Falling Through The Cracks

 

Falling Through the Fractured Systems

The Struggle for Mental Health Support

 

TRIGGER WARNING:

While I have refrained using any graphic language and moderated the content to be reader friendly there are a couple of suicide helplines and descriptions of mental health issues which might be triggering. Consider if you are in the right frame of mind personally before reading this.

Introduction

Very often we find ourselves stepping into the shadows of this realm where our cries for help reverberate off the walls of indifference and our emergent needs are met with crushing inefficiency. As we dig deeper into mental health issues, we find ourselves tangled in a labyrinth with red tape and paperwork and stand glaring at a system where the clocks tick louder than the beating of anxious hearts and where there are gaps big enough to flood the rest of our lives with tears.  Yes, the system does not work and it’s time we declare war against it.

This article aims to understand the inadequacy of the mental health system, analyse factors contributing to it and explore potential remedies to the same.

Social Stigma

This is the grass root problem. It seems intuitive to many of us that if a person is going through something difficult and painful, they require help and would reach out for it. However, the aura of taboo surrounding these issues highly discourages people from asking for help and in fact legitimises their apathy. This includes being dismissive of the pain the person is going through, asking them to “suck it up” or telling people to “calm down” and not “overthink it.” Though these statements might be made from a place of concern it is highly counterproductive to the issue at hand. There are 4 broad concerns in this regard:

1.     Gaps in Understanding what mental health really means:

a.     It is sad that the concept of mental health and wellness in medical terms has only evolved over the last couple of decades. Therefore, much like gaps in knowledge with technology, there are significant doubts over what mental health entails and what the appropriate measures are. Thus, there is an information asymmetry affecting our capacity to respond to mental health crisis.

b.     The discourse regarding mental health doesn’t receive appropriate engagement as a result of ignorance owing to the prevalence of stereotypes and prejudices that arise in the absence of this information from a really young age. The reason humans are generally resistant to change is because we grow up listening to and experiencing these narratives on a daily basis and that becomes an important aspect of our identity and beliefs, which we don’t want to part with, because it doesn’t seem “normal” or “right thing” to do. Thus, any change along those lines is met with not just resistance but with significant backlash which plays its role in perpetuating these stereotypes in order to justify their stance.

2.     Media:

a.     It plays a crucial role in shaping public perception towards mental health. When what we see and hear from media sources is often the worst of the issues people face because that is the only thing which is of a magnitude significant enough to capture viewers which help their TRPs. This sensationalisation and inaccurate portrayal of mental health issues further instigate the perpetuation of false narratives.

3.     Social and professional fears:

a.     Many societies and cultures have traditionally placed emphasis on stoicism, self-reliance, and the idea of not burdening others with personal struggles. As a result, seeking help for mental health issues is often seen as a sign of weakness or failure to cope.

b.     Toxic Masculinity: Young boys and men in this patriarchal society may feel the pressure to conform to toxic standards of masculine traits from societal or cultural expectations such as men needing to be the breadwinner and bearers of the financial burden in a family and considering any form of emotional outlook towards things as weak. It is significantly worse when it is viewed as a duty which is owed by men and when not conforming to those standards comes with a label of being “not manly enough.” This is fuelled by social media narratives of being an “alpha” or “sigma” male whose solution to mental illness is working hard at the gym and your job and thereby instilling “focus” and “strength” which would make you rich.  

c.     In addition, there are legitimate fears of people losing their jobs owing to the absence of mental health coverage under their paid leave criteria even in salaried jobs. This is worse for a blue-collar worker who depends on the daily wage to feed his family and cannot rely on savings to quit work or go to therapy.

4.     The rise of “therapy speak”:

a.     This refers to the major extension of psychological and medical language and concepts into everyday life outside of the academic arena. It includes using terms like "toxic" or "gaslighting" when talking about friendships or personal relationships and labelling the desire to tidy up as "OCD" or a temporary difficulty focusing as "ADHD" and making speculative psychiatric diagnoses of others. This devalues and dehumanises the actual experiences people go through and consequentially signals that your situation either needs to be drastically bad to reach out for help or is not that bad enough to reach out for help just yet.

Dearth of Mental Health Resources

It is positive to note that treatment of mental health has shifted away from beauty parlours and mental health asylums which treated people like pariahs to outpatient care and community mental health centres. This would have been a wonderful idea if it was properly funded.

In the status quo there is a shortage of mental health providers be it therapists or social workers out there and even the ones who exist do not have the adequate resources to provide efficient care. As per the National Survey of Mental Health Resources carried out by the Directorate General of Health Services, between May and July 2002, against the required 11,500 psychiatrists in the country, only 3800 existed.           

Thus, there is a nexus between supply and demand which plays out in a couple of ways:

1.     There aren`t enough suppliers in a market where demand is widespread. There are increasing waitlists and 65% of therapists claim not to have the proficient capacity to deal with a huge inflow of cases. This is because hospitals and clinics do not have a functioning mental health care centre. Even if they did they often prioritize patients with any physical illness in the ER over any case of mental illness, which prolongs the waiting period for these patients.

2.     Mental healthcare becomes insanely unaffordable and therefore inaccessible to millions of people who need it the most. In a metropolitan city in India, the average cost of seeing a therapist is Rs 1500 per hour and Rs 750-1000 for a counsellor. This has two impacts

a.     Discourages people to seek help. Even a middle-income parent who might otherwise be persuaded to let their kids go to therapy would be now less likely to let their kids get the help they needed and adults themselves would not want to incur these expenses over a period (as usually therapy does take a good amount of time to work) as it takes away a significant chunk of their income which is important for the smooth functioning of a household.

b.     The costs also mean that the inequality between the rich and the poor widens as affording to go to therapy comes from a position of privilege which is exclusionary. Insofar as your clients are predominantly well-off individuals, you as a therapist or a counsellor have no incentive to reduce your costs. 

