you to advise many government officials in mental health policy over the course of the past few years. What are your thoughts on our current situation?

Howard: Well, in President Trump’s 2019 Fiscal year Budget, he has revealed his Administration’s priorities for the remainder of his term. To some degree, he is following through with his previous declarations of support for mental health: over the course of next five years, $10 billion will be allocated to combat both the opioid epidemic and serious mental illnesses (Howard para. 7). This allocation, though not specifically directed, shows some alleged support for the mental health crisis. Likely a response to nationwide pressure, Trump is demonstrating some interest in improving the mental health crisis.

However, Trump does not follow through on this promise as he also promises to reduce Medicaid by $1.4 trillion, Medicare by $500 billion, and Social Security Disability Insurance by $10 billion over the course of the next ten years (Howard para. 9).

The much greater magnitude of the detraction of health support than the enlargement of mental health spending show Trump’s true intentions: in his attempt to decrease federal spending he is largely neglecting the needs that are rising from the mental health crisis. It is possible that his Administration could even attempt to repeal the Affordable Care Act (ACA), which expanded eligibility and funding for Medicare and Medicaid and ensured health care protection to citizens across the nation. Currently, these programs pay for more behavioral services than health insurance companies or individual patients themselves.

Therefore, a reduction in funding or an annulment of the ACA could lead to a loss of coverage for countless people across the nation and a subsequent worsening of the mental health crisis.

Thompson: Ms. Howard, the ACA is not doing anything to improve the mental health crisis: in 2016, 6 years after Obamacare was passed, the prevalence of mental illnesses among U.S. adults was 18.3% (or roughly 1 in 5 Americans), but only 43.1% of people living with such mental illnesses received treatment (“Mental Illness” para. 5-6). This means that more than half of people living with mental illnesses failed to receive any treatment at all, despite the alleged success of Obamacare. While it fails to achieve the goals of improving the lack of mental health treatment, the ACA actually constricts the health care sector and subjugates44 American families by forcing them to pay into a system that they do not want to participate in. Furthermore, expansion of Medicare and Medicaid puts further pressure on the citizenry through an increase in taxes and government spending in a sect of the economy that the people don’t support. A free market would allow

more people to buy into coverage that they want, and mental health parity laws will ensure that this coverage will include equal protection of mental and physical health.

Howard: Let’s not be penurious45, Ms. Thompson. We had a free market without collectivized health care in the decades before Obamacare: it led to notorious46 high insurance rates and a mass of the population who couldn’t even receive basic health care. If a system is not working for so long, we must do something to change it. Obamacare was the right solution we needed to make a positive impact at that time. Without it, how would families have been able to afford health insurance needed to cover basic health needs?

Thompson: Buying health insurance off the individual market can be expensive, but that is not the only option for people to buy affordable insurance. Many employers provide more affordable health insurance as a part of their employee benefits.

Howard: That is true, but not all employers provide such insurance, not all of these plans cover the same treatments, and not all people are employed and would have access to such coverage. Employer-dependent accessibility of health insurance differs from employer to employer, so not all people are afforded the same opportunities of coverage. Everyone in the country deserves a chance to receive comprehensive coverage, and the only way we can do that is through standardizing care through the government. We have already made great strides: ten years after the implementation of the Affordable Care Act, the number of Americans without health insurance is the lowest on record ever (Johnson, “What ACA Repeal Could Mean” para. 8). This must be because, 37

as you mentioned earlier, the ACA enacted such sweeping reforms in the way our nation does health care: plans are more affordable and accessible to those who truly need it, and people are able to enjoy their natural rights of health. Although you may not enjoy the higher tax rate, think of the innumerable people who can now receive affordable care and are as a result physically more capable of going to work and boosting the economy. Furthermore, the law does not “force” families to pay into the system, instead, it ensures that families have the protection they need that will prevent bankruptcy due to medical expenses.

Baker: Mr. Johnson, you have been reporting on mental health issues for many years. Do you think that the ACA is improving the current lack of mental health treatment, or worsening it?

care. Although some obvious disparities were addressed, there is still a clear difference across the nation between the availability of behavioral mental health services and traditional health care. At its core, this problem stems from the limitations of health care plans themselves in providing mental health services as opposed to the accessibility of health insurance itself. For example, health care agencies typically use different utilization management plans

ferent health insurance companies, it wouldn't make sense to change one's business model without others changing as well. For many Americans seeking mental health care treatment, this meant that they possibly had to seek treatment outside of the health insurance network on the individual market. According to a 2017 report by actuarial firm Milliman, although out-of-network providers offered only 6% of all medical/ surgical care in the country, they provided upwards of 32% of behavioral outpatient care (Johnson, “Mental Health Parity Remains a Challenge” para. 10).

Out-of-network providers only compose of a small portion for health care for most types of treatments, but since most health care plans do not cover mental health treatments, outof-network providers are able to gain a significantly larger amount of customers. This signifies a great problem: the most accessible way for people to receive treatment was outside of their health care plans, which most likely meant exceedingly high prices for medically necessary services.

Although Obamacare was a necessary step towards providing mental health treatment for everyone, we must make that step more effective by enforcing parity laws.

"there is an obvious inequality between the way we provide mental health treatment and traditional physical or surgical treatment"

Johnson: The Affordable Care Act took the first step in solving the deficiency of mental health treatment: some people were finally able to purchase health insurance plans for the first time, and if their plans covered it, this would allow them access to behavioral health services. However, this great stride made it clear that the real underlying reason why there is still such a lack of mental health treatment is because there is an obvious inequality between the way we provide mental health treatment and traditional physical or surgical treatment. In an attempt to ameliorate this situation, Congress enacted the Mental Health Parity and Addiction Equity Act in 2008 to mandate “parity,” or 38 equality of treatment, in health

to assess47 the necessity of mental and physical health services. Additionally, the health care providers themselves may offer limited behavioral mental health services in their contracts (Johnson, "Mental Health Parity Remains a Challenge" para.

9). Because it is difficult to standardize equality of care within their own institutions and across states, these limitations prevent health care agencies from providing true equality of care within their plans. As there is an unspoken standard between dif-

Baker: Dr. Poulsen, what are your thoughts on the disparity of treatment?

Poulsen: For many years now I have been wondering if such a great degree of attention to mental health reform is necessary. During the

sixties, the influential psychiatrist Thomas Szasz argued that mental illnesses are, in fact, not real (Poulsen para. 3). Instead, he believed that in our attempt to categorize our natural problems as diseases, our society in reality might just be trying to medicate the human condition of feeling struggles. Although Szasz has been proven wrong by modern science, his ideas are still worth consideration… We shouldn’t mistake medicine for magic. As mental health care is expanding, more psychopharmacological treatments become available, and our definitions of mental illnesses themselves are broadening and adapting, the issue of medicalizing natural feelings expands as well.

I believe that instead of focusing so much on potentially superfluous48 traditional treatment for mental health conditions, we can make an impact on the lives of people living with mental illnesses by introducing vital lifestyle improvements such as better exercise, eating habits, and stress coping mechanisms.

Baker: Dr. Hinshaw, I believe your years of research have contributed to a greater understanding of the biological nature of mental illnesses.

What do you think of the idea that we are medicalizing human nature?

Hinshaw: Well, there’s no mistaking the fact that mental health is complicated. There are a myriad49 of factors that can contribute to a person developing a mental illness.

Definitely, as Poulsen describes, traumatic events which may be a part of the “human condition” play a role. However, the effect these traumatic events go further than simply promoting negative thoughts. In fact, traumatic events cause a phys-

iological response: our biochemistry actually may change. In people with genetic dispositions to mental illnesses, this response may be so profound that the macromolecules can actually fundamentally and physically alter people’s mental functioning (Hinshaw, "Another Kind of Madness" 263). Through years of research, I have found that mental illnesses are in fact best treated when there is a combination of psychotherapy or social support and medicine. Because of its complexity and highly individualized nature, we are still determining the best methods of treatment, but right now it seems the best course of action is to combine treatments for comprehensive care.

At times, treatment plans (which should be individualized for patients due to the highly individual nature of mental illness) might be more comprehensive than treatments for most traditional physical ailments.

This indicates that we must place great emphasis on ensuring treatment availability and accessibility to all Americans, and that this will be more difficicult financially than covering traditional physical treatments.

Without Obamacare as it is today, we would see a great decline in the percentage of Americans covered and a result, a decline in the amount of Americans who could even afford such comprehensive treatment.

Baker: Dr. Crowe, how has your recent research affected your opinion on mental health care?

Crowe: My research has allowed me to realize that another problem which prevents many from receiving treatment is the fact that health care services are extremely fragmented.

Integrated care, or the inclusion of

mental health services in primary care, would improve accessibility for everyone. If primary care providers were trained to diagnose mental conditions and people would be able to receive recommendations for further care, many nominal50 steps that could prevent people receiving treatment are eliminated. Furthermore, this would give primary care providers the chance to treat co-occurring chronic physical and mental conditions. Although currently primary care visits are meant to solely treat physical conditions, underlying psychological issues are involved in more than 70% of primary care visits and 68% of American adults who have mental conditions also have physical conditions that would have brought them into the primary care center (Crowe et al. para. 9).

This shows a fundamental reason for a lack of treatment: people who go to their primary care doctors with issues that are directly related to mental illness are not able to articulate and identify their issue, and unfortunately, neither can their doctor who is untrained to do so. Therefore, there must be a great excacerbation of symptoms until a mental illness is more identifiable and people go to the proper physician to find treatment. Additionally, physical conditions can cause mental conditions and vice versa, so each treatment would provide benefits that reciprocate51 the other. Obamacare has prompted the development of integration by ensuring access to both primary and mental health care, but we must engender52 greater change by integrating at a more fundamental level.

Baker: Well said. Thank you all for your coridal53 argumentation.

t h a n k yo u

MENTAL HEALTH How mental illnesses are misunderstood

By Willis Casa & George Ren

"mental health issues aren’t real issues"

In 2017, the Substance Abuse and Mental Health Services Administration (SAMHSA) conducted a nationwide survey to ascertain the true nature of the mental health crisis which affects so many other aspects of our nation. From this, we learned that although approximately 1 in 5 American Adults reported living with Any Mental Illness (AMI), approximately 20% of these people had a perceived unmet need of mental health services. Furthermore, over 1 in 25 American adults reported living with a Serious Mental Illness (SMI), yet approximately 40% had a perceived unmet need of mental health services (“Slides Based on the 2017 NSDUH Annual Report” 47, 75). This clearly shows that too many people living with mental illnesses are not receiving the treatments that could allow them to live with some sense of the stability that they deserve. When left untreated, people living with mental illnesses can be driven to act out against their own will. Because of our deep-rooted negative stereotypes of people living with mental illnesses, this behavior is what we imagine when we think of the classically “crazy person” and can lead to other crises such as increased substance abuse problems, suicide rates, homelessness, and gun violence.

As a result, not only are their lives affected, but our entire nation suffers. Mental health issues are clearly widespread, affecting more people directly than most might perceive and affecting the entire nation indirectly.

40

"MENTAL ILLNESSES ARE indicative of INTELLECTUAL DISABILITY"

Mental illnesses are like any other physical illness: they constitute a fundamental alteration of the “normal” biological physiology. Instead of indicating an underlying intellectual disability, mental illnesses typically result from a chemical imbalance that prevents normal physiology (Hinshaw, "Another Kind of Madness" 260). Theoretically, a rebalancing of these chemical deficiencies should allow for homeostasis, or a stable physiological state and normal intellectual functioning. However, this idea of treatment is much more difficult than it seems: the individual nature of mental illness prevents health care providers from developing one size fits all treatments for the different ailments that we see. This has led researchers to develop a number of alternative treatments for people living with mental illnesses to try. When they work, these treatments allow these people to live normal lives, with just as good intellectual skills such as reasoning and problem solving as the general population.

"mental

Although many believe there are no effective treatments, there are actually many effective treatments available for people living with mental illnesses. For example, one may choose to utilize psychotherapy, in which a trained mental health professional explores the thoughts and feelings of a patient to see how together they can improve the patient’s well being.

Medication to help improve any symptoms a patient may experience or a support group in which a group of individuals living with mental illnesses work together to achieve a shared goal of recovery may also be useful (“Mental Health Treatments” para. 1-5).

