In 1993, New York senator Daniel Patrick Moynihan highlighted America’s troubling trend of “defining deviancy down.” Moynihan argued that Americans, facing rising crime and disorder, had responded by redefining these pathologies as “normal.” Thirty years later, his message resonates more than ever, and especially in the context of mental illness. Americans have come to accept extraordinary levels of disorder and violence stemming from untreated mental illness, with grave consequences for both the mentally ill and the public.
Consider a partial tally from late last year. A mentally ill man committed the deadliest shooting of 2023, killing 18 in Lewiston, Maine. A schizophrenic man in Brooklyn was arrested for killing his mother and stuffing her into a box. A depressed commercial pilot took illegal hallucinogens and tried to bring down an 83-passenger flight. An untreated mentally ill man known to police pushed a young woman in front of a subway car. A bipolar schizophrenic man, who had been in and out of hospitals for the “better part of two decades,” tried to commit suicide by jumping into the 9/11 memorial in Downtown Manhattan.
Since around 1960, American cities have seen growing numbers of people with untreated serious mental illness become perpetrators and victims of everything from quality-of-life offenses to violent crime. The trend has its roots in the deinstitutionalization and civil rights movements. In the 1960s, states moved thousands of patients out of state mental hospitals and into the community, a process that would persist in the ensuing decades. States saw the rise of anti-psychotic drugs and heard from “experts” claiming to know how to prevent mental illness. These developments, combined with strong financial incentives, led states to shutter or significantly reduce the censuses of their public psychiatric hospitals. States’ optimism that mental illness could be eradicated or no longer require institutional care was premature. The causes of serious mental illnesses remain unknown. And many patients, even with the help of medication, struggle to integrate into society, lacking the structure and routine provided by an institutional setting.
Activist pressure also contributed to the asylum’s decline. In the mid-twentieth century, the public became less comfortable with institutions, viewing them as mechanisms of social control. The emerging ethos of the civil rights movement, in tandem with grim reporting on overcrowded and generally squalid conditions in many asylums, inspired a narrative that labeling a person “mentally ill” was merely a means of stigmatizing them and denying them their individual rights. Advocates recast mental-illness policy as a quest to improve the nation’s “mental health,” blurring the lines between serious psychotic disorders and normal emotional reactions to adversity.
The availability of short- and long-term institutional care for people with psychotic disorders has diminished substantially—not owing to fewer cases but because, in addition to the driving factor of cost, a robust legal framework prevents involuntary, and in some cases even voluntary, commitment. Today, state-run psychiatric hospitals operate with 95 percent fewer beds than they had in the middle of the twentieth century, and their capacities continue to shrink. The mentally ill now constitute a disproportionate share of the homeless, jail, and prison populations. Save for the exceptional case when a person’s behavior presents an immediate danger to himself or others, seriously mentally ill individuals are left to “die with their rights on.”
Elected officials seem aware of these consequences. They continue to spend money on “mental health,” but without much progress in solving the problem. Despite the U.S. spending around $280 billion on mental health in 2020 alone, between 40 and 50 percent of individuals with serious mental illness receive no treatment.
Redefining the rightful focus on serious mental illness as a quest to improve the whole nation’s mental health has enabled the bloat of an entire industry, which now gets ample funding for programs related to vague social goals, such as reducing poverty, bullying, and unemployment. Little evidence suggests that these programs alleviate the disability caused by serious mental illness or help reduce rates of homelessness, violence, and incarceration.
The mental-health industry continues to cite “stigma” as the biggest barrier to treatment for people with mental illness. Research does not support this contention. “Considerable progress has been achieved in improving public awareness of mental illness and reducing its stigma,” researchers Cristina Mei and Patrick D. McGorry observe. “However, this has not driven substantial changes in access to and quality of mental healthcare.” And while billions have been spent on anti-stigma and mental-health-education campaigns, the public is more concerned about violence stemming from mental illness than ever before. Indeed, more Americans appear to associate mental illness with violence than was the case decades ago.
The stubborn truth remains that the best way to destigmatize mental illness is to pursue the policy that will most effectively reduce violence caused by mental illness: treatment. Mental-health practitioners recognize that “[a]ctive outreach by the necessary services and a more enlightened approach by courts will do a lot more to reduce involuntary treatment than an ongoing rights versus treatment debate.”
By redefining mental illness as a lack of “mental health,” the United States has lost its focus in mental-illness policy. We have come to expect the violence, disorder, and tragedy associated with untreated serious mental illness. Policymakers should dedicate their efforts to providing adequate treatment to the most seriously mentally ill, rather than trying to social-engineer mental illness out of society by calling it an experience common to all. Recent mental-illness-related tragedies need not be the norm. A clear-eyed policy approach that serves the few whose mental illnesses leave them gravely disabled—prioritizing such care over the rest of us “worried well”—might surprise us with its comparative success.