“Will Single Payer and Mental Health Advocates Ever Join Forces? – I – revised
Facts & Figures for Policy Wonks”
Jack Carney, DSW, Coordinator
North Country Access to Health Care Committee
September 25 — November 29, 2021
#PassNYHealth — #buildamassmovement
Preface: The question posed above is more complicated than one might suppose and requires an equally nuanced answer. This paper is written to disentangle the complexities and attempt to formulate a reasonable answer. A confounding factor which I’ll identify at the outset is that the country’s mental health system and its medical overseer, psychiatry, have become integral parts of both the US Healthcare system and the enormous U.S. carceral system, the latter charged at present with supervising the lives of 6.6 million Americans. Much of this paper will be devoted to describing the systemic connections between them.
Most single-payer and healthcare advocates have little awareness of these complex relationships because an interesting phenomenon occurs when mental health and healthcare intersect — healthcare, disappears from view and healthcare practitioners reflexively question whether the problem being presented is delusional or real. Munchausen’s syndrome, that old medical school chestnut, meant to signify a factitious or self-invented physical disorder or problem, enters the examining room, no matter how briefly, and medical care suffers, short-shifted or neglected. A barrier has been raised, one not easily breached, putting the person seeking treatment and the mental health peers and advocates helping her/him in the position of “outsider”, both familiar and unwelcome.
The paper’s objective is to spell out the barrier, actually barriers, in detail and propose alternatives or bridges to surmount them, however speculative. My intended audience – healthcare and mental health practitioners and peer advocates. I believe I’m in a fortuitous position to attempt this, thanks to my forty-year long career in mental health, which includes twenty-plus years developing and directing an Intensive Case Management program in New York City.
For those of you who may not be familiar with the term, “single-payer” healthcare in the U.S. is so called because the government, whether national or state, becomes the sole payer to treatment providers for the costs of all medical services, including dental, optical, pharmaceutical and mental health, incurred by their subscribers. It’s a role now played by the Center for Medicare and Medicaid Services (CMS) for persons 65 and older who are recipients of Medicare and for those who are recipients of Social Security Disability Benefits. When and if single-payer is enacted, commercial or private for-profit health insurance companies, the primary healthcare payers for their subscribers for the past fifty years, will no longer play that role; which explains, in large part, the fierce opposition to single payer’s enactment. Billions of dollars are at stake.
At present, the national single-payer healthcare program being proposed, with the Federal Government as payer, has been titled Medicare for All (M4A): identifying it as a part of Medicare and signifying that all residents of the US will be eligible for this program. Several states are also considering their own single-payer programs: in New York State, the NY Health Act (NYHA), with the State government’s Health Department as payer and all NYS residents automatically subscribed once the NYHA is passed by the State legislature.
I – Introduction: I identify myself, by training and personal preference, as a community organizer. I have lots of initials and professional identifiers after my name – google me if you’re curious; but I’ve looked for and attempted to create community and solidarity wherever I’ve lived, wherever I’ve worked. I’m involved now as an advocate for single-payer health care as a member of the Campaign for NY Health.
Two or so months ago, prompted by the need to recruit more folks to our struggle to pass and enact the New York Health Act, I began to take a look at our current cadre of activists. In a paper I recently wrote, “The Cork in the Bottle: the Road to Single-Payer Goes Through New York (www.paddlingupstream.org/northcountryforum-recentposts, Sept. 2021), I noted that among those assembled in our periodic leadership meetings, only one person, and that only recently, had identified himself as a psychiatric survivor. I wasn’t clear why this was the case – fear of stigma; little awareness or understanding of single-payer health care; outright indifference; so I decided to contact some of the folks, mental health advocates, I’ve known for years and ask.
Their collective response can be summarized as “Diagnosis, Medication, Hospitalization,” a three-word characterization of their personal experience with psychiatry and the U.S. healthcare system. To me, these words signify the three-headed hydra that has come to dominate both: Big Insurance, Big Pharma, Big Medicine. Which essentially means that neither the advocates nor the folks they represent trust the healthcare system.
For starters, they find that all mental health treatment requires the assignment to them by psychiatrists and other mental health professionals of diagnoses that have no scientific bases yet fragment their identities and reduce them from persons to pejorative labels. Further, these diagnoses or labels complicate the access of those that have them to needed medical treatment.
As I wrote in the Preface, and it bears repeating, once the ill person arrives in the ER’s or clinic’s examining room and the assigned medical provider checks the chart and discovers a psychiatric diagnosis, i.e., once the medical and the mental health/psychiatric intersect, the former slips into the background and the treating provider speculates out loud whether the individual’s presenting complaint or problem is real or delusional. This was certainly the experience of most of the several thousand members of the Intensive Case Management program I directed in New York City for nearly twenty years, as reported by them and corroborated by the Intensive Case Managers (ICMs) who accompanied them to ER and clinic visits when they became ill. The usual consequence was poor or indifferent care.
I’m certain that mental health advocates have noted this, and have also witnessed the corrosive impact that psychoactive medications have on those so avidly prescribed them, destroying their imaginations and confounding their cognitions.
Which should lead healthcare practitioners to ask, what is “mental health” in actual clinical practice? Seth Farber, Ph.D., in his paper “Institutional Mental Health and Social Control: The Ravages of Epistemological Hubris”, offers a definition …
“There is a widespread misconception in society that Institutional Mental Health [a term intended to cover all “mental Health professionals] provides valuable services to individuals in need of health and generally attempts to foster personal change or ‘growth.’ I argue in this paper that the praxis of Institutional Mental Health is based on a model that is not oriented primarily toward generating change, but toward maintaining social control. Thus, this model is problematic on ethical as well as epistemological grounds: it understimates the individual’s capacity for change and it consequently undermines this very capacity” (The Journal of Mind and Behavior, Vol. 11, #34, 1990).
