Society, Stigma, and Collective Illusions: America’s Mental Health Tale
By: Robert J. Horne & Jim Bialick
PART 1: New Dimensions in Mental Health series / Published January 12, 2023
Key Takeaways
More Americans will seek medical help for a mental health condition this year than there are doctors to treat them, and this disparity is broadly expected to worsen in the years to come. This is a massive problem for policymakers as it calls into question whether the U.S. strategy for improving mental health, which is heavily focused on funding medical responses to mental health conditions, is the right approach.
The authors believe that a few factors informing the current state of mental health in America have not been given proper consideration by policymakers, and new approaches to policymaking that consider these dynamics might create once-in-a-lifetime opportunities to repair American society.
New Dimensions in Mental Health, a Forest Hill Labs issue series, considers the role of society in shaping the origins of U.S. approaches and systems of mental health and how it is contributing to what some are calling a mental health crisis in America.
The series will explore the benefits of reimagining society’s approach to mental health to promote more frequent, substantive, and proactive relationships between individual Americans and mental well-being. The series will conclude with ideas policymakers can use to achieve this future state.
Introduction: Mental Health - An American Tale
This first article seeks to reimagine mental health policy in America by refocusing the conversation in Washington D.C. to ensure sufficient consider is given to proactive approaches that can head off incidents of poor mental health in American society. The hope is that in doing so, American society can move beyond its current differences. The first article in this series focuses on an overlooked aspect of this issue – the roles of society in shaping the mental health of America.
The origins of American attitudes towards mental health have been shaped by historic and sometimes inhumane approaches by society:
For millennia, society did not treat persons suffering from depression, autism, schizophrenia, and other mental illnesses much better than slaves or criminals: they were imprisoned, tortured, or killed. During the Middle Ages, mental illness was regarded as a punishment from God: sufferers were thought to be possessed by the devil and were burned at stake or thrown in penitentiaries and madhouses where they were chained to the walls or their beds. During the Enlightenment, the mentally ill were finally freed from their chains, and institutions were established to help sufferers of mental illness.
In some ways, the national approach to mental health policy can be described as a continuation of so-called Ugly Laws more common in the 19th and 20th centuries, which taught an out-of-sight, out-of-mind approach to individual health problems of the mind and body. From the Congressional Research Service:
The early U.S. health care system offered little treatment for mental illness. People with serious mental health conditions often ended up in prisons or shelters for the poor. Few privately or publicly funded asylums had been established by the mid-19th century, when state psychiatric hospitals began to grow in number and size. Institutional mental health care was viewed as a state responsibility and was not funded by the federal government. Community based (i.e., noninstitutional) mental health care was mostly unavailable.
Even as institutionalization was on the rise, the foundations for its decline were emerging in the form of perceived problems with institutional care and benefits of community-based care. Stories of poor living conditions in psychiatric hospitals raised concerns about the well-being of their patients. During World War II, psychiatrists began to forego or shorten hospitalizations as they learned that patients fared better when rapidly reintegrated into their social milieu. Approval of the first antipsychotic medication (chlorpromazine) in the 1950s made community-based treatment of mental illness seem more feasible. These developments set the stage for the decline of asylum.
Aspects of this public stigma remain and manifest as “a pervasive barrier that prevents many individuals in the U.S. from engaging in mental health care.” For instance, generations of Americans to this day avoid discussing mental health and illness with their children. Mental health challenges are often rooted in family history and passed on to future generations through genetics, trauma, and negative early experiences.
The Role of Societal Norms & Collective Illusions
Society’s role in shaping Americans' mental health is not limited to the stigmas that informed the development of mental health systems in the United States.
The concepts Americans have accepted as unique touchstones of their communities, such as table manners, causes for gift-giving, holiday rituals, social distancing, and worship, are examples of cultural norms in use today. Like non-tangible heirlooms passed between generations, cultural norms are the shared, sanctioned, and integrated systems of beliefs and practices that characterize cultural groups and foster group cohesion. These norms are made up of shared expectations and rules that are first experienced at birth through early connections with parents or caregivers and solidified by social interactions with peers, community leaders, and others to whom they look for guidance.
