Bridging the Gap: Addressing Economic, Social, and Legal Barriers to Achieving Mental Health Equity in the United States

By: Bhavya Arora, Ayse Betul Ilyas, Ava Duncan, Ishana Ira, Jaiden Makadia, Gabe Naranjo, Sahanashree Rajeshkumar, Lasya Voonna, Emma Zuarino

Teen Think Tank Project | 2024 Summer Change Agent Academy | Financial Stability Research Cohort | Research Coordinator: Matthew DeSantis | Research Assistant, Atiyah Hack-Russell | August 8, 2024

Abstract

This research paper will explore the economic, social, and legal barriers contributing to the mental health crisis in the United States. It will focus on identifying the inequities within the American mental health service system and propose potential solutions to address these challenges. The paper will examine the economic impediments, particularly the geographical disparities that impact mental health access, and analyze the social impediments, such as stigma, incarceration, and childhood trauma, that hinder mental health equity. Additionally, it will investigate legal barriers, including the impact of the Americans with Disabilities Act (ADA) on employment discrimination, the deterrence of mental health services in schools, and the shortcomings of current laws and policies in achieving mental health equity in the U.S. By shedding light on these obstacles, this research aims to propose actionable solutions to advance mental health equity for all Americans.

Keywords: mental health crisis, economic barriers, social barriers, legal barriers, stigma, trauma, trauma, discrimination, health equity

Introduction

The United States is currently facing a significant challenge in achieving mental health equity. Millions of Americans are affected by Serious Mental Illnesses (SMI), yet many are unable to access the necessary care due to a variety of barriers. Enhancing accessibility to mental healthcare has the potential to transform countless lives, generating substantial economic and social benefits for the nation. Thus, addressing the mental health crisis is not only a matter of improving individual well-being but also an urgent imperative to enhance the overall quality of life in the country.

Economic barriers, particularly geographical disparities, represent one of the most pressing challenges to mental health equity. Individuals residing in rural areas encounter considerable difficulties in obtaining adequate mental healthcare compared to those living in suburban regions. This disparity is largely attributed to increased distances from essential services, such as hospitals and schools, combined with a shortage of mental health professionals in these areas. To mitigate these challenges, it is crucial to enhance access to mental health services in rural communities through initiatives such as telehealth, increased funding, the implementation of school-based and community-based mental health programs, and fostering collaboration among stakeholders.

In addition to economic barriers, social impediments play a significant role in hindering mental health equity. Social issues, including stigma, exert a profound impact on mental health and can prevent individuals from accessing the care they need. The pervasive stigma surrounding mental health contributes to systemic discrimination and self-stigma, where individuals feel ashamed of their mental health conditions. To combat these issues, it is essential to advocate for increased mental health awareness, enforce mental health parity laws, and promote activities that foster well-being and self-worth. Addressing the impact of incarceration on mental health is also critical; efforts to reconnect incarcerated individuals with their families, reduce violence in jails, and improve overcrowded and inadequate prison conditions are necessary. Furthermore, understanding and addressing childhood trauma and environmental factors through improved support systems is crucial to achieving mental health equity.

Legal impediments further complicate efforts to achieve mental health equity and require governmental intervention. The current landscape of mental health support in schools is marked by a complex interplay of funding inadequacies, rural-urban disparities, and inconsistent state laws. Addressing these issues necessitates increased funding, standardized laws, and enhanced mental health education to create a supportive environment for students. Additionally, the Americans with Disabilities Act (ADA) plays a pivotal role in preventing employment discrimination against individuals with mental health disorders. Strengthening enforcement of the ADA, improving employer education, streamlining accommodation processes, and raising public awareness are essential steps in addressing these legal challenges. Implementing comprehensive legislation, adequately training first responders, and adopting successful strategies from states like Virginia can contribute to building a mental healthcare system that genuinely supports and protects individuals in crisis.

Achieving mental health equity in the United States is a challenging but attainable goal that requires significant effort and commitment. Addressing mental health inequity is an urgent issue that demands comprehensive solutions. Through this research paper, we will explore the economic, social, and legal barriers to mental health equity and propose actionable solutions to improve the accessibility and effectiveness of mental healthcare in the United States.

Economic Impediments

Economic recessions and healthcare deserts represent two significant economic impediments to mental health care, each contributing uniquely to the barriers faced by individuals seeking mental health services. During economic recessions, the widespread financial instability exacerbates mental health issues such as anxiety and depression while simultaneously straining the healthcare system, making it difficult for those affected to access necessary care. The Great Recession and the COVID-19 pandemic are prime examples of how economic downturns can lead to increased mental health disorders and reduced access to care due to budget cuts, job losses, and increased stress levels.

On the other hand, healthcare deserts — areas with limited or no access to mental health services — primarily affect rural and underserved urban communities. These areas suffer from a chronic shortage of mental health professionals and facilities, forcing residents to travel long distances for care or go without it entirely. The lack of resources in these areas often results in untreated mental health conditions, exacerbating the already significant disparities in mental health outcomes between urban and rural populations.

Both economic recessions and healthcare deserts highlight the systemic challenges in achieving equitable mental healthcare access. While recessions create widespread economic hardship that diminishes the capacity of the healthcare system to respond to increased demand, healthcare deserts represent a persistent and localized lack of resources that perpetuates inequality in access to care. Addressing these dual challenges requires innovative solutions, such as the expansion of telehealth services and mobile mental health clinics, to ensure that all individuals, regardless of their economic situation or geographic location, have access to the mental health care they need.

Effect of Economic Recession on Mental Health Care.

Throughout American history, economic recessions have repeatedly taken a toll on the nation’s mental health, significantly diminishing access to care when it’s most needed. The link between economic downturns and mental health crises is well-documented, with recessions exacerbating anxiety, depression, and other mental health disorders. According to the International Monetary Fund (n.d.), an economic recession is characterized by “a significant decline in economic activity spread across the economy lasting more than a few months normally visible in production, employment, real income, and other indicators.” This decline in economic stability often leaves mental health care systems under-resourced, highlighting a critical issue of economic classism in access to care. Notable examples such as the Great Recession and the COVID-19 pandemic underscore the urgent need for more innovative solutions to address the growing mental health crisis during economic downturns. Therefore, it is essential to explore how economic recessions negatively impact mental health and access to care and why developing creative and sustainable solutions like the Mobile Mental Healthcare (MMHC) program is crucial to address these challenges on a national scale.

The Great Recession

The Great Recession (2007–2009) was a moment of economic hardship and a rise in mental illness. Many of the people who had major economic losses experienced increased psychological stress, yet they couldn’t seek mental health care because of the financial crisis. Multiple studies by the National Bureau of Economic Research determined that the Great Recession caused a staggering amount of mental illnesses and suicide instances. To illustrate, mental health was negatively impacted by under-employment and mass foreclosures during the Recession period. Additionally, economic uncertainty prompts the imagining of different negative scenarios and damages psychological well-being (Shambaugh & Strain, 2021). The psychological damage caused at this time increased and continued to impact those who suffered during the recessionary years after it officially ended.

One study reports an increase in the number of individuals seeking professional help for depression or stress, which went from 9% to 14% between 2010 and 2013. This same study also uncovered that by 2013, 61% of individuals believed their family finances would not recover to what they were pre-recession. Forbes and Kreuger recently found increased odds of depression, panic, generalized anxiety, and problematic substance use 3–4 years after the recession had concluded among those who experienced even a single financial, job-related, or housing impact during the recession (Koltai & Stuckler, 2020).

These issues negatively impacted not only adults but also adolescents during the recession. This shows how an economic downturn isn’t just harmful to the workplace; it is negative for the quality of life for all individuals. An analysis of a nationally representative repeated survey discovered that the self-reported number of mentally unwell days experienced during the past 30 days increased among adolescents in the Great Recession, particularly those from middle- and low-income families (Hiilamo et al., 2021). The Great Recession was one of the first times a mental health decline in accordance with economic hardship was recorded, and the recession during COVID-19 had similar effects on mental health.

COVID-19 Pandemic

The COVID-19 pandemic caused socioeconomic problems on a global scale. It led to many issues in the economy, such as production shortages and job loss. As a result of the economic stress, as well as the stress of an unknown global pandemic, the mental health crisis increased significantly. Studies by the South African Journal of Psychology have reported effects related to anxieties of being infected, the consequences of quarantine, and living experiences such as a sense of imprisonment reminiscent of traumatic experiences, intolerance to inactivity, boredom, and depression. This also included interpersonal relationships and conflictual cohabitation in reception centers. Additionally, in some outpatient services after the beginning of COVID lockdown measures, appointments for psychiatric evaluations were unavailable for most individuals or were constrained only to emergencies (Bhugra et al., 2022). This shows that despite the need for mental health services during an event that contributed to the mental health detriment at the time, accessing those services was more difficult due to the focus of medical and healthcare resources on the ever-present virus.

As a result of the unpredictability of the COVID-19 virus, mental health care providers were unprepared for the influx of mental health issues that required care. There was also limited access to mental healthcare facilities in the post-pandemic era. Hospitals and the healthcare system were ill-equipped for COVID-19, which led to taking resources away from mental health services to focus on the virus. Many psychiatric facilities and outpatient departments were converted to help manage COVID-19. Therefore, people with mental illness were less likely to seek aid from these services because of the fear of infection. Many pharmaceutical industries changed their focus to the preparation of COVID-19-related drugs and vaccines, which may have prevented the production and advancement of psychopharmacological drugs. Perceived job insecurity, financial problems, and unemployment contributed to significant risks for psychiatric disorders and posed an important barrier to accessing proper mental healthcare (Vadivelu et al., 2021). In this specific event, healthcare providers were fighting not only the virus but also the economic decline during this period. Trying to maintain mental health care at this time was critical to ensure society could move forward after the quarantine was concluded. However, since the threat of COVID-19 was made the priority, care remained limited.

Access to Care During Recessions

Economic crises result in shortages, job loss, and less access to mental health services. In times of crisis, more accessible and affordable healthcare is certainly the preferred pathway to care, with the subsequent increase in unaddressed need for specialized care. During these times, reduced mental health budgets cause a decrease in the availability of mental health services, and these services may become unaffordable due to the lack of coverage from health insurance providers, reduction of households’ disposable income, or the introduction of copayment into public healthcare (Silva et al., 2020). Considering the fact that money is intentionally taken away from these services when they are needed most in crisis, this only makes the situation worse, which can lead to an increase in harm and suicide nationwide.

Leaving these issues unaddressed and decreasing the funds appropriated to mental health services just contributes to the severity of the problem at hand. Within 48 studies conducted by the Behavioral Sciences Journal on Psychology assessing suicide mortality rates (SMR), almost all studies discovered an increase in suicide rates during and following the period of recession. In a study of SMRs in the USA between 1928 and 2007, SMR rates were found to consistently increase during recessions and decrease during expansions (Guerra & Eboreime, 2021). These SMRs and mental health declines can be managed by changes made by healthcare providers and community outreach. Examples of this include expanding telehealth services so that more people, including those from low-income households, have access to care; creating more community-based programs tailored to the communities they are meant to serve; and integrating mental health into primary care to make it as accessible and important as physical illnesses.