To which the advocates would surely add, and I would agree, that this model is fundamentally coercive, holding over the individuals caught up in it the threat of forced hospitalization or criminal justice incarceration should they fail to comply with the treatment orders issued them. It’s important to always keep in mind that incarceration, which includes removal to jails, prisons, mental hospitals and immigrant internment camps, even nursing homes, of all persons considered “other”, i.e., found troublesome because of their caste or ethnic membership or their gender or religious identity, is an integral feature of US society. An era of mass incarceration was launched by Nixon’s War on Drugs in 1971; exacerbated by the Rockefeller Drug Laws enacted in 1973 which called for the harshest penalties in US legal history, mandating prison sentences of 15 years to life for drug dealers and those who used even small amounts of illicit drugs; Reagan’s War on Drugs, embodied in his Crime Bill of 1984, which dramatically increased Federal penalties for drug possession and sale and established the corrupt-from-the-outset Drug Enforcement Agency (DEA) ; and culminated in Clinton’s Crime Bill ten years later, setting off a Federal prison construction boom to house all these drug offenders.
The modern American carceral state had been established. Its vast societal presence – 6.6 million Americans under its jurisdiction at present – essentially countered psychiatry’s contention that prisons were filling up because State hospitals had been closed, a theory termed “transintitutionalization”. What psychiatry continues to fail to comprehend is that hospitalization ßà incarceration exists along a nationwide continuum, mattering little to Government why or how a person gets to wherever she/he winds up . (More below and in “Mental Health: Myth and Misnomer,” Chapter 6, J. Carney, Nation of Killers …, 2015.)
Rebuffed in their efforts to resuscitate the old State hospital system, the source of much of its power, psychiatry and its allies have turned their attention to Involuntary Outpatient Commitment. With the political support of family advocacy organizations like the National Alliance of the Mentally Ill (NAMI), 47 states were speedily persuaded to enact outpatient commitment laws, among the first of which, Kendra’s Law, was adopted in NY State in 1999 and is now a permanent part of NY’s mental hygiene law. These laws allow local jurisdictions to secure court orders re-hospitalizing individuals who appear to be failing to comply with their post-psychiatric hospital treatment plans and have become “symptomatic,” i.e., are exhibiting behaviors discomfiting family members, neighbors and treatment providers. Petitions for these orders are usually brought by those charged with treating the individuals for whom orders are sought, usually at the behest of and often with the involvement of their family members.
(My own assessment of Kendra’s Law and the role that ICM Programs like the one I directed were obliged to play can be found in two articles I wrote for Mad In America: “New York’s Assisted Out-Patient Treatment Program: Racial Myths and Other Stereotypes,” June, 2012, and “More on New York’s Kendra’s Law: Opponents Lining Up for Decisive Battle in 2015,” October, 2012.”)
Similarly to a state’s involuntary psychiatric inpatient commitment orders, which outpatient commitment neatly complements, the orders in New York are carried out by law enforcement – the latter by a county’s sheriff’s department, the inpatient commitment by the local police department, which adds to the stigma the orders carry and the fear and embarrassment they inspire for the person affected and her/his family. Which also adds to their dangerousness – in NYC, from 2015-18, “14 persons died at the hands of the police responding to a call involving an “EDP” (emotionally disturbed person) (The City, March, 2019). It also increases the likelihood that an “EDP” will wind up in jail: more than half of the 80K NYPD responses to these calls in 2018 resulted in one of three outcomes — police escort to the local ER and quick discharge back to home or the streets; in-patient hospitalization, voluntary or involuntary; or arrest and escort to jail once medically cleared and if believed to be guilty of a misdemeanor or low-level felony. For poor New Yorkers, the Rikers Island jail is a black hole.
As per the 2019 City article, the ante in NYC and elsewhere has been upped — “EDP” calls continue to increase; poor neighborhoods and New Yorkers of color are most adversely affected. Yet, the NY Police Department’s touted Crisis Intervention Training for all police officers is stalled – less than one-third of NYPD officers have been trained – and, since 2015, only a handful of the innovative Co-Response Teams, comprised of a police officer and a mental health professional, have so far been deployed. Hence, the increasing clamor by those most affected for reforms in this area, adroitly resisted by the traditionally reactionary Patrolmen’s Benevolent Association (PBA), the police officers union, and City officials.
As I wrote above, 6.6 million Americans, the great majority poor, preponderantly men and women of color, are currently under carceral system/criminal justice supervision, 2.2 million of whom actually incarcerated: 750K in jail; 1.4M in prison, over 300K of whom estimated to be ”mentally ill.” In addition, 1.4 million live in nursing homes, removed from family and friends; 60K reside in State mental hospitals, the residue of deinstitutionalization; as many as 500K persons are held during the course of a year in immigrant detention facilities; 120K American residents are estimated to live on the streets. (All data, from various sources on Google, for 2019-20.) In sum, removal of socially undesirable persons from society, deprived of their civil rights, has become an American commonplace.
The advocates also know that the neuroleptic medications prescribed so cavalierly to persons deemed seriously mentally ill to control their presumed psychoses will, if prescribed long enough, cause serious damage to their hearts and livers, a condition known as metabolic syndrome that will eventually kill them. The classic study completed in October, 2006, by the National Association of State Mental Health Program Directors, reviewed the case histories of thousands of Medicaid-insured individuals treated long-term with neuroleptic medications in Boston mental health facilities. The findings revealed serious cardiac ailments coupled with diabetes II, i.e., metabolic syndrome, in the great majority of those whose charts were studied, and a loss of life expectancy averaging 25 years (“Morbidity and Mortality in People with Serious Mental Illness,” (NASMHPD) Medical Directors Council, Alexandria, Va., 2006). Thirteen years later, a European replication, albeit with a smaller cohort of individuals with similar characteristics, revealed nearly identical findings (“Dying Too Soon: Excess Mortality in Severe Mental Illness,” Front Psychiatry, Vol. 10:855, 2019).
What, then, explains the advocates’ reluctance to involve themselves in the single payer struggle? It’s evident to me that their involvement, their wealth of firsthand experience, which matches and more so that of most other single payer advocates, will increase our chances not only of establishing single payer healthcare in NY State and throughout the country but of changing a corrupted healthcare system that fragments and refuses to acknowledge those admitted to it as unitary persons. (I treat this issue at greater length in the paper I referenced at the outset.)
