Overhauling Our Mental Health System

In this exclusive video, Eric Reinhart, MD, a political anthropologist, psychoanalyst, and medical resident at Northwestern University in Chicago, discusses the “Treatment Not Trauma” campaign. This initiative by the Chicago Collaborative for Community Wellness seeks to create a crisis response for mental health-related emergencies and to reopen a number of Chicago mental health clinics.

The following is a transcript of his remarks:

Treatment Not Trauma is an initiative that’s been years in the making in Chicago that’s been embraced by the new mayor, Brandon Johnson. [It’s] a policy agenda to build a robust non-police crisis response system for the city of Chicago and to reopen a total of 19 community mental health centers that used to be run by the Chicago Department of Public Health, but have since been closed — except for five of them still continue now, although largely defunded and de-staffed.

The most important and exciting part, in my view, of the whole agenda is this third component, which is building out a large-scale community care workforce to fundamentally transform what public mental health systems mean, what they can look like, what they do. To move away from both police and psychiatrists, towards a community conceptualization of care — a de-medicalized, democratized form of care.

If we’re going to design effective community mental health infrastructure, we have to relocate the center of power, the center of authority, the center of funding, away from professional workers into communities themselves, into workers who are employed from these communities who do not necessarily have fancy degrees, but have everyday lived experience that’s incredibly important for delivering effective care and designing effective care delivery systems.

It’s very, very difficult to get access to mental health care in the city of Chicago, like it is in most places in the U.S., if you don’t have adequate resources to pay for it. The other issue is that the quality of care that you get isn’t really that great, because it’s largely built on a psychiatric model that’s reactive: you have symptoms, you have disease, we’ll give you medication, we’ll give you a 10-minute appointment.

The fact is [that] those medications aren’t very effective. Our own studies within the field of psychiatry have shown this time and time again. There was a meta-analysis published last year, I believe in 2022 — John Ioannidis [MD] was one of the authors of it — that looked at the history of randomized controlled trials within psychiatry and looked at the effect sizes of both psychotherapeutic and psycho-pharmaceutical interventions. What they found is that the effect sizes are tiny. And this hasn’t really shifted over the years.

We aren’t good at what we do within the field of the mental health industry, more or less, but people don’t have other options. They don’t have other options because we, the professional systems and the professional workers, gobble up the funding resources. It’s incredibly ineffective and expensive.

What we see is that there is no strong association between the density of mental health providers and the overall mental health disease burden dropping. It doesn’t seem to do that. In fact, studies have shown that if you provide really high-quality care and high-density care, that the proportion of burden of mental health symptoms that you can reduce is actually pretty small. It’s like 20-30% in most cases.

So, the business as usual model — I’m using language that Vikram Patel [PhD, MBBS] and others have used in a recent article in Lancet on redesigning mental health systems globally – they say the business as usual model that we have right now is failing. We need to confront the fact that the way we’ve designed our mental health systems isn’t working.

What we’re trying to do in Chicago is to take on that lesson and say that simply putting more and more money and more and more resources into a failing model isn’t the solution. People should have access to care, absolutely, and we should have more money for this. But we should have more money that’s invested smartly in addressing root causes and delivering the everyday supportive care that people need, not in more emergency department funding, for example, or necessary inpatient psychiatric units.

These things can be important and medications can be really important too for some individuals. But when you try to make these kinds of medicalized forms of care do more than they are capable of doing, what you end up doing is causing harm. At a systems level, that’s absolutely what the mental health industry in the U.S. is now doing.

We have to have a new model. That’s what Treatment Not Trauma is trying to do. It says we need places for people to go when they are in crisis, when they’re struggling, or ideally before they’re in crisis, when they need support, when they need connection, when they need everyday social care.

When they are in crisis, they shouldn’t have to call 911 and have police officers come, which often results in violence. People with unmet mental health needs have a 16 times greater risk of being killed by the police than anybody else in the U.S. right now. They should be able to have community care workers respond to them, people who are perhaps mental health specialists. Maybe that means professional workers, maybe it means people who are non-professional workers but are trained to respond to mental health crises in the kinds of systems that we’re designing, like Treatment Not Trauma.

So you need those two systems. You need non-police crisis response, you need places for people to go — home bases for care teams — and, then, you need a workforce. We can call them community health workers, but what we need is to empower residents of dispossessed communities where there are very high rates of everyday social needs that then become transformed into so-called psychiatric needs when they aren’t met. We need to employ those kinds of people, give them adequate support and training, and that means compensation at a level equal to what the police get right now, for example.

So, in Chicago, you start in the high $50,000s as a police officer, and within a few months your salary increases to about $80,000. And you have really robust benefits and good job protections. We should be giving that to care workers. Why are we always investing more and more money in the U.S. into punishment systems and punishment workers rather than in preventive care workers? That should be a career position.

When I talk about this with people, they often say, “Oh, you can’t consign people to these low-level poverty jobs as community health workers.” What’s often taken for granted is the idea that a community health worker should be a poverty job. That shouldn’t be a poverty job, that should be a career job. That’s an incredibly important role that we as a society should value.

And it shouldn’t be based on what kind of revenue you bring to a for-profit health system. It should be understood as a public service, just as the police are right now understood as a public service. We should have community care workers that are employed by local departments of public health to do this.

What this enables us to do is begin to think about non-pharmaceutical-based models of care, which is really, really important. Because something that is not talked about enough, I think, in the U.S. right now is that very high rates of psychiatric prescriptions also carry a lot of iatrogenic harm.

Antipsychotics, for example, can result in elevated blood glucose levels that over time can drive diabetes. They have all sorts of metabolic disturbances that they affect. We don’t fully know the range of harms that a large number of psychiatric medications may cause. When we have other kinds of systems, then we can begin to prescribe more judiciously, more carefully, in a way that’s designed to be effective for each individual patient rather than just as a reflex where somebody comes to me, I give them a drug.

I think this is what Treatment Not Trauma enables. It’s not just about a public care system. It’s not just about non-police crisis response. It’s about transforming our entire conceptualization of what community mental health is, of what mental illness is. Is mental illness perhaps, in many cases, just unmet social needs that, if we meet, no longer require psychiatric response or psychiatric attention?

A lot of basic definitional issues are raised by this kind of model of care, and I’m very excited about the possibility of trying to build something new that would allow us to negotiate these longstanding questions and problems in a very different kind of way when we have the backing of a real public care system.