Solutions

During times like recessions, it can be a real challenge to ensure people get the mental health care they need. Some initiatives have actually worked. Health insurance coverage with programs like Medicaid has made it easier for people to access mental health services. Research shows that expanding Medicaid has led to positive mental health outcomes, lower rates of undiagnosed depression, and less financial stress (White House, 2022). Social safety nets have also played a role in helping individuals cope with the health effects of economic downturns (National Center for Biotechnology Information, 2018). Efforts to bring mental health services into communities and make them easier to access and more affordable have been gaining traction as well (Psychiatric Times, 2012). However, these programs often have limited funding and systemic issues.

Mobile Mental Health Clinics (MMHCs) offer a possible solution to expand access to mental health care during challenging economic times. These clinics are essentially large, specially equipped vehicles that bring mental health services to people in areas where mental health care is difficult to find. These mobile clinics could travel throughout the country to serve rural and struggling urban areas. These mobile clinics would be similar to mobile dental clinics. A study on mobile dental clinics in rural Virginia found that the program provided care to over 5,000 underserved patients in its first year of operation (Woodside et al., 2010). MMHCs could do the same with their services and become even more impactful. Instead of dentists, each MMHC would have a team of mental health professionals who can offer services like counseling, medication, and crisis intervention. The clinics would operate on a regular schedule, so it could be easier for people to plan their visits and receive the help they need. This approach could help many people who might otherwise go without mental health care or suffer from more detrimental experiences that worsen their mental health. This program could be funded by government aid, private donations, and Medicaid. With enough community engagement and advocacy, these MMHCs could be operated for many years to come and improve the mental health of many individuals throughout the country.

Conclusion

Economic instability has negatively impacted mental health and access to care for decades. As seen throughout the Great Recession and the COVID-19 pandemic, this has been an ongoing issue. These events caused an increase in anxiety, depression, and other mental health issues. However, these recessions made it hard to receive proper mental health care to cope with the stress during these events. Therefore, many individuals were prevented from receiving adequate care. By addressing the need for consistent mental health services that can be sustained throughout economic hardship, society can foster a more secure and supportive environment for all individuals in need of care.

The Geographical Impact on Mental Health Care

The accessibility and quality of mental health services are significantly influenced by geographical location, raising critical questions about healthcare equity. Patients in rural areas often face greater challenges in receiving adequate care compared to those in suburban regions, leading to the phenomenon known as mental health care deserts. This disparity is largely due to the increased distance to essential services such as hospitals and schools, compounded by the fact that rural communities are frequently lower-income. Additionally, the ongoing decline in the number of mental health professionals, including psychiatrists, therapists, and psychologists, exacerbates the situation, leaving many patients without the necessary support. By examining the causes behind the presence of mental healthcare deserts and seeking solutions to the issues arising from a lack of mental health services in underserved areas, we can take significant steps toward creating mental health equity for all Americans.

Understanding Mental Healthcare Deserts
A mental health care desert is a region where access to in-person treatment centers and services is limited due to an inadequate number of healthcare providers and facilities, high costs of services, and other socio-cultural factors. Mental health deserts began to appear in the mid-20th century, specifically during the 1950s and 1960s (Horwitz, 2010). This timeline underscores how long society has neglected to address this issue and the lack of action taken to resolve it.

These mental health care deserts are most prevalent in rural communities, where a disproportionate lack of mental health care facilities exists. “Seventy-five percent of rural counties across the country have no mental health providers or fewer than 50 per 100,000 people…In fact, there are currently 570 counties in the U.S. without psychologists, psychiatrists, or counselors. That’s 17% of counties in the country” (Livingston & Green, 2022). Suppose mental health service providers continue to leave these facilities. In that case, it will become increasingly difficult for people to get the help they need, leading to longer waits and fewer treatment options.

One of the primary reasons for the prevalence of these mental healthcare deserts is the closure of hospitals and healthcare clinics throughout the country. Notably, there were 136 rural hospital closures from 2010 to 2021, including a record 19 closures in 2020 alone (American Hospital Association, 2022). This proliferation of mental health care deserts is a significant problem because it prevents people from getting the help they need, leading to untreated conditions and unnecessary suffering. This gap in services can deepen social inequalities and strain families and communities.

Mental health deserts are most prevalent in rural states and cities. “The American Psychiatric Association recently found that South Dakota was among the worst ‘mental health care deserts’ in the nation, with 47% of the state’s counties having no providers of care whatsoever” (Pfankuch, 2023). This finding indicates that rural states, such as South Dakota, barely have any mental health care facilities, leaving half of the state without access to mental health care. This situation poses a significant problem, as rural areas cannot access the same quality and quantity of treatment as urban areas.

A Worsening Problem
Unfortunately, mental health deserts in rural towns are worsening as more mental health specialists quit their jobs. Consequently, when people with minor mental illnesses in rural areas cannot get help, their condition may become more severe, leading to a crisis. For example, someone with a serious mental illness who cannot access adequate healthcare in rural areas might experience an episode or, in the worst cases, engage in violence.

“Average trips for medical, dental, or mental health services are about nine miles longer in rural regions. Those with a personal vehicle can be adversely affected by rising gas prices, making longer trips more expensive. For those without a personal vehicle, traveling long distances can be especially burdensome. People who do not have access to a motor vehicle often have to rely on public transportation services, and destinations are not always located on a public transportation route” (ABC News, 2019). The fact that low-income families and other marginalized groups cannot access mental health care facilities near them and must pay extra money for gas adds to their medical bills and highlights the urgent need for mental health care facilities in rural areas.

At-Risk Populations. The major populations affected by the lack of mental health care are the homeless, rural area residents, low-income individuals, and marginalized communities. These challenges result in decreased quality of life, social isolation, increased risk of severe mental illnesses, financial strain on families, and more. This situation creates a social and economic stigma around certain groups of people, limiting their everyday activities. Moreover, it prohibits them from pursuing education or staying focused at work.

Homelessness. One of the largest populations at risk in the mental health crisis is the mentally ill homeless. “Twenty-one percent of individuals experiencing homelessness reported having a serious mental illness, and 16 percent reported having a substance use disorder” (Saldua, 2023). They typically suffer from illnesses such as depression, anxiety, and PTSD (HealthDay, 2024). To make matters worse, they often lack the necessary transportation, insurance, funding, stable housing, etc., to access sufficient care. This can ultimately lead to worsening conditions and, in the worst cases, an increased risk of violence. Problems like these can impede their ability to acquire housing and permanently damage their emotional and physical well-being.

The impact of wage disparity on social issues is multifaceted. For example, communities with high levels of economic inequality often experience higher rates of crime and violence. This correlation can be attributed to the lack of economic opportunities and social mobility for low-wage workers, leading to increased frustration and desperation. Additionally, economic inequality can limit access to essential services such as healthcare and education, further entrenching social disparities.

Low-Income Individuals. Low-income individuals, especially those in the agricultural industry, often struggle with limited access to mental health care due to high costs and a lack of services, primarily in rural areas. “In recent years, the economic outlook for farmers and ranchers has been worsening, leading to comparisons to the Farm Crisis of the 1980s. Increasingly, agricultural families and communities are struggling, contributing to higher rates of suicide among farmers” (Rural Health Information Hub, 2024). This lack of access means that many people will not receive the care they require, worsening their financial instability and reducing job opportunities. The demanding nature of agricultural work, combined with untreated mental health issues, can also lead to poorer physical health, trapping them in a cycle of poverty and poor well-being. To make matters worse, America relies on the agricultural industry as a source of its food. Thus, when individuals such as farmers do not get the mental health care they need, it impacts the nation as well, potentially leading to an economic crisis.

Lack of Qualified Providers. Most mental health care providers do not desire to transition to rural environments, preferring instead to reside in large towns or cities. Providers who stay may become overwhelmed, risking the quality of care they can offer and their own well-being. This shortage could also worsen mental health crises, strain other parts of the healthcare system, and negatively affect communities. It is crucial to address this issue promptly to ensure everyone can access the mental health support they require.

Solutions

There are many ways to address this problem of mental health care deserts. For example, telehealth, increased funding, school-based mental health services, and community-based mental health care services. Telehealth is a major game changer as it can be done remotely and does not cost that much.

In a recent case study about telehealth, “‘Sandy’, a tele-behavioral health therapist, and “Jacob,” a psychiatrist…began seeing clients at a shelter for families experiencing homelessness…“Jennifer,” a resident at the shelter, was seen by both providers during the time she resided at the shelter. Jennifer” learned skills to manage symptoms and behavior in the shelter environment …. “Jennifer” gained stability with emotions and thoughts, which led to increased attendance to appointments for housing and other social services as well as enabled “Jennifer” to maintain employment throughout this time…Clients reported improvement in symptoms…”(Shore, 2023).

In addition to mental health care deserts, there are other types of deserts, too, called “essential service deserts.” Fortunately, there are other segments of society addressing the problem of essential service deserts. They depend on the collaboration between many groups of people, such as non-profits, government, local communities, etc. Thus, anyone could, for example, raise awareness for mental health care deserts not only through social media but also through various different ways such as social media, supporting local efforts to combat mental health care deserts, and supporting legislation and funding toward this cause.

There are various ways to support mental health care deserts that don’t take much time. Through the use of telehealth services, enhanced funding, the implementation of school-based and community-based mental health programs, and collaboration between numerous funders and stakeholders, we can work towards closing the gap in mental health care accessibility and building a stronger, more supportive mental health care system for everyone.

Social Impediments

While financial and economic issues play a significant role in the lack of access to mental healthcare, there are a variety of social impediments that significantly hinder mental healthcare reform, including stigma, incarceration, childhood trauma, and inefficient mental health protocols in schools.

Stigma is identified as a critical barrier to mental healthcare. Public stigma, characterized by societal attitudes that view mental health issues negatively, leads to systemic stigma where policies and legislation further restrict access to mental health care. This stigma extends into self-stigma, where individuals internalize societal negativity, leading to shame and reluctance to seek help. These layers of stigma create a complex barrier that prevents many from receiving the necessary care.

Incarceration is another major impediment. Many individuals with severe mental health conditions end up in prison due to inadequate community-based mental health services. The prison environment, characterized by violence, isolation, and dehumanization, exacerbates mental health issues rather than alleviating them. Overcrowding, lack of proper mental health care, and the harsh conditions of prison life contribute to the deterioration of inmates’ mental health, making it a significant social barrier to effective mental healthcare.

Childhood trauma, particularly Adverse Childhood Experiences (ACEs), is highlighted as a profound factor influencing long-term mental health outcomes. The article discusses how childhood neglect, physical and emotional abuse, and exposure to domestic violence can lead to severe mental illnesses in adulthood. The lack of early intervention and support for children who experience these traumas further perpetuates the cycle of mental health issues into later life.

Schools play a crucial role in addressing mental health but are often hampered by inadequate funding, disparities between rural and urban institutions, and inconsistent state laws regarding minors’ consent and confidentiality. Despite the significant time adolescents spend in schools, many lack the resources to provide adequate mental health support, leaving a large portion of students without the help they need. The article argues for increased funding, standardized laws, and enhanced mental health education to create a more supportive environment in schools, which is vital for addressing mental health issues early and effectively.