II – Some History – Back to the1960’s: To repeat what I wrote above, the advocates and those they represent don’t trust the health care system and the practitioners who represent it. Nor do I. We’re aware of the hegemonic position that healthcare, including psychiatry, which considers itself integral to the medical profession, has occupied in American society ever since the enactment of the revised Social Security Act of 1965 establishing Medicare and Medicaid.
As per Paul Starr, Harvard sociologist and author of The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry (1983), the law was transformative for American healthcare. In short order, it awarded hundreds of millions and, over the years, billions of taxpayer dollars to physicians and hospitals to care for the nation’s senior citizens and in the process empowered them to define the country’s ills, whatever their cause or source. It established the Federal government as the single payer of all the bills physicians, hospitals and their insurance company representatives were submitting; and it enabled the Center for Medicare and Medicaid Services (CMS) to develop a billing paradigm that continues today as the model for providers and insurance companies: matching patient diagnosis, i.e., her/his illness, with procedure performed, identified by respective codes, then calculating the fee to be paid to the billing providers or their insurance company intermediaries.
One consequence, identified by Sociologist I.K. Zola in 1972, was the establishment of “Medicine as an Institution of Social Control,” characterized by him as the classic response of a key ruling class entrepreneurial institution, viz., to distort a law designed to benefit ordinary Americans to serve its own ends. Specifically, he expressed alarm at the unchallenged emergence of
“Medicine … becoming the new repository of truth … where absolute … judgments are made by supposedly morally neutral and objective experts… [T]his is not occurring through the political power physicians hold or can influence, but is largely an insidious and often undramatic phenomenon accomplished by ‘medicalizing’ much of daily living, by making medicine and the labels ‘healthy’ and ‘ill’ relevant to an ever increasing art of human existence …” (The Sociological Review, vol. 20, #4, November, 1972.)
Psychiatry’s response was to seek to label any behavior that discomfited those in authority as well as the public at large as a “disorder” – “oppositional defiant disorder” for children and adolescents who resisted authority; “post traumatic disorder” for military veterans who acted out the horrors of war they had managed to survive, to cite two omni-present examples (c.f., Caplan, P., When Johnny and Jane Come Marching Home: How All of Us Can Help Veterans, MIT Press, 2011).
The cultural phenomenon Zola described, medicine and M.D.s in control, should have served to reassure the country’s conservatives, i.e., right-wing Republicans and the Democrats’ Southern Dixiecrat wing, who were in a state of alarm at the avalanche of progressive laws just passed in response to demands for reform from many Americans. The establishment of Medicare and Medicaid had been preceded only two years earlier by the Community Mental Health Centers Act, which had authorized the use of Federal funds to establish community-based treatment centers throughout the country. Was socialized medicine far behind? The year before, 1964, the Civil Rights Act had been passed; followed by the Voting Rights Act the very next year; followed by the Housing Rights Act in 1968; touched off in 1964 by the Economic Opportunity Act, which authorized a War on Poverty. Was the Revolution just around the corner?
Since the advent of FDR’s New Deal and the introduction of Social Democracy-based policy measures into the American political mainstream, any legislation on the national level that has benefited the bulk of ordinary Americans, particularly Black Americans, has been met with fierce pushback by the ruling class and its right-wing political surrogates. In 1968, it came with Nixon, who entered office with a determination to blunt if not put an end to Federal social welfare spending and the continuation of an entrenched government-funded
safety net, both of which were portrayed by the national media and the Dixie-bound Republican Party as primarily benefitting Black Americans. He had a war to bring to a satisfactory conclusion, to achieve peace with honor.
III – Nixon, Medicine for Profit and the War on Black Americans — After failing to convince Congress to end Medicare and Medicaid and to repeal the Community Mental Health Act, Nixon struck his two master blows, initiatives which have lasted into the present. The first was the passage of the Health Maintenance Organization (HMO) Act of 1973 which had the explicit message of controlling health care costs, a mantra which persists in healthcare propaganda today and is used to camouflage its true intent to control access to healthcare and reduce services to most Americans. Specifically, it allowed HMO’s to be organized as profit-making institutions rather than as non-profits as had been customary for health care providers throughout modern American history.
Private insurance companies, which had previously followed the Blue Cross-Blue Shield model of foregoing profit from their healthcare policies, were among the first to jump at the opportunity to explore this opportunity to generate profits for themselves. Today, they are fully integrated into the health care market and collaborate with Medicare to determine reimbursement rates for providers’ services and with state insurance agencies that establish the costs and benefits of insurance policies.
To illustrate private insurance’s omnipresence, private health insurance expenditures in 2019, pre-Covid, amounted to $1,195T. Further, for-profit insurance companies have also been enlisted by the Federal government, which has distanced itself from the role envisioned for it in the New Deal as guardian of ordinary Americans, in the ever-accelerating privatization of Social Security, including Medicare. (I treat this at some length below in this paper and in the “Cork in the Bottle …” article referenced above.) Which is precisely what single-payer healthcare would put a halt to.
Nixon’s second initiative, in 1971, was to declare the first “War on Drugs”, and target young Black men. If you remember your Nixon history, HR Haldeman, Nixon’s chief of staff, had noted in his diary the infamous Nixonism – “… The whole problem is really the blacks …” Nixon was referring to the thousands of angry Black men who had taken to the streets to protest the oppression they and their families were still experiencing despite the promises of a better life that had been made to them. He wanted them out of sight and mind.
Many black men had already been arrested and jailed in the Black Power protests; many had proven so difficult to manage in jail that they had been transferred to the public mental hospitals that, consequent to deinstitutionalization, had been slowly emptying out. How to justify this? What diagnosis to give to them?
If you want the long answer, read Jonathan Metzl’s comprehensive account of what occurred, The Protest Psychosis: How Schizophrenia Became a Black Disease (2013).