However, cultural norms are not always accurate representations of majority views within a democratic society at a particular point in time because free societies are constantly evolving, and no two generations think the same.
These are called Collective Illusions or situations in which an individual or groups of individuals supports a view they personally disagree with because they incorrectly assume it is a social norm supported by most others.
Collective illusions can create environments within a society conducive to life-altering decisions people would not otherwise choose for themselves. The mental health consequences of such situations can be devastating, life-alternating, and generational.
When spread throughout an entire generation, the impact of these illusions can be bad for all of society. For instance, when enough people buy into the same illusion, the conditions are sufficient for society to make illusions into permanent rules governing how society should function using laws, regulations, and new social norms. A collective illusion in such instances can become a new baseline for how all individuals within a society are taught to behave as children and adults, leading them to make choices contrary to their self-interests and values as well as those of their community.
And herein lies the danger for America:
When the rules governing American society fall out of sync with an individual's expectations of their community, the functions of a free society will likely suffer. And when enough generations are caught in the cycle, extreme and sometimes violent reactions to remove these rules are the result.
Thankfully, collective illusions have historically been few, but that appears to be changing rapidly as the United States progresses through the third decade of the 21st Century. Technology-enabled connectivity has brought the world closer to a global village than at any time before. The relative ease of connecting and sharing information online has led to a proliferation of collective illusions in recent years which are contributing to a mental health crisis in America.
The Makings of a Mental Health Crisis
One powerful collective illusion in American society today is the belief that mental health is purely of medical concern when in fact the term regards a person’s pursuit of psychological and emotional well-being. The United States strategy for improving mental health in society appears heavily influenced by this cultural ‘mistaken identity.’
This approach to funding and promoting health sector responses to mental and behavioral health as a strategy for improving mental health in America has proven woefully inadequate. The incidences of poor mental health in America is the proof.
The Coronavirus Disease 2019 (COVID-19) pandemic has contributed to unprecedented psychological and social strife felt by our entire country and world. Over 50% of adults have reported increased anxiety and depressive symptoms related to the pandemic. Many adults have also reported new or increased substance use due to stress, and unfortunately the rates of overdose have also increased by nearly 30%. Older adults were impacted by COVID-19 most severely with high mortality rates. Those over 55 also reported psychological distress at doubled the rate with it tripling for communities of color and low-income adults. The pandemic has most significantly impacted the mental health of children and young adults. For example, mental health-related visits to the emergency department for children aged 5 to 11 years old and adolescents aged 12 to 17 years old of increased by 24% and 31%, respectively in the past year.
Experts suggest the gap between supply and demand has been growing for years and, combined with issues associated with the COVID-19 pandemic, have increased the size of this gap to a significant enough degree as to result in what some federal lawmakers are calling a mental health crisis. The opportunity costs American society has had to shoulder because of this crisis are incalculable. Bold reforms will be needed to get ahead of this problem which we will cover in subsequent articles so stay tuned for more.
You can read more about how medical workforce dynamics are disrupting the healthcare market and the consumer-centric health system to come as a result here.
Conclusion
Society has improved its relationship with mental health over the past few years, and a national conversation on the importance of mental health is underway. Well-publicized incidents of violence, including school shootings, have sustained awareness and education on the importance of good mental health by underscoring the dangers to society posed by those with poor mental health. And an increasing incidence of public figures and others speaking out about their own mental health continues to have a destigmatizing effect; all necessary to support policymakers taking a new approach to mental health in America.
We will share our thoughts on what the future of mental health in America could look like in subsequent articles. A parting thought: a society free to critically weigh the changing views of generations of Americans against each other is a society that can succeed in growing along with its people.
Until then, here is to us trying.
*The authors would like to give special thanks to Dr. Todd Rose for his research on collective illusions."