Responding to perceptions of a mental-health crisis, various states have taken steps to support and expand their mental-health workforces. Texas, for example, last year committed over $130 million to boost compensation for staff employed in state psychiatric hospitals, part of a multibillion-dollar commitment to expanding and upgrading those facilities. It is hard to imagine a more on-the-mark investment for people with serious mental illness, such as schizophrenia and bipolar disorder, whose lack of treatment represents the most pressing aspect of America’s mental-health crisis.
Other initiatives, including ones launched in Ohio and New York, have sought to address the shortage of mental-health workers upstream. Those states have increased education and training funding for behavioral-health professionals, such as by offering loan relief and scholarships. These programs’ benefits will be more uncertain. History suggests that any initiative designed to bolster generally the ranks of “mental-health workers” risks diluting the focus and overlooking the patients most seriously in need.
We have been down this road before. Postwar America faced dire mental-health-workforce shortages. Doctor-to-patient ratios at state hospitals were sometimes as high as 1:500 and nurse-to-patient ratios as high as 1:1,320. Reformers pushed for more federal spending on personnel to strengthen both the existing asylum system and the then-emerging community-based system. The 1946 National Mental Health Act, which created the National Institute of Mental Health, set aside funds for training psychiatrists and other mental-health professionals.
The reformers’ strategy did not go as planned. Between World War II and the mid-1980s, thanks to over $2 billion in federal training subsidies, the number of psychiatrists, psychologists, and psychiatric social workers collectively grew over 1,300 percent. But these newly trained professionals avoided asylum work and those community-based programs for the seriously mentally ill. They wound up mainly serving the “worried well”—functional Americans struggling with less severe problems.
In twenty-first-century America, about 30 percent of the seriously mentally ill receive zero treatment. Sometimes this happens because their community lacks psychiatrists or psychologists; but for the seriously mentally ill, who pose the greatest risks to their communities, the most formidable obstacle to treatment is their own disinclination to pursue it. These individuals either prefer an unmedicated life on the streets or don’t accept that they are sick to begin with.
This is the problem we need more trained and dedicated professionals to address—people willing to work with seriously mentally ill adults, even if those adults are violent, which, for psychiatric technicians and aides in hospital-based programs, is an all-too-real occupational hazard.
States should take the lead on these investments, given their primary responsibility for mental-health treatment and their direct control of public university systems. Since many mental-health professionals first considered a career track in health and human services, states should consider how to divert more social workers, nurses, and doctors to working with the seriously mentally ill. One potential model comes from Texas, which recently launched a scholarship program dedicated to fellowships in forensic psychiatry.
The shortage of mental-health workers is most pronounced in rural America and is not confined to the mental-health system proper. Jails and prisons, host to roughly 300,000 seriously mentally ill individuals, face chronic personnel shortages. Retention can be a problem in urban areas, too, because of competing professional opportunities.
The American mental-health crisis should not be framed as a straightforward problem of supply and demand. Demand for mental-health services is highly price-driven. Many will avail themselves of a therapist’s services if the cost is manageable; otherwise, they make do without. Last year, more than 67 million Americans received some sort of mental-health treatment, but the overwhelming majority were not seriously ill. A better targeting of resources—above all, human resources—is in order.
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