The more concise … the American Psychiatric Association, eager to demonstrate psychiatry’s continued utility , and its DSM-II (1968) to the rescue, with commentary by me.
DSM-II was published sixteen years after “I” and was notable for several reasons.
Most pertinent to our discussion, DSM-II flipped the symptomatic indicators for schizophrenia. It de-emphasized the “negative” symptoms – anhedonia, social withdrawal, avolition, or a paralyzing disinterest in life, evident in those patients given the DSM-I diagnosis of schizophrenia, and it heightened the importance of the “positive” symptoms – hallucinations, delusional and disorganized thinking, speech and behavior, the so-called Schneiderian first rank symptoms, which appeared to match the descriptions of the out-of-control black men transferred from penal to psychiatric institutions and eventually back to penal institutions when deinstitutionalization emptied out the state hospitals.
Interestingly, Erving Goffman in his myth-shattering 1961 treatise, Asylums: Essays on the Social Situation of Mental Patients and Other Inmates, cited these same “negative” symptoms as evidence of long-term institutionalization. Psychiatry, presumably threatened by Goffman’s findings, ignored them. (An important illustration of psychiatry’s social control function — DSM II was the last to categorize Homosexuality as a psychiatric disorder, removed from the DSM in 1973 under tremendous pressure from the then nascent gay rights movement and its supporters. Which has proved to be a key to open the pathway for the members of the LGBTQ community to secure legislative protection of their civil rights in this country and around the world [Rubinstein, G., “The decision to remove homosexuality from the DSM: twenty years later,” American Journal of Psychotherapy, Summer, 1995, vol 49 #3.])
DSM-II marked the high point of the reliance of the APA on psychodynamic theory to categorize and define psychiatric “illnesses”. Its successor, DSM-III, published in 1980 and considered by most psychiatrists as revolutionary, shifted its ideological emphasis, forsaking psychodynamic theory as explanatory in favor of a stricter disease classification and, accordingly, diminishing the importance of psychotherapy in treatment in favor of biological interventions, i.e., psychotropic medications, which the APA regarded as the true province of psychiatrists as physicians.
The move towards biomedicine was also tactical, typical of a profession in retreat, an attempt to ward off the steady encroachment into psychotherapy of therapists from other disciplines. [Kawa & Giordano, “A brief historicity of the DSM: Issues and implications for the future of psychiatric canon and practice”, Philosophy, Ethics and Humanities in Medicine, online, Jan. 13, 2012, vol. 7, #2.]) It also has had serious political and economic consequences, mainly adverse for ordinary Americans, contributing mightily to the rise of Big Pharma and its accumulation of wealth and power (Zaitcheck, “How Big Pharma Was Captured by the One Percent,” The New Republic, June, 2018.)
Despite the apparent influence of the DSM, it’s important to keep in mind that each of the six editions of the DSM published between 1952 to 2013, as the illnesses and disease categories addressed within each were expanded, has been marked by a successive decline in statistical validity and inter-rater reliability. Much has been written about this and so I refer the interested reader to the world-renowned publication by Dr. Paula Caplan, They Say You’re Crazy: The Inside Story of the DSM, 1995, and the more modest effort by me, published in MIA in March, 2013, “The DSM-5 Field Trials; Inter-Rater Reliability Ratings Take a Nose Dive,” while I was serving as national coordinator of the Committee to Boycott DSM-5.
I became well-versed in these conflicts with psychiatry during my twenty-years-plus involvement with NY City’s Intensive Case Management Programs and the wide range of social policy questions related to it. It was the first proactive “in the streets” program funded in New York in the aftermath of deinstitutionalization to support individuals leaving prisons and hospitals by enrolling them in an ICM program immediately prior to or at the point of community re-entry. ICM was grounded in psycho-social rehabilitation theory and practice and its aim was to prevent or forestall recidivism by connecting participants with necessary survival and support services – housing, treatment, Medicaid and SSI , and with their families whenever possible — and secure their re-settlement in a City neighborhood most facilitative of this goal.
As the Director of the ICM Training Program at the Hunter College School of Social Work (1989-1997) and of the Parole and Double-Recovery (how quaint!) ICM programs, the first of their kind to be housed at a large NYC non-profit (1993-2010), I received my graduate education in the abuses which NY City’s & State’s criminal justice and mental health systems and their streets were capable of meting out.
Lesson 1: Every one of the several thousands of Black man and woman referred to us from NY State Correctional Facilities, as well as from many hospitals, arrived with a diagnosis of schizophrenia – the men – or schizoaffective disorder – the women. When we inquired into this phenomenon with each, we were informed that he or she had experienced hallucinations prior to or while in prison. When we inquired further, we were informed that, as a child or adolescent, each had experienced poverty; had been raised by one parent or parental figure who often was not fully competent; experienced or witnessed physical and/or sexual violence within their homes and/or neighborhoods; brutal treatment at the hands of the police or other figures of authority; been a victim of and/or perpetrator of a crime, often one involving violence; had used drugs or alcohol to anesthetize themselves; had or may have had a traumatic brain injury; did not finish high school.
Lesson 2: We saw little evidence of a “mental illness” but concluded that nearly all had been highly traumatized during their lifetimes, including their time spent incarcerated, and were suffering from a variety of physical, cognitive and emotional injuries. We periodically made attempts to have diagnoses changed, with little success — we had little clinical leverage with psychiatrists; we were able to make better cases, with the help of program participants, with medication changes and reductions.
Lesson 3: The two biggest causes of death for our enrollees – suicide and metabolic syndrome. The former we addressed assiduously and with some success over time: our enrollees were imprisoned by their pasts, living out Faulkner’s aphorism, “The past is never dead, it’s never even past.” To address the cardiac problems and diabetes that afflicted most of our program members and for which they received inadequate medical care, we pursued connections with neighborhood Family Health Centers. We also developed an eight-session-long “Self-Advocacy” Training program: taught by medical practitioners, it described for participants in detail the neuroleptic medications being prescribed them and their adverse physical and neurological side effects. Two of the eight sessions were devoted to advocacy skills training, to be employed with treatment providers; all eight were attended by ICM enrollees and their ICMs to enhance communication between them, with the former proving to be eager participants. Over the course of my last two years in the program before I retired, one hundred or so members and their case managers completed the training.