Individuals can use any of these treatments, or even a combination of treatments to increase effectiveness, to alleviate their symptoms and improve their conditions. It is true because of the highly individualized nature of mental illnesses, not all people can find an treatment method that works for them. However, the bigger problem is that some people do not have access to these treatment methods at all. If people had greater accessibility to mental health treatment (they could afford it or they knew where to get assistance from), the number of individuals living with untreated mental illnesses would greatly decrease.

Fig. 51 People / Cartoon / Man in Suit. Tux Paint, New Breed Software. Accessed 6 Apr. 2019.

Fig. 50 Granlund, Dave. Trump Cancels His Military Parade: Political Cartoons. 17 Aug. 2018. Los Angeles Daily News, Media News Group. Accessed 6 Apr. 2019.

Padded Room. Imgur. Accessed 6 Apr. 2019.

"treatment is ineffective"

"people are born with mental illnesses"

Although people are not born with mental illnesses, they can be born with a genetic disposition towards mental illnesses. Many people can grow up without this disposition ever revealing itself and live with general mental stability. However, people who experience high levels of trauma, especially when from a young age, can experience a change in their chemical physiology that can initiate symptoms of mental illness (Hinshaw, "Another Kind of Madness" 260). Here’s how this works: when experiencing trauma, we have an increase in hormones such as cortisol and epinephrine (adrenaline) that initiate bodily states such as increased metabolism, low blood pressure, and fatty acid release (alternative energy source for the body) that allow the body to more effectively respond to the situation at hand. If a person experiences elevated levels of these types of macromolecules for a prolonged period, they may trigger the transcription of genes allow for a disposition towards mental illness. Therefore, to understand the true nature of mental illness we must account for both internal and external factors.

illneses are..."

41

people living with

mental illnesses are...

"unreliable or dangerous"

This negative stereotype of people living with mental illnesses is largely untrue for people who are able to receive treatment for their illnesses. Many of these people choose to not disclose their illnesses for fear of the pitying stare or discriminatory limitations that they might face. On the other hand, people who are unable to receive treatment are unable to prevent their symptoms from being displayed through their behavior. Therefore, the examples of people living with mental illnesses that we see in the public are extreme versions of people unable to receive treatment such as people who initiate school shootings. These images contribute to an extreme version of people living with mental illnesses that are unrepresentative of the entire population of people living with mental illnesses. Because this causes an increase in stigma, this has a circular negative effect, causing people who are able to hide their illnesses to try even harder to do so and preventing a true image of people living with mental illnesses to be developed by our society.

"seeking attention"

In the midst of stigma surrounding mental illnesses, many people feel ashamed of their symptoms or unsure if the symptoms they are experiencing qualify as a mental illness. Some people who choose to hide their illnesses are unable to find the support they need to cope living with their condition. Society urges them to fit this image of the “normal,” happy” people who do not have mental illnesses. By trying to hide their illnesses to fit this societal standard, these people have to sacrifice a part of their identity. On the other hand, some brave people living with mental illnesses choose to advocate for themselves by telling their story. As a result, they begin to destigmatize and therefore normalize mental illnesses by raising awareness and becoming role models for all those who feel unaccepted because of their illnesses. By embracing their conditions and talking about their symptoms, these people can also find personal support and can be more true to their personal identity. Instead of “seeking attention,” these people are seeking the help and support that they deserve.

"incapable of success in the workplace"

Our negative stereotypes surrounding mental illnesses, such as the idea that people living with mental illnesses are unreliable or dangerous, can lead some people to believe that these people can never be productive and therefore should be prevented from high-level jobs. However, the this could not be more untrue: many highly successful people are open about living with mental illnesses. Beloved by our society, successful leaders such as Carrie Fisher, Stephen King, Howie Mandel, Drew Barrymore, Paula Deen, and Michael Phelps have all opened up about living with mental illnesses (Rowlands para.

5-16). As successful actors, authors, personalities, and athletes, these people clearly display that mental illnesses do not have to be a hindrance to one’s work.

In fact, despite the challenges they faced that came with living with their mental illnesses, they all had such a passion for the things they love to do that they were able to work through them and achieve to this high standard. In doing so, and in being open about living with mental illnesses, these people also serve as role models for the entire nation in their drive to destigmatize mental illnesses.

"unwilling to get better"

People living with mental illnesses want to find treatment, but most of the time, they do not know how. According to SAMHSA, over 50% of adults living with Serious Mental Illness (SMI) could not afford the cost of their treatment, and over 30% did not know where to go for services (“Slides Based on 2017 NSDUH Annual Report” 76). This shows that the leading problems preventing mental health treatment accessibility are completely out of the control of the patients themselves. Instead of blaming people living with mental illnesses, we should look to the problems in our own system to see where we can improve their situation.

Fig. 52 & Company, Declan. Generic Drugs. New York Times. Accessed 28 May 2019.

Stuck in a cycle of endless perscriptions with no improvement?

You don't have to roll the dice for good health.

Fig. 53 Mental Health Stigma. Michigan Health Lab, Regents of the U of Michigan. Accessed 23 May 2019.

Talk to your doctor about your options today. ("Mental Health Treatments" para. 1)

stop the stigma have a conversation today www.stopthestigma.org

(rรถssler 9)

43

How our seemingly stoic54 government offices may be deceiving us

By Rosalind Rale

Our country is currently teetering at the precipice55 of a potentially disastrous situation: our federal debt owed by our government has accumulated to trillions of dollars1. This is because over the course of the past few decades, government expenditures have increased greatly. Our federal budget is dedicated to two major payments that have become even more expansive over time: our military and social welfare programs. With an increase in international tensions, we have injected more money into our military programs. Additional44 ly, our nation's popula-

1 The federal debt is the amount of money that our country owes to its creditors due to spending of borrowed money. Not only do we owe money, but each year that the federal debt persists we have to pay bigger and bigger interest payments.

2 Mandatory spending includes social welfare spending such as that on Social Security, Medicare, and Medicaid. All other spending is considered Discretionary spending, of which the biggest program is defense spending (“A Budget for a Better America� 109). Mandatory spending, of course, is unable to be changed: we cannot simply stop spending on social welfare programs which are promised to our people. On the other hand, Discretionary spending is more flexible and can be changed.

tion is aging: a lager number of older individuals need Social Security and Medicare.

Indicating that we will not see a decrease in major mandatory expenditures anytime soon, this situation becomes especially concerning as we plunge further and further in federal debt2. With the growing federal debt looming over our heads, it is clear to everyone that we must prioritize our discretionary spending in order to lessen deficit spending, reduce debt, and avoid bankruptcy.

However, is our current administration moving in the right direction?

Fig. 54 Morigi, Paul. Trump. Fortune. Accessed 28 May 2019.

federal budget: room for expansion of health care?

RECEIPTS OUTLAYS DEFICIT

6000

4000

0

2018

2020

2022

2024

2026

2028

BUDGET TOTALS AS A PERCENT OF GDP AS PROMISED BY THE TRUMP ADMINISTRATION 25

RECEIPTS OUTLAYS

20

(“A Budget for a Better America” 111)

15

10

DEFICIT

Fig. 56 Bhatt, Priya. Budget Totals as a Percent of GDP as Promised by the Trump Administration. Google Docs. Accessed 26 May 2019.

2000

Fig. 55 Bhatt, Priya. Budget Totals (In Billions of Dollars). Google Docs. Accessed 26 May 2019.

BUDGET TOTALS (IN BILLIONS OF DOLLARS) 8000

the gross domestic product will increase at a rate of approximately 5% a year (“A Budget for a Better America” 111). This booming increase in the gross domestic product would justify such increases in receipts and outlays: a better economy would mean more money for the American people to give to their government to pay for social welfare programs and more money to justify a gradual increase in government spending. Let’s take a look at the budget totals as a percent of GDP:

In this graph created by information drawn directly from President Trump’s 2020 Fiscal Year Budget, we can see that over the next decade, our nation may show 2018 2020 2022 2024 2026 2028 some progress in reducing deficit spending, or the excess amount of money we spend over the amount of money we take in (in this graph, it is shown as the orange line). (“A Budget for a Better America” 111) However, in order to bridge that gap in spending while also accounting for the immutable increasing cost of As a percentage of GDP, the increase in receipts does mandatory expenditures, Trump plans on increasing re- not seem that severe. Additionally, the national outlays ceipts by over $2 trillion dollars per year each3. It makes actually seem to be decreasing. This information also sense that outlays would increase to some degree due to continues to show a gradual decrease in deficit spending the aging population and resulting increase in the num- over the next decade. By only slowly increasing receipts ber of people who require social welfare benefits. How- (or taxes) on the American republic and decreasing outever, Trump’s increases in the budget do not just come lays, it seems that we will be able to reduce deficit spendfrom mandatory expenses; his budget includes major ing and stop contributing to the federal debt to such a increases in defense discretionary spending. This forces great degree. Although the federal debt at large would Trump and his administration to scramble to increase still remain, we would not be contributing to it as much taxes (receipts) to account for his increase in government as we currently are. This graph makes the Trump Adspending, even though their ministration’s plan over the previous platform has been so course of the next decade 3 Receipts are gains in money for the federal treadependent on “respecting our seem perfect: they would taxpayers” by reducing taxes sury that the government gains, mostly through be achieving the goals that taxation.

Outlays are the expenditures of this and halting the growth of the would put us on the path money that our government must make for the federal debt by reducing defito saving our nation from maintenance of our nation ("A Budget For a Better cit spending. bankruptcy.

America" 110).

One main justification for the This graph clearly shows increase of taxes and a subsethat even when considered quent increase in Discretionary spending is the Trump as a percentage of a rapidly growing GDP that would Administration’s promise for a rapidly growing econo- reflect a booming economy, there is still a planned inmy. It would make sense that as the economy improves, crease in taxation which is contrary to Trump’s declared people’s incomes would increase and they would be conservative policy. However, compared to the graph of more capable of paying taxes. One way to measure how the budget totals not dependent on GDP, it seems an inwell the economy is doing is through the gross domes- crease in GDP that results from a booming improvement tic product, or the value of all of the goods and services of the economy would ensure that this increase in 45 purchased in a given year. According to Trump’s budget, taxes would not be that severe.

5

0

of gross domestic product as calculated by the impartial Congressional Budget Office: BUDGET TOTALS AS A PERCENTAGE OF GDP CALCULATED BY THE CONGRESSIONAL BUDGET OFFICE RECEIPTS

30

OUTLAYS DEFICITS

TRUMP ADMINISTRATION

40000

CONGRESSIONAL BUDGET OFFICE

30000

20000

10000

0

2018

2020

2022

2024

2026

2028

Fig. 57 Bhatt, Priya. Growth of the Gross Domestic Product in Billions. Google Docs. Accessed 26 May 2019.

GROWTH OF THE GROSS DOMESTIC PRODUCT IN BILLIONS

( “A Budget for a Better America” 111; United States, Congress, Congressional Budget Office 10) To be sure, it is hard to predict how gross domestic product, which is dependent on a variety of fluctuating variables, will change over the next decade. However, how could two supposedly credible institutions have such different predictions for the growth of the GDP?

On the other hand, the Trump Administration certainly has an agenda that would prompt them to boast a prediction for a booming gross domestic product. Trump display how fervent56 he is by promising that his reforms would cause the economy to grow exponentially, and the nation, more specifically the media, scrutinize his every move to see whether or not he will follow through on these promises. Therefore, it makes sense that he and his administration feel the need to justify their huge increase in taxes and lack of decrease in spending.

46 Let’s reexamine the budget totals as a percentage

10

0

2018

2020

2022

2024

2026

2028

(“A Budget for a Better America” 111; United States, Congress, Congressional Budget Office 10) When looking at the budget totals as a percentage of GDP calculated by a more reliable, impartial source, we can see that the Trump Administration’s plan to reduce deficit spending holds up: the difference between outlays and deficits seems to be closing by 2029. However, it is clear that in order to do this, receipts or taxes will be drastically increasing disproportionate to the growth of the GDP in order to offset growing outlay costs. Obviously, looking at this graph, it is clear that receipts will be increasing substantially, and it will be hard on the American people. The achievement of the goal of reducing deficit spending had to come at the expense of raising taxes on the American population, and because that is contrary to Trump’s fundamental platform, it seems that they had to make up unjustified numbers for the growth of the economy to make it seem as if this raise in taxes is not severe. To me, it is worrisome that such wily57 deceit is occurring at the federal level of government, which is meant to be the ultimate representative body of our nation.

Fig. 59 A Budget for a Better America. PBS, Newshour Productions. Accessed 26 May 2019.

