Content includes: substance use, suicide, homelessness
There’s a thing we say (said) in the world of community mental health that I always forget is not common language. “Living in the community”. It’s on forms and in notes and spoken between providers. I’ve accidentally said it in many settings that did not match, prompting questions from all the people around who have never had a strange woman come into their lives with a clipboard, promising resources.
“Living in the community” is a term that simply means that your living situation is not connected to services. You’re not sleeping in jail or a nursing home or transitional housing or sober living or an emergency shelter. It also means you’re not street homeless, as that has its own box you can check. If you pause for one moment, the question asks itself. What, in this case, is community? If you try to visualize it, is it the building you live in? Your block? Your family? The neighborhood? The city?
Like many of us, I’m guilty of using the word community a little fast and loose. We usually invoke “community” to put people with a shared signifier into a bucket. Individuals at the same place and time with the same identity do not constitute a community, but a crowd. You can feel it when you’re in true community. There are common goals, inter-network connections, and shared vision that cannot be assumed from simple identity factors. I consider myself deeply community-oriented, meaning that I’m connected to others through the labor of relationships. When it comes down to it, we all understand there is a difference between the shorthand of “The LGBTQ Community” and your own community that is LGBTQ, right? Maybe they just started using that first one because advertisers can’t call us what they used to anymore.
I feel comfortable guessing that most readers of this silly essay would technically Live In The Community if they had to check a box. But they really don’t. The difference is that you don’t Live In The Community if you are never told that you do. If there is never a piece of paper in front of you with this phrase on it and you never hear it out loud, it doesn’t apply to you. Housing status is just the beginning of the assumed community projected onto people who have needs that are made public.
Today, I’m here to posit that it all comes down to the Community Mental Health Act of 1963. Here’s how the history is written:
Remember the abandoned asylums you’ve heard scary stories about? With chains and straight jackets and horrible things? They’re haunted and empty because they were all closed down. In 1963, our beautiful boy, John F. Kennedy, decided to do away with these miserable places and grant autonomy to our family members by instead providing services directly to people with mental illness and cognitive and developmental disabilities at Community Mental Health Centers (CMHCs) nearby where they live independently or with roommates or family, with the rest of us! In his address to Congress, the sweet king promised that “reliance on the cold mercy of custodial isolation will be supplanted by the open warmth of community concern and capability. Emphasis on prevention, treatment and rehabilitation will be substituted for a desultory interest in confining patients in an institution to wither away.” From then on, involuntarily hospitalized patients had a right to the least restrictive possible environment. Can you say progressive? Can you say utopia? What a hero to the disabled people of America! It just so happens that the least restrictive possible environment is the cheapest one for the government to fund!
If you’ve ever walked down the street in any city in the country, you already know how it turned out. This fiction was written in real-time. It wasn’t just the leadership of the two major parties. Social movements overlapped in such ways that created an outpouring of liberal and left-wing support. The civil rights and women’s liberation movements highlighted how weaponized misdiagnosis of mental illness led to the psychiatric incarceration of domestic violence victims and Black men distrustful of police. Descendants of the disability rights movement, the independent living and psychiatric survivors movements, shed light on the warehousing of patients and physical abuse rampant in psychiatric institutions. They also began promoting the social model of disability, identifying restrictions placed on disabled people by structures of social exclusion, calling the concept of mental illness into question. The supporters of deinstitutionalization weren’t exactly all Cato Institute lanyards. That’s not to say left wing activists weren’t in a coalition with deeply conservative institutions. So, through the will of diverse political actors, the invention of Thorazine, and some say, the publishing of One Flew Over the Cuckoo’s Nest the hospitals were emptied.
Quick stats: The initial CMHCs caseloads were only comprised 4-7% of patients discharged from long-term state hospitals, and those percentages decreased until the program was block-granted (killed) in 1981. The other 93-96% of the caseloads comprised of what we call the “worried well”, mainly middle-class people with issues of anxiety or mild mood disturbances. And the rest of the state hospital patients? We didn’t keep great track, but frequently, jail, homeless, or no longer alive. Only about half of the CMHCs were ever even built, and they were never fully funded. We never intended to care for the sickest patients. We deal with the same issues today because as a society we don’t care about people with serious mental illness.
If someone would have said those last 2 sentences to me in grad school, I would have interjected because I took issue with the use of the words“sick” and “patient” and even the term “serious mental illness”. It would have gone on for like, 5 minutes. I wonder if there were people in the room thinking what I am now: your focus on language is moving us further from materiality and deconstruction doesn’t get anyone off the streets. In fact, using the most woke possible language seriously obfuscates the problem. It is stigmatizing to avoid speaking about someone’s reality at all costs.
2020 was a tipping point for me. Every day I saw articles and IRL invocation of “community” as both a mechanism and outcome for politics. Community-based interventions. Community solutions to violence. Community care. Community-based crisis response. One of two issues showed up each time I encountered someone invoking community in this way: either they didn’t know that the thing already existed, or they knew but wanted it to be disconnected from institutions in order to keep people safe from police, prisons, and punitive mental health interventions.
I started getting frustrated, and then I felt guilty for being frustrated. I also thought about all ways I tried to do all of the fill in the blank community ____ outside of my career through mutual aid organizing in existing organizations, inside of grassroots organizations, and in my organic social networks. In my experience, it was mostly miserable work. I was happy to learn new skills and figure things out on the ground, but in times of crisis, we were working with no resources. No matter how important the cause may be, there is a particular agitation in trying to scrape together funds to complete a task that any functioning government should take care of without consequences, like first aid, childcare, or overdose prevention. Then I thought of all the times I had done community ______ as part of my job. Mobile crisis response. Therapy by the side of the highway. Doing the work people advocate for incessantly, county governments pat themselves on the back for publicly, and that people like social workers are completely alone in. Because when you’re really living In Community, going to a Community Mental Health Clinic, engaging in Community Based Therapy, with the phone numbers of your Community supports scribbled down, and something goes wrong, no one is obligated to help you. Except sometimes me. The weight of the federal, state, county, and city government failure is too heavy. As a social worker, you sometimes find yourself being the only thing standing between someone and jail time or relapse or missing their meds or missing a doctor’s appointment or losing their job or sleeping outside. And as a kind supervisor might remind you, it’s not your responsibility to do it all. You’re just there to support.
Who’s responsibility is it then? No one’s. The community’s.
You can find part 2 here:
Ooof; harsh but true. The Venn diagram of people I've met who have a utopian vision of how to treat mental illness, who don't really believe that mental illness actually exists, and who have clearly never witnessed someone lose all contact with reality, is a circle. A lot of these people generally support progressive social policy but recoil at the idea of long-term residential care, which is sad because the only alternative for most people with severe mental illness, as we've seen over and over again, is a piece of cardboard on the sidewalk.