Introduction

When we ask who is labeled mentally ill and what the consequences of such labeling are, we ask questions that are central to the sociological understanding of mental disorder. Such questions are relevant to those who are concerned that so many people with serious mental illnesses go unlabeled and untreated (Regier et al., 1993; Wang et al., 2005). Such questions are also relevant to people attempting to recover from mental illnesses who often feel that they suffer as much from being labeled mentally ill as they do from mental illness itself (Deegan, 1993).

As a society, we have created specific professions (including psychiatry, clinical psychology, psychiatric social work, and psychiatric nursing) upon whose members we confer the authority to define, label, and treat mental illnesses. Social processes determine who encounters these professionals and many of the important consequences that might follow from such an encounter. The treatment they receive may ameliorate their symptoms, improve their well-being, and enhance their social and occupational functioning. At the same time, along with treatment comes the possibility of pejorative labeling and stigma. Social science research on labeling and stigma can help us understand the processes involved, and, by bringing those processes to light, open the possibility of addressing some of their negative consequences.

Introduction

In the United States, federal statistical agencies are required to report statistics for five racial groups (white, black, Asian, Native Hawaiian or other Pacific Islander, and American Indian or Alaskan Native) and one ethnic category (Hispanic) (Office of Management and Budget [OMB], 1997). These categories are socially constructed and with almost 70 percent of Hispanics preferring to have Hispanic included as a racial category (Tucker et al., 1996), this chapter treats all the categories as “races,” and examines the extent to which these categories predict variations in mental health status. Racial groups are more alike than different in terms of genetic characteristics, with humans being identical for about 75 percent of known genetic factors, and with 95 percent of human genetic variation existing within racial groups (Lewontin, 1972; Lewontin, Rose, & Kamin, 1984). Since the first US Census in 1790, no two censuses have used identical racial categories (Nobles, 2000), with historical events and political factors playing an important role in determining which racial categories are officially recognized at a given time (Williams, 1997a).

When Allan Horwitz and Teresa Scheid prepared the first edition of this volume in 1998, there was much apprehension over the future of mental health care reform. This apprehension increased with the second edition, and is somewhat abated with the passage of the Affordable Care Act, which provides the opportunity to improve mental health service offerings. A series of tragic mass shootings – especially those at Sandy Hook Elementary School in Newton, Connecticut, and at the Emanuel African Methodist Episcopal Church in Charleston, South Carolina – has also provided impetus for policy makers to examine mental health services. At the same time, there is also renewed interest in exerting greater social control over people with mental health problems (i.e., loosening criteria for involuntary commitment, imposing additional limitations on the ability to possess guns). In Part III, we address the system of mental health care services and those policies that shape care delivery systems.

Mental health care must be understood in terms of its wider social context: the care and treatment provided to individuals with mental health problems reflects wider social values and priorities. Hence, the mental health system (i.e., the network of organizations, services, and health care professionals) will change as society changes. Specifically, widely held values and beliefs about mental health and attitudes toward the mentally ill as well as professional treatment preferences will shape the political climate, economic priorities, and the type of services available. It is for this reason that it is so difficult to achieve consensus on what type of system of care will work, and why it is so difficult to implement change (Mechanic, 2006).

As David Rochefort (1999) has argued, mental health policy has been plagued by recurrent tensions and ambiguities. Mental health care in the public sector is shaped by federal, state, and local policies and varies widely from community to community. While there have been several federal reports on the state of mental health care in the US (e.g., the 1999 Surgeon General's Report on Mental Health, the 2003 Presidential Commission on Mental Health), there has been no clear-cut federal policy such as that which emerged in 1963 with the Community Mental Health Reform Act. As noted by Wolff (2002), in the US mental health policy is framed at the state level, and there is tremendous state variation.