We found over time that most of our program participants responded to the warmth and kindness of the case managers, most women of color, often recovered or developed many of their mis-or unused social skills and felt sufficiently encouraged to begin intimate and lasting relationships, pursue formal education, training opportunities and employment opportunities. As they improved and felt better, achieving self-confidence and a more secure sense of self, many slowly distanced from most if not all treatment and were discharged, the usual route taken by most persons captured by the mental health system.
Most were never reincarcerated; those that were, were charged largely for technical parole violations, rarely for the commission of a new crime.
These years proved to be the most rewarding of my professional career. Unfortunately, within a year of my retirement in 2010, the State dissolved all Intensive Case Management programs throughout the State, replacing irreplaceable case managers and their hands-on, collaborative work, with “targeted” case management, i.e., case management via computer. ICM and its stepped-down companion, Supportive Case Management, with their wraparound funds for those being enrolled in them, had apparently proved too expensive. The persons who had led this initiative, headed by Richard Surles, had come from states and cities that had been among the most innovative in funding community support services during deinstitutionalization. When they and the experienced people that had accompanied them left throughout the 1990’s, they took with them the psychosocial rehab culture they had introduced. The ICM/SCM program had lost its key proponents and was ripe for plucking from the State budget, an all too common phenomenon and an admonition to all who seek lasting change from government.
I discussed in some detail the replacement state-wide program, termed Mental Health Homes, still in operation, in two MIA articles published in 2012: “Mental Health Homes Open Their Proverbial Doors … Part I,” and “Mental Health Homes … Caveats, Part II.” The final blow for the program I directed was the bankruptcy of the agency that housed it.
When all was said and done, Nixon got what he wanted, with a timely assist from the American Psychiatric Association (APA): Black men were crazy, schizophrenic, and needed to be locked up either in a prison or a state hospital. His War on Drugs, which Rockefeller and Reagan doubled down on and expanded, took young Black men off the streets and into Federal and State prisons, largely for drug-related crimes. The era of mass arrests and incarcerations, the capstone of the United States as the world’s premier carceral state, had arrived and is still with us. As is the War on Drugs [and on poor Americans, for the most part people of color]. Accordingly, anyone considered an “other” – people of color; new immigrants; Muslims; persons labelled “mentally ill” or drug-addicted – continues at high risk for arrest and/or violence at the hands of U.S. criminal justice agencies.
IV— Reform & Its Barriers — Pushback & Counter-Pushback: A long-awaited pushback from reform advocates has begun, driven by the same forces that launched deinstitutionalization – concerns about the civil rights of those incarcerated and the increasing consequent costs. Many states have responded, legalizing marijuana for recreational use; expunging the criminal records of those incarcerated for simple possession of illegal drugs and charged with low-level felonies; granting early release for these same individuals. Unfortunately, the principal mistake made at the outset of deinstitutionalization, lack of funding for community support services for those released into their home communities, which left them vulnerable to a speedy return to the recidivism treadmill – homelessness, mental hospitalization, reincarceration – appears likely to be repeated.
In New York State, correctional facilities’ (c.f.’s), have declined in population from a high of 70K+ inmates in the 1990’s to approximately 40K at present. Since 2009, 23 CF’s have been closed, with at least 6 three slated for closing in 2022 (Wikipedia, List of NYS Prisons, 2019; “Six NYS Prisons to close …,” NCPR, Nov., 2021). The populations of NYS psychiatric centers, the State’s long-term psych facilities, have shown similar recent declines – less than 3,000 patients are currently filling 5,600 beds (NYS Office of Mental Health, OMH Monthly Report: August 2021).
On another front, State-certified acute in-patient beds have been reduced, in the face of rising State and NY City populations, from 6000+ to 5400 over the past 20 years. Private non-profit hospital providers have begun to challenge the cuts. The NYSNA (NYS Nurses Association), in its article “Key Findings on NYS’s Mental Health Emergency” & white paper “A Crisis in In-patient Psychiatric Services in NYC Hospitals,” August, 2020, contends that these cuts are calamitous and emanate from Gov. Cuomo’s push to cut Medicaid spending. (For those interested, NYSNA’s White Paper spells out the Governor’s political deal-making with Trump’s CMS and the resulting conflicts between him and the providers in great detail.)
I can understand the nurses’ position, fighting for their patients’ and would-be patients’ well-being; but, from the perspective of those of us who oppose the carceral state and want to see it taken apart, NYSNA’s position supports the status quo and would be a sure point of contention for the advocates this paper is addressing. We think there are better, non-coercive, alternatives – Soteria House, replicated successfully throughout North America and Europe, comes to mind as a model (Mosher, Loren R., “The Soteria Project: The First Generation American Alternatives to Psychiatric Hospitalization”, in Warner, R., ed., Alternatives to the Hospital for Acute Psychiatric Treatment, 1995, Washington DC: American Psychiatric Publishers; & Ingle, M., “How Does the Soteria House Heal?”, MIA, Sept., 2019 ). In short, a potential deal-breaker and a good illustration of the barriers that could keep us apart, yet one that also contains its own resolution: use single-payer healthcare to fund Soteria respite houses not more psychiatric beds, all within the US Healthcare system and not the Carceral system. To be continued …
In 2004 and 2009, Governors Pataki and Patterson, respectively, repealed the worst elements of the Rockefeller laws, dramatically eliminating mandatory sentences for drug offences and reducing the length of drug sentences overall. Many other states have followed suit. Other reforms approved by the NYS Legislature: in 2020, bail reform, to reduce the number of persons incarcerated in jails because they can’t meet bail requirements (Center for Court Innovation, “Bail Reform in New York: Legislative Provisions and Implications for NY City,” April, 2019); and passage of the HALT law – Humane Alternatives to Long-Term Solitary Confinement – in 2021, ending the use of long-term solitary confinement, euphemistically termed Special Housing Units (SHUs), for those inmates who are “hard to manage”, another corrections euphemism applied to those in the general prison population who become depressed or appear “out of control” (NY Civil Liberties Union, “The Humane Alternatives to Long-Term [HALT] Solitary Confinement Act, November, 2021).
