Our Broken Mental Health System

Barbara Ehrenreich is the author of thirteen books, including the bestselling Nickel and Dimed. This article was originally published in her blog.

Leaving aside the issue of WMM (Weapons of Mass Murder, aka guns), the massacre at Virginia Tech has something to teach us about the American mental health system. It's farcically easy for an American to be diagnosed as mentally ill: All you have to do is squirm in your fourth grade seat and you're likely to be hit with the label of A.D.D. and a prescription for Ritalin. But when a genuine whack-job comes along--the kind of guy who calls himself "Question Mark" and turns in essays on bloodbaths--there's apparently nothing to be done.

While Cho Seung-Hui quietly - very quietly - pursued his studies, millions of ordinary, non-violent, folks were being subjected to heavy-duty labels ripped from the DSM-IV. An estimated 20 percent of American children and teenagers are diagnosed as mentally ill in the course of a year, and adults need not feel left out of the labeling spree: Watch enough commercials and you'll learn that you suffer from social phobia, depression, stress, or some form of sexual indifference (at least I find it hard to believe that all this "E.D." is purely physical in origin.)

Consider the essay "Manufacturing Depression" in the May issue of Harper's. Hoping to qualify for a study on "Minor Depression" at the Massachusetts General Hospital, the author, Gary Greenberg, presents himself with a list of problems including "the stalled writing projects and the weedy garden, the dwindling bank accounts and the difficulties of parenthood," in other words, "the typical plaint and worry and disappointment of a middle-aged, middle-class American life..."

Alas, it turns out he does not qualify for the Minor Depression study. "What you have," the doctor tells him, "is Major Depression."

In the early sixties, the renegade psychiatrist Thomas Szasz argued, in The Myth of Mental Illness, that the real business of the mental health system was social control. Normal, physically active, nine-year-olds have to learn to sit still. Adults facing "dwindling bank accounts" have to be drugged or disciplined into accepting their fate. What therapy aimed to achieve was not "health," but compliance to social norms.

Szasz still rings true every time I've been confronted with a "personality test" which reads like a police interrogation: How much have you stolen from previous employers? Do you have any objections to selling cocaine? Is it "easier to work when you're a little bit high"?

Then there is the ubiquitous Myers-Briggs test, which seems obsessed with weeding out loners. Presumably, someone in the HR department can use your test results to determine whether you're a good "fit" - a concept the libertarian Szasz must cackle over. (And incidentally, Myers-Briggs possesses no category, and no means of detecting, the person who might show up at work one day with an automatic weapon.)

But for all the attention to "personality" and garden-variety neurosis, we are left with the problem of the afore-mentioned whack-jobs, and the painful question today is: If Cho Seung-Hui's oddities had been noted earlier - say, when he was still under 18 - could he have been successfully diagnosed and treated? Journalist Paul Raeburn's 2004 book, Acquainted with the Night: A Parent's Quest to Understand Depression and Bipolar Disorder in His Children suggests that the answer is a resounding no.

When his own children started acting up, Raeburn found that there are scores of therapists listed in the Yellow Pages, as well as quite a few inpatient facilities for the flamboyantly symptomatic. But nothing links these various elements of potential care into anything that could be called a "system." The therapists, who all march to their own theoretical and pharmaceutical drummers, have no reliable connections to the hospitals, nor do the hospitals have any means of providing follow-up care for patients after they are discharged. Then there is the matter of payment. Between 1988 and 1998, Raeburn reports, managed-care plans cut their spending on psychiatric treatment by 55 percent, putting mental health services almost out of the reach of the middle-class, never mind the poor. Hence, no doubt, the fact that three-quarters of children and teenagers who receive a diagnosis of mental illness get no care for it at all.

If we have no working mental health system, and no means of detecting or treating the murderously disturbed, then there's only one thing left to do: Limit access to the tools of murder, i.e., end the casual sale of handguns.

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