The Congressional Budget Office is a nonpartisan organization commissioned by Congress to conduct analyses of our federal economic situation in order to provide information to guide legislative decisions. Especially given the current hostile domestic political climate, in which decisions can oftentimes be clouded by partisan aims, one of the CBO’s main objectives is to remain impartial and provide objective data. Therefore, their projection of the growth of the gross domestic product is not dependent on any personal objectives: they have no agenda besides providing truthful data.

20

Fig. 58 Bhatt, Priya. Budget Totals as a Percentage of GDP Calculated by the Congressional Budget Office. Google Docs.

Accessed 26 May 2019.

But is this predicted increase in GDP and discussed improvement of the economy truly what will happen to our economy over the course of the next decade? Where are these numbers for GDP coming from? I decided to check these numbers with another source to see if they would hold up.

Trump's proposed "Budget for a Better America." Although promising, this budget may be worse than expected.

Besides spending in general, let’s take a closer look at how the Trump administration plans to allocate its money. Although committed to reducing deficit spending, Trump recognizes that there are certain “critical national priorities” in which we must invest such as defense spending, the VA MISSION Act, infrastructure, Education Freedom Scholarships, paid parental leave, and debt service (“A Budget for a Better America” 112). Of course, there is no doubt that these programs are very beneficial to our nation. However, because we must cut back on discretionary spending in some area, we have to make tough choices. Are there any programs which could stand to be dialed down?

In the past, Trump has dialed back on health care, including mental health care. In his 2019 Fiscal Year Budget, he proposed a reduction in Medicare funding by $1.4 trillion, Medicaid funding by about $500 billion, and Social Security Disability funding by $10 billion over the course of the next decade (Howard para. 8). These programs are vital to providing health care for the poverty-stricken, elderly, and handicapped, respectively. Without it, the high price of health care in our country prevents these people from receiving treatment for even the most basic health necessities. These health problems, which could be simply fixed by making basic health care more accessible, prevent these people from living stable lives. Not only does this affect people unable to receive health care, it also affects the entire nation: when these people don’t go to work and utilize their potential, there is an overall loss of earnings. This means that GDP growth will be

Fig. 60 Trump 2020 FY Budget. Wall Street Journal. Accessed 26 May 2019.

One of the hallmarks of our nation, our military receives billions each year to carry out their functions. In this year’s budget, the Department of Defense plans to bolster what they consider to be the linchpin58 of our nation’s stability by rebuilding the readiness of our armed forces, an increase in nuclear capabilities, and creating a United States Space Force (“A Budget for a Better America” 30). There is no doubt that our antecedent59 of military greatness has proven beneficial to our nation in the past, but how much is too much? Do we really need to create a space force to defend our country from threats in space? Spending greater and greater amounts of money in the military leads to a neglect of other problems that are rapidly going downhill, such as the mental health crisis. Why do we have enact such severe cuts of health care and, as a result, mental health care, when we are also bolstering the defense program which is a part of our discretionary budget? Will an ignorance of our domestic problems lead to an unexpected inner snowballing of these issues?

less than it could be if we provided health care and encouraged a growing workforce. Some people object to the raising of taxes simply to pay for other’s healthcare.

To some degree, this is understandable: we have to make the hard choices in all areas of the budget in order to reduce the deficit and keep taxpayers happy. But does a disproportionate reduction of health care spending coupled with an exponential increase in military spending indicate "tough choices" across all areas of government spending? Is the Trump Administration making choices that are fair to the entire nation?

Trump unveiling the 2020 Fiscal Year Budget.

What is the Trump Administration doing about mental health? They would boast that they are doing quite a lot: the Department of Health and Human Services recognizes that there is a serious crisis resulting from a lack of mental health care, and assures the nation that they are working to improve this situation through provisions for several community mental health service programs (“A Budget for a Better America” 40). Like the federal debt situation, it is great that this administration can recognize that there problem, but saying that they are going to to do something and actually following through are two very different ideas. Overall, the amount of money that the Department of Health and Human Services says they are allocating for mental health adds up to just over $1 billion to bolster a few programs (“A Budget for a Better America” 40). However, the amount of discretionary funds that the Department of Health and Human Services will receive is going to decrease from $20.4 billion in 2019 to $15.2 billion in 2020 (“A Budget for a Better America” 135). These cuts must come from somewhere, and mental health care will not emerge unscathed. It seems as if they understand the problem of mental health but are willing to compromise spending to achieve their goals of reducing deficit spending and bridging the gap of the federal debt.

47

Even health care in general is becoming less of a national priority as the 2020 budget proposes over $1 trillion in “mandatory” health savings to reduce the deficit (“A Budget for a Better America” 39). Meanwhile, they are requesting a $718 billion increase in defense spending (“A Budget for a Better America” 23), displaying that their priority is not that of providing basic health needs for our citizens, but instead of "protecting" our citizens to a degree that may not be necessary.

Why is mental health not also considered a critical national priority?

Let’s say you are in the middle of a health crisis: you were in a terrible car accident and your hospital bills are adding up. Would you spend your money immediately to fix problems of your health, or would you continue to save money in case of other emergencies? The choice seems obvious: you spend the money to improve your immediate health situation. On a larger scale, would you rather the government use your taxes to pay for your healthcare and alleviate that stress to get you back on your feet, or would you rather they place their money in preparing for what ifs? To me, it seems like there is no question: we must allocate resources to meeting the basic health needs of our citizens, while dialing back on unnecessary aspects of military spending. Especially given the lack of mental health care, which is a sector of health that faces double the hurdle due to a general lack of knowledge of treatment, we must push to provide our people with the treatment they desperately need. Once we improve the drastic nature of this situation, we may begin to examine how we can prepare our country for potential conflicts and bolster military spending.

Why is military spending so different? In our country, we have a patriotic faith in our military and its importance to our society. Many believe that the United States has both a unique duty to protect international peace through our military intervention and a distinct difficulty in providing adequate security for our citizens. These beliefs, so deeply rooted in our country’s philosophy, have justified increases in military spending over 48 the past few decades. However, this aim for our

country is also in direct conflict with ideas of reform for our people and cries for improvement that we hear every day.

While our country does play a role in protecting other nations, there is no way that we can pretend that our domestic situation is ideal. Throughout this issue of SOCIETY, our authors have striven to show just how severe the mental health crisis is. Although we have placed a lot of focus on the issue of mental health, it is critical to note that this is not the only problem our country must face. Our past issues have also explored problems such as the water crisis in Flint, the looming consequences of climate change, lack of equality of education across ethnic groups in our country, and the substance abuse epidemic. With the possibility of huge increases in federal defense spending, many are wondering why such problems are not being addressed. Stephen Miles, one such advocate and the director of the Win Without War organization, stated, “When our nation can’t manage to turn the lights on for the people of Puerto Rico, when we can’t help those suffering from opioid addiction get treatment, and when we can’t ensure education and healthcare to all of our citizens, how is it possible we can justify spending billions more on weapons that don’t work to fight enemies that don’t exist?” (McCarthy para. 5). Miles’s opinion, although seemingly extreme to some and contrary to the ideal of a glorified military, contains definite truth: we must solve these pressing issues at hand before looking beyond our country. In such a time when resources and capital is in such short supply, we must reassess and determine where the most critical problems lie.

Furthermore, one of our military’s main focuses is to protect our citizens against threats to our security, but how much protection do we really need? According to the Stockholm International Peace Research Institute, the U.S. spends more on our military than combination of the outlays the next eight countries (McCarthy para.

7). Who do we have to protect ourselves against? When the U.S. spends exponentially more than all of the other countries, it seems that the threats to our security are not that severe at all. Further still, although we spend so much to protect our citizens, we still can’t protect our people from the mass shootings that have occurred time after time on our own soil. Our own students can’t feel safe in their classrooms without the threat of being shot.

Where is the protection for these people? How can we prevent such violence? This circuitous60 problem could be solved with a greater attention to domestic problems: as we have shown, a greater emphasis on mental health could allow for improvement of gun violence.

this is

S O C I E T Y Over the course of the past month, we have learned a lot about the hidden plight of ourselves, our communities, and our nation as a whole. Clearly, the mental health crisis is urgent, and it needs a solution now.

Our people are suffering from a terrible lack of treatment for their illnesses that cause a lack of normal functioning and a subsequent promotion of negative stereotypes that further inhibit them.

what now?

By Priya Bhatt

In

progress.

our

procress of improvement, each of us can make an effort to become more educated about mental health, and this will allow for siginificant growth.

However, progress cannot only be made on a local level, our government must also do what they can to initiate real positive development on a larger scale. We at SOCIETY call on you to talk to your representatives so that we may initiate large-scale reform and do what we can to help those who need it.

process.

Throughout this issue, we have broken down the mental health crisis to discover how we might make progress.

Of course, we must focus on providing these individuals the treatment they need by ensuring mental health treatment is accessible, but we also need to rethink our mindset concerning people living with mental illnesses so that we may provide a better environment for everyone.

positive development.

thank you!

Bhatt 1 Priya Bhatt Darrin Broadway AP Language and Composition (5) 3 November 2018 Annotations "The Affordable Care Act Should Be Repealed." ​The Affordable Care Act,​ edited by Tamara Thompson, Greenhaven Press, 2015. At Issue. ​Opposing Viewpoints in Context,​ http://link.galegroup.com/apps/doc/EJ3010925211/OVIC?u=otta7357&sid=OVIC&xid= dd367c00. Accessed 4 Nov. 2018. Originally published as "After Repeal of Obamacare: Moving to Patient-Centered, Market-Based Health Care," ​Heritage.org​, 31 Oct. 2013.

The Heritage Foundation’s article states that Obamacare should be changed to better appeal to free market competition by letting people choose their own health insurance, letting providers present the health care services that people want, encouraging employers to include health insurance as a part of their employee benefits program, providing assistance to those who need help, and protecting the rights of unborn children. Currently, Obamacare is controlling health care and forcing families to pay into a system that they do not want to participate in. By allowing people to purchase their own insurance, the government would allow portability for insurance. Equalizing tax incentives between employer-provided health insurance and private insurance would also encourage people to purchase this individual insurance. This article refutes the Obama Administration’s claim that people with chronic illnesses are failing to receive treatment by asserting that

Bhatt 2 this is only a problem in the individual market. If people are unable to purchase their own coverage, the state could provide to this limited number of people. Next, this article states that because people are unable to purchase the plans they need, they should be able to purchase insurance across state lines. This would increase competition and boost the economy.

The Heritage Foundation’s argument that Obamacare is flawed and their proposals for reform are widely debated. However, many of these reforms were supported by Donald Trump as he took office. Similarly, the Wall Street Journal’s article ​Trump’s Health Care Progress​ talks about Donald Trump’s initial reforms to Obamacare such as the replacement of individual mandate and the privatization of health insurance. However, the Wall Street Journal discusses this issue after a couple years of Trump’s conservative rule, well after the Heritage Foundation published this article. This shows that the reforms proposed in this article are, to some degree, doing the economy well. It is important to note the Heritage Foundation’s notably Republican reputation.

In my argument, I will use this article to develop my concession/refutation section.

Specifically, I will use it in my round table article to develop the opinion of someone who is opposed to expanding government-sanctioned health care, even for mental health purposes. The Heritage Foundation has helped me understand the argument against expanding government-controlled health care. I did not cite this article in my round table, but instead used other sources to support this line of thinking. Some assertions of the

Bhatt 3 article confuse me because they directly refute things I have heard from my parents or at school, so I will research further to find the truth. From these articles, I am learning that assessments such as how the economy is doing are complex: there may be evidence supporting both sides. This article helped me by showing when people are forced to pay into government health care, they may become disgruntled and want to switch to privatized, individual health care.

"A Budget for a Better America: Fiscal Year 2020 Budget of the U.S. Government." The White House, 11 Mar. 2019, www.whitehouse.gov/wp-content/uploads/2019/03/budget-fy2020 .pdf. Accessed 16 Apr. 2019.

In this government-issued document, the White House explains its detailed budget for the 2020 fiscal year. Each department of Trump’s cabinet has a detailed explanation of their plans for the receipts that they are allocated and outlays they plan on enacting. To make the load of information easier to comprehend, they included a variety of summary tables at the end of the document which show the calculations which lead them to make the conclusion that they are bridging the federal deficit while continuing spending for “necessary” national expenditures. For example, they have a table which shows the total receipts, outlays, and calculated deficit over the course of the next ten years and these same numbers as a percentage of the calculated gross domestic product. These tables go into detail for all of the expenditures in the different departments as well.