In summary, the article emphasizes the need for a comprehensive approach to mental healthcare reform, addressing stigma, improving mental health services in prisons, supporting children who have experienced trauma, and enhancing mental health resources in schools. These efforts are essential to overcoming the social barriers that currently impede access to effective mental health care.

The Effect of Stigma on Mental Healthcare

A person who is having major health problems, maybe someone in a hospital bed or someone who is physically extremely sick. However, sometimes those struggling with health may show no physical signs at all and can appear fine at just a glance. The reason some may picture an extremely physically sick or disabled person when thinking of an ill person is that society doesn’t prioritize mental health care nearly enough. The reality is mental health care belongs in the discussion of healthcare equity just as much as physical healthcare because it’s a major issue. Twenty percent of Americans suffer mental health issues in a given year; that’s one in five people– an alarming and significant portion of the population (Mental Health Facts in America, n.d.). So why is mental health pushed to the side? Stigma.

Stigma exists when it comes to the discussion around mental healthcare, especially in certain communities, and is one of the many reasons mental healthcare isn’t provided to its fullest potential. The mental health crisis in America can all be drawn back to the social issue of the stigma surrounding mental health in general. The way people in a community view or treat mental health creates a public stigma, which then paves the way to systemic stigma by placing legislation and policies to reduce access to mental health care, ultimately creating self-stigma where, because of these factors, an individual has internalized shame associated with mental health issues.

Public Stigma

Public stigma is the overarching issue surrounding mental health that refers to the negative attitudes, beliefs, and stereotypes that society holds about individuals with mental health conditions. This stigma can be displayed in various ways, including discrimination, prejudice, and social exclusion, and affects how people with mental health issues are perceived and treated by others.

When people don’t have accurate information about mental illness, they are more likely to rely on stereotypes or misconceptions. For instance, they might believe that mental illnesses are a sign of personal weakness or that people with mental health conditions are dangerous or unpredictable (Brouwers, 2020). These misconceptions can lead to negative attitudes and discriminatory behavior. Without a proper understanding of the biological, psychological, and social factors contributing to mental illness, people might unfairly place the blame on the individuals affected. They might think that mental illness is simply a result of poor choices or a lack of willpower rather than recognizing it as a legitimate medical condition.

All these different ways that public stigma is formed create a negative lens on people who have serious mental health issues. Humans are designed to live in communities and, in this way, care about what others think. So when a large majority of the population deems a negative outlook on mental health, it not only prevents access to mental healthcare but also creates even more problems in many different ways. Public stigma has detrimental impacts on the lives of mentally ill people that lead to issues and barriers in an individual’s “pursuit of vocational, housing, and healthcare goals” (Corrigan, 2015). Stigma can be merely described as prejudice or discrimination, but it has major effects. For example, stereotypic beliefs can lead to “power groups — employers, landlords, and healthcare providers — to restrict opportunities of people labeled with mental illness” (Corrigan, 2015). It is in all these ways that community, social, or public stigma can prevent mental health equity and create major problems for those already facing the struggles of mental illness.

Systemic Stigma

As previously mentioned, public stigma can dictate many things in the area of mental health care. So when society decides to have a negative view of mental health, they will also place policies and legislation that coincide with these negative opinions and stigma. It is this public stigma that leads to systemic stigma, which makes it harder for individuals with mental health issues to access care due to law and legal policies/reasons.

Systemic stigma is a big factor as to why people who need mental health care cannot receive it because “stigma can act as a disincentive to invest in mental health services” (Sharac et al., 2011). Because of stigmas related to mental health, corporations, and businesses may not be inclined to invest money into solving the issues for numerous different reasons. Whether the stigma relates to not believing in the serious issues of mental health, the negative characteristics associated with mental health, or any other reason, the fact is that mental health equity will not be achievable when systemic stigma is preventing care from being provided due to lack of funding because of certain policies and beliefs.

There are also laws and policies passed by governmental institutions that make mental healthcare difficult to receive for many individuals. The system that society has set up in terms of treating mental health care is not conducive to creating equity for those suffering from mental health issues. Certain laws may lack protections against discrimination for people with mental health conditions, failing to address the systemic barriers they face. For example, laws regarding involuntary commitment can make it difficult for individuals with severe mental health issues to receive care unless they meet specific criteria. This delay in treatment can allow a condition to grow worse and even prevent care from being provided at all (Hedman et al., 2016). This creates a major issue because people are suffering but can’t get adequate and timely care due to laws and policies put into place, and the longer these types of issues are put off, the worse they can get.

Internal Stigma

Now, there is a public stigma that creates a negative view of mental health for society, so naturally, society creates laws and systemic impediments to prevent mental health care because it’s been decided by society that it’s not needed or it’s a bad thing. These two types of stigma together create self or internal stigma. As one thing leads to another, an individual who is now being told by society and by law that their mental state is something bad or to be ashamed of it obviously is going to have negative effects on that person’s ability to receive care or worsen their condition/feelings in general.

The experience of stigma can lead to feelings of shame, guilt, and low self-esteem. When people internalize the negative attitudes and stereotypes associated with mental illness, it can worsen their emotional distress and contribute to a sense of worthlessness or self-blame. The internalization of stigma negatively impacts “self-efficacy, self-esteem, and hope, and is associated with decreased empowerment, weakened social support, and decreased quality of life” (Fox et al., 2018). When someone is experiencing mental health issues, there should be no reason to add more negative feelings to the problem, yet people’s conditions still worsen because of the way they see themself and their illness. Since self-stigma can affect self-esteem and hope, it also has the potential to “undermine one’s confidence in the ability to successfully seek treatment and get better” (Fox et al., 2018).

Another way internalized stigma can negatively impact those suffering from mental health issues is fear, fear of seeking help. Fear of being judged or discriminated against can prevent individuals from seeking necessary mental health support. This reluctance can delay treatment and lead to the deterioration of their condition, as they avoid professional help or therapy that could provide relief and support. Internalized stigma can be broken into two parts: the stigma around having a mental illness and the stigma around seeking help (Fox et al., 2018). As previously mentioned, self-stigma can worsen mental health conditions because of just having the illness in general. But it’s different when it comes to seeking help because now this stigma is preventing a real possibility of getting better rather than just making the individual feel worse. So now, this internal issue is having negative external outcomes, which is a huge problem when trying to reach mental health equity.

What Can We Do?

Addressing public stigma surrounding mental health is crucial for improving the way mental health is viewed and, in return, the treatment and support of individuals with mental health conditions. There are many ways to combat the public stigma surrounding mental health, and it starts with promoting accurate information. The public should be educated about mental health conditions, their causes, and treatments in order to dispel myths and misconceptions. This accurate information can reduce fear and misunderstanding. Ways for society to become literate in mental health is to integrate mental health education into school curricula and workplace training. This way, society can foster understanding from a young age and in professional settings. Another big factor in public stigma is media representation. As a society, we need to advocate for more accurate and positive representations of mental health in the media and encourage media outlets to depict mental health issues with empathy rather than stereotypes. Because many people in today’s world absorb information from the media as a main source, it’s important to the way we portray mental health because it can heavily influence the public.

Ways to improve systemic stigma differ slightly from the previous way of going about public stigma. To make real changes, people need to advocate for anti-stigma legislation and support policies and legislation that promote mental health awareness and anti-discrimination measures in employment, education, and housing. Mental health laws based on systemic stigma prohibit all of these things that everyone should be entitled to have access to, regardless of their mental health status. This is also why advocating for enforcement of mental health parity laws is needed to ensure that mental health services are covered equitably.

The hardest task at hand is challenging internal stigma because it is a complicated matter where an individual’s mindset has to be challenged. While it’s impossible to reconstruct someone’s mind completely, cognitive restructuring when it comes to mental health is very possible and important. Individuals struggling with mental health should work on identifying and challenging negative beliefs about themselves. These cognitive-behavioral techniques can help reframe these beliefs and develop a more balanced self-view. Another important step in reducing internalized stigma is having self-compassions and practicing affirmations. When individuals partake in self-compassion and use positive affirmations to counteract negative self-talk, it helps eliminate the negative view of mental illness and supports understanding and kindness. In this same way, it’s important for individuals to prioritize self-care when dealing with mental health. Activities that promote well-being and self-worth, such as exercise, hobbies, and relaxation techniques, can all be useful in combating negative feelings towards oneself about mental health.

While all these different stigmas exist in the realm of mental health, it’s important for society to combat this social justice issue because it affects so many people. People who may be friends, family, or just complete strangers. All these individuals have their own lives and aspirations and deserve access to help and treatment for their mental health conditions. Stigma and misconceptions should not be the reason we cannot achieve mental health equity, so it is up to us to bring acceptance and awareness to provide for all.

Impact of Incarceration on Mental Health

For many, the prison system is a painful testament to the failure of mental health care in society. Individuals with severe mental health illnesses are often incarcerated, and the conditions of prison can worsen their conditions significantly. The harsh reality of prison life can profoundly impact one’s mental health, often in ways that are profound and devastating. The prison cell is bleak and cramped, with gray concrete walls and a small window that hardly allows light. The air is thick with the rancid odor of unwashed bodies and the harsh clang of metal doors slamming shut. Prisoners are packed tightly, while outside in the corridors, there is a loud echo of voices shouting with aggression. Constant violence occurs between inmates, each time more traumatizing than the other. The environment of prison can take a significant toll on one’s mental health. Including that, the separation from loved ones and society can cause significant physiological strain on individuals. Incarceration devastates mental health by isolating individuals from their loved ones, subjecting them to relentless violence, and confining them in dehumanizing environments.

The Incarceration of Mental Health Patients

According to the American Physiological Association, 64% of individuals in jail, 54% of individuals in state prison, and 45% of individuals in federal prison have reported experiencing mental health concerns(Taylor, 2022). The cost of mental health is enormous, and there is a frequent feeling of isolation, anxiety, and despair in trying to live through such detrimental conditions.

Why is This the Case? For decades, there has been an inadequate amount of mental health resources for those who have a mental illness. Those who have mental health conditions had two options: community-based centers or prison, the only two places where the mentally ill would find care. Individuals with mental illness who come into contact with the criminal justice system are often arrested due to the lack of adequate procedures to divert them into community-based treatment programs. In addition, most mentally ill end up in jail often because of the lack of treatment programs like these, high in capacity, or located in places inconvenient to many. According to police records, many officers arrest individuals with mental illness because of a lack of treatment alternatives. (Fisher, Silver, Wolff, 2010). Many communities still lack the resources and structures necessary to see through the effective management of those with mental health problems. Subsequently, many persons with serious mental illnesses are eluded from treatment and support, making them vulnerable to imprisonment. Today, policing, arrest, and criminal punishment have become a default response not only to violence and other harms but also to poverty, mental health crises, drug use and addiction, HIV and other health conditions, and school discipline. (Warth,2022). The lack of mental health care and resources causes more mentally ill patients to resort to incarceration to provide them with the facilities needed for betterment.