Goofy Alternatives

This gives rise to teletherapy and Silicon Valley apps which claim to help with mental health issues. The problem however is they are here merely to exploit the vacuum which exists given that no one else is out there competing by providing amazing care at affordable rates. Eg: Cerebral has been known to overprescribe Aderol to its patients despite knowing the fact that these are the patients who are most likely to develop a dependence on that drug. It is also very fishy to note in this context, the tie up these companies have to pharma corporations who manufacture these drugs prescribed and the lobbying power they hold in the congress.

In addition, since these apps hide behind a veil of distance and lack of professional accountability, they find no qualms in hiring untrained workers to assist in suicide help lines and further do not spend any time or money training these individuals to equip them with life saving skills. The AI which these apps employ is also counterproductive in dealing with these scenarios precisely because of a sheer lack of knowledge to deal with such life-threatening situations reflected in its programming.

Thirdly, everyone now is a mental health expert on social media these days. Infinite reel loops with people with no professional training sharing mental health advice primarily based on what they’ve heard or what worked for them in their capacity is dominant. For a person who is on their phone for a considerably long time, they are likely to engage more with such similar posts over time owing to the algorithm of these social media platforms. Obviously, seeking mental health advice on a platform synonymous with misinformation is shooting yourself in the foot.

Cost and Insurance

The cost of a session with a therapist is often more than a person`s monthly wage in India. In addition to the nexus between demand and supply discussed earlier, a couple of contributing factors would be the lack of insurance coverage and legislation regulating the price cap in this specific field. This unfolds in 4 ways:

1.     Insurance companies not willing to pay their share has become a cliché at this point. The problem is mental health care does not come under the ambit of most healthcare policies. In addition, insurance companies like Anthem claim that the reason they did not extend their policy coverage on mental health to specific areas is that the “area is saturated and doesn’t have enough mental healthcare providers or people subscribing to their policy.”

2.     Ghost networks are formed when health insurance providers ostensibly provide coverage, but direct customers to non-existent or unavailable doctors and providers. Insurance companies strictly restrict their coverage to these padded lists with these numbers of professionals in your locality that are no longer active or are strapped for capacity and thereby seek to avoid any liability if claims arise.

3.     What is worse, is insurance companies not making payments to therapists, even if the insurance amount of the patient was sanctioned and their bureaucratic structures make them opaque and hard to be held accountable. This would further incentivise therapists to adopt methods like increasing costs per session or receiving payments as lump sump just to secure their livelihood while the costs are still borne by the people who are suffering from crippling mental illness.

4.     Owing to the ambiguity of terms in the contract such as “deemed medically necessary”, many insurance companies often threaten to pull funding or significantly reduce their liability by claiming that often crucial life-saving treatments like rehab centres may or may not be successful or necessary to patients.

Access to Minority Groups

Minority groups are harmed in 3 ways in this regard:

1.     It is indeed sad to note that people stuck in the intersectionality of gender, race and sexuality often are the receiving end of bad mental health outcomes. A low income African-American woman in the US or a Dalit woman in India are the ones who are statistically identified to be mostly in need of these services but often cannot access help, not just because of monetary troubles, but also because of their seclusion to their private spheres and having to work two shifts or hours in the field or at someone`s house to provide for their family means they got little to no time for themselves in their life.

2.     It is crucial for patients to be felt understood and heard by their therapists. The problem, however, is that people of colour and gender minorities often feel that their healthcare providers are very dismissive of their issues that are closely tied to their identities or are unable to analyse the issue from the perspective of their patients. This extends beyond bigotry because it is not just stereotypical views hindering cars, but crucially an absence of basic studies, knowledge and skill addressing these specific needs of minority groups.

3.     But it is also important to understand that this does not call for a blanket narrative or protocol over collectives, rather it calls for an individualistic approach and a case-by-case evaluation as every individual has varying needs and varying social factors which might contribute to these needs. This also looks like the need to have mental health workers specialised to deal with teenagers at different levels like school and university and elderly patients who come nowhere near the ambit of discussion of mental health. Their needs are different and their problems are different; this particularly necessitates the presence of such mental health workers.

What can be done about it?

1.     Firstly, governments must allocate funds to invest in mental health infrastructure over a particular time frame with specific goals to achieve along the way. This should happen on a scale ranging from recruiting and training mental health care providers, offering scholarships and grants for their tuition, and setting up community health care centres specifically catering to mental health issues.

2.     Secondly, loopholes in legislation must be addressed and parity laws must be enforced strictly, which would force insurance companies to cover mental health under their policies and subsidise premiums for the same. To get politicians and the government to care about mental healthcare it needs to become a voting issue which is at least close to being as important as physical healthcare facilities. For this, we are largely dependent upon weaponizing media narrative and accelerating grassroots change.

Conclusion

If the arc of history teaches us anything, it is that change comes from getting people to care. Each wave of feminism has progressed so far because people started to care about specific issues to a great extent and requests became demands.  Though this is easier said than done, getting people to open up and talk about their mental health without being judged, is a perquisite to accelerate change in status quo. 

Within the framework of our society, the fractures in our mental healthcare system resemble the cracks in a weathered building. It is our collective duty to mend those cracks, reinforcing a foundation of support, compassion, and accessible care, ensuring that no one slips through the crevices of despair unnoticed.