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Most of my training and career have focused on the individual or family sitting in front of me asking for relief from their suffering. I have spent many hours learning how to engage, evaluate, and treat complex human beings who walk through the clinic door. It’s hard and rewarding work; but the problem is that the work is becoming harder.
Several years ago I gave my first lecture on health disparities to medical residents after reading Donald Barr’s book on the topic. That book upset me for a couple of reasons. First, I quickly realized my knowledge of healthcare disparities was superficial, at best. Dr. Barr took me to school and taught me how deep and pernicious the inequalities really go.
Second, I learned that big structural powers like a really effective public health system kick the butt of healthcare every day of the week and twice on Sunday. I learned how public health reforms like the building of sewers, the regular collection of garbage followed by incineration or disposal in a landfill, the provision of clean water and the draining of standing water to prevent the breeding of mosquitoes saved millions of lives.
None of my clinical training covered this! While I was learning how to use sculpt a family a la Virginia Satir, my public health colleagues were learning how to control infectious diseases and prevent pandemics. I asked myself, “If public health is so effective, should I stop coming to work?”
While I was still reeling from this new revelation, I attended a lecture by Don Berwick, the renowned pediatrician and quality improvement pioneer. The lecture felt cozy and safe until Dr. Berwick hit me with this doozy: “Healthcare is a weak tool, it’s nearly impotent if we want vitality in populations.” Et tu Berwick?
I slowly came to grips with the reality that healthcare has serious limitations, that a thirty or sixty minute weekly appointment can only do so much for a patient.
I began to see structural powers like public health as a fence at the top of a great hill that keeps people from falling. I also began to see healthcare as the ambulance at the bottom of the hill for any Jack and Jill with broken bones or heavy hearts.
I now hold several things in my mind as true. First, structural problems (political, social, economic) contribute to distress in significant ways. Second, unrelenting distress can lead to mental health problems for some people. Third, some of these individuals may benefit from mental healthcare.
I have written previously about the long wait times for mental healthcare and recent efforts to infuse the system with more funding. I also celebrated when John Oliver highlighted mental health in his show over the summer.
Throughout all this, I have become transfixed on the idea that our mental healthcare systems needs to be bigger, better, and integrated. Yes! That is the right solution for the growing diseases of death and despair. More is better, right? Give the people what they want! More therapists, more psychiatrists, and more teams working together!
But then I read an opinion article by Danielle Carr and I began tapping the brakes. She argues that we have medicalized normal distress and too quickly concluded that more mental healthcare is the right solution. We have become mesmerized by the glittering mental health tech start-ups that “promise to solve the crisis through a gig economy model for psychiatric care”.
Like watching a predictable rom-com, I knew where Danielle was going and knew she was right. Yes, our stress levels are high; yes, our healthcare system is stretched thin; yes, funding is important; yes, we need a national suicide hotline.
But if the root cause of the problem is structural, then the proposed treatment of more mental healthcare is off base. If people need housing, food security, education, child care, job security, and the right to organize at work, then training and hiring more mental health professionals is not going to help. Doing more of the same is akin to palliative care.
Today I still prepare my students to become mental healthcare professionals, but I also teach them to think systemically and notice the primary drivers of inequality and distress. I also resist the temptation to follow after quick and easy solutions for our societal needs and advocate for big structural changes. Yes, healthcare is a weak tool, but it is the one in my hand right now. I will try to make the most of it.