Mental Healthcare Often Isn’t Care at All

Two weeks ago, New York mayor Eric Adams issued a directive to city agencies to involuntarily hospitalise homeless people deemed mentally unwell. Adams, who is leading a longer-term push to close homeless encampments, argued the move was part of the city’s “moral obligation” to help vulnerable people.

Many non-disabled people in the US responded to the news with dismay. That policies seemingly designed for care were being deployed as a means of managing people seen by the state to be unproductive, undesirable or unsightly is clearly repugnant. But many disabled people – including those who self-identify as ‘mad’ or ‘mentally ill’ – know this kind of social control has always been a core function of institutionalisation. While reprehensible, this development isn’t an errant misapplication of mental health and disability law. In fact, it’s merely an expansion of how these laws already function. 

Controlling the ‘surplus class’.

Like the prison system, disability incarceration emerged in line with the rise of capitalism as a means of controlling what Beatrice Adler-Bolton and Artie Vierkant describe as the “surplus class” – people viewed as a drain on, or disruptive to, capitalist economies. In Britain, ‘lunatic asylums’ rapidly expanded in tandem with the capitalist system, as the 19th century ‘poor laws’ stripped people of their financial support and the industrial revolution shifted production from the home to the factory. While mad, mentally ill and disabled people had overwhelmingly lived and laboured in the community until this point, their bodies and minds weren’t amenable to the fast-paced, gruelling factory line. Since their loved ones were being swept into factories and workhouses, there was also no one to care for them in the community. And so poor people in particular began to be institutionalised en masse, and by the turn of the 20th century there were more than 100,000 people detained in British county pauper asylums. The conditions in these spaces were infamously brutal, representing warehouses of punishment rather than places of ‘asylum’. Institutionalisation, however, was a predictable outcome of an economic system that made people mad and valued them only according to how exploitable they were.

‘Deinstitutionalisation’ – the process of closing down asylums or ‘mental hospitals’ – took place across Britain and many other nations including the US in the second part of the 20th century. But the economic system that birthed these institutions hadn’t really changed, and so mad, mentally ill and other disabled people continued to be controlled by the state in different ways. Deinstitutionalisation, which had been taken up as a neoliberal project in Britain under Margaret Thatcher, gave way to the Mental Health Act, which today is used to forcibly hospitalise and treat people who are judged to be ‘mentally disordered’. Forced treatment and psychiatric detention (also known as ‘sectioning’) affect those who are deemed to be a risk to themselves or others, but in reality, these laws disproportionately affect poor and marginalised people. Detentions under the Act are over three times higher in the most deprived areas in England when compared to the least deprived. Black people are almost five times more likely to be detained under the Act than white people – mirroring the institutional racism of the criminal punishment system. Black people are also 40% more likely to make contact with services through the police and the criminal punishment system. Many people in psychiatric detention also have histories of abuse, deprivation, homelessness, unemployment and substance addiction. Forced hospitalisation is therefore a medical response to a wide range of issues that are economic and political in origin.

Policing mental health.

In recent years, the Black Lives Matter movement has drawn attention to the violence of the police and prison systems. There’s a greater understanding that these institutions fail to deliver on their fundamental promises. They outsource ‘justice’ to the state, simultaneously allowing the state to individualise and define justice in line with the violent demands of capital. Fundamentally, they punish poor and racialised people for ‘crime’, rather than getting to the roots of ‘crime’ or interrogating how ‘crime’ is constructed. 

But it’s also important we acknowledge the carceral nature of our mental health system. Police are an ingrained part of the state’s mental health crisis response – they section people, and up to 40% of police time is spent responding to incidents linked to mental health. People who are detained under the Mental Health Act are often held for indefinite periods with little control over their release, and some even remain in custody for decades. Just as the supposedly bygone asylum system did, mental health detention serves to contain those members of society who are seen as least productive and most disruptive. 

