The Mental Health Crisis and the Necessity of Medicare for All
by Karl Locher
Our mental health has been falling to pieces for an awfully long time.
It takes a lot of numbers to summarize the obvious truth, which is that humans of the 21st century are increasingly isolated and distracted, living in deteriorating communities and struggling to keep touch with something akin to reality. The foundations of our mental health are being stripped away from us and the novel coronavirus pandemic is laying this problem bare. Indeed, the anxiety and isolation of the pandemic are exacerbating social dynamics that pre-date the novel coronavirus by decades. Before the pandemic, in 2018 48,344 people in America died by suicide, 67,367 died by drug overdose and about 88,000 die annually of alcohol related illnesses. In Dane County alone, we are already experiencing an increasing number of overdoses and suicide attempts as the pandemic escalates. The aptly named “deaths of despair” make this crisis of mental health an exceptionally lethal one.
This may feel like a new crisis, certainly the statistics indicate that the collective mental health of people in the United States is deteriorating in unprecedented ways. However, it is a mistake to understand the current crisis of mental health as a singular and novel event. Both rhetorically and statistically, the phenomenon of this crisis that has drawn the most attention is white male suffering – and, inadvertently, the violence caused by white men. Indeed, the leading indicator of “deaths of despair” is the declining life expectancy of white men in the United States since the turn of the century. This indicator is often quoted unironically, and without the important context that white male life expectancy is still longer than that of black men. Even a brief examination of the social conditions of this latest iteration of the American crisis of mental health reveals a pattern as old as our country itself.
Going back through the history of the United States, and therefore the leading edge of capitalist development, there have been a series of mental health crises. The most striking difference between those of the past, and the crisis of today, is that prior crises were put upon oppressed people by way of race, gender, and sexuality and therefore were not crises of despair, suffering, or mental health, but of deviancy, psychopathology, and subhuman misery. Indigenous peoples were among the first to suffer from the trauma of colonialism and to witness the cruel transformations of community and body that occur through the intergenerational transmission of that trauma. Over time, three crucial elements of mental health were stolen and stolen again from indigenous peoples: a sense of safety, identity, and self-efficacy. As capitalism developed in the United States, and indigenous struggle was repeatedly purged from collective memory and history, we arrive at a present in which indigenous mental health is only recognized as a genetic pathology of alcohol use disorder, not one of intergenerational trauma.
Similar crises have played out in the bodies of black people, white women, and many people whose spirits have been under the heel of American capital. A unique feature of a capitalist crisis of mental health is the way in which original psychological suffering can be turned into abstract pathology which can then be repurposed to subjugate and commodify the individual. In the mid-19th century, Black slaves who yearned for and took steps towards their own freedom were diagnosed with “drapetomania,” an invented illness that shares eerily similar diagnostic features to the psychotic illnesses of which black men are diagnosed – but do not actually experience – at disproportionately high rates in the United States. Women who fought in their homes and in the streets for their liberation were diagnosed with hysterical personalities and banished to mental health hospitals just as black people were “treated” in facilities that were nothing more than re-branded plantations.
Each iteration of this crisis of mental health can find its genesis in collective and intergenerational trauma, bound together by the death of identities and communities, the despair of self-efficacy, and the theft of bodily autonomy. In a basic sense, each crisis has an origin in the dispossession of a reasonable sense of safety within society. In a more elaborate way, these traumas occurred in context of the more gradual process of depriving people of the foundations of mental health. Humans need to be heard by one another, to experience compassion and separation, to be challenged to grow and nurtured as they do, to be able to play and encounter risk while also having a safe home to which they can return. People need to be experienced as humans by other humans, humans who have unique and meaningful experiences and imaginations. It takes little imagination to realize how the social changes of the last century deprived great numbers of people of such foundational conditions. Trends of suburbanization of communities, evisceration of public education, and decimation of unionized work, have made it such that even our opportunities to play and converse with one another are isolating and alienating. Living in a society that is actively hostile to one’s livelihood, well-being, or even fundamental existence is devastating to mental, as well as physical, health the effects of which ripple through time in insidious ways. In this framework, it should then be little surprise that the specific trauma of neoliberalism and the intergenerational trauma of toxic masculinity has finally caught up to white men.
The coronavirus pandemic has revealed a great deal of cruelty in our society and many people are now realizing that it isn’t worth returning to the “old normal.” People already oriented to socialist politics, or having already experienced the most cruel forms of oppression themselves, are unsurprised by this revelation. This dynamic is pertinent to the exacerbation of the mental health crisis throughout the coronavirus pandemic. Clearly, the foundations of our mental health have been deteriorating for a long time, but now that the bottom has dropped out from underneath us, a sense of safety and belonging in society is even more difficult to attain than it was before the pandemic. Of course, the pandemic didn’t have to turn out this way, and only feels so inhumane on account of a society that has been structured around capitalist accumulation, rather than human flourishing.