Bhatt 4 Like ​Trump on Mental Health​, this document clearly displays Trump’s opinion on how our government should function. However, this document is more comprehensive and goes into a lot further detail about how exactly Trump’s administration will be allocating taxpayer money. This document is not just about mental health, it is about all of the expenditures that our government has to worry about. None of my other source are official government documents, so this source is unique for its seemingly thought-out nature.

This source will lend itself best to my article about the federal budget and how it pertains to mental health care. I will be using the summary tables to sum up Trump’s opinion about how resources are should be allocated and how he is trying to bridge the federal deficit. However, I will show how this fundamental document has information that is unsupported, showing how the current administration does not truly have a handle on their spending and on bridging the deficit. Therefore, the idea that we must cut back on spending on healthcare, which includes mental health care, upon which the administration has built their platform is not being followed.

Crowe, Allison, et al. "Self-Stigma, Mental Health Literacy, and Health Outcomes in Integrated Care." ​Journal of Counseling and Development​, vol. 96, no. 3, 2018, p. 267. ​Student Resources in Context,​ link.galegroup.com/apps/doc/A544712013/GPS?u=otta7357&si d=GPS&xid=4d1c3b5d. Accessed 3 Nov. 2018. (Confirmation)

Bhatt 5 This study, led by Allison Crowe, explores the relationships between self-stigma of mental health, mental health literacy, and health outcomes in an integrated care center.

Defined as the stigma against oneself that leads to a lack of self-confidence or prevents one from seeking help, self-stigma results from the internalization of public stigma surrounding mental health. The researchers postulate that one factor that may decrease such self-stigma is mental health literacy, or the knowledge of mental disorders that can aid proper management of the illness. It is widely known that low health literacy typically leads to worse health outcomes, higher costs, disparities between groups being treated, and an overall increased mortality rate of the older population. After conducting a survey of individuals at an integrated care center, they found an inverse relationship between self-stigma and mental health literacy.

Because this source was a scientific study, it stayed true to the scientific method: Crowe et. al detailed their methods for gathering and analyzing data. As a result, they were able to draw justified conclusions from their data. This is unlike any other source I have used: NAMI’s information sheet on mental illness contained information drawn from other respectable institutions and Hinshaw’s memoir ​Another Kind of Madness​ contained work drawn from studies done by other researchers. However, all three sources are considered reliable. Crowe et. al’s careful attention to detail, NAMI’s use of information from other national institutions, and Hinshaw’s drawing of statistics from other research papers all lend to the credibility of their sources.

Bhatt 6 This study will best lend itself to my confirmation. Specifically, I have used information from this source in my round table to develop a refutation against those who believed that health care expansion is futile, in my crossword puzzle to provide information about stigma, in my interview with Stephen Hinshaw to illustrate the importance of decreasing stigma, in my succeeding article about the importance of stigma, and in an ad that I created to show the importance of improving mental health literacy. Because Crowe et. al were able to display an inverse relationship between mental health literacy and self-stigma of seeking treatment, and this data was conducted in a scientifically sound manner, I can draw the conclusion that we must improve mental health literacy by improving health education for students, their parents, and employees around the nation.

This way, we can see an increase in the percentage of adults who have mental disorders that receive help and as a result, witness the increase of productivity of our workforce and an improvement of the mental health crisis.

Fox, Peter D., Ph.D., and Peter R. Kongstvedt, M.D., FACP. "A History of Managed Health Care and Health Insurance in the United States." The Essentials of Managed Health Care, 6th ed., Burlington, MA, Jones & Bartlett Learning, 2013, samples.jbpub.com/ 9781284043259/Chapter1.pdf. Accessed 15 Feb. 2019.

In this chapter from their textbook ​The Essentials of Managed Health Care​, Fox and Kongstvedt describe the origins of health insurance and managed health care. From 1910 to the 1940s, managed care organizations were in their early stages. One such

Bhatt 7 organization, called the Group Health Association (GHA), was created in 1937 and was intended to regulate medical expenses in order to reduce the number of mortgage defaults. The GHA, like many other managed care organizations of the time, faced opposition from its local medical society who threatened GHA physicians with expulsion from their society. From the mid-1940s to the mid-1960s, the U.S. witnessed an expansion of health benefits. The 1942 Stabilization Act, which imposed wage and price controls on businesses in response to inflation and a tight labor supply during World War II, led to a great increase in the number of employed individuals who had health benefits (which were not constrained by wage controls). In 1945, the McCarran-Ferguson Act led to the regulation of insurance companies at the state level rather than the federal level, which further resulted in variability between government oversight of insurance companies throughout the nation. Serving as a model for the modern independent practice association (IPA) since 1954, the San Joaquin Medical Foundation paid contracted physicians regular salaries with money from their consumers’ monthly premiums. They also benefited their consumers by hearing their complaints and regulating their overall quality of care. In 1965, Medicare for the elderly and Medicaid for selected low-income populations were established in the Social Security Act. Providing separate benefits, Medicare Part A paid for hospitalization using taxes on earned income and Medicare Part B paid for physician services paid by general revenues and enrollee premiums. The third party payment system caused great inflation of health care costs. In 2012, the percentage of all healthcare costs paid by patients declined steadily from 55.9% in 1960 to 11-12%. Meanwhile national health expenditures as a

Bhatt 8 percentage of the gross domestic product (GDP) grew from 5.2% in 1960 to 5.8% in 1965 (the year before Medicare was implemented) to 7.4% in 1970 and finally to 17.2% in 2012. In 1973, the HMO Act was passed, developing “health maintenance organizations” as federally qualified prepaid health care providers as opposed to third-party providers. Over the next couple of decades, many managed care organizations began to consolidate until 1999, when multistate firms such as Kaiser Permanente represented three-fourths of U.S. enrollment in managed care plans. Modeling the national trend, the Blue Cross Blue Shield Association voted to allow its member plans to convert from not-for-profit to for-profit organizations in 1994. Hospital consolidation gave provider organizations greater negotiating power over commercial health plans, leading to an increase in hospital prices to private payers by 20% between 1994 and 2001 and 42% between 2001 and 2008. In 1996, the Health Insurance Portability and Accountability Act (HIPAA) was enacted, limiting health plans ability to deny coverage to individuals based on health status. Backlash against the managed health care system led to an investigation by the Government Accountability Office (GAO) who, in 1997, found that of 1150 physician contracts from 529 HMOs there were no instances of a gag clause, or a part of the contract that would prohibit physicians from informing their patients about their best medical options. The July 12 issue of ​Time​ magazine ran this cover story in 1998, embodying general negative feelings towards managed health care systems. In 2003, the Medicare Modernization Act (MMA) expanded funding for Medicare and expanded to provide drug benefits. From 14% in 1999, the number of

Bhatt 9 uninsured Americans rose to 17% in 2009. In 2010, the Patient Protection and Affordable Care Act (ACA, or “Obamacare”) was enacted with sweeping changes to managed care.

Similar to Schwartz’s powerpoint, Larson’s article, and Haider’s article, Fox and Kongstvedt chapter provides a history over the course of the past century. Although the others pertain to the specific topics of mental health and mental health in pop culture, Fox and Kongstvedt focus on health care in general. For example, Schwartz includes details about mental health policy over the past few centuries such as John F. Kennedy’s dedication to the improvement of mental health services. Larson included details about the history of mental health such as the opening of early American psychiatric hospitals such as Oregon State Hospital. Haider talks specifically about the appearance of mental health in movies such as the recent blockbuster hit Silver Linings Playbook. In contrast, many of the policies and events that Fox and Kongstvedt describe do not pertain specifically to mental health, but to health care as a whole. For example, they talk about the rise of managed care organizations which have become widely known as insurance providers. These policies and events affect mental health because mental health must be covered through health insurance policies.

This source will be used in my narration section, specifically in my timeline. Because I had done some preliminary research about health care because it pertains so closely to mental health care, all of the information in this source made sense to me. Therefore, this will support my argument by providing greater context to how mental health care is

Bhatt 10 provided and the problems with health care that in turn affect the availability of mental health care treatment. Furthermore, the information that I draw from this source will set readers up for the ensuing arguments concerning health care in general and how that can pertain to mental health care. Specifically, I used it in my article describing the state of health care provision in our nation today.

Haider, Arwa. "How Cinema Stigmatises Mental Illness." ​BBC Culture,​ BBC, 28 Aug. 2018, www.bbc.com/culture/story/20180828-how-cinema-stigmatises-mental-illness. Accessed 26 Jan. 2019.

In this web article on BBC Culture, Arwa Haider discusses the presence of mental illness in the movies ver the past century. First, she describes how the movie ​Mad to Be Normal shows how the character RD Laing radically treats mental illness and how an upcoming Netflix series called ​Maniac​ in which characters participate in a drug trial that promises to cure all traces of mental illness. Later, Haider writes about the “classic” film ​One Flew Over the Cuckoo’s Nest​ from 1975. In this movie, the unpredictable convict RP McMurphy faked a mental illness to escape prison labor, leading to disastrous consequences. Because of its dramatic depiction of the ECT treatment, this film shaped America’s perception of the brutal treatment of the mentally ill. In 1980, ​The Shining similarly depicted Jack Nicholson as the murderous showman. In 1960, the movie ​Psycho developed society’s attitudes towards mental illness through the “eerily iconic” Norman Bates and the “unhinged strings” of Bernard Herrmann's score. In the 1980s,

Bhatt 11 slasher-movie monsters furthered the public image of “crazy” as evil for rhetorical purposes. In 1980, ​Friday the 13th​ furthered the idea that people from psychiatric hospitals are violent and dangerous. Embodying the idea that mental illness is “otherworldly,” the 1926 silent film ​A Page of Madness​ creatively uses masks and dream sequences to show the relationship between a married couple in an asylum. In 1995’s ​12 Monkeys,​ ​Mad Max,​ 1994’s ​The Madness of King George,​ or 2010’s ​Shutter Island​, “madmen” are depicted as the antagonists. Female hysteria is depicted in 2010’s ​Black Swan,​ and 1986’s ​Betty Blue​. In 1987’s ​Fatal Attraction​, actress Glenn Close portrays the characteristic “mad woman.” According to Close herself, her character is “considered evil more than a person who needs help, which astounds me.” In 2000, Darren Aronofsky’s ​Requiem for a Dream​ depicts a Brooklyn boy and his friends who become “mentally and physically shattered through their respective drug addictions.” In 2012, cinema began to develop with ​Silver Linings Playbook​ a story about a man recovering from bipolar disorder and a woman recovering from depression.

As this source pertains to culture and is from a magazine news source, it is not as credible as most of my other sources, which are scholarly publications by distinguished authors.

This source does not provide a thorough analysis of how mental illness is stigmatized in cinema, but it provides countless examples that display how it does. These examples illustrate how society felt about mental illness at different times throughout the past century. Similar to Larson’s article, this article provides information that pertains to the history of mental illness. However, Haider’s article focuses on mental health in the

Bhatt 12 movies, which is a specific cultural display of our society’s attitudes towards mental illness. The author may have only chosen examples of movies that supported her claim, but the sheer number of examples does support her argument.

I plan to use this article in my narration section to build my timeline. The movie examples will provide contrast to my information on policy change and important mental health landmarks throughout the past couple centuries. I think that more people would be able to connect to the movies because that is something we are all familiar with. These movies greatly influenced society’s attitudes towards mental illness, and in turn must have affected the policies developed in response to mental illness. Although meant to be dramatizations, these ideas about mental illness were internalized by many Americans and are sure to influence American opinion in the years to come.

Hinshaw, Stephen. "Mental Health Stigma JEP." Received by the author, 27 Nov. 2018.

In this email, Dr. Hinshaw shared that his book ​Another Kind of Madness r​ ecently became the winner of Best Book Award, Autobiography/Memoir at the American Book Fest (2018) and a finalist for the Best Book Award, Psychology/Mental Health at the American Book Fest (2018).

This email explains accolades won by Hinshaw’s book, ​Another Kind of Madness,​ which is another one of my sources.

Bhatt 13

This source will aid me in my confirmation as it provides ethos for Hinshaw in his interview. Specifically, I used it in the introduction of my interview with him.