Introduction

In this chapter, we deal with culture as a major variable in the conceptualization, development, and administration of mental health systems. The study of culture has typically referred to the beliefs, values, symbolic meanings, and normative behavioral practices of a specific human group. But in social science research today, cultural groups are usually categorized and compared along axes such as Western versus non-Western or modern versus traditional. In recent years, there has been increasing attention to differentiating individualistic cultures, which give primacy to individual rights, from collectivist or sociocentric cultures which focus on group loyalties and social role obligations (Triandis, 1995). These respective modes of categorization in many ways tend to distinguish the wealthier, industrialized nations from the developing world. Thus, they represent differences not only in worldview and norms, but in resources available for the provision and structure of health care. Within nation states, modal cultural attitudes as well as intergroup differences may shape the accessibility, appropriateness, and effectiveness of services for population subgroups such as racial or ethnic minorities (Substance Abuse and Mental Health Services Administration, 2015b; Takeuchi, Uehara, & Maramba, 1999).

Introduction

The Patient Protection and Affordable Care Act of 2010 (ACA; full activation in 2014) and the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA; full activation in 2010) provide significant opportunities for expanding mental health treatment and addressing the highly fragmented system of care for persons with serious and persistent mental illnesses (Mechanic, 2011). This is significant, especially for individuals with severe mental illnesses. They have a significantly higher risk of comorbid medical disorders including diabetes, hypertension, heart disease, asthma, and gastrointestinal disorders, than those without a mental illness (Dickey, Normand, Weiss, Drake, & Azeni, 2002). Yet, gaps in quality of care for those with severe mental illnesses exist in both the primary care and specialty mental health settings (Miller, Druss, Dombrowski, & Rosenheck, 2003).

Directives under the ACA call for greater integration of services both by bringing specialty mental health care into primary medical care settings and by offering primary medical care for co-occurring medical disorders within the specialty mental health sector (Raney, 2015).

Introduction

Among the most profound social divisions in our culture is the one we make by gender. Whether we are male or female shapes our access to resources and our life choices and options. It colors the ways we relate to others, what people expect of us, and what we expect of ourselves.

Mental health and mental disorder represent two different areas of theory, research, and policy implications, reflecting our common tendency to dichotomize healthy and sick, normal and abnormal, sane and insane. David Mechanic (2006) argues that the term “mental health” has no clear or consistent meaning, and in terms of the sociological literature, this is generally true. Mental health is not merely the absence of disease or disorder; it involves self-esteem, mastery, and the ability to maintain meaningful relationships with others. While most of us fall short of optimal well-being (or happiness), those who experience mental health problems or psychological distress have been the focus of most sociological research.

However, definitions of mental health problems, illnesses, or disorders are also not so straightforward. Following Horwitz (2002b), “mental diseases” reflect underlying internal dysfunctions that have universal features (i.e. schizophrenia and to a lesser degree bipolar disorder). A valid “mental disorder” reflects some internal psychological system that is unable to function as it should, and this dysfunction is socially inappropriate. For most disorders, symptoms are not specific indicators of discrete, underlying diseases (such as schizophrenia), instead many conditions arise from stressful social conditions (such as depression, anxiety, eating disorders). Cultural processes shape the symptoms associated with mental disorders, and it is important to distinguish mental disorders from normal reactions to social stressors. Horwitz (2002b) uses the terminology of “mental illness” to refer to those conditions which a particular group has defined as a mental illness (and often point to behaviors that are deemed deviant, for example homosexuality in previous psychiatric classifications). For simplicity, we will use the term mental health problem or disorder in this introduction – but students should keep in mind the implications of using the term mental illness. In Chapter 1, Horwitz argues that sociological approaches regard mental health and mental health problems as aspects of social circumstances. He provides a very thorough overview of how various social conditions affect levels of mental health and mental health problems, and in turn how social contexts shape the definition as well as the response to mental health problems. Chapter 1 develops a framework for a sociological understanding of mental disorder and mental health problems and also directs the reader to other chapters in the volume that illustrate Horwitz's arguments.

Introduction

In the classic Beatles song, “I Get By with a Little Help from My Friends” (1967), the questions, “How do you feel at the end of the day? Are you sad because you're on your own?” are memorably answered with the response, “No, I get by with a little help from my friends.” This is the crux, in perhaps its most distilled form, of sociological understandings of the connection between social support and mental health.