If capitalism got us into this mess, it is clearly trying to convince us that it can get us out of it. With each new version of this crisis, the symptom is turned into a commodity that can once again fuel the cycle of exploitation. Nearly every moment I’ve spent online in the last month has been flooded with advertisements for novel mental health products. I stopped counting all of the new services and apps being marketed on Instagram a while ago when I realized the insipidly relaxing promotional videos had all blended together into a nauseatingly similar message. Just relax, everything will be fine if you just tune it all out. Whether it’s a meditation app that promises to wipe away my obviously irrational worries about our collective welfare or integrated online psychiatric services offering evidence-based solutions to my pathological isolation from other people, the markets clearly agree that something is amiss with our mental health.
Don’t mistake my sarcasm for an attempt to erase the distinction between healthy, adaptive concern and pathological, life-ruining anxiety – or any other form of psychological suffering. My target isn’t those who suffer, but those exploit the suffering. To treat psychological suffering, of clinical significance or not, as somehow discrete from our social conditions is repulsive. The underlying message is that the problem is you not the world you live in and it’s a message that allows human suffering to be commodified.
There is a strong evidence to suggest that social inequality is a unique cause of serious psychopathology, such as borderline personality disorder, psychotic disorders, and substance use disorders. The gross inequalities of our society are the product of brutal oppression and exploitation, but also the subtler abrasion of market ideology. These qualities of our society are evident in our mental health care as well. America’s largest mental health facilities are prisons and the centuries-old practice of locking up the mentally unwell is still America’s favored treatment. In our broader healthcare system, the enthusiasm for evidenced-based treatments that produce no discernibly beneficial outcomes is creating a system in which neither the patient nor the therapist actually matter. Treatment systems today virtually erase the individual and are hell-bent on finding the “right” treatment for the right pathology, a philosophy that has shown virtually no clinical benefits, yet has unquestionably improved the bottom line for corporate health systems.
Still worse, an appalling number of people simply don’t have access to mental health care at all. 27 million Americans went without health insurance in 2018, a number that is steadily rising. Even those with insurance often go without any or adequate mental health care. The reasons for this are numerous, ranging from insurers violating the federal mandate for parity of mental health and medical benefits, to fragmented provider and payer networks that prevent people from seeking care where it is available, to a dearth of mental health providers in rural areas (and even many urban areas). In context of the failure of commercial health insurance to provide mental health care, it is entirely unsurprising that a market has emerged for apps and private services to exploit the void.
Commodified healthcare doesn’t work. It really doesn’t work for mental healthcare. Individual mental health is better when our collective mental health improves. In order for us all to do better, we need Medicare For All. To provide lasting healing, our practices of care must acknowledge and respond to the collective social conditions of a suffering individual.
If our current crisis of mental health illustrates the need for universal healthcare, it may also be able to illuminate how to organize a system of socialized healthcare. In particular, the pandemic has revealed the urgent need for democracy in healthcare. The opacity of distribution of protective equipment amongst healthcare workers, staff furloughs and shortages occurring within the same community, and persistently worse health outcomes for people of color, trans and queer people, and women point to the need for a healthcare system that is responsive to both its workers and its patients. This is to say that healthcare must be deeply democratic as much as it must be socialist. Our current system of commodified health care necessarily obstructs this kind of democracy. In a very real sense, our healthcare is in the hands of our employers, not our own. Just the same, hospitals and clinics have traded the medical patriarchy of the 20th century for the data-driven tyranny of insurance companies.
To heal people from the trauma and dispossession of capitalism, we need to reorganize power within medicine. It will take a tremendous feat of organizing and democratic power in order to realize Medicare For All. In building a single-payer, national healthcare system, socialists and healthcare providers alike can change the very conditions in which healthcare is provided. By shifting the organizing principle of health systems to the wellbeing of patients, our hospitals and clinics would demand greater input from the care workers who are present with patients. Such a system would grant all people the same economic power within the healthcare system. Shifting power within healthcare would result in a major transformation of a foundational system of social reproduction. Doing so would allow for people to build greater power for challenging other capitalist systems of exploitation and oppression. In organizing together, and by providing better healthcare for one another, we would create more empathetic capacity to care for one another, to be able to listen and respond to conflict, to alleviate isolation and exist in a shared community. These things, as much as any clinical treatment, are crucial to our shared mental health and should guide our health politics in this time of crisis and beyond.
 For an outstanding illustration of the workings of intergenerational trauma, see D.A. Luepnitz’s The Family Interpreted: Psychoanalysis, Feminism, and Family Therapy, specifically chapter 15.
 Yet more sarcasm