Hinshaw, Stephen P. ​Another Kind of Madness: A Journey through the Stigma and Hope of Mental Illness.​ New York, St. Martin's Press, 2017. (Narration)

In this memoir, Dr. Stephen Hinshaw recounts how the stigma surrounding mental health affected his formative years and later relationship with his father. As a child, he loved his father dearly, but memories of his long absences and episodes of wild behavior remind Hinshaw of the lack of “normalcy” he experienced in his household. When Hinshaw became a young adult, his father felt as if he could tell his son what his doctors had prevented him from saying all these years: he had been suffering from bipolar disorder.

Hinshaw describes the series of revelations concerning his childhood he had over the next few years as he learnt more about his father’s illness. His scholarly description of stigma aids his retrospective description of his childhood. Drawing upon personal history and qualified research, Hinshaw concludes that stigma surrounding mental illness is still present and should be addressed.

Hinshaw’s memoir certainly does not lack the professionalism displayed in other scholarly writings such as Wulf Rössler’s journal article “The Stigma of Mental Disorders: A Millenia-Long History of Social Exclusion and Prejudices.” Both

Bhatt 14 thoroughly define terms essential to arguments concerning stigma such as “self-stigma” and “courtesy stigma.” Additionally, both cite statistics to explain the breadth of the problem at hand. However, whereas Rössler’s article provides a solely professional and somewhat clinical view of stigma and its history, Hinshaw’s personal story adds a layer of reality to his argument. By connecting the issue of stigma to a real-life story that is exceptionally intriguing, Hinshaw appeals to readers’ emotions. The way Hinshaw explains his story makes the reader feel as if it could have happened to anyone, and makes the reader wonder how many other people went through similar situations without such a positive outcome. The anecdotes present throughout the memoir realistically explain the effect of stigma on a normal household. Hinshaw may be biased towards taking real action against stigma, but it is situations like his that justify action in the first place.

I will use this memoir in my confirmation section, specifically in my crossword puzzle for a specific detail about the negative effects of mental illness, in my interview to explain how stigma is based off of false stereotypes, in my article refuting mental health misconceptions, and in my round table to develop my opinion about stigma in relation to government-managed health care. Hinshaw’s practical applications of key terms and statistics concerning stigma will be useful to help me explain the significance of this information in my argument. Additionally, his writing provides me with a real-life example of how stigma can affect a family. His interesting anecdotes are representative of the views concerning mental health during the late twentieth century. Because

Bhatt 15 Hinshaw includes a combination of personal narratives and scholarly writing, I can use his book to develop the narration of my argument, but his information will also help me build my confirmation. This book has lead me to another book by the same author, “The Mark of Shame,” that contains a deeper background on mental illness stigma. I expect that source to be a more comprehensive history similar to Rössler’s article.

Howard, Caren. "How Trump's Budget Will Affect People with Mental Health Conditions."

Mental Health America​, 15 Feb. 2018, www.mentalhealthamerica.net/blog/how-trumps -budget-will-affect-people-mental-health-conditions?scrlybrkr=8e1037ea. Accessed 5 Nov. 2018. (Confirmation)

In this article, Caren Howard addresses Trump’s 2019 Fiscal Year budget and what seems to be his Administration’s priorities for the course of his term. Following through on promises of commitment to mental health, Trump requested $10 billion to combat the opioid epidemic and serious mental illness and $15 million for an Assertive Community Treatment for people with serious mental illness. However, his administration has also reduced some of the biggest resources for mental health care: Medicaid was reduced by $1.4 trillion, Medicare by ~$500 billion, and Social Security Disability Insurance by $10 billion over 10 years. Furthermore, the budget cuts back on funding for the Substance Abuse and Mental Health Services Administration’s Mental Health and Substance Abuse Treatment Program and completely discontinues funding for the Screening, Brief Intervention, and Referral to Treatment program.

Bhatt 16

Similar to NAMI’s statement, this blog post addresses the flaws behind President Trump’s promises to support mental health initiatives. NAMI is more subtle in addressing Trump’s statement with positive assertions that there should be greater spending on mental health care initiatives and that institutionalization is not the cure-all solution to the issue of mental health. On the other hand, Howard simply displays Trump’s lack of support through facts such his request for trillion dollar cuts to Medicaid and Medicare and funding for mental health care initiatives. Howard’s article is also similar to The Heritage Foundation’s article in that both describe Republican reforms to government funding. By describing the reasoning behind such large budget cuts to Medicare and Medicaid, The Heritage Foundation justified some of the cuts highlighted

by Howard’s post. On the other hand, Howard just focuses on mental health in general by describing all of Trump’s actions concerning mental health in the budget, not justifying or rejecting Trump’s actions.

This article helps me gain a better idea of how Trump hopes to bridge the federal deficit, but also shows how mental health will severely suffer as a result. Specifically, his requests in the budget will contribute to both my narration and concession/refutation section. I use this article in my “Mental Health Today” article which explains the mental health crisis today and how these problems arose, in my article about “The State of Our Healthcare” to explain how our leaders are spending on health care, in my crossword puzzle to show how much Trump is affecting the budget, in my article about the federal

Bhatt 17 budget to explain changes being implemented in government spending, and in my round table to develop the opinion of someone who does not appreciate how Trump is delineating the cause of mental health. I would show that although Trump may say that mental health is important, his actions speak louder than his words: huge cuts to mental health initiatives could lead to disastrous results for people seeking help.

Johnson, Steven Ross. "Mental Health Parity Remains a Challenge 10 Years after Landmark Law." Modern Healthcare, Crain Communications, 15 Oct. 2018, www.modernhealthcare .com/article/20181005/NEWS/181009925. Accessed 20 Feb. 2019.

In this article, Johnson describes how mental health parity is still not a reality 10 years after the Mental Health Parity and Addiction Equity Act. “Unfortunately,” according to John Snook, executive director for the Treatment Advocacy Center, “we’re still not taking serious mental illness as seriously as we need to. I think the realities around the costs that we incur are still not there when we're talking about covering those costs on the front end” (Johnson para. 3). Although some of the more obvious disparities between mental health treatment and physical and surgical treatments have been addressed, many states lack proper enforcement of parity laws. Health care agencies face limitations as their utilization management differs between physical health and mental health and some of their provider networks offer limited behavioral healthcare services. These limits cause many patients to go outside of health care plans to find treatment. In 2017, the actuarial

Bhatt 18 firm Milliman found that whereas out-of network providers offered 6% of all medical/surgical care, they provided 32% of behavioral outpatient care in 2015. The organization ParityTrack, started by mental health parity advocate and former U.S. congressman Patrick Kennedy, assessed the mental health parity laws in all 50 states, giving low marks for 43 while only giving high marks to Illinois.

Similar to Johnson’s other article, “What ACA Repeal Could Mean for Mental Health Coverage, Johnson describes how legislation can affect the services we receive from healthcare providers. Whereas his other article focuses more on this issue in relation to the Affordable Care Act, this article focuses on this issue in relation to its key problem: mental health parity. Similar to Schwartz’s presentation, Johnson glorifies the gains made by the Mental Health Parity and Addiction Equity Act. However, Johnson goes far enough to describe how this law is followed in today’s society. This shows how historically important legislative acts can shape society, and how they may fail to live up to their functions.

This article will prove useful as I navigate my Round Table discussion and my article about mental health parity. Many of the specific statistics and quotes can be used to refute some of the arguments I anticipate. For example, Johnson includes a specific statistic that shows how people living with mental illnesses have to turn to out-of-network health care to receive treatments for their ailments, signalling extremely high expenses. In this article, Johnson explains how even though we have implemented parity laws in the past,

Bhatt 19 there is still an obvious lack of mental health care. This will help me argue that we must strengthen and enforce parity laws to continue bridging the mental health gap.

Furthermore, this shows that the idea of provision of health care itself is not the only problem preventing mental health treatment. Therefore, arguments that Obamacare is ineffective at improving the mental health crisis are incomplete. Finally, I will use this article in conjunction with Johnson’s other article to develop his overall opinion in my Round Table article.

Johnson, Steven Ross. "What ACA Repeal Could Mean for Mental Health Coverage." ​Modern Healthcare,​ vol. 47, no. 5, 30 Jan. 2017, go.galegroup.com/ps/retrieve.do?tabID =T003&resultListType=RESULT_LIST&searchResultsType=SingleTab&searchType=B asicSearchForm¤tPosition=16&docId=GALE%7CA479741495&docType=Article&sort =Relevance&contentSegment=&prodId=GPS&contentSet=GALE%7CA479741495&sea rchId=R3&userGroupName=otta7357&inPS=true. Accessed 17 Dec. 2018.

(Confirmation)

In this article, Steven Ross Johnson describes the progress we made with the Affordable Care Act and the possible consequences of repealing the Act with the introduction of the Trump Administration. About 9 years ago, Congress first began implementing mental health parity legislation which was later strengthened by the Obama Administration through the Affordable Care Act. However, repealing the essential benefits provision of

Bhatt 20 the Affordable Care Act could make mental health parity meaningless. Senator Tim Murphy supports repealing the ACA, stating that the act has failed to improve the mental health system while expanding unnecessary policies. However, the number of Americans without health insurance is the lowest on record. Although Republicans have proposed multiple alternatives to the ACA, such as the Patient Freedom Act and a block-grant program, people are unsure of how the situation will play out. This is extremely crucial because medicaid accounts for 26% of all spending on mental health services and is generally more comprehensive than private health insurance services. Repealing the ACA would mean 30 million more Americans would be uninsured in 2019, according to the Urban Institute.

Similar to the CBPP’s website, Ross uses statistics to develop his argument against the repealing of the ACA. Both websites argue against changes to the Affordable Care Act as it is by Republicans such as Trump. However, Johnson’s argument was more relevant during Trump’s election when most were unsure of how he was going to handle health care, especially in relation to mental health. On the other hand, the CBPP is responding to action taken by Trump recently and relating these actions to their effect on mental health.

Together, these arguments leave the reader with the impression that Trump’s administration is less concerned with mental health specifically and more concerned with the cost of healthcare as a whole to this country.

Bhatt 21 This article will help me refute the argument against spending more money on mental health care. Specifically, I used it in my round table, my crossword puzzle, and my article about mental health parity. By including data that shows how important Medicaid and the Affordable Care Act were to Americans across the country, Johnson makes it clear that spending money on health care is crucial to improving the mental health situation.

Through his argumentation, Johnson bridges the gap between the mental health crisis and the general provision of health care. Seemingly two unconnected subjects, it is crucial to understand the argument behind universal health care to begin arguing for specific solutions of the mental health crisis. This source will help me argue that universal health care as drawn up by Obamacare is necessary to improve the mental health crisis.

Kvaale, Erlend P., et al. "The 'Side Effects' of Medicalization: A Meta-Analytic Review of How Biogenetic Explanations Affect Stigma." ​Clinical Psychology Review​, PDF ed., no. 33, 12 June 2013, pp. 782-94.

In this published article, Kvaale et. al are displaying the results of their meta-analyses on medicalization and its effects on stigma. In their abstract, which summarizes the study, they write that biogenetic explanations of psychological problems caused a decrease in placing blame on patients, but they also saw an increase in pessimism towards mental illnesses in general. Biogenetic explanations also perpetuate stereotypes that people living with mental illnesses are dangerous to society.

Bhatt 22 Similar to Allison Crowe et. al, Kvaale et. al uses standardized scientific techniques to gather data and find a statistically significant relationship between stigma and some other aspect of society. Whereas Crowe et. al studies the effect of mental health literacy on self-stigma, Kvaale examines the effects of biomedical explanations of mental illnesses on public stigma. Similar to Rössler, Kvaale includes explanations of different factors and how they may affect stigma. However, Kvaale’s assertions are more credible because he backs them up with mountains upon mountains of data.

I will use this information in my article about mental health stigma. I argue that there needs to be greater education surrounding mental health, but this article proves that there needs to be more than education. By telling people the truth about the biomedical nature of mental illness, we will allow these people to improve their notions of what truly is.

However, this information shows that in order to improve our public connotations of mental illness we must go further beyond this education to dispel inaccurate stereotypes that signify stigma. Kvaal’s study shows how important it is that we take the concept of stigma seriously and that we must intelligently approach destigmatization.

Larson, Zeb. "America's Long-Suffering Mental Health System." ​Origins: Current Events in Historical Perspective​, Ohio State University, Apr. 2018, origins.osu.edu/article/ americas-long-suffering-mental-health-system. Accessed 26 Jan. 2019.