Why is This Bad? Prison is not the place to be if experiencing a mental health condition. The conditions endured by incarcerated individuals are pretty severe and can often exacerbate the mental health conditions the individual is undergoing. Many people who are not able to deal with the devastating conditions of jail resort to suicide or self-harm. Regarding affirmatively causing harm to incarcerated people, New York State’s largest jail, Rikers Island, is in crisis mode. Thus far in 2022, through November 4th, 18 people have died at Rikers — the most in a single year since 2013, when the jail’s population was twice as large as it is today.”. Of the 12 who died, or for whom death was suspected, by confirmed or suspected suicide or overdose, seven of the 12 had known mental health concerns(Warth, 2022). This crisis continues to worsen as more mentally ill patients are taken to prisons instead of being provided with the proper care facilities. As we explore the traumatic impacts of incarceration on individuals with mental illness, it becomes clear that those with mental health challenges face increasingly severe difficulties.

Isolation

Incarceration separates individuals from their loved ones, leading to increased feelings of isolation and loneliness. The deprived support from family and friends leaves them with no affirmation of their well-being and exacerbates feelings of depression and hopelessness. With no one to provide assurance or share a laugh with, individuals tend to go into significant physiological distress.

Parents who are incarcerated and have young children report elevated rates of depression and thought problems, such as hallucinations, unusual thoughts, and self-harming behaviors. Among incarcerated parents, the prevalence of mental health symptoms is three to five times higher than that of the general population, including high rates of comorbidities(Warth, 2022). Adults who have young children have excessive levels of depression and hallucinations due to the lack of support from loved ones. Individuals turned to self-harm with no hope left for themselves or their families who are suffering without them.

Incarceration also separates individuals from society, and they experience a loss of purpose during their time in prison. The prisoners are forced to be locked up in prison cells and have limited access to physical activity. Remand and sentenced prisoners, as well as uniformed staff, have highlighted the detrimental impact on prisoners’ mental health resulting from being confined for up to 23 hours a day. Remand prisoners typically do not engage in work or have access to education, while many sentenced prisoners have limited access to both. The lack of activity and mental stimulation has been reported to lead to extreme stress, anger, and frustration among prisoners(Nurse et al., 2003). The lack of physical activity and engagement influenced higher levels of stress, anxiety, and depression. Incarcerated people have no control over what they do daily, thereby losing their societal purpose.

Furthermore, incarceration causes some to feel degraded or infantilized because of the conditions they are enduring. With their identities stripped, everything they were known for before prison, their skills, talents, and achievements are all tossed in the dirt, contributing to their loss of purpose in life. It takes away their self-worth and makes them feel disgusted with themselves for having to demean themselves from the status they were at before prison.

Understandably, some of them may have felt infantilized and believed that such squalid conditions they were living in served only to remind them, time after relentless time, of their reduced social status and stigmatized role as inmates. This could chip away at the sense of self-worth and personal value. In the most extreme cases of institutionalization, this symbolic meaning may then be internalized from the externally imposed lower-than-standard treatment and circumstances, leading prisoners to feel they are no more than the degradation and stigmatization that they have been accorded since entering prison (UCal, 2001).

In such situations, the degradation and infantilization imposed by the prison environment can create a vicious cycle. The constant reminders of status diminishment can cause immense feelings of distress and worthlessness. The feelings of worthlessness and societal prejudice emanating from this can severely impact their ability to reconstruct their lives after release.

Physical and Sexual Violence

Physical abuse and sexual abuse are frequent in prison, either if it is staff member to inmate or inmate to inmate.

Guards have used various methods of physical violence against inmates, such as stun guns, batons, punching and kicking, and excessive force. Inmate and inmate violence is also common due to the stress and frustration of being in a strenuous environment. This violence can directly impact inmates’ health both mentally and physically, creating a more stressful environment for inmates. Approximately 21% of male inmates are physically assaulted during six months. (Wolff, Shi, 2010). The fear, trauma, and frustration of both being in such a stark environment and abusive officers can take a significant toll on the mental health of individuals.

Unfortunately, sexual violence occurs more often in prison than outside of prison. Statistics from the BSJ revealed that allegations of sexual assault in adult prisons increased drastically between 2011 and 2015. There were 8,768 reports in 2011 compared to 24,661 four years later(Schlaht, 2021). Numerous individuals allegate that guards threatened them with violence, denied them access to necessities like food and medical care, and forced them to engage in sexual acts for them to enjoy the benefits to which they are entitled. Therefore, prisoners are forced to watch out for other prisoners who are being raped after years of sexual abuse. It should come as no surprise that these violations have permanently impacted their mental and physical well-being.

Exposure to violence in prisons and jails can exacerbate existing mental health disorders or even lead to the development of post-traumatic stress symptoms like anxiety, depression, avoidance, hypersensitivity, hypervigilance, suicidality, flashbacks, and difficulty with emotional regulation (Quandt, Jones, 2021). This pervasive violence not only impacts individuals’ immediate physical well-being but also influences their long-term mental health. The trauma can worsen existing conditions and pose the development of new illnesses as well.

Psychological Violence

Physical violence does not only affect the individual/s who directly encounter it but also the people who witness it. Participants in Novisky and Peralta’s study reported witnessing frequent, brutal acts of violence, including stabbings, attacks with scalding substances, multi-person assaults, and murder. They also described the lingering effects of witnessing these traumatic events, including hypervigilance, anxiety, depression, and avoidance(Widra, 2020). As the violence in prisons increases, more fear and trauma get instilled in the individuals witnessing the incident, mainly impacting their mental health.

Mental Violence

Physical violence is not the most potent violence; the most powerful violence lies in words. Words can build people up or tear them down entirely based on their use. Therefore, something someone says can impact one’s mental well-being more than what someone does. Being demeaned, insulted, and threatened with violence, loss of privileges, and solitary confinement takes a significant toll on inmates’ mental health. Treating them inadequately for their illnesses creates even more problems(Schlaht, 2021). Mental violence is so powerful because it has the power to get to the individual’s head and exacerbate the mental illnesses that the person already has.

Physical Environment and Overcrowding

The physical environment of a prison is not the most settling at the least. The concrete walls, limited natural light, and lack of privacy can cause discomfort and isolation from the real world. Through our findings, we have demonstrated how broader environmental and organizational elements impact prison mental health settings. This qualitative data generated from this series of focus groups shows how lengthy periods of being locked up with little activity or mental stimulation go on to hurt the mental health of prisoners whether or not they had a formal mental illness(Nurse et al., 2003). The environment of a prison cell can have a detrimental impact on the mental health of prisoners. Furthermore, the limited stimulation and lack of physical engagement can cause boredom and distress, which are linked to losing self-identity.

The overcrowded environment in prisons can also lead to a greater probability of mental and physical ailment. Where prisons become more and more overcrowded, so does the level of depression and hostility among the prisoners. This is mainly brought about by increased stress and a reduced amount of personal space. As prisons become more and more overcrowded, this leads to a higher average rate of depression and hostility for People incarcerated in those prisons. The people who are in prisons with less overcrowding have less depression and less hostility, and as the overcrowding increases, so do the mental health effects(Edgemon, 2022). In settings where prisons are less overcrowded, the prisoners generally show lesser degrees of depression and hostility, thus directly relating prison population density and outcome of mental health. As such, with the increased overcrowding in prisons comes an increase in mental health issues.

Solutions

Reconnection with Family. Vital family communication programs enable prisoners to stay connected through visits, phone calls, and video conferencing. Reintegration programs with support for job training, education, and social skills development make this move more manageable and less lonely. Continuous therapy and counseling for mental health conditions are used to manage the conditions and provide their self-identity back to themselves. Therefore, social and recreational activities help provide a sense of normality and self-expression if conducted within prisons. The participation of family members and community groups in the inmates’ rehabilitation process aids in expanding their support network. These two strategies can be applied to help mental health patients maintain their attachments to their families and society, as well as to themselves, during their imprisonment and upon discharge.

Reduce Prison Violence. Increasing supervision by utilizing additional staff and incorporating advanced surveillance technologies ensures better monitoring of inmate interactions, allowing for timely intervention before conflicts escalate. Better training for the guards is crucial. Better training influences decreased staff violence and intimate violence. They should be trained in crisis management and conflict resolution to more effectively reduce violent situations. Moreover, extensive rehabilitation programs through education, vocational training, and counseling facilities address the root cause of violence.

These programs decrease frustration and aggressive behavior as they arm the prisoners with essential skills and fulfill their psychological needs. This regular psychological support of staff and continuous professional development further enhance their ability to manage such difficult situations. Together, these strategies are more likely to create an environment that is more controlled, positive, and less violent and contribute to prison safety.

Reduce overcrowding. First, sentencing reform that would reduce the number of people flowing into prisons, especially for nonviolent crimes, would help alleviate the overcrowding problem. Second, increasing alternatives to imprisonment, including community service or rehabilitation programs, helps reduce prison populations.

Improve physical conditions of prison. Investments must be made in renovating existing facilities, providing better sanitation, improving ventilation systems, providing adequate space, and implementing safety measures. New facilities could be built using more modern designs in keeping with humane conditions, which can help in population management. As stated earlier, better management policies can be adopted, such as limiting the length of stay for nonviolent offenders and increasing early release programs. These strategies would provide a much safer and more humane prison environment and address the systemic overcrowding issues.

Conclusion

In conclusion, the intersection of mental health challenges and incarceration reveals a critical need for systemic reform. The current prison environment exacerbates the inmates’ mental health problems through overcrowding, alienation from family and society, and pervasive violence, issues that are disastrous to individuals’ well-being. Effective solutions require a multi-faceted approach: enhancing family communication programs, improving mental health support, and implementing robust reintegration strategies can help reduce isolation and maintain connections to the outside world. In addition, the reduction of prison violence through better supervision, training, and rehabilitation programs is another important factor in making the environment inside a prison more secure and supportive. Addressing overcrowding by reforming sentencing practices and investing in facility improvements will contribute to a more humane system. Together, these measures can transform the current prison experience into one that prioritizes mental health, safety, and rehabilitation, ultimately benefiting individuals and society.

The Adverse Effects of Childhood Trauma in Early Childhood

In the labyrinth of childhood development, where every twist and turn shapes the future, the shadows of early experiences can cast long and profound effects on growth. These shadows are called Adverse Childhood Experiences, more commonly known as childhood trauma.

There are many types of childhood experiences, positive and negative; for example, a joyous childhood may include proper emotional management from the caregiver’s side, a nurturing home environment for the child, and constant care for the child in every way, physically (i.e., necessities like food and shelter) and emotionally (i.e., early compromise teaching, constant reassurance, and autonomy encouragement). ACEs are the opposite. They are considered complex stressors in early development that have the potential to disrupt normal development (Sheffler et al., 2020). They can range from central to minor, significant being something as severe as surviving a war when you are young and minor being economic hardships and a separation/divorce or a parent.

ACEs are relatively familiar, with approximately 64% of US adults experiencing at least one ACE before age 18. Repeated ACEs without early intervention, like repeated domestic violence, put a child at increased risk of developing a mood, depression, personality, or anxiety disorder, which can escalate into Severe Mental Illness (SMI) (Rosenberg, 2019). By examining how mental health correlates with environmental factors such as neglect, trauma, and physical and psychological abuse, plus biological factors like heredity, we can gain better knowledge of how we can create better mental health outcomes, especially for children.

