The past and future of mental healthcare in the US

Words: Srilekha Cherukuvada

Most gross injustices aren’t seen on the evening news. Most are hidden within the normalities of the everyday systems that keep our world running. That includes healthcare, and particularly, mental healthcare – in the way it’s administered, and in who it’s administered to. 

Mental health, as we know it, is a relatively new concept. According to the US National Library of Medicine National Institutes of Health, before 1946, there was no clear-cut concept of mental health in American medicine. 

At the start of the 19th century, European imaginings of mental asylum systems traveled over the Atlantic. Those running the institutions often subscribed to archaic, pseudo-religious beliefs that mental illness was caused by supernatural spirits. Some performed exorcisms on patients, while others practiced invasive surgeries like trepanation (drilling holes in the skull). In some areas, these practices continued well into the 20th century, despite the lobbying efforts of figures like Dorothea Dix, who investigated and campaigned against the unjust treatment of mentally ill people after experiencing her own emotional breakdown.

But a more benevolent belief – that those with mental illnesses could heal – drove others to build treatment centres where patients met with relative kindness. In 1814, the Quaker community established the first moral treatment centre called the Friends Asylum. The staff were laymen rather than medical professionals, a change which pushed against the commonplace dehumanisation of patients and their symptoms. Kirkbride hospitals, which emphasised air circulation and natural light and had buildings designed to allow for maximum outdoor time, also opened throughout the 1800s.

By the 1890s, though, US institutions were receiving less and less state support, which meant becoming less and less pleasant places to be. To save money by reducing the hospital populations, the medical establishment developed the idea of ‘mental hygiene’: Mental Health America was originally formed in 1909 as the National Committee for Mental Hygiene. The mental hygiene movement sought to prevent the illnesses that people were institutionalised for from appearing in the first place by teaching the public how to take care of themselves. In many ways, it’s the ancestor of the kind of ‘self-care’ discourse we see on our Instagram feeds today, which acknowledges the environmental and behavioural factors that can contribute to the development or exacerbation of mental health problems.

The depression of the 1930s didn’t help with the overcrowding in mental health institutions, though, and World War II caused desperate shortages in resources. The outcome was a rise in abusive and unjust practices, with subdual rather than healing taking over as the central aim. A new generation of antipsychotic drugs led to a trend towards deinstitutionalisation and community care, but for those still confined, worse was in many ways still to come.

The mid-20th century remains notorious for clinical and violent treatments – most famously, electroshock therapy and lobotomies – which have been immortalised in iconic literary works from the time like One Flew Over the Cuckoo’s Nest (1962) and The Bell Jar (1963). (Some forms of both of these therapies are still in use, although the dangers associated with them have reduced dramatically as practices have evolved.)  These novels observed the role of inequality and injustice – racial, economic, and gendered – in mental healthcare, and posited much of it not as a public good, but as a tool of oppression. It’s not coincidental that the 60s were also a time of great social upheaval, with certain groups finding their grip on socio-political power loosening for the first time, and a concerted effort ongoing to push interlopers back into their place. Byberry Hospital, which operated in Philadelphia from 1907 to 1987, has since been compared to the Nazi concentration camps. 

Today, political context as a theme appears more and more in conversations around mental health. Research has shown that communities in the US that suffer discrimination – which both includes and can lead to confined social mobility, and higher poverty levels – are more likely to experience mental health issues. One survey from the Healthcare Commission showed that people of Black African and Caribbean heritage are up to 39% more likely to be admitted unwillingly to a psychiatric hospital compared to white people. What would once have been put down to individual (or more likely, genetic) predispositions is now observed and understood against a traumatic social backdrop. For some, the only meaningful form of self-care is the agitation for fundamental legal and political change.

The irony is that mental healthcare continues to be as limited as any other public service by the injustices that contribute to the issues it seeks to solve. Homosexuality was classed as a mental disorder until 1973 in the US; the WHO only removed the ‘disorder’ label from transgender identities last year. It’s against this historical backdrop that the suicide rate for LGBTQ+ youth has been recorded as four times that of cis-het youth. Medical practice has always been informed by its political context, and with that context now appearing to regress, the fear is that it always will be.

Moving forward, that’s the question we need to ask: can attempts to treat mental health problems ever be productive in a society that continues to be beset by prejudice? Education about inequality is the next mental health hurdle, and one that some organisations are working towards: since 2008, for example, July in the US has been designated BIPOC Mental Health Month. This is good, but it’s also not enough. With the turn towards individualisation that accompanies the corporatisation of mental health discourse, it’s more important than ever to acknowledge that mental healthcare in the 21st century must be accompanied by a movement for change. It seems inevitable that fifty years from now, we’ll look at the injustices of today with the same horror movie-style discomfort with which we look at the asylums of the 1800s.

learn more

  • PODCAST: States of Mind
  • RESOURCE: Mental Health America
  • BOOK: Madness: An American History of Mental Illness and its Treatment – Mary de Young
  • National Suicide Prevention Hotline: 1-800-273-8255 (USA), 116 123 (UK)

Srilekha Cherukuvada is a freelance writer based in Austin, Texas. She has multiple bylines in Business Insider, Urban Asian, The Tempest, Redefy, and more. Srilekha also founded a nonprofit organization, Plannr Consulting, focused on spreading mental health awareness. Learn more about Srilekha here, or connect with her on the following socials: Instagram, Twitter, LinkedIn.