Bhatt 23 This article by Zeb Larson describes the history of America’s approach to mental health and illness. Currently, Americans are living in the midst of a struggling mental health system made apparent by national calamities such as the Parkland shooting. The numbers are not in our favor: 1 in 5 Americans live with a mental illness, those with severe mental illnesses live about 25 years less than other Americans, almost one third of individuals with serious diagnoses do not receive consistent treatment, people with mental illnesses are 10 times more likely to be victims of violence than the general public, and a quarter of homeless American sare seriously mentally ill. Additionally, almost a fifth of all prisoners in the U.S. have some sort of mental illness, and between 25 and 40 percent of people living with mental illnesses will be incarcerated at some point in their lives.

Because there is a lack of mental health facilities, many mentally ill end up in jails, where they are likely to be regularly abused by prison guards. The source of this lack of attention towards mental illnesses may stem from Ronald Reagan's 1981 Omnibus Budget Reconciliation Bill, which slashed domestic programs such as those geared towards mental health. However, our previous tendencies to favor short term solutions for mental health such as psychotropic medications or eugenics, our determination to make the mental health system as cheaply as possible, and the generally held idea that the mentally ill are somehow undeserving as they have a genetic defect or should be curable may have also encouraged lack of attention towards mental health treatment. These ideas developed back in the nineteenth century, when asylums began to develop in America.

Kept in asylums because their symptoms were hoped to be “curable”, “acute” cases were considered very different from their “chronic” counterparts who were treated at home. As

Bhatt 24 lifespans lengthened in the 19th century, so did the amount of sufferers. This propelled the growth of state-run institutions. One such institution, Oregon State Hospital for the Insane, had 412 patients in 1880, had nearly 1,200 by 1898, and had to open a second state hospital in 1913 for their patient population which had more than quadrupled since its opening. It was also the setting for the Ken Kesey’s movie One Flew Over the Cuckoo’s Nest in 1975. This led to the development of a “moral treatment,” a new therapy which included exposing the mentally ill to “normal” habits such as “restorative” work. However, as more patients were not expected to improve, the role of doctors shifted to that of caretakers. Furthermore, many doctors turned to eugenics as a method of ensuring the next few generations would not carry mental illnesses. In 1896, Connecticut prohibited marriage for epileptics, imbeciles, and the feeble-minded, and in 1907, mandated that if a board of experts recommended it, individuals must be sterilized. These actions were supported by the Supreme Court in cases such as Buck v Bell. In the early twentieth century, doctors began to focus on biological treatments such as ECT. In 1927, Austrian therapist Manfred Sakel developed the insulin shock therapy for schizophrenia.

This embodied how doctors were able to experiment to see what they would think works for treatment. Most of these “treatments” either traumatized the patients or caused lasting physical and mental harm. During the Great Depression, funding for hospitals decreased, worsening the situation for many people living in institutions. In 1948, journalist Albert Deutsch wrote The Shame of the States to highlight the various abuses he witnessed in such institutions, and the movie The Snake Pit of the same year visualized many of these abuses.

Bhatt 25

This article provides a general history of the government-assisted mental health system in America throughout the past couple of centuries. Similar to Schwartz’s presentation, Larson explains how legislation relates to mental health treatment. However, Larson focuses in more on the actual institutions that treated various individuals living with mental illness. He describes what qualified as mental illness throughout the years, where the mentally ill could get treatment, and how experimental treatments developed over time. Larson is a Ph.D. candidate writing for Ohio State, a reputable institution, so his writing is credible, but not as credible as Schwartz’s detail-driven presentation or Rössler’s explanatory article.

Larson’s article will help me develop both my narration and confirmation sections of my argument. Several specific details will prove useful for my timeline, and I can use several of the provocative images Larson includes. I also used some of his facts in my crossword puzzle. Many of the facts he includes can be used to display the prevalence and exigency of my argument. Additionally, it is leading me to explore other sources that would be indicative of societal attitudes towards such as mental illness such as how mental illness is portrayed in pop culture. Larson’s history can also support my confirmation section as it shows how important government support can be to supporting proper treatment of individuals living with mental illnesses. Overall, this source further substantiates my claim that the government should take greater control over mental health initiatives through policies.

Bhatt 26

"Mental Health Facts in America." ​National Alliance on Mental Illness,​ www.nami.org/NAM I/media/NAMI-Media/Infographics/GeneralMHFacts.pdf. Accessed 5 Nov. 2018.

Infographic. (Narration)

This infographic neatly displays a variety of data presented by the National Alliance on Mental Illness. For example, 1 in 5 Americans experience mental illness and nearly 1 in 25 adults live with serious mental illnesses. In America, nearly 60% of adults with mental illnesses did not receive mental health services. This lack of care leads to devastating consequences: approx. 10.2 million adults have co-occurring mental health and addiction disorders, approx. 26% of homeless adults staying in shelters live with serious mental illnesses, and approx. 24% of state prisoners have a “recent history of a mental health condition.” Additionally, this leads to an increased number of suicides as 90% of those who die by suicide have a mental illness (and suicide is the 10th leading cause of death in the United States). Finally, serious mental illness costs $193.2 billion in loss of earnings every year.

Like the National Institute of Mental Health’s information, this infographic simply provides statistics pertaining to mental illness in America. However, the National Institute of Mental Health solely provided data pertaining to prevalence and treatment, and breaks this down by sex, age, and race/ethnicity. On the other hand, this infographic

Bhatt 27

by NAMI contains some of the same broad data but also includes data pertaining to the consequences and impact of the lack of care on our society.

I used the statistics in this infographic to build my “Mental Health Today” article, which shows the exigency of solving the mental health crisis. All of the problems arising from the mental health crisis are pressing, and showing their importance through clear statistics can provide powerful imagery to readers. Each datum proves a different point: for example, in order to prove people wrong who may think we are spending too much money on government-provided health care, I would argue that without providing more of these services, we will see a bigger cost of loss of earnings ($193 billion). It might be interesting to use the other data such as the fact that 26% of homeless adults staying in shelters live with some mental illness to explore the consequences of leaving the mental health crisis as it is. I also used this source once in my letter from the editor to show the fundamental fact about how 1 in 5 Americans live with mental illness.

"Mental Health Treatments." ​Mental Health America​, www.mentalhealthamerica.net/ types-mental-health-treatments?scrlybrkr=9d075eaa. Accessed 5 Apr. 2019.

In this short article, Mental Health America describes several courses of mental health treatment such as psychotherapy, medication, case management, hospitalization, and support groups.

Bhatt 28 Like Larson’s article, this article shows various types of mental health treatments.

However, although Larson gives a history of mental health treatments over time, this article shows current effective mental health treatments and describes how they can help patients. Unlike the aggressive treatments that Larson describes such as the lobotomy which play into our negative stereotypes against people living with mental illnesses, the treatments in this article are known to be effective and typically not harmful.

I will use this information as a part of my mental health myths article. This will be helpful in showing that there are a variety of effective treatments out there, and therefore these people can and should be helped. This disproves the inaccurate belief that people living with mental illnesses are beyond help and illustrates how we can humanely treat these people. I also used it in an ad explaining how people have multiple options available to them concerning treatment.

McCarthy, Tom. "Does the US Really Need a Huge Boost in Military Spending?" The Guardian, Guardian News & Media, 9 Feb. 2018, www.theguardian.com/us-news/2018/ feb/09/senate-budget-deal-us-military-spending. Accessed 29 Apr. 2019.

In this article, Tom McCarthy addresses the huge increases in government spending that the Trump Administration calls for. First, he writes that although it has faced much criticism, the bipartisan federal budget includes a 13% increase in federal defense spending by the Pentagon. According to the Stockholm International Peace Research

Bhatt 29 Institute and a UN report, the United States spends more on our military than the next 8 countries combined. Some argue that the United States, unlike most other countries, has a reputation and duty to secure international order and has a harder job of providing security for its citizens. According to this article, Trump’s increase in military spending in his proposal was actually a key to selling his budget deal for the bipartisan Congress.

The public may be disillusioned by this reasoning, however, by the fact that according to an internal audit by Ernst & Young, $800m had been lost track of by the Pentagon. Even more argue that this spending will increase the deficit. However, Conservatives remain optimistic, with Speaker of the House Paul Ryan arguing that without military spending, we would still have a deficit.

Like “A Budget For a Better America,” this article contains information that pertains to federal spending, especially concerning the military. However, McCarthy’s article actually explains the federal government’s decision-making from an outside-the-government perspective. It seems that additionally, unlike the federal government’s official budget, this article gives bipartisan opinion without leaning strongly to either side. Furthermore, it provides some justification as to why the Trump Administration made the decisions that they did in their budget.

This information will prove useful in my article pertaining to the federal budget.

Although I have already begun the process of analyzing Trump’s budget proposals, this article gives me a broader perspective as to why these decisions are made. A few of the

Bhatt 30 quotes, especially the one from Stephen Miles, are extremely powerful and will provide a pathetic argument as to why we should spend less on the military. Furthermore, this article provides me with ideas beyond the economic effects as to why we should decrease military spending. For example, it does not make sense that we spend so much more on defense spending than other countries when the whole purpose of the military is to provide security for our citizens against other threats. Furthermore, by including examples of perspectives on all sides of the political spectrum, this article reminds me that this aspect of my argument is greatly subject to individual political opinion. This argument is very hard to navigate when people truly disagree about the fundamental importance of the military in our society, and I must remain decorous as I continue moving through my argumentation.

"Mental Illness." ​National Institute of Mental Health,​ Nov. 2017, ​www.nimh.nih.gov/health/ statistics/mental-illness.shtml. Accessed 16 Dec. 2018.

This web page issued by the National Institute of Mental Health contains data from the Substance Abuse and Mental Health Services Administration from a survey they conducted in 2016. Overall, the prevalence of any mental illness among U.S. adults was 18.3% (or approximately 1 in 5 Americans). However, only 43.1% of U.S. adults with such mental illnesses received mental health treatment (meaning 56.9% did not receive treatment). Specifically, 4.2% of U.S. adults reported a serious mental illness

Bhatt 31 (approximately 1 in 25 Americans). Of these people, 64.8% received treatment (35.2% did not receive treatment).

This source primarily focuses on the data presented from SAMHSA. Similarly, NAMI’s Mental Health Facts In America​ explores the statistics behind mental health. However, NIMH’s web page provides greater detail than NAMI: they include the breakdown of sex, age, and race/ethnicity in regards to the prevalence of mental illness. NAMI, on the other hand, uses this data briefly and shows other statistics such as the potential consequences of ignoring the mental health crisis.

The data presented by SAMHSA and NIMH are useful for displaying the exigency of my argument: we must focus more on providing mental health services for everyone because so many Americans go without receiving care. Alarmingly, even Americans with serious mental illnesses go without care; this is especially dangerous because it spurs other problems our country is facing such as gun violence and substance abuse. This data will fit well in the narration of my argument, and I have used it in my “Mental Health Today” article to display current statistics concerning the mental health crisis, in my article about stigma to show how stigma can create tangible negative effects, in my crossword puzzle to highlight a statistic, and in my round table to develop the opinion that health care should be expanded.

Bhatt 32 "NAMI's Statement Regarding President Trump's Recent Comments On Mental Health Care."

National Alliance on Mental Illness,​ 2 Feb. 2018, www.nami.org/About-NAMI/NAM I-News/2018/NAMI-s-Statement-Regarding-President-Trump-s-Recen. Accessed 5 Nov. 2018. (Confirmation)

In this short statement, the National Alliance on Mental Health addresses the inaccuracies in recent political rhetoric that propagate negative stereotypes, therefore preventing a realistic conversation on the improvement of the issue of mental health. The organization describes their vision of a society that integrates mental health care into people's’ daily lives and highlights how our nation fails to meet this standard. Proposing several solutions to this dilemma, NAMI calls for community interventions and increased ability of mental health care. Finally, NAMI displays their diplomacy by stating that they are willing to work with the government to achieve a solution to the problem of mental health.

As this is an official statement as opposed to an article, the goal of this source was to address a specific situation. This is similar to how Vanessa Romo’s article for NPR describes Trump’s initial assertions broadly supporting mental health following the Marjory Stoneman Douglas High School shooting. Both sources describe political opinion and propose solutions to the issue of mental health. However, NAMI’s reputation as an mental health educating institution shows that they are more credible than the President on this issue. Like NAMI’s statement, Melissa Warnke’s ​LA Times​ article

Bhatt 33 “People with Mental Illness will suffer under proposed GOP Plans” describes the faults in President Trump’s Approach to mental illness. However, NAMI addresses a specific instance of the president’s speech that addresses mental illness whereas Warnke addresses broader Trump actions that didn’t have anything to do with mental illness.