Child Neglect

Child neglect is one of the most prevalent forms of child abuse. While some might think that neglect and abuse are separate, studies show that neglect can significantly disturb a child’s developmental progress the same way abuse would. Neglect is “an act of omission in the care leading to potential or actual harm. It may include inadequate health care, education, supervision, protection from environmental hazards, and unmet basic needs.”(APA Dictionary of Psychology et al., 2024) Emotional neglect, in particular, involves failing to provide proper care and nurturing from a parent or guardian, which is very common for children in group homes or the foster care system.

If not resolved early, neglect can manifest through behavioral challenges, mood disorders, substance abuse, suicidal ideation, or the aggravation of preexisting conditions (APA Dictionary of Psychology et al., 2024). For example, children who experience neglect may internalize it as their fault, leading to low self-confidence, aggression, and a need for psychiatric intervention.

Domestic Violence

Physical abuse can have severe to catastrophic consequences whenever it occurs. It is a common form of domestic violence. Early childhood physical abuse can alter a child’s brain chemistry, leading to lifelong disabilities or brain injuries. Consequences of untreated physical abuse in children can include hearing and vision loss, cognitive delays, and severe emotional issues (Nationwide Children et al., 2024). Many children develop mood and personality disorders, which the National Institute of Health defines as conditions primarily affecting a person’s persistent emotional state. Abuse can also prevent people from accessing proper mental health resources due to internal struggles with needing help (NIH, 2024).

Nature vs. Nurture

The interplay of different etiology of Severe Mental illnesses can be separated into nature, which is things like hereditary traits, and nurture, which is how a person is raised. Genetic outcomes can be determined from simple tests like blood and saliva tests. However, on the other hand, environmental outcomes can only be determined by interviewing the patient in length, focusing on childhood and significant events since that time; the interaction between environment and genetic predisposition is what triggers an event to happen, like the trauma of any kind, a young child may have a genetic predisposition for depression, but they may be unaware of it because they do not live with their biological parents, therefore with the right environment they may never develop depression or the opposite. A child has no genetic predisposition for an SMI, but they develop one regardless due to a severe (or multiple) ACE(s). there is also a third and significantly worse outcome. When both genetic predisposition and a childhood with major ACE(s) mix (Rosenberg, 2019).

Adverse Reactions to ACEs

The Severe Mental illnesses associated with Adverse childhood experiences are most often standard yet extremely difficult to manage due to the nature of the trauma. Diseases like Bipolar, Borderline Personality Disorder, Post Traumatic Stress Disorder, anxiety, and depression affect 27% of past-year domestic violence women and 13% of men, in comparison to women and men who were not survivors of Domestic Violence, who reported 9% and 5% Severe mental illness, respectively (office of justice programs 2024).

Early onset SMI is also caused by mental health exacerbation combined with environmental triggers (which can be everyday stressors). However, the interesting fact in the statistics of SMI treatment is that the socioeconomic area plays a significant role in access to care and successful outcomes, especially in People of Color communities. The first concern is diversity within the system. People of color generally do not feel a connection with white therapists because they have not had to experience racial systemic oppression. Therefore, the person’s thoughts are often, “We cannot connect without common experiences.” (NIH, 2014).

Interventions and Programs

The US healthcare system has never been one for preventative care; therefore, there are few resources to prevent ACEs, especially those as familiar as DV. At the federal level, there is a 24/7 hotline that works directly with committees and crisis specialists to asses the safest way to help a victim in active or passive danger.

Treatments to support the victims/survivors of DV or ACEs are more widespread across the country; treatment includes programs as simple as therapy support groups or as intensive as 1–1 intensive therapy programs like a partial hospitalization program. Every patient’s reaction to these programs is different, which is why a case manager has been proven to improve the chances of successful intervention.

In California, where mental health courts were established, they do not hand out prison sentences; they hand out mandated medication, treatment, or hospitalization for those who cannot be let out in the world without some sort of help. These individuals are immediately set up with a caseworker, who is responsible for finding the providers of a patient and is also responsible for getting them all together once a week for anywhere from 5 to 15 years (Rosenberg, 2019). This is what is called a long-term rehabilitative program, where a patient is not just deserted after initial acute treatment, setting them up for failure with no follow-up care.

Socioeconomic Factors and Risk Amplification

Socioeconomic factors have a surprising amount of influence on a patient’s mental health outcomes, meaning the more resources you have to get help, the better chances you have at recovery, and the fewer resources you have, the less help you receive. Seek out, and the chances of recovery become worse.

A study in Glasgow, which contains eastern Europe’s highest areas of concentrated poverty, proved that the area has less-than-favorable health outcomes (NIH, 2020), primarily mental health. Results have also shown that the same outcomes can be seen in high-poverty areas of significant cities like Chicago.

Low-income households have a much greater risk of unfavorable mental health outcomes, which is a direct result of cumulative stress, which is defined as “Stress from one incident that may not be fully resolved before another incident occurs and triggers stress once again” (motgomeryschoolsmd). Moreover, more often than not, the stressor is financial, leading to frustration, depression, anxiety, substance abuse, and rage. The disproportionate amount of POC families below the poverty line puts them at extremely high risk of long-term complications of cumulative stressors, which lead to SMI.

Adverse childhood experiences, including abuse, neglect, and family dysfunction, have a significant impact on mental health, increasing the risk of disorders such as depression, anxiety, and post-traumatic stress syndrome. These experiences can alter brain development and stress response systems, leading to long-term emotional and cognitive problems. Addressing ACEs requires early identification and trauma-informed care, including recognition and response to the impact of trauma, as well as interventions that build resilience and support for affected families. Future research should focus on understanding the mechanisms that link ACEs to mental health problems, including genetic and environmental interactions and the effectiveness of interventions over time. Improving support systems includes integrating mental health services into primary care and education settings, promoting multidisciplinary collaboration, and raising community awareness. A comprehensive approach, which considers biological and environmental factors, is essential to treating Adverse Childhood Experiences and promoting mental health effectively and safely.

Mental Health Crisis in Schools

Adolescents today face a wide range of emotions related to stress, trauma, and life transitions. Approximately half of all children encounter trauma such as abuse, violence, or devastating loss. An estimated 49.5 percent of adolescents have experienced a mental health disorder at some point in their lives, equating to about 1 in 2 (U.S. Department of Health & Human Services, 2022). Despite this high prevalence, less than half of these individuals receive the mental health services they need (Maghsoodi et al., 2018). Inadequate funding, disparities between rural and urban schools, and inconsistent state laws on minors’ consent and confidentiality significantly hinder effective mental health support in U.S. schools.

Current Challenges in Schools

Federal and state governments offer numerous grant programs to support mental health in schools, yet these initiatives often fall short of meeting the extensive needs of students. Rural schools, in particular, face significant disparities compared to urban schools, struggling with inadequate funding and a lack of mental health education. The variability in state laws regarding minors’ consent and confidentiality further complicates access to mental health services for adolescents.

Schools are a key setting for addressing mental health issues, given that there are 128,961 public and private K-12 schools in the U.S., with more than 76 million youths in attendance (2019–2020 National Center for Education Statistics). Despite this potential, many schools lack the necessary resources, such as trained professionals and mental health education, and are hindered by the requirement for parental consent to access services.

Need for Change

Adolescence is a critical developmental period where teens make decisions with long-lasting impacts on their health and safety. Schools, where adolescents spend approximately 15,000 hours by age 18 (Hoover & Bostic, 2021), should provide comprehensive support, including mental health care. Untreated mental health issues can lead to poor academic performance, social disassociation, and higher risks of substance abuse and suicide (Hoover & Bostic, 2021). Addressing these challenges through a more comprehensive and equitable approach is crucial for improving mental health support in schools.

Funding

The federal and state governments grant programs that are designed to support schools in improving access to the quality of mental health treatment for students and promoting awareness fail to meet the extensive mental health needs of all students; such programs are often insufficient because of high demand and their focus on multiple aspects, such as training, awareness, and education, rather than directly improving the quality of mental health care (Hoover, S., & Bostic, J. 2021)

The Student Support and Academic Enrichment (SSAE) program, for instance, is a federal initiative under the Every Student Succeeds Act (ESSA) that aims to provide students with a well-rounded education. This includes supporting safe and healthy students and the effective use of technology. However, the funds allocated to the SSAE program are insufficient to meet the quality of mental health needs because they must be shared with other critical areas such as arts, STEM education, and school safety initiatives. As a result, the portion of funding available specifically for mental health services is often not enough.

The Mental Health Service Professional Demonstration Grants program is another federal initiative that seeks to address the shortage of mental health professionals in schools by funding innovative partnerships between institutions of higher education and local educational agencies. These partnerships are designed to train school-based mental health service providers. However, this program is limited in scope and size, making it unable to meet the nationwide demand for trained mental health professionals in schools.

Similarly, the Substance Abuse and Mental Health Services Administration (SAMHSA) grants, which aim to reduce the impact of substance abuse and mental illness on America’s communities, primarily focus on raising awareness and providing training rather than offering direct services. These grants often fund programs that educate school staff and students about mental health issues, but the funding is frequently inadequate to cover the costs of direct mental health services for all the schools that need support. This emphasis on training and awareness, while valuable, means that many schools are left without the necessary resources to provide direct mental health care to students. Moreover, Budget cuts pose a significant limitation across all states as well. The funding is being used on things that are not as big a necessity as healthcare. These programs are mostly hindered by insufficient funding, which makes them less effective in addressing the mental health crisis in schools. Additionally, the application process for these grant programs is highly competitive, frequently leaving some schools, particularly those in rural or marginalized communities, without funding.

Varying State Laws

Federal laws provide a minimum standard for confidentiality protections, but variations in state legislation relating to minor consent, special health care services, and confidentiality exemptions create large variability in adolescent confidentiality rights across the country (Pathak & Chou, 2019). Teenagers may give their consent for their own healthcare in some states if they reach a certain age or become parents; in other states, however, they may only give consent for certain sensitive healthcare services related to substance abuse, STIs, or reproductive health. This research uses five states, for example — California, New York, Texas, Illinois, and Washington — to compare and explore how each addresses consent for mental health services among minors. This comparative analysis will highlight the unique aspects of each state’s approach, uncovering the limitations and implications for minors seeking mental health support.

California. In California, minors aged 12 and older can consent to outpatient mental health services if deemed mature enough by a professional, eliminating the need for parental consent if the minor is at serious risk. For instance, a study by the National Center for Youth Law discusses how a 13-year-old girl in California accessed therapy for depression and anxiety without her parent’s knowledge, illustrating the benefits of the state’s more permissive laws (National Center for Youth Law, 2019).

Texas. In contrast, Texas law requires parental involvement for most mental health services, which can hinder access. An article by the Texas Tribune highlights the story of a 15-year-old boy with suicidal thoughts who struggled to get help because of his parents’ reluctance, demonstrating how restrictive laws can delay or prevent necessary treatment (Texas Tribune, 2020).

Illinois. Illinois law allows minors 12 and older to independently consent to up to five counseling sessions, after which parental consent is necessary. A report from the Illinois Department of Public Health details the case of a 14-year-old girl who benefited from the initial five sessions but had to discontinue therapy because of the need for parental consent afterward, underscoring the limitations of such policies (Illinois Department of Public Health, 2018).

New York. In New York, minors 16 and older can consent to outpatient services, but younger teens typically need parental consent unless they are emancipated or in specific situations like substance abuse. Research from the New York State Office of Mental Health highlights cases where minors sought help for substance abuse without parental consent, including a 15-year-old boy who accessed treatment but faced barriers to other mental health services, reflecting the inconsistency in access (New York State Office of Mental Health, 2017).