In a similar way to the criminal punishment system, government mental health messaging also individualises mental distress and frames it as something that must be exclusively outsourced to authorities outside of the community. Neoliberal campaigns emphasise the importance of ‘reaching out’ to mental health services, overlooking the fact that, for many racialised people in particular, being honest about suicidal thoughts may result in being restrained, locked up, secluded in padded cells or forcibly drugged in the mental health system. While these measures may temporarily preserve life for some, they also frequently lead to death and trauma. In fact, psychiatric detention is responsible for 60% of deaths in state custody in England and Wales. A number of high profile cases, like the deaths of Seni Lewis and David ‘Rocky’ Bennett, have drawn attention to the prevalence and danger of restraint on psychiatric wards. Many people who are sectioned report it was one of the most traumatic experiences of their life, with studies suggesting that suicidality tends to increase after detention. 

Stripping people of their bodily autonomy and locking them up for indefinite periods also destroys the potential for a genuinely caring relationship between people and professionals. This is because the potential for trust and honesty is severely reduced. This phenomenon doesn’t only affect the 50,000 people who are sectioned in England each year. It affects everyone who interacts with mental health professionals, including private therapists, most of which are obliged to break confidentiality if they feel a ‘client’ is at risk of harming themselves or another person. While these policies are so ubiquitous that most people don’t think to question them, they have a tangible impact on the quality and depth of care that’s possible in these forums. For instance, if a person knows discussing suicidal thoughts with their therapist may result in the police being called to section them, they will likely avoid discussing these feelings altogether. This renders suicide, something that’s already a societal taboo, as something unspeakable even in therapy – potentially increasing the individual’s sense of isolation. This mirrors the physical practices of the mental health system, which see suicidal feelings as something to forcibly lock up, restrain and suppress, rather than a painful reality that we can sit with and support one another through.

What does real care demand?

As detentions under the Mental Health Act rise, the expansion of carceral approaches to mental health in Britain is worrying. But as shown by the draconian measures introduced by Adams in the US, forced hospitalisation and treatment responds to political problems. For New York’s homeless population, for instance, the most obvious form of support people need is housing. We can extend this logic to identify all kinds of social transformation that would ameliorate a large amount of mental distress and crisis in our society. Social isolation is one of the greatest risk factors for suicide, while poverty, racism, transphobia, addiction, abuse and poor working and living conditions also lead others to become mentally unwell. One million people sit on an NHS mental health waiting list, with many denied any form of support until they reach crisis point or are deemed to be ‘disruptive’, at which point they are treated punitively. If our social and economic conditions were conducive to good mental health – if we lived in a world that actually cared for people rather than exploited and neglected them – these problems would cease to exist in the way we currently understand them.

In such a world we would, of course, have to generate, practice and pour resources into non-carceral crisis responses to ensure disabled people aren’t abused or neglected when they need support. There are tried and tested precedents for this. Project LETS, a US-based collective led by mad, mentally ill, disabled and neurodivergent people, has pioneered non-carceral, peer led mental healthcare, emphasising the importance of non-hierarchical and person-centred care. Other peer support networks encourage people to make support plans outlining exactly what treatments and care they would want in a crisis, providing their loved ones with a clear ‘mandate’ that honours their consent even if they find themselves in an ‘altered state’, or unable to make decisions for themselves or communicate. In Italy, the ‘Trieste model’ of mental healthcare has also prefigured a non-carceral approach – the town’s mental health system has virtually outlawed institutionalisation, detention and forced treatment. Services have no waiting list, and in crisis situations, they emphasise “relentless negotiation” between people and practitioners – always looking for creative and alternative responses to coercion. In the UK, non-coercive ‘crisis houses’, which, like Trieste, pioneer the policy of ‘no locked doors’, also show us kinder ways of supporting people. 

There are too many alternative approaches to mental distress to detail here – and many more that are yet to be dreamed of. The future of mental healthcare demands millions more experiments, including hyperlocal, culturally contextual, unique and personalised approaches. There is no one cause of suffering, madness or mental illness, and so there will be no one blanket response that works for everyone. We must champion infinite creative community alternatives to ensure no one can be punished by the state for their suffering, and so that everyone, finally, can have their needs met.