In short order, a counter-pushback has begun and largely succeeded in altering, even blocking, these particular measures, spearheaded by the State’s upstate conservative district attorneys, the State’s and City’s Corrections Officers unions and the NY Police Department’s rank and file police officers’ union, most of whose members are staunchly conservative. Unsurprisingly, they all reflexively tootled the old canard that these prison and bail reforms largely benefit Black and Brown New Yorkers.
The Bail Reform Law, passed in 2020, was amended in 2021 to reduce its more progressive measures and render it less effective in reducing jail stays. The law’s opponents can be expected to renew their attempts at repeal in 2022; it is sure to be hot-button election issue when the entire legislature and the Governor will be up for re-election. HALT was signed into law by Governor Cuomo shortly before he left office this past August, the consequence of a several-years-long campaign by a Brooklyn-based community organization, the NY Campaign for Alternatives to Isolated Confinement (CAIC). It was actively supported by mental health advocates since it offered immense relief to inmates seriously depressed or in the midst of psychotic episodes. Unfortunately, opposition to the law from, once again, the State’s and City’s Corrections Officers Unions, has been so fierce that it has yet to be implemented in State correctional facilities or NY City’s Rikers Island jails: in May of this year, the former filed a yet to be resolved Federal lawsuit blocking the law, contending it exposed its members to increased dangers and therefore violated their civil rights (Dan Clark, “NY correction officers sue to overturn new Halt …, NPR, May, 2021). The City corrections officers union has been waging a complementary unofficial sick-out in protest, which has also served to stall the Bail Reform Law. In sum, law enforcement evidences little hesitation in showing their contempt for these laws and for the individuals the laws – and presumably they – are supposed to protect.
Many Americans, including this one, had hoped that the mass street demonstrations led by Black Lives Matter activists since May, 2020 would check police brutality directed at Black Americans. George Floyd’s murder in May, 2020, at the hands of Derek Chauvin and three Minneapolis police accomplices, triggered the protests that have continued to the present, fueled by the memories of a dozen high profile police murders, beginning with Eric Garner’s and Michael Brown’s in 2014, which led to the formation of BLM, continuing into 2020 with the deaths of Ahmaud Arbery, whose killers have just been found guilty of murder, then of Breonna Taylor and Mr. Floyd. That string of murders culminated in the conviction and sentencing of Derek Chauvin, sergeant in the Minneapolis PD (MPD) to 22 years in prison for 2nd degree murder (N. Dungca, et al, Washington Post, June, 2020). The trial of Chauvin’s three MPD accomplices remains pending. Lamentably, police killings of civilians continue at the same rate, approximately 1000 persons per year, as they have since Mr. Brown’s death in 2014. (c.f., “Fatal Force: 915 People Have Been Shot and Killed by the Police in the Past Year,” Washington Post, November, 2021.) As per Statistas, October, 2021, 241 Black Americans and 169 Latinx number among last year’s 915. The protests have continued apace.
Searching for solutions, many Americans, again multi-hued and -ethnic in composition, began calling for Abolition of the Police, particularly in Minneapolis, as well as for Police Reform, with an emphasis on changing police on-the-street involvement with EDP’s, the NYPD’s acronym for “Emotionally Disturbed Persons, to obviate the risks I discussed earlier. Again, mental health advocates embraced this idea, suggesting police/mental health partnerships or the ceding of what had been, by law, solely a police function to mental health peers and professionals. Their objective was to protect the person in emotional distress and lessen the trauma of being escorted to a hospital for incarceration there, no matter how benign and helpful the experience proved to be (“Police Reform from the Perspective of Mental Health Professionals…, ” Psychiatric Services, November, 2021; Kim, et al, “Defund the Police – Invest in Community Care, Interrupting Criminalization, May, 2021).
Again, the corporate media, prodded by privileged white conservatives, confounded abolition and reform, alarmed ordinary and ill-informed Americans, and created a hardened constituency opposed to any changes in police functions and responsibilities. Not unexpectedly, a ballot proposition in Minneapolis calling for the replacement of the existing police department with a department of public safety went down to resounding defeat. In New York City, as I noted above, and in other locales, the steam, at least momentarily, has gone out of the enthusiasm for experiments in police-mental health partnerships and will require renewed leadership from advocates and whichever political allies they can muster. I’m sure that Black Lives Matter will be at the forefront of any renewed effort.
It’s important to know that mental health peers and professionals had pursued similar objectives less than ten years ago, focused not on police reform but on the adoption by the US Senate of a UN Human Rights initiative, “Convention on the Rights of Persons with Disabilities’ (CRPD). Their principal objective was to prevent the involuntary hospitalizations of persons in severe emotional distress. In fact, in 2013, as consequence of testimony by American mental advocates led by lawyer and psychiatric survivor, Tina Minkowitz, before the UN Commission on Human Rights in Geneva in March of that year, the UN’s Special Rapporteur on Torture declared psychiatric, indeed any, hospitalizations against a person’s will, acts of torture. This occurred after the US Senate refused to ratify the Convention, which would have given it the force of law in the US, despite two concerted attempts by then Secretary of State John Kerry to secure its ratification. (Cox & Pecquet, “Senate Rejects UN Treaty for Disabled Rights …” The Hill, December, 2012;” also discussed at some length in the above referenced Carney, J., “Mental Illness: Myth & Metaphor,” 2015.)
Some history: the Convention was adopted in 2007 and became effective a year later. The US is only one of six countries never to have ratified it. Since the Reagan presidency, this nationalistic course in relation to the UN has essentially become US policy. The explanation proffered is one of two usual refrains: the US already has the laws to address the issue at hand, as was the case when the Disability Rights Convention was rejected by the Senate; or the long-standing traditional explanation, first presented when the Congress rejected membership in the League of Nations post-WWI: the US will not suffer foreign interference in the country’s internal affairs. Hence, no membership in the League then, and none in today’s World Court.