Washington. Washington law allows minors 13 and older to consent to outpatient treatment without parental consent, though inpatient treatment still requires parental approval for those under 18. A study by the University of Washington reviews the outcomes of adolescents who accessed mental health services independently, including a 16-year-old girl who successfully managed her anxiety through outpatient therapy, showcasing the positive impact of more autonomous consent laws (University of Washington, 2021). These ongoing variations in privacy and confidentiality protections by states significantly affect adolescents’ ability to access mental health services. The variability can lead to confusion and barriers to care, as teens in different states have different levels of autonomy in managing their mental health needs.

Confidentiality

Many teens face barriers when seeking help because of concerns about confidentiality. “Therefore, people want to ask for help but they do not want to risk their parents knowing” (Ijadi-Maghsoodi et al., 2018, p.440). This hesitation is partly because of the requirement for teacher permission to leave class and parental consent for mental health treatments, including counseling programs and medication management. The widespread use of electronic health records (EHRs) — digital versions of patients’ paper charts — has further complicated these concerns. EHRs have been increasingly adopted to improve the quality and accessibility of healthcare. The introduction of Open Notes, which allows patients to access their health records online, has increased the accessibility and transparency of health records for caregivers, including parents or guardians, heightening the risk of breaching confidentiality. As EHR interoperability — the ability of different information systems to exchange and use health data — advances, data collected under one state’s legal framework may be transferred to jurisdictions with different legal standards. Healthcare practitioners tasked with ensuring compliance with local, state, and federal regulations often lack awareness of the confidential treatments minors may receive under state law (Sharko et al., 2022). Healthcare practitioners are responsible for ensuring that medical consent and access to health information comply with local, state, and federal regulations; however, they are often unaware of the confidential treatments a minor may receive under state law (Sharko et al., 2022).

Parents also receive regular updates on the topics discussed in therapy sessions, which can deter teens from seeking help because of fear of their parents discovering their issues. This requirement may feel intimidating or invasive, making it less likely that a student will seek help initially. Similarly, the need for parental authorization for clinic services can be a major obstacle if a student fears their parents will find out about their visit. Early mental health issues often persist or recur later in life, with nearly half of individuals with mental illnesses reporting that their initial symptoms began before the age of 15 (Gronholm et al., 2018). The likelihood of young people seeking treatment is significantly influenced by their perception of how confidentially professionals will handle the information shared with them (Radez et al., 2021). Also, Ahn eet al.found that a distinct obstacle to teenagers’ willingness to seek professional mental health help is their parents’ fear of invading their privacy (2023).

Teens dealing with family-related issues and sensitive information face particularly significant challenges. For example, an LGBTQIA+ (lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual, and other sexual orientations and gender identities) teen who has not come out to their parents may wish to keep this information confidential. However, if the teen’s stress is related to their identity, the school must notify the parents, which could have serious consequences, especially if parents hold homophobic views. Similarly, in families with significant stigma — negative attitudes and beliefs about mental health — parents may not only refuse to grant permission for mental health support but also shame the teen for seeking help. This stigma can exacerbate the teen’s challenges, further hindering their access to necessary care and support.

How Can We Improve Mental Health Services in Schools?

Addressing the mental health needs of students in schools requires a multifaceted approach that encompasses several key strategies, such as allocating more funds, strengthening confidentiality protections, and enhancing mental health literacy. By implementing these measures, schools can create a supportive and comprehensive framework that addresses the mental health challenges faced by students. This holistic approach not only ensures that students have access to necessary mental health services but also fosters a school environment that promotes overall well-being and resilience.

Allocate More Funds. Allocating more funds for mental health services in schools is essential to address the growing demand for support among students. Schools need increased funding specifically dedicated to mental health services to ensure that students receive the care they need. This includes hiring more mental health professionals, such as counselors, psychologists, and social workers, who are trained to address a wide range of mental health issues. These professionals can provide individual and group counseling, crisis intervention, and preventive programs to promote mental well-being.

Federal and state governments should prioritize mental health funding in education budgets to ensure that all schools, regardless of their location or demographics, have adequate resources. This prioritization is crucial because mental health issues can affect students in both urban and rural areas, though the resources available often vary significantly. Rural schools, in particular, face unique challenges, such as a lack of access to mental health professionals and services. By allocating more funds to these areas, governments can help bridge the gap and ensure that students in all regions have access to necessary mental health support.

In addition to government funding, schools can seek grants from various organizations and nonprofits to supplement their funding. Numerous grants are available that focus on improving mental health services, providing training for school staff, and developing innovative mental health programs. By actively pursuing these grants, schools can access additional resources to enhance their mental health services. Increased funding can also support the development and implementation of comprehensive mental health programs that go beyond traditional counseling services. These programs can include mental health education, preventive initiatives, and community partnerships. Schools can collaborate with local mental health organizations, healthcare providers, and universities to create a network of support for students. Such collaborations can provide students with access to a broader range of services and expertise.

Moreover, adequate funding can help reduce the stigma associated with seeking mental health support. Schools can use funds to organize awareness campaigns, mental health days, and peer support programs. By normalizing mental health discussions and promoting a culture of openness and support, schools can encourage more students to seek help when they need it.

Confidentiality Protection

Strengthening confidentiality protections is essential to ensure students feel safe seeking help. This includes aligning state laws to minimize variability and confusion around minors’ consent for mental health services. By creating a more consistent and protective legal framework, students can access the care they need without fear of unnecessary breaches of privacy. Establishing uniform national standards for minor consent and confidentiality in mental health services could significantly improve the accessibility and quality of mental health care for adolescents across the United States. The current variability in state laws creates confusion and barriers for students seeking mental health support, with different rules about the age of consent, confidentiality, and parental involvement. National standards would provide consistency, ensuring that all students, regardless of where they live, have the same rights and access to mental health services.

One of the primary benefits of uniform national standards would be the reduction of barriers to care. Adolescents often refrain from seeking help because of concerns about confidentiality and the fear of parental notification. National standards would establish clear guidelines, making it easier for students to understand their rights and access the services they need without undue fear of their privacy being compromised. This could lead to earlier intervention and better mental health outcomes.

Another significant benefit would be the simplification of the legal framework for mental health professionals and educators. Currently, professionals must navigate a complex web of state-specific laws, which can lead to variations in the care provided. Uniform standards would streamline these processes, allowing professionals to focus more on delivering quality care rather than navigating legal intricacies. This could also facilitate better training programs, as educators and mental health workers would have a clear and consistent framework to follow.

However, implementing uniform national standards also presents several challenges. One major obstacle is the balance between federal oversight and state rights. States have historically had the authority to regulate health services, and there may be resistance to federal mandates that could be seen as infringing on state autonomy. Additionally, the diverse cultural, social, and political landscapes across states mean that a one-size-fits-all approach might not address specific local needs and concerns.

Another challenge is the potential for pushback from parents and guardians who may feel that their rights are being diminished. Ensuring that parents understand the importance of confidentiality in encouraging adolescents to seek help will be crucial. Effective communication strategies and educational campaigns would be necessary to gain parental support and alleviate concerns about the implications of such standards.

Moreover, the implementation process itself would require significant resources and coordination. States would need to adjust their existing laws and regulations, and schools would need to update their policies and training programs. This transition period could be complex and require substantial investment in training, public awareness campaigns, and administrative adjustments.

Engaging in activism and raising awareness about the importance of mental health services in schools can drive significant change. This can involve organizing campaigns, using social media platforms, and collaborating with mental health organizations. Conducting research to identify the most pressing mental health needs in schools and using this data to advocate for policy changes is crucial. Lobbying policymakers at the local, state, and federal levels to enact laws that support school mental health programs is essential. Additionally, organizing and participating in rallies and public demonstrations can draw attention to the need for better mental health services in schools.

Mental Health Literacy

Integrating mental health education into the curriculum should be approached systematically. It can begin with age-appropriate lessons at the elementary level and become progressively more detailed and complex through middle and high school. Topics should include basic concepts of mental health and well-being, common mental health disorders, coping mechanisms, stress management techniques, and how to seek help. Interactive activities, such as role-playing, group discussions, and scenario-based learning, can help students better understand and internalize these concepts.

Providing resources and workshops for parents can increase their understanding of mental health and how to support their children. These workshops can cover topics such as recognizing signs of mental health issues, effective communication strategies, and ways to create a supportive home environment. By educating parents, schools can ensure that mental health support extends beyond the classroom and into the home.

Teachers and school staff also need training to effectively support students’ mental health. Professional development programs should include training on identifying signs of mental health issues, responding appropriately to students in distress, and integrating mental health education into their teaching. This will enable teachers to create a classroom environment that promotes mental health and provides students with the support they need.

Reducing the stigma associated with mental health is a critical component of mental health literacy. Schools can organize awareness campaigns, mental health days, and peer support programs to encourage open discussions about mental health. By normalizing conversations about mental health, schools can help students feel more comfortable seeking help and supporting their peers.

Conclusion

In conclusion, the current landscape of mental health support in schools reveals a complex interplay of funding inadequacies, rural-urban disparities, and inconsistent state laws. Despite federal and state grants aimed at improving mental health services, these programs fall short of addressing the comprehensive needs of all students. Rural schools are particularly disadvantaged, receiving less funding and lacking adequate mental health education. Moreover, the variability in state laws regarding minor consent and confidentiality further complicates adolescents’ access to mental health services, creating significant barriers. Addressing these issues requires a more unified and equitable approach, ensuring that all students, regardless of their location or state laws, have access to the mental health care they need. This calls for increased funding, standardized laws, and enhanced mental health education to create a supportive environment where students can thrive.

Legal Impediments

The current legal framework surrounding mental healthcare in the United States, while robust in some areas, faces significant challenges that impede substantive reform. Two major areas of concern are the effectiveness of the Americans with Disabilities Act (ADA) in preventing employment discrimination and the inadequacies in first responder care for individuals experiencing mental health crises.

The ADA was designed to protect individuals with disabilities, including those with mental health conditions, from discrimination in the workplace. However, despite its intentions, the ADA’s impact on mitigating employment discrimination against individuals with mental health disorders has been inconsistent. Many individuals with mental health conditions are reluctant to disclose their disabilities due to stigma and fear of discrimination, which undermines the effectiveness of the ADA’s protections. Moreover, even when disclosed, the enforcement of accommodations under the ADA is often fraught with challenges, including legal complexities and limited awareness among employers.

In addition to the challenges posed by the ADA, the inadequacies in first responder care represent another significant legal impediment to mental healthcare reform. Many states lack appropriate laws and policies that equip first responders with the necessary training to handle situations involving individuals with mental health issues. This gap in training often leads to tragic outcomes, where situations could have been de-escalated but instead escalate to violence or fatal consequences. The case of Yong Yang, a man with bipolar disorder who was shot by police during a mental health episode, underscores the urgent need for better protocols and training for first responders.

Addressing these legal impediments is crucial for advancing mental healthcare reform. Strengthening the ADA’s enforcement, improving first responder training, and adopting comprehensive mental health crisis response policies are necessary steps to create a more equitable and effective mental health care system. By focusing on these areas, we can work towards a system that not only prevents discrimination but also provides the necessary support and care for individuals with mental health conditions.