The Oxford Illustrated Dictionary defines support, in part, as to “keep from failing or giving way, give courage, confidence, or power of endurance to … supply with necessities … lend assistance or countenance to” (1975: 850). What distinguishes social support from this broader definition is that it always involves either the presence or implication of stable human relationships. The domain of social support has been addressed under a variety of labels, including “social bonds” (Henderson, 1977), “social networks” (Wellman & Wortley, 1989), “meaningful social contact” (Cassel, 1976), “availability of confidants” (Brown, Bhrolchain, & Harris, 1975), and “human companionship” (Lynch, 1977), as well as social support. Although these concepts are not identical, they are similar and share a focus on the relevance and significance of human relationships.

Introduction

When a young person dies as a result of suicide, it is often viewed by society as a terrible tragedy. This kind of death seems particularly devastating to relatives, friends, and community members. Those who knew the deceased, such as parents, siblings, classmates, coaches, and neighbors, are frequently left wondering if they could have done something to prevent that young person's death. One such death was that of Garrett Lee Smith, son of former US Senator Gordon H. Smith (R–Oregon). In September 2003, Garrett, then a 21-year-old college student, died by suicide. Smith proposed the Garrett Lee Smith Memorial Act, which recognized suicide as a leading cause of death among youth aged 10 to 24 years (Babington, 2006). In 2004, President George W. Bush signed the Garrett Lee Smith Memorial Act, authorizing $82 million for suicideprevention and awareness programs at colleges (US Library of Congress, 2004).

Suicidal behavior presents a major challenge to public health in the United States and around the world (World Health Organization, 2014). Though fatal (suicide) and nonfatal (suicide attempts) suicidal behavior is a public health concern across the lifespan, it is of particular importance for youth aged 10–24 years. According to the most recent data, in 2013, suicide claimed the lives of 41,149 people and was the tenth leading cause of death overall in the United States, accounting for about 1.6 percent of all deaths (Centers for Disease Control and Prevention [CDC], 2005).

The HIV–Mental Health Challenge

The Centers for Disease Control (CDC) first noted five cases of the disease we now know as acquired immunodeficiency syndrome (AIDS) in the June 1981 issue of the Morbidity and Mortality Weekly Report (MMWR): it described young men who had sex with men (MSM) who were treated in the prior eight months at three different hospitals in Los Angeles for a type of pneumonia that appears almost exclusively in immunosuppressed patients (pneumocystis carinii pneumonia; CDC, 1981). From that time to the present, the challenges posed to mental health professionals and policy makers by AIDS and its cause, human immunodeficiency virus (HIV), have been conditioned by multiple, sometimes rapidly changing, influences. These influences include disease-related characteristics, such as its epidemiology, symptoms, common comorbidities, course, and outcome; developments in our understanding of the disease and how best to respond to it in terms of prevention, therapeutics, and palliation; and the evolving social and cultural contexts that assign meaning to the disease, the battle against it, and the effort to live with it.

While the most prominent feature of the landscapes we survey is the dramatic change brought about by the development of effective antiretroviral therapies, traditional biomedical “search for the cure” narratives neglect the continuing important role played by psychological, social, and behavioral processes in understanding, and responding to, the epidemic.

Introduction

Historically, there has been a lack of strong federal involvement in US mental health policy making. The result has been a highly fragmented mental health system with significant differences at the state and local levels of government. In this chapter, we provide an overview of the history of US mental health policy from the seventeenth century to the present, with a particular focus on polices affecting people living with serious and persistent mental illness (SPMI). We have divided the chapter into three broad periods of reform. The first period, the late 1700s through the 1940s, was a time marked by increasing social control over the lives of people with mental illness as states started to assume more responsibility for their care. This period culminated with the state psychiatric hospital (also known as the asylum) as the primary locus of mental health treatment. The 1950s–1980s was a time of advocacy leading to the movement of patients from state mental hospitals and into the community. This period was also marked by increased recognition of the rights of people living with mental illness, albeit with relatively few polices or resources to support them.