I assume advocates will continue focused on this human and civil rights violation, possibly the most detested intrusion into the lives of psychiatric survivors. For those interested in this issue, Ms. Minkowitz published several articles in MIA around this time that detailed what was at stake and described her and her colleagues’ experiences in preparing for and then testifying before the UN’s Human Rights Commission. I should also note that the HALT Law is similarly grounded in UN Human Rights Conventions, specifically the Mandela Rules, which spell out the human rights of persons who are incarcerated regardless of the crimes for which they have been convicted. In 2015, those rules were updated to include solitary confinement, stipulating that involuntary seclusion lasting beyond 22 uninterrupted hours constitutes psychological torture. The HALT Law conforms to those standards.
In the midst of all this, Federal prison populations, comprised mainly of drug offenders, remain static, largely consequent to the determined opposition of the Drug Enforcement Agency (DEA) to any drug legalization, particularly of marijuana, possession of which continues to be a classified as a Schedule I felony. Both the Republican and Democratic parties, right of center parties, essentially conservative and highly supportive of US foreign military adventures, which often employ drug trafficking as a tool of US foreign policy, continue to steer clear of this issue (c.f. Peter Dale Scott, “Drugs, Oil and War: The U.S. in Afghanistan, Colombia & Indochina,” 2003). This might sound implausible, but simply remember Reagan’s Iran-Contra adventure, from 1985-7, when Noriega in Panama shipped cocaine to the Contras in Honduras, who then sold it to narco-traffickers in Mexico who shipped it for sale to the gringos in American cities; whereupon the Contras used the proceeds to buy guns from Iran that they used to kill Sandinistas in Nicaragua. When Congress investigated, Col. Ollie North fell on his sword for Reagan. A recent article in The New Yorker – Jon Lee Anderson, “False Friends: Corruption, Crisis, and American Complicity,” November, 2021 – details the long-term consequences for Honduras, a failed state and center of Central American narco-trafficking.
V – Solidarity Forever — Summary & Conclusions: When I write I learn. Writing, for me, is an opportunity to pull together ideas, use them to examine the assumptions which led me to write and possess or alter them accordingly. I wrote this paper and the “Cork in the Bottle …”, the article that preceded it, as complementary articles, spelling out the barriers that separate Healthcare and Mental Health advocates, identifying those common to both as well as those peculiar to one or the other. I learned much from one paper to the next, particularly what I neglected to include in the first; and I found myself obliged to revise my assumptions about what separates us. I’ve concluded that the ruling class and its surrogates are unified in opposition to us. We need one another.
First and most pertinent to this paper, mental health, particularly the “institutional mental health” that Dr. Farber identified at the outset of this paper, is more a part of the US Carceral State than it is of the US Healthcare system. Just to remind the reader, institutional mental health follows all the rules set down by psychiatry and the government and insurance payers about the centrality of diagnosis and medication and the consequences of treatment defiance. Accordingly, mental health advocates want no part of either system, both of which endorse these rules, and are opposed to any initiative that would tie them more tightly into what they regard as the sources of their oppression. Which is how they view single payer health care. To quote a self-identified psychiatric survivor’s vehement response to one of my Facebook postings about the NY Health Act, “Medicare for All kills disabled people.”
One could view the respondent as ill-informed, irrational; but to me what he wrote reminded me of Baldwin’s comment about Black integration into US society:
“… but I do not know many Negroes who are eager to be ‘accepted’ by white people, still less to be loved by them; they, the blacks, simply don’t wish to be beaten over the head by the whites every instant of our brief passage on this planet…” (The Fire Next Time, 1963.)
Interestingly, Will Hall, widely respected survivor advocate, recently urged his brother and sister advocates to follow the lead of Black Lives Matter, recognizing that Black Americans know more about white Americans – and the consequences of white supremacy and white privilege – than anyone else; further, that they have more experience and more audacity in successfully opposing American white supremacists than any other Americans; and that they have developed the paradigm of opposition to oppression that all other American outsider groups seeking to secure their civil and human rights have followed (Hall, W., “Why Mental Organizations Should Endorse the Movement for Black Lives,” https://medium.com@willhall, Sept.19, 2021).
He anticipates pretty much what I say in “The Cork in The Bottle”:
“The power of the pharma and medical industry lobbies is too great: only with comprehensive political change can we ever hope to make mental health reform
happen… the Movement for Black lives is a leading part in a deeper challenge … that can make real social change possible … for all of us … We will never get real mental health change without real social change …” (W. Hall, ibid.)
I’ve drawn the same conclusion. The first half of “… Cork …” is spent listing the array of powerful opponents that single-payer has attracted. The stakes are enormous, $3.8 trillion or almost one-quarter of the US annual gross domestic product (GDP), the amount spent on health care in 2019, and constantly rising. A mass movement is called for.
Heading the list is the Federal Government, whose power has been marshalled by the American right-wing to overturn LBJ’s healthcare reforms of the 1960’s. Taxpayer monies – at present, close to $1.5T annually (as per CMS, the Center for Medicare and Medicaid Services) — have been used to enlist Big Insurance, Big Pharma and Big Medicine, which collectively control the US Healthcare system, to implement programs designed to selectively ration healthcare while generating huge profits for themselves and concurrently undermining Medicare. As a consequence, US Healthcare has become a wholly capitalist enterprise, where relationships between health care providers and between them and their patients have become transactional rather than collaborative, a venue for winners and losers. Healthcare professionals, particularly nurses, have been leaving in increasingly large numbers; Covid is apparently the final straw, but nursing flight has been occurring for years (Gellasch, P., “The Driving Forces Behind Nurses Leaving the Profession,” Nurse Leader, 2015).