The ADA’s Impact on Mental Health and Employment Discrimination

Mental health conditions significantly impact the professional lives of many qualified individuals. Despite their skills and knowledge, these professionals often face substantial barriers due to stigma, prejudice, and discrimination. Over half of those with mental illnesses do not receive treatment, usually avoiding or delaying seeking help out of fear of being treated differently or losing their jobs. This issue underscores the importance of the protections provided by the Americans with Disabilities Act (ADA) in preventing employment discrimination. However, the effectiveness of these protections in mitigating discrimination against individuals with mental health disorders remains a subject of ongoing debate. We must examine these laws, analyze the mental outcomes of those they serve to protect, and address any insufficiencies if we hope to provide adequate access to mental health care to all Americans.

The Americans with Disabilities Act

Protection for those with physical and mental deficiencies has not always been afforded to all Americans. In fact, the Americans with Disabilities Act (ADA), which establishes a critical legal framework for combating discrimination against individuals with disabilities, was not enacted until July 26, 1990 (Harris et al., 2019). By positioning disability alongside other protected categories such as race, color, religion, sex, and national origin, as delineated by the Civil Rights Act of 1964, the ADA underscores the principle of equal protection under the law.

The ADA’s central objectives include ensuring equal opportunity, facilitating full participation, promoting independent living, and advancing economic self-sufficiency for individuals with disabilities (Harris et al., 2019). The Act defines disability broadly, encompassing any physical or mental impairment that substantially limits one or more major life activities. This inclusive definition covers a wide array of mental health conditions, including major depressive disorder, bipolar disorder, anxiety disorders, schizophrenia, and personality disorders (U.S. Equal Employment Opportunity Commission, 1997).

Insufficient Protections

The ADA requires employers to provide reasonable accommodations, such as flexible scheduling, modified job responsibilities, and accessible communication methods, to support employees with mental health disorders. These accommodations are designed to mitigate the impact of disabilities on job performance and to facilitate a more inclusive work environment. Despite the ADA’s robust provisions, the persistent challenges of employment discrimination highlight ongoing issues with effectively implementing and enforcing these protections.

The employment gap between individuals with substantial psychiatric disabilities and those without is striking, with only 38.1% of the former employed full-time compared to 61.7% of the latter (U.S. Bureau of Labor Statistics, 2022). This significant disparity highlights systemic barriers and stigmas that people with mental health conditions face in the workplace. The fact that 64% of respondents in a survey believe their mental health condition negatively impacts their employment prospects further underscores the pervasive challenges in achieving workplace equity (Amazon — One Medical, 2023). These figures are concerning not only because they reflect underutilized potential but also because they indicate broader societal issues, such as insufficient mental health support and workplace inclusivity.

Moreover, these statistics reveal the deeply ingrained biases that still exist within many organizations, where mental health is often misunderstood or deprioritized. This environment can lead to a lack of necessary accommodations and support for those who need it, perpetuating a cycle of discrimination and underemployment. The economic implications of this disparity are also significant, as the underemployment of individuals with mental health conditions can contribute to higher rates of poverty and reduced economic productivity on a national scale. It’s contradictory that America tends to pride itself on caring about the well-being of its citizens when updates show that two-thirds of homeless people have a mental health disorder (Mundell, 2024). This highlights a gap between the public narrative and the reality that many face on the ground, especially when it comes to how mental health is treated in systems that frequently misunderstand or undervalue these problems.

Compounding Issues

Despite the presence of codified protections, people with mental health conditions often suffer from the fear of the stigma of disclosing their disability status. Coupled with the discrimination these individuals can face at the hands of employers, those who would otherwise be protected by the provisions of the ADA tend to be cautious about disclosing their disability status. This reluctance to disclose can hinder their ability to request reasonable accommodations, which is essential for creating inclusive work environments.

As a matter of fact, stories from individuals reveal the ongoing struggles of disclosing a mental illness in the workplace, as revealed in a recent study examining stakeholder perspectives. One major disadvantage of disclosure is the potential for discrimination. Individuals who disclose their mental health conditions may be perceived as financial risks, leading to actions such as not being hired, being offered only temporary contracts, or receiving lower salaries. HR professionals identified numerous ways disclosure could lead to discrimination, including attempts to terminate the employee and limiting opportunities for advancement. An HR manager highlighted this concern, saying, “If you ask me ‘What do you want, as an employer?’ I want to know everything. Yes, seriously! Because that allows me to assess the risks” (van Zelst, 2019).

Stigma is a major drawback of disclosure, often leading to gossip, disrespect, and lowered performance expectations from colleagues (Wheat, 2012). This stigma can create a hostile work environment, hindering individuals’ ability to thrive. HR managers, for instance, have observed that disclosure can increase the likelihood of rumors, unpleasant verbal reactions, and inappropriate jokes. Moreover, colleagues may disproportionately focus on any mistakes, attributing them to the individual’s mental health condition. One HR manager admitted, “The moment I hear a [mental health] condition during a job interview, it is stored in my memory… After that, the job applicant can talk all he wants, but I have already heard it” (van Zelst, 2019). This revealing quote underscores the persistent bias.

Furthermore, expectations and experiences of discrimination are common among individuals with mental health conditions. This includes the belief that they wouldn’t be hired if they disclosed their condition, experiences of unfair treatment in the workplace, loss of credibility in the eyes of others, and the ineffectiveness of legislation in providing protection. A study found that 40.1% of participants with schizophrenia reported that their employers showed dissatisfaction with their taking sick leave (Wheat, 2012). The fear of becoming a target for gossip and experiencing rejection or ostracism further deters individuals from disclosing their mental health issues. Isolation from co-workers and the breakdown of relationships are common consequences of such disclosure.

In addition to these direct disadvantages, other reasons for non-disclosure include the desire to keep one’s illness private, the belief that the information is too personal to share, and the perception that others do not want to know about their mental health issues. Some individuals manage to keep their mental health conditions concealed, a process known as “passing,” which allows them to be treated the same as anyone else in the workplace (Wheat, 2012). Others may find themselves in jobs that naturally accommodate their needs or where having personal experience with mental health problems is advantageous, such as in mental health advocacy or support work.

The disadvantages of disclosing a mental illness in the workplace — such as discrimination, stigma, and social exclusion — often deter individuals from coming forward, despite the protections ostensibly provided by the Americans with Disabilities Act. This reluctance to disclose hinders their ability to request reasonable accommodations, further complicating efforts to create truly inclusive work environments. The consequences of non-disclosure extend beyond the individual, affecting team dynamics, workplace culture, and overall productivity. When employees feel unsupported or unable to be their authentic selves at work, it can lead to disengagement, reduced morale, and higher turnover rates. Employers, in turn, miss out on the full potential of their workforce and may inadvertently perpetuate an environment where mental health issues are stigmatized and ignored.

Enforcement Issues

In addition to the limitations that are present when protected individuals choose not to avail themselves of the act’s protection, enforcement of the ADA faces several legal obstacles that undermine its effectiveness. One significant barrier is the complexity of proving discrimination and the burden of demonstrating that an impairment substantially limits one or more major life activities (Harris et al., 2019). This often requires extensive documentation and can be particularly challenging for individuals with mental health conditions, whose impairments may be less visible or episodic.

Additionally, there needs to be more awareness and understanding of the ADA among both employers and employees, leading to unintentional violations. Employers may need to comprehend their obligations under the ADA fully, and employees may need to learn their rights or how to assert them effectively. Limited resources for enforcement and legal action further complicate the situation. Government agencies tasked with enforcing the ADA, such as the Equal Employment Opportunity Commission (EEOC), often need more money and staffing shortages, limiting their ability to investigate complaints thoroughly and take timely action.

Moreover, individuals who experience discrimination may lack the financial means to pursue legal remedies, as litigation can be costly and time-consuming. This is evident in numerous cases where employees have struggled to obtain necessary accommodations due to employers’ ignorance or refusal to comply with ADA requirements (Job Accommodation Network, n.d.). The legal challenges are compounded by court interpretations of the ADA that can sometimes narrow the scope of its protections. For instance, courts have occasionally set high thresholds for what constitutes a “substantial limitation” of a major life activity, thereby excluding some individuals with mental health conditions from protection. This legal landscape creates an environment where, even when discrimination is evident, achieving justice and securing accommodations can be arduous and uncertain.

Lack of Employer Education

Despite ongoing challenges, the enforcement of the Americans with Disabilities Act (ADA) has demonstrated notable successes in addressing employment discrimination against individuals with mental health disorders while also revealing areas needing improvement. The ADA’s impact on workplace inclusion can be illustrated through key legal victories and settlements that highlight both progress and areas where further efforts are necessary. For example, in the case of EEOC v. TrueBlue and PeopleReady, a $125,000 settlement underscored the importance of implementing robust, reasonable accommodation policies and ADA compliance training. This case involved an employee with a psychiatric disability who was terminated upon returning from medical leave, raising critical issues about the application of reasonable accommodations and the necessity of comprehensive ADA training for employers (U.S. Equal Employment Opportunity Commission, 2022). The outcome not only provided compensation for the affected individual but also served as a significant reminder for organizations to review and strengthen their policies to prevent similar occurrences. This case illustrates the ADA’s effectiveness in securing justice for individuals facing discrimination, yet it also highlights a persistent need for increased awareness and education regarding disability accommodations in the workplace.

Similarly, in EEOC v. Party City Corporation, the company agreed to a $155,000 settlement to resolve a lawsuit that stemmed from discriminatory remarks made to a job applicant who required a job coach due to severe anxiety and autism. This case accentuates the ongoing challenges faced by individuals with mental health disorders and developmental disabilities when seeking employment. The discriminatory remarks and subsequent legal action underscore the need for employers to be vigilant in their adherence to ADA requirements, particularly in ensuring that job applicants with disabilities receive fair treatment and necessary accommodations (U.S. Equal Employment Opportunity Commission, 2019). The settlement reflects a growing recognition of the importance of fostering an inclusive work environment but also serves as a call to action for continued improvement in employer education and compliance with ADA standards. These cases collectively emphasize the critical need for ongoing employer education and rigorous adherence to ADA requirements to create workplaces that are truly accessible and supportive for individuals with mental health disorders and other disabilities.

Recent developments further illustrate both progress and areas for improvement. For instance, on November 7, 2023, a letter of findings against the City of Anoka, Minnesota, exposed egregious violations of Title II of the ADA and the Fair Housing Act. By denying tenants with mental health disabilities equal access to emergency assistance, the city perpetuated harmful stereotypes and created barriers to independent living. The proposed consent decree, encompassing a $175,000 settlement and comprehensive policy and training reforms, represents a crucial step towards accountability and systemic change. However, it is essential to recognize that this case is indicative of a broader pattern of discrimination experienced by individuals with mental health disabilities in housing and emergency services across the nation (Office of Public Affairs, 2023).

Similarly, the State of Nebraska faced findings on May 14, 2024, for unnecessary segregation of individuals with serious mental illness (SMI), highlighting deficiencies in service provision and community integration (Office of Public Affairs, 2024). These cases collectively underscore the effectiveness of the ADA’s protections in many instances while also pointing to areas requiring continued vigilance and reform to ensure comprehensive and equitable treatment for individuals with mental health disorders in the workforce.