Furthermore, NAMI’s statement differs from other information available on their website: NAMI’s statement contains mostly descriptive language calling for action whereas their infographics imply a call to action through numbers. Both are considered credible resources because of NAMI’s well-upheld reputation.

This statement provides the basis upon which I will build my confirmation. It illustrates the main problems with mental health in our nation, shows how they are being addressed currently, and proposes viable solutions for improvement. Although it does not go into great detail, I can still use this source as an outline to organize my thoughts and explore other sources that go into greater depth. I will explore other resources from NAMI, as well as reach out to the Toledo chapter of NAMI to see if they have other writings pertaining to my argument.

Poulsen, Bruce, Ph.D. "Revisiting the Myth of Mental Illness and Thomas Szasz." ​Psychology Today​, 17 Sept. 2012, ​www.psychologytoday.com/us/blog/reality-play/ 201209/ revisiting-the-myth-mental-illness-and-thomas-szasz​. Accessed 9 Dec. 2018.

Bhatt 34 In this article, Bruce Poulsen, Ph.D., reflects upon the ideas of the late Thomas Szasz, leader of the anti-psychiatry movement. Poulsen begins with a description of a story of a town whose inhabitants start going off their antidepressants to provoke thoughts of society’s dependence on others to qualify and treat our social troubles. As one of the earliest critics of this reliance on psychiatry, Thomas Szasz, MD, argued that mental diseases are not real. Instead, people struggle with “problems in living” and choose to dump these problems on trained professionals instead of pushing through on their own.

He drew comparisons between mental illness and homosexuality: physiologically, neither could be considered diseases. By using diagnostic systems to categorize “mental illnesses,” professionals are inherently implying that the basic struggles of human life should be medicated. Proven wrong by credible institutions such as the American Medical Association, American Psychiatric Association, and National Institute of Health, Szasz’s radical view that mental illnesses are not biologically valid is now known to be incorrect. However, Poulsen writes, Szasz’s ideas are important to reflect upon, especially as we broaden criteria for what might be considered a mental illness in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)​. Instead of broadening help for the masses of people, Poulsen argues that we might be subjecting normal experiences to be considered fixable by someone else. Finally, he argues that we should explore a wide range of avenues for self-help, such as lifestyle changes and coping mechanisms, as opposed to immediately reverting to medicine. As Szasz said, we should not “mistake medicine for magic.”

Bhatt 35 This source effectively explains the origins behind the anti-psychiatry movement. Both this article and NAMI’s statement explore how we as a society explore mental health.

However, NAMI clearly addresses the presence of mental illnesses and proposes that we implement more programming to aid those with mental illnesses whereas Poulsen supports Szasz’s radical assertions that by classifying mental illnesses we are trying to mend the natural human condition of suffering. NAMI clearly states its interest in placing more support behind our mental health programming, whereas Poulsen implies that broadening access to treatment could instead shape our notions of “normality” in a negative way. Both authors are careful to not offend anyone by using politically incorrect language such as “crazy people,” lending to their credibility. Similarly, Poulsen’s Ph.D. status and NAMI’s reputation as a credible institution also contribute to their credibility.

Poulsen’s logical explanation of why the expansion of mental health treatment may be unnecessary could be extended to justify cuts to health insurance that the government is currently enacting. This claim could easily be used as a part of my concession/refutation, specifically, in my round table article. Certainly, I can concede to Poulsen’s points that we may be redefining the terms of normality, but I will refute this by asserting that there are certainly biological factors behind these problems that can qualify them as diseases.

Unfortunately, the best way to diagnose these diseases is through psychiatric assessment, but these trained professionals should be able to tell the difference between people who are “faking it” and people who truly have a diagnosable problem. I also used this source in my crossword puzzle for to highlight the fact that this opinion exists.

Bhatt 36

Rössler, Wulf. "The Stigma of Mental Disorders: A Millenia-Long History of Social Exclusion and Prejudices." ​EMBO reports,​ vol. 17, no. 9, 2016, pp. 1250-53. ​National Center for Biotechnology Information,​ doi:[10.15252/embr.201643041]. Accessed 4 Nov. 2018.

(Narration)

To introduce his historical exposition of the stigmatization of mental disorders, Rössler explains that the word “stigma” carries negative connotations due to its original ancient Greek definition meaning a brand to mark slaves or criminals. From being burned at the stake for being believed to be possessed by the devil during the Middle Ages, to being freed from such treatment but still institutionalized during the Enlightenment, to an unusual spike of discriminatory behavior during the Nazi reign when the mentally ill were murdered or sterilized, the mentally ill have been treated as slaves and criminals.

Although our society has improved and we do not kill or imprison the mentally ill, our societal standards and attitudes still cause an underlying belief of the inferiority of the mentally ill. To explain the concept of stigma, Rössler writes that cognitive stereotypes must be separated from emotional prejudices and acts of behavioral discrimination. For mental illness, common stereotypes include assumptions of danger, unpredictability, and unreliability. This stereotype may be useful for quickly assessing a group, but is not properly applicable to individuals. Therefore, to tell whether or not an individual is dangerous, unpredictable, or unreliable, we must first get to know them. As we develop stereotypes, we begin to apply an emotional response to that generalizing stereotype. For

Bhatt 37 example, when saying “I am afraid of schizophrenics,” one is using their stereotypes to define people by their illness, and developing a fear from that generalization. This leads to discriminatory behaviors as people begin to act on their emotions. As a scientific discipline, the study of mental disorder stigma became widely recognized in the mid to late twentieth century. American sociologist Erwin Goffman’s ​ 1​ 963 book ​Stigma: Notes on the Management of Spoiled Identity​ laid the foundation for stigma research. Years later, Thomas Scheff described mental illness as being a result of labelling, but Bruce Link modified this view by showing how as the mentally ill deviated from social norms and standards, their vulnerability to psycho-social stress would increase. Goffman, Scheff, Szasz, Ronald Laing, and Michel Foucault claimed that the consequences of stigmatization could be ascribed to psychiatry as opposed to the illness itself. Whatever the origins of stigma may be, there is no question that it is present everywhere: in a survey of respondents from 27 countries, almost 50% of people with schizophrenia reported discrimination in their personal relationships. Up to ⅔ of these people anticipated discrimination when faced with job applications. Rössler details three levels of stigma: ​macro​ which includes societal perceptions, ​intermediate​ which includes healthcare professionals, and ​micro​, which includes the individual. The ​macro​ views are heavily influenced by the media: films, television, and news programs propagate biased views. Even the words used to describe the diseases can produce stigma: the negative connotations associated with the metaphorical use of “schizophrenia” are transferred to people who have the disease. Rössler also acknowledges the phenomenon of self-stigma in which affected persons begin to experience lower self-esteem because of their illness

Bhatt 38 and courtesy stigma surrounding the relatives of the affected person. By introducing the difference between biological and psycho-social causes, Rössler is able to examine the recommended treatments (psychiatrists versus psychologists). Finally, Rössler proposes three channels to reduce stigma: mass media to improve general attitudes, opinion leaders to influence the masses, and direct contact to inform people about the truth of mental disorders.

Rössler’s history of stigma is similar to Hinshaw’s book ​Another Kind of Madness because both contain scholarly explanations of stigma and their complexities. Both define terms such as self-stigma and courtesy stigma and discuss various empirical research projects which were conducted concerning stigma. However, whereas Hinshaw’s book was a memoir and contained a narrative relating to stigma, Rössler contained more academic detail. Instead of appealing to pathos by including anecdotes, Rössler maintains a professional yet urgent tone throughout his paper. Additionally, he provides specific details about historical examples of discrimination which Hinshaw did not include. This article was also similar to NAMI’s statement regarding President Trump’s comments regarding mental illness: both propose education as an option to improve stigma.

However, Rössler’s article addresses stigma much more specifically than NAMI. Because his assertions support NAMI, a well known institution, Rössler’s credibility is improved.

As it includes history, statistics, and a definition of the problem of stigma as it is today, this article will lend itself best to the narration of my argument. I can use the assertions

Bhatt 39 here to help define the scope of my argument. Not only will this help display the breadth of the problem, it will also show the exigency and urgency of the argument. Specifically, I used information from this source in my interview with Dr. Hinshaw to help me develop my ideas of what exactly stigma is and how it should be addressed. I also used some details in my crossword puzzle and in an ad to show how talking about mental health can improve the issue of stigma.

Rowlands, Sheila. "15 Extremely Successful People Who Suffer from Mental Illness." ​The Clever​, 20 Mar. 2017, www.theclever.com/15-extremely-successful-people -who-suffer-from-mental-illness/. Accessed 5 Apr. 2019.

In this article, Rowlands writes short descriptions of several celebrities or famous people that have been known to talk about living with mental illnesses. She writes that Demi Lovato, Catherine Zeta-Jones, Carrie Fisher, Stephen King, Howie Mandel, Drew Barrymore, Brooke Shields, Chrissy Teigen, Paula Deen, Robin Williams, and Michael Phelps have all opened up at some point about living with various mental illnesses.

Similar to Haider’s article, this article gives several examples relevant to pop culture today that pertain to mental illness. Silver Linings Playbook, one of the movies that Haider describes, is a blockbuster movie that everyone knows about. Similarly, the celebrities Rowlands describes are common household names that everyone can connect to. However, Rowlands’s article describes specific people that live with mental illnesses.

Bhatt 40 Unlike any of my other sources, Rowlands’s information gives real examples of these people living with mental illnesses.

This information will best be used in my refutation section as a part of my article in which I debunk mental health myths. I believe that this information will be particularly powerful because it clearly displays several people whom we all know and love and shows how they too deal with mental illnesses. Their success in life is clear, and this shows that they were able to work through any setbacks they might have faced due to their mental illnesses.

Schwartz, James, Ph.D. "Mental Health Policy - the History of Mental Health Policy in the United States." ​LinkedIn Slideshare,​ LinkedIn, 25 Oct. 2015, www.slideshare.net/ jamesswartz1/mental-health-policy-the-history-of-mental-health-policy-in-the-united-stat es?from_action=save. Accessed 26 Jan. 2019. (narration)

In this PowerPoint presentation, Dr. James Schwartz, an associate professor at the University of Illinois Chicago, presents an overview on the development of mental health policy in the United States. First, he writes that legislation and legal mandates are supposed to alter human behavior in the right direction, but the actual adjustment of people's’ realities may lead to unintended consequences. From the 1790s to the 1900s, he wrote that the mentally ill were supposedly receiving “moral treatment”, or humane care through environmental intervention. This lead to the creation of state mental hospitals,

Bhatt 41 but became skewed as clinics turned into insane asylums. The champion of this treatment, Phillipe Pinel, a Frenchman who is considered the father of modern psychiatry as he transformed the field from violent treatment to more careful psychological evaluation and care. In America, Benjamin Rush developed the field in a myriad of ways: he published the first textbook on mental health in the US titled ​Medical Inquiries and Observations upon the Diseases of the Mind ​(1812), advocated for insane asylums and involuntary psychiatric treatment, and developed the idea of addiction as a disease. One of the first acts of legislation in this area was the Indigent Insane Bill, which provided land for the “insane” and an opportunity to live in “moral treatment” asylums but was vetoed by President Franklin Pierce in 1854 who did not believe in government support for health care. However, with Dorothea Dix’s advocating, the US entered the “Era of the Asylum” from the 1850s to 1950. This is widely considered the “low point” of psychiatric care as ideas of eugenics reigned and pseudoscience led to the development of mislead treatment techniques. Rather than receiving treatment, many were treated as if they were in custody with stays lasting many years. During the late 1950s, however, we began deinstitutionalization due to journalistic exposés, a psychopharmacologic revolution, and President Eisenhower’s study of the mentally ill population, developing a public connotation of mental institutions such as Pennsylvania’s Byberry and Ohio’s Cleveland State as inhumane. In 1955, Congress passed the Mental Health Study Act in which the final report in 1961 found that immediate care should be made in community settings, full-staffed mental health clinics should be accessible to all people in the US, and community based aftercare and rehab should be provided to patients. With family

Bhatt 42 experience with mental illness, JFK addressed Congress by announcing his commitment to the growth of mental health treatment and beginning the Community Mental Health movement which lasted from the 1960s to the 1990s. In fact, that year on October 31, the Mental Retardation Facilities and CMHC Construction Act was signed, providing grants to community centers so they can provide better treatment to all individuals. In the early 1970s President Nixon tried to discontinue the program and in 1974, Gerald Ford vetoed an extension for the act. However, with deinstitutionalization and the rise of advocates such as Thomas Szasz who argued that mental illness isn’t real also came the worsening quality of life of the mentally ill. As a result, the NIMH implemented Community Support Programs reaching most of the states by 1982. In 1980, the National Mental Health Systems Act was passed in order to reinvigorate the CMHC program to treat those with chronic mental illness, but was soon repealed by the Omnibus Budget Reconciliation Act (signed by Reagan) causing CMHC’s to switch to Medicaid funding.