Wall Street, financial capital of mega-capitalist America, has sniffed out the privatization underway, the investment opportunities present in the healthcare system; has loosed its private equity and hedge funds, sharks in the water, and begun to gobble up and spit out vulnerable providers. Between 2006 and 2021, as per the American Investment Council, private equity firms have invested nearly $1 T in healthcare and now own 4% of US hospitals and 11% of nursing homes (“Private Equity is Buying Up US Healthcare …”, Blue Ridge Public Radio, September, 2021). The consequences are usually dire for these entities’ staffs and patients: their resources are bled out, staff and support services get cut, all to boost profits, with the result, to quote the February, 2021 headline in Vox, “Private Equity ownership is killing people at nursing homes.” Remember, older Americans occupy nursing home beds often bereft of family and friends, living in for-profit residential facilities that are part of both the healthcare system and the carceral state, that control their residents’ every move. As we learned to our regret during Covid’s early emergence in New York, State governments and not Medicare provide oversight, often indifferently.
To make matters worse for ordinary Americans, the Federal Government, via the Center for Medicare and Medicaid Services (CMS), has given the green light to private for-profit insurance companies to prey on older and disabled Americans who rely on Medicare for their health coverage. Since 1997 and Clinton, for-profit insurance has been developing Medicare Advantage programs – lovely euphemism for privatizing a taxpayer funded program, once again labelled a cost-control initiative – and is being paid by CMS $800 per Medicare subscriber who is induced to enroll in Medicare Advantage. Presumably an identical Medicare facsimile, it has lower premiums than Medicare supplement programs, and offers more benefits than standard Medicare — what’s not to like? In fact, 42% of all Medicare recipients have been persuaded to switch.
Yet, there’s always a hitch, particularly if their sponsoring insurance companies have to turn a profit. For starters, MA programs cherry-pick their subscribers – no pre-existing conditions, i.e., they’re not sick when they enroll; no or few persons of color since they’ve usually gotten lousy healthcare most of their lives and probably do have pre-existing conditions; and limited number of providers in their networks, so treatment out of network comes out of subscribers’ pockets; plus, depending on the policy you buy, high deductibles and co-payments. In sum, if you’re healthy, a good deal; if you get sick, you might lose your policy and be obliged to return to US Medicare, where you’ll always be welcome. For now.
At present, CMS is preparing to drop the final privatization shoe, designed to impact all subscribers who have stayed with Medicare, realizing the pitfalls with MA plans that lay ahead for them as they aged. After years of experimenting with Accountable Care Organizations, ACO’s, borrowed from the ACA to, yes, control costs, which it didn’t, and to bring additional funding to small rural providers, which it also failed to do, CMS has decided to bite the bullet and develop hand-in-hand with for-profit insurance companies
what it terms Direct Contracting Entities, DCE’s. Which will be assigned specific regions of the country to serve and will offer insurance coverage to all current Medicare subscribers as well as those who are Medicare-eligible and have refused enrollment in MA plans. The kicker here is that CMS is considering not offering these individuals a choice but simply assigning them to the DCE that serves the area where they live (Kemble and Sullivan, “The Latest Attempt to Privatize Medicare September 12, 2021,” One Payer States).
Should this come to pass, it will mark the end of Medicare as a publicly funded safety net program, will limit choice of providers and will adversely affect all persons who suffer from serious and long-term illnesses – – and I don’t mean “mental Illnesses” – many of whom will be psychiatric survivors or currently involved in mental health treatment. Most significantly for me as a proponent of single-payer health care and my single-payer colleagues, Medicare for All and its State replications like the NY Health Act will be kaput: with single payer’s titular model effectively erased, Medicare for All will be a misnomer, and a crucial social reform will reside only in our memories as a what-might-have-been.
Principal proponents of single-payer – National United Nurses in California; Physicians for a National Health Plan (PNHP) in New York and Chicago and other major cities; the NYS Nurses Association; the Campaign for NY Health; and several major healthcare unions, including SEIU-1199 in NY City and the Northeast – are only beginning to grapple with this potential eventuality. I know, and they will, too, that we can’t turn aside the Federal government and its for-profit capitalist allies by ourselves, that we will need to be part of that aforementioned mass movement; which is inspiring to contemplate but hard to put together. Which is why no one yet has, and which is why this appeal.
Will Hall and his psych survivor colleagues and their peers also appear to know that they can’t win their freedom from the Carceral state that continues to entrap them – and us, too – by themselves; which is why he’s urged alliance with BLM. They know, as do many in the single payer movement and in other anti-fascist organizations in this country and around the world that the US is on the path to becoming a rogue country. As I wrote earlier, the US government, contrary to UN Human Rights conventions, continues to support the incarceration of emotionally distraught individuals in hospital-based detention facilities against their will; to submit emotionally distraught individuals to psychological torture via involuntary isolation in prison holding cells as a management strategy that benefits their custodians.
In October of this year, the Mandela Tribunal, the investigative arm of the Spirit of Mandela Coalition, an international organization whose mission is to investigate human rights abuses, convened in Harlem, in the same hall where Malcolm X was assassinated; and after hearing testimony from a wide range of individuals and organizations …
“unanimously found the United State guilty of the following five counts, which … fit well within the internationally accepted definition of genocide:
- Police violence and killings
- Mass incarcerations
- [Incarcerating without trial] Political Prisoners and Prisoners of War
- Environmental Racism
- Public Health Inequities”
(“Panel of International Jurists Render Verdict that US is Guilty of Genocide,” https://Spiritofmandela.org/panel-of-international-jurists-render-verdict-that-u-s-is-guilty-of-genocide.)
Taking Will Hall at his word, I invite him and all psych survivor advocates and peers, particularly my fellow members in Mind Freedom International, one of the oldest and largest peer advocacy organizations in the world, to join us in what promises to be an all-encompassing struggle. Bring along with you whoever else is willing.
To close with Baldwin …
“It has always been much easier . . . to give a name to the evil without than to locate the terror within. And yet, the terror within is far truer and far more powerful than any of our labels.” Nobody Knows My Name, 1961.
Having named our fear, we will not be afraid.
Jack Carney, November 24, 2021