Solutions

To address the insufficiencies of the Americans with Disabilities Act (ADA) in preventing employment discrimination against individuals with mental health disorders, a multifaceted approach is necessary. This includes improving enforcement mechanisms, enhancing employer education, reducing stigma, and simplifying the process for requesting accommodations.

Establishing a dedicated Mental Health Disability Enforcement Unit within the Equal Employment Opportunity Commission (EEOC) would be beneficial. This specialized unit would focus on understanding the unique challenges faced by individuals with mental health conditions, thereby improving the quality and effectiveness of investigations and legal proceedings. By providing targeted guidance and resources, the unit could enhance both employer compliance and employee support. Research indicates that specialized enforcement units can significantly improve compliance and outcomes. For instance, the EEOC’s Disability Program has led to increased awareness and enforcement related to disability rights, and similar success could be expected with a unit dedicated to mental health (U.S. Equal Employment Opportunity Commission, n.d.). Such a unit would build on existing successes and address the specific needs of individuals with mental health conditions.

Another critical solution is implementing mandatory annual ADA compliance and mental health training for all employers. This training should focus on understanding mental health conditions and creating inclusive workplaces, incorporating practical scenarios and interactive elements to engage participants effectively. Comprehensive training programs have been shown to improve employer knowledge and employee outcomes. For example, a study found that employers participating in disability and mental health training were more likely to provide reasonable accommodations and support a positive work environment (Bonaccio et al., 2019). Additionally, programs like “Mental Health First Aid” have demonstrated effectiveness in improving mental health awareness and reducing stigma, further supporting the need for widespread training (Mental Health First Aid, 2001).

Developing a standardized and streamlined process for requesting accommodations is essential. An easy-to-use online platform where employees can submit and track accommodation requests would reduce the administrative burden on both employees and employers. Research into process improvement highlights that simplified and accessible systems lead to better compliance and user satisfaction. For instance, the streamlined application processes used by the Social Security Administration have improved user outcomes (Social Security Administration, 2012). Similarly, the “Reasonable Accommodation Request Portal” by the Department of Veterans Affairs has effectively streamlined accommodation requests, suggesting that a similar approach could benefit ADA-related requests (U.S. Department of Veterans Affairs, n.d.).

Encouraging employers to adopt comprehensive mental health wellness programs is another vital strategy. These programs should go beyond basic compliance to actively promote mental health in the workplace, including elements such as employee assistance programs, mental health days, and wellness resources. Proactive mental health initiatives have been shown to improve employee well-being and productivity. For example, a report by the World Health Organization found that such initiatives resulted in reduced absenteeism and increased job satisfaction (WHO, 2022). Successful examples like the “Workplace Mental Health Promotion Program” in several large corporations have demonstrated lower absenteeism and higher employee engagement (Mental Health America, n.d.).

Finally, launching a nationwide public awareness campaign focused on mental health and disability rights can help reduce stigma and foster a more inclusive work environment. Highlighting positive stories and successes of individuals with mental health conditions in the workforce can shift attitudes and encourage openness. Public awareness campaigns have proven effective in changing perceptions and increasing understanding. For instance, campaigns by organizations such as the National Alliance on Mental Illness (NAMI) have been successful in altering public attitudes toward mental health (Grappone, 2018). Similarly, the “Time to Change” campaign in the UK has reduced the stigma around mental health, leading to more supportive attitudes and policies in workplaces and communities (Henderson et al., n.d.).

By implementing these solutions, we can create a more inclusive and equitable workplace for individuals with mental health conditions, ensuring that the ADA fulfills its promise of equal opportunity for all Americans.

Conclusion

The adequacy of the protections provided by the Americans with Disabilities Act (ADA) in preventing employment discrimination against individuals with mental health disorders is complex and multifaceted. While the ADA offers a robust legal framework aimed at combating discrimination, significant challenges persist. These include the stigma surrounding mental health, the reluctance to disclose conditions, and the difficulties in enforcing ADA provisions effectively. To address these issues, there is a critical need for enhanced enforcement, improved employer education, streamlined accommodation processes, and broader public awareness. By strengthening these areas, the ADA can more effectively fulfill its role in preventing discrimination and ensuring equitable treatment for individuals with mental health disorders in the workplace.

The Need to Improve Mental Health Crisis Response Policies & Practices

In the whole of the United States, 1 out of every 20 people has been to jail, and 1 out of 5 people has a mental disorder (Friedhoff, 2024). Furthermore, these two categories often overlap in significant ways. In fact, 25% of state prisoners have a recent history of mental health conditions (Lane-McKinley et al., 2018). Many of these prisoners are in those prisons for reasons, not for crimes against society, but directly or indirectly for actions related to their mental health issues.

In many states, there is a lack of appropriate laws and policies regarding mental health care. The main issue is that first responders are not adequately trained to handle, let alone treat, those with a mental illness. In the most extreme cases, this leads to first responders escalating situations that result in the injury or death of a person experiencing a mental health crisis.

Given the state of the American mental health crisis, new solutions should be sought to address this problem when it comes to first-response care for those who are suffering mental and behavioral health crises. Comprehensive legislation that provides better first-response protocols needs to be implemented to ensure that Americans in every state can enjoy a behavioral health system that allows them not just to survive but thrive.

The Inadequacies of First Response Care

Many first responders do not know how to treat those with mental illnesses. This is, in part, because of a lack of training for situations in which mentally ill people are involved. This lack of proper communication skills can result in significant harm, including physical injury or even fatal outcomes. This outcome is widespread: nearly a quarter of those shot and killed by officers faced some sort of mental illness (Lane-McKinley et al., 2018). This poses a serious problem because if they do not know how to speak to someone with a behavioral health issue, it can lead to misunderstandings and escalate the situation.

Case Study: Yong Yang. One example of this occurred in early May of 2024. The LAPD received a call from the parents of the Yang family, who were requesting help with their son, Yong Yang, during a mental health episode. Yong Yang was diagnosed with bipolar for the past 15 years; when police arrived at the address, they opened the door to see a distressed man holding a knife, yelling, “You are not invited!” and indicating that he did not want them in his home. The police, feeling threatened, shot Yong Yang three times instead of trying to calm the situation down, resulting in the man’s death. They could have de-escalated the situation and changed what had happened in many other ways.

This tragic incident underscores the pressing need for better training and protocols for first responders when dealing with individuals experiencing mental health crises. Effective communication and de-escalation techniques are crucial to preventing such outcomes. First responders should be equipped with the skills to recognize signs of mental illness and respond appropriately, prioritizing the safety and well-being of the individual in crisis.

Addressing the Problem

Addressing any mental health and behavioral health-related social issue is difficult, but providing a universal solution becomes even more complicated when government personnel and services are involved. However, with a few focused and deliberate actions on the state and local levels, we can help create an environment that is more conducive to helping individuals in crisis.

Same Day Access. Virginia’s “Right Help, Right Now” initiative is a three-year plan to fix the state’s behavioral health system. Virginia Senate bills 823, 1336, and 601 allow for advancements in crisis intervention by building a better behavioral health system through a series of advancements, including same-day help for behavioral health crises, expanding the capacity to serve people, and strengthening the behavioral workforce.

Having same-day access to behavioral health care is very important. Gillian Gmitter, a licensed counselor and a member of the Adult Behavioral Health Same-Day Access Unit, said that same-day access to behavioral health care lowers the number of mental health crises by 60% (Gmitter, 2024). With it, we can intervene in any suicidal or harmful thoughts, we can give crucial care to those in a mental health crisis, and we can reduce first-response wait times.

Virginia’s approach demonstrates the importance of immediate access to mental health services. By ensuring that individuals can receive care on the same day they seek it, the state can prevent many crises from escalating. This proactive approach not only benefits those in crisis but also alleviates the burden on emergency services and reduces the overall strain on the healthcare system.

First Responder Protocols. Many states do not have the correct laws and policies to help those with mental health issues. Take, for example, Texas, where one law, Chapter 573, allows a peace officer to detain someone they believe has a mental illness and bring them to a suitable place for someone with mental illness for 24 hours against the person’s will (Mental Health Law, 2024). The current inadequacies in training for first responders often lead to tragic outcomes.

Virginia’s Marcus David Peters Act, which created the Marcus Alert, is a state law signed into law in December 2020. The act was named after Marcus David Peters, a black biology teacher killed by Richmond police in 2018 after facing a mental health crisis. The goal of the Marcus Alert system is for people having a behavioral health crisis to be helped with an appropriate behavioral health response instead of a 911-triggered law enforcement response.

In many jurisdictions, in a 911 call involving an individual having a mental health or behavioral health crisis, law enforcement personnel are the first to respond. As we saw above, this becomes problematic if the uniformed officers are not adequately trained to deal with such issues. The Marcus Alert system allows for a response team trained in a mental health crisis to intervene and respond to such calls. This way, if someone is ever having a mental health crisis and calls 911, law enforcement will direct them to 988, the suicide and crisis hotline. Then, they can talk to a licensed clinician, and the clinician can determine if the person needs immediate Emergency Services. (Jones, 2024).

The Marcus Alert system represents a significant step forward in the way mental health crises are managed. By diverting calls to a specialized hotline and involving trained clinicians, the system aims to provide a more appropriate and effective response to individuals in crisis. This approach not only reduces the likelihood of violent encounters with law enforcement but also ensures that individuals receive the care and support they need.

These programs provide immediate access to behavioral health services and establish protocols for first responders to manage mental health crises better. By adopting similar measures nationwide, we can create a mental health system that provides timely and effective care, ensuring individuals receive the support they need to thrive.

Conclusion

The need for comprehensive mental health care reform in the United States is clear. By implementing more comprehensive legislation, adequately training first responders, and adopting successful solutions from states like Virginia, we can build a mental health care system that genuinely supports and protects individuals in crisis. This holistic approach will not only improve outcomes for those with mental health issues but also create a more just and effective system for all Americans.

Summary

In conclusion, achieving mental health equity in the United States is an urgent and attainable goal, demanding a concerted effort to address the myriad challenges that currently hinder access to necessary care. The millions of Americans affected by Serious Mental Illnesses (SMI) face significant barriers, including economic, social, and legal obstacles, that prevent them from receiving the support they need. The economic disparities, particularly in rural areas, exacerbate the difficulties in accessing mental healthcare, while social stigmas and legal complexities further compound these challenges.

However, by enhancing access to mental health services through telehealth, increasing funding for rural communities, promoting mental health awareness, and enforcing mental health parity laws, we can begin to bridge the gap. Addressing the impact of incarceration, understanding childhood trauma, and improving support systems are also critical components of this effort. Moreover, strengthening the enforcement of the Americans with Disabilities Act (ADA), standardizing laws, and enhancing mental health education in schools are essential steps toward creating a more equitable mental healthcare system.

The potential benefits of achieving mental health equity extend far beyond individual well-being, promising substantial economic and social gains for the nation as a whole. As we explore the economic, social, and legal barriers to mental health equity in this research paper, our goal is to propose actionable solutions that will enhance the accessibility and effectiveness of mental healthcare across the United States, ultimately improving the overall quality of life for all.

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