As the mentally ill became unable to find care, there was an increase in homelessness and incarceration. In 1993, the Health Security Act would have established health care, including mental health care, for all Americans. From 1990s through 2010, America has been witnessing the Managed Care Era, but also from the 2000s through today, we have seen the Recovery Era. In 2003, the Bush Administration established the President’s New Freedom Commission on Mental Health to study mental health treatment and make recommendations for improvement and the Medicare Prescription Drug Improvement and Modernization Act to provide drug benefits to Medicare recipients. In 1996, the Mental Health Parity Act was enacted but had many loopholes. In 2008, the Obama

Bhatt 43 Administration continued this work under the Mental Health Parity and Addiction Equity Act. As of now, there is still an inadequate supply of mental health treatment, inequality of surgical and mental treatment, and segregated services. As of right now, Cassidy-Murphy has proposed the Mental Health Reform Act, meant to integrate physical and mental health and establish other reforms.

As it is a thorough history of how the U.S. has approached mental health policy over the past century, this presentation is very useful in understanding how society has changed in their attitudes mental illness over time. Because it is written by a Ph.D. and associate professor at a reliable institution, this source is reliable. Similar to Rössler’s article about the history of stigma, this presentation provides many historical examples that illustrate mental health in society. However, Schwartz’s presentation focuses more specifically on legislation enacted by the government throughout American history. This legislation reflects general attitudes towards mental illnesses as our representatives in government are meant to embody the public’s desires through their work. Additionally, both Schwartz and Rössler are reliable authors. Similar to the ​Center on Budget and Policy Priorities web page about Medicaid, Schwartz’s presentation explains how government spending on health care relates to mental health. However, the CoBPP’s page explains the impact of a recent specific potential action by the government whereas Schwartz’s presentation explains the origins of mental health spending in Medicare and Medicaid.

Bhatt 44 This source will best lend itself to the narration section of my argument as it provides a detailed history of how mental health policies have progressed in the United States. This will lay the foundation for the rest of my argument by helping to explain the outcomes of certain actions and how that should shape our decision making in mental health policies for the future. By shedding light on how certain stereotypes and prejudices may have developed throughout the years, this has reinforced my thinking towards my argument.

Specifically, I will be using many of these details in the timeline of my magazine and a couple in my crossword puzzle. Swartz’s illustration of mental health policy throughout the years help display the context of mental health policy and will allow me to suggest new reforms in our mental health policies in the years to come in order to show further improvement.

Slides Based on 2017 NSDUH Annual Report.​ 2017. ​Substance Abuse and Mental Health Services Administration​, www.samhsa.gov/data/report/slides-2017-nsduh -annual-national-report. Accessed 29 May 2019.

In this PowerPoint presentation by the Substance Abuse and Mental Health Administration, readers are exposed to a variety of graphs and charts that describe different quantitative measurements of our nation’s mental health and substance abuse situation. Specifically, of outstanding importance for my project are their descriptions of the number of people with Major Depressive Episodes (MDE) and the prevalence of mental illness (35.4 million for any mental illness excluding serious mental illnesses, and

Bhatt 45 11.2 million with serious mental illness). They also have a graph showing the correlation between Substance Use Disorders (SUDs) and MDEs. A slide showing the types of mental health services shows the different methods people take advantage of for mental health services.

Like other sources such as NAMI’s infographic, this source gives a comprehensive, data-supported picture of our mental health situation. However, this source also gives information about the potentially related consequences of the mental health crisis: there is a severe substance abuse problem and suicidal rates are high. This report is especially helpful given its comprehensive nature and the credibility of the SAMHSA. I believe it is especially interesting that SAMHSA, the organization that conducts many of the studies that display the severity of the mental health crisis and provide much of the support needed for people to improve their individual situations, is losing funding because of the actions of the current administration.

This source is pertinent in my refutation section: I will be using it to refute “mental health myths” in one of my articles. Many of the details included in this study can be used in different ways to refute some unsupported views of people living with mental illnesses.

For example, this study shows that a lack of mental health treatment is prevalent in our society and therefore shows that the issue of mental health is a “real issue.” Additionally, these slides show that the leading cause of a lack of treatment is that people are unable to

Bhatt 46 afford it, disproving the assumption that people just don’t want to get better. I also use the statistics in this source in my article about “The State of Our Healthcare.”

"Taking Away Medicaid for Not Meeting Work Requirements Harms People with Mental Health Conditions." ​Center on Budget and Policy Priorities​, 14 Dec. 2018, ​www.cbpp.org/ research/health/harm-to-people-with-mental-health-conditions-from-taking-away-medicai d-for-not.

This source states that Medicaid is the nation’s largest payer of mental health services. As of right now, 27 percent of adults with serious mental illnesses are covered by Medicaid.

However, President Trump recently began allowing states to take away Medicaid from people not working a specified amount of hours each week. Although some people may qualify for exemptions from this rule if they are seen as incapable of working due to a medical condition, many don’t qualify for these exemptions or are unable to prove their inability to function. In Arkansas, the first state to implement such a policy, the amount of people who actually lost Medicaid coverage exceeded the target population: those who aren’t working and don’t qualify for an exemption. According to Tipirneni et al., 20% of all enrollees and 32% of non-working enrollees of Medicare have some functional impairment linked to mental disabilities. However, in Arkansas, only about 12% of beneficiaries qualified as medically frail. To continue, CBPP shows that only 17.8% of adults with serious mental illnesses worked in 2012: they face major barriers such as inability to function like others at work or past involvement with the criminal justice

Bhatt 47 system. The possibility of losing health care coverage is added stress that might exacerbate their condition. To remediate this, states could provide voluntary employment services programs for the mentally ill. Several states, such as Iowa, Mississippi, Wisconsin, and Washington, have already begun implementing such policies. In conclusion, this article states that work requirements could undo the strides Medicare expansion has made: people have easier time getting access to treatment, and the concurrent treatment of mental and physical ailments will improve these peoples’ shortened life expectancy.

This article draws attention to an exigent aspect of mental health care. Like the National Institute on Mental Health’s website on the prevalence of mental health in America, this source shows specific data gathered by respectable institutions (SAMSHA and Tipirneni et al.). However, the CBPP’s article not only includes the statistics, it uses these statistics to support their argument against work requirements for Medicaid enrollment.

Furthermore, this source provides ideas for how to breach the disconnect between Medicaid and and lack of mental health treatment, whereas the National Institute of Mental Health simply displays that disconnect. Perhaps the most interesting aspect of this article is the way CBPP refutes the argument against implementing work requirements: this naturally strengthens their argument.

This article and the statistics within it will fit into my confirmation section: I will use the ideas in here to support my argument for the expansion of Medicaid. Because Medicaid is

Bhatt 48 the most important provider of behavioral health services and coverage is needed to work and function, we must focus on expanding Medicaid to provide for as many people who can’t afford private health insurance. Without it, many of these people will be left untreated with a mental illness that impairs their ability to work, leading to an overall loss of productivity in the economy. Taking away Medicare from people who do not meet work requirements unnecessarily takes away aid for millions of people across the country, preventing them from getting the treatment they need to have stable enough lives to meet those requirements in the first place. Specifically, I used this information in my “Mental Health Today” article and crossword puzzle.

Trump on Mental Health: "In the Old Days, We Had Mental Institutions, a Lot of Them."

Directed by Tim Hains, 2018. RealClearPolitics, www.realclearpolitics.com /video/2018/02/26/trump_on_mental_health_in_the_old_days_we_had_mental_instutiton s_a_lot_of_them.html. Accessed 26 Feb. 2019.

In this news clip, Trump is reacting to the Marjory Stoneman Douglas school shooting and the shooter's mental illness. He says that “In the old days, we had mental institutions.

We had a lot of ‘em!” Because they all knew “something was off,” they should have been able to “nab” the perpetrator before the terrible event even occurred. He continues, “You used to be able to bring him into a mental institution, and hopefully he gets help or whatever. But he’s off the streets.” Trump continues to imply negative stereotypes as he says, “you can’t arrest him, I guess.” He continues to say, “our government closed them

Bhatt 49 because of costs.” Trump recognizes that there is a problem: there is currently not a stable treatment for people who display a possibility of acting out.

Similar to NAMI’s statement, this video contains information that pertains to President Trump’s reaction to the MSD shooting. However, whereas NAMI’s statement was a reaction to Trump’s comments, this video contains the actual content of what he said.

Unlike other articles that assess the government’s current stance on mental health and health care, this video zooms in on President Trump’s opinion on the mental health crisis.

I will use this video in my confirmation section, specifically in my article about stigma and its prevalence in our nation. Because President Trump is a representative of our entire nation, his unintentionally stigmatized comments shed light on the general population’s attitudes, perceptions, and stereotypes surrounding mental illnesses. He is legitimately seeking for a solution to the mental health crisis, but by choosing institutionalization as his preferred form of treatment as opposed to a better treatment that integrates people living with mental illnesses into society. His quotes serve as examples of stigma in action, and I will be able to draw a picture as to how to recognize it and how to overcome it. I used the information in this video to help me draw an idea for one of my political cartoons.

Bhatt 50 United States, Congress, Congressional Budget Office. The Budget and Economic Outlook: 2019 to 2029. Congressional Budget Office, Jan. 2019, www.cbo.gov/system/files/2019-03 /54918-Outlook-3.pdf. Accessed 16 Apr. 2019.

In this report, the Congressional Budget Office shows numerical calculations of our nation’s economic outlook over the next decade. They show this information through calculations concerning spending deficits, debt, revenues, spending (outlays), and the economy in general. First, they write that they currently project that deficit spending will greatly increase. Next, they predict that because of these large deficits, the public federal debt will grow steadily. Additionally, with the expiration of the 2017 tax act, federal revenues will rise rapidly. At the same time, federal spending will also increase due to an increase in social welfare costs and the exacerbation of the interest on debt. Finally, the gross domestic product, a measurement which encompasses how well the economy is doing, is growing over the next few years, but the percentage of growth is decreasing.

Furthermore, the Congressional Budget Office predicts that output is projected to continue to slow.

Although also a government publication, this document is dissimilar from Fiscal Year 2020 Budget because this does not come from the White House (President Trump’s Cabinet), but from the Congressional Budget Office, a nonpartisan committee commissioned by Congress to provide impartial information about the economy and budget information. Because this information is gathered without a political agenda, it is

Bhatt 51 more trustworthy to me than the justifying budget information in the 2020 Fiscal Year Budget. Unlike my sources which provide information about mental health and health care in the past, this source includes supported predictions for the future, and is much more broad than mental health or even health care in general.

I will use this source in my article about the Federal Budget and how it relates to mental health care. The information provided by the Congressional Budget Office will refute some of the assumptions made by Trump’s Administration in the 2020 Fiscal Year Budget. For example, to justify the increase in tax receipts in his budget, Trump’s administration boasts a booming growth rate of gross domestic product. However, the Congressional Budget Office’s carefully collected data plainly refutes this huge growth: they write that the growth of gross domestic product is slowing down. This fundamental discrepancy in the justification of allocation of funds in the main pillar of our government leads us to one of the most current pressing questions of our nation: where is the accountability in our government? Although the information in this source seems to be much more broad than my topic allows, lessening federal debt is one of the main justifications for the limitation of mental health care. Therefore, it is important to understand what our government is doing to solve this problem and see if this limitation is even justified.

Bhatt 52

Bhatt 53

Bhatt 54

MAKE A CHANGE. CALL YOUR REPRESENTATIVES TODAY.

Fig. 61 Honaker, Edward. Looking For Help. Edward Honaker Photographer. Accessed 22 May 2019.