By Maura O’Sullivan
Food, clothing, and shelter: a refrain as old as time. Their universality transcends demographics and diagnoses—alongside healthcare and social support, these basic needs apply to just about everybody. People with serious mental illness (SMI) share these universal needs but require greater support to meet them. Stefancic et. al. describe homelessness as a frequent cause of secondary problems for mentally ill people. It corresponds with a lack of access to medical care, social support, community integration, and resources like food (1195). One crucial difference is that for those with SMI, supportive housing and medical care are typically prerequisites for meeting other needs. Without foundational resources, few are able to work towards better health.
In the absence of effective societal safety nets, mentally ill people often depend on family to meet basic needs. It’s far from an ideal circumstance—for people with SMI, it might mean dependence on an abuser who exacerbates their symptoms, or a lifetime spent in an under-resourced household. (The archetypal madwoman in the attic comes to mind, cloistered safely away from the public eye.) For family members, it can turn filial love into a full-time job. Kim Martin, a disability lawyer, recalls an early morning phone call from a client whose son had just been involuntarily committed for trying to kill his parents (O’Sullivan); a recurring delusion had convinced him that they’d been replaced with imposters.
Structural dependence on family members is neither equitable nor realistic for many people with SMI. In an article for The Atlantic, David Brooks describes the failure of nuclear family systems to provide consistent support. While highly educated (largely white) family structures have remained stable since the 1950s, marginalized groups face “utter chaos.” Brooks claims that the reason for this inequity is that “affluent people have the resources to effectively buy extended family, in order to shore themselves up.” (60). In other words, those who already have extensive resources can privately outsource care needs. But as society shifts away from large-scale social care networks, it becomes increasingly difficult for laypeople to provide for a family member with high support needs. Those who are most vulnerable—people without the affluence or privilege to access either social or privatized care—slip through the cracks.
What structural fallbacks for psychiatric care do exist beyond the home frequently fail to meet people’s needs and strip them of agency. The best-known housing and care alternative for mentally ill patients is institutionalization, a system that has faced criticism for over a century. Mental institutions were originally conceived as a moral, humane source of social support for people with SMI. As early as the 1800s, though, they came under fire for overcrowding, poor living conditions, and mistreatment of patients. In her 1887 exposé “Ten Days in a Mad-House,” investigative journalist Nellie Bly describes food shortages, widespread physical illness, and physicians who laughed at patients when they tried to plea sanity (Chapter 12).
Human rights violations aside, institutionalization is not realistic across the lifespan, which raises the question of what happens to those without family support when released. In his interview with Carolina Efird through the Southern Oral History Program, Tim Grizzard says that he returned to Dorothea Dix Mental Hospital for a place to live because his parents couldn’t take him on after his admission for cocaine overdose (14-15). Anecdotes like this indicate a cyclical pattern of insufficient care—even when medical treatment succeeds, patients’ community care needs are not addressed well enough to facilitate independence from medical systems.
While some patients have access to insufficient care through institutions, others are forced into them without just cause. According to Dr. Vijay Ghate, a former physician at Dix, institutions are frequently misappropriated. He describes how Dix slowly became a place where anyone without a support system was sent for housing and care—even patients with physical conditions like epilepsy (28). Nellie Bly found the same in 1887; many patients were immigrants who didn’t speak English, unmarried women, or low-income (Chapter 8). The consistency of this issue across centuries speaks to the need for a different support system entirely.
Individuals with SMI who lack family support may fall prey to another structural backup for care: the carceral system. This system is not a formal source of care; it was not designed for it and doesn’t cater to psychiatric wellbeing. Despite this supposed disconnect, links between mental illness and incarceration are extensively documented. One study found that when controlling for other case characteristics, misdemeanor arrestees with a diagnosis of major mental illness were 50 percent more likely to receive a jail sentence (Hall 1088). The fact that mentally ill people are over-represented in this punitive system may be indicative of a lack of social support, disparities in mental health between privileged and marginalized populations, or a justice system biased against atypicality. Regardless, prison is unpleasant by design, and it’s worth questioning why mentally ill people are disproportionally subjected to it.
In terms of resources, incarceration is worse than nothing. The carceral system goes the extra mile to actively harm the well-being of both inmates and their extended support systems, especially those from marginalized backgrounds. Wildeman and Wang describe indirect effects of incarceration on health ranging from “substantial mental health deterioration” among women with incarcerated partners to increased anxiety, depression, and obesity among children of incarcerated parents (1469). This insinuates a compounding psychological injury to those involved with the prison system, even tangentially. They further note the relationship between solitary confinement and “potentially fatal self-harm (including hanging and ingesting poison)” (1467-1468). Evidently, incarceration is not a viable or safe source of structural support for people with SMI.
The human toll of America’s haphazard array of structural responses to mental illness is enormous, but it doesn’t have to be. The strong correlation between mental illness and homelessness speaks more to the lack of adequate infrastructure for those who need it than it does to the liabilities of mental illness. There is immense potential to improve SMI people’s quality of life through support systems that focus on people’s basic needs instead of punishing perceived deficits. Grizzard mentions a post-discharge experience with supported living, which “tried to help people get back in the community, working.” He describes how he “lived in that house for, I guess, a year, year and a half… it was a good deal… they’d try to give us jobs, jobs like working in a snack bar or cleaning and stuff like that” (15). With consistent housing and support, Grizzard was able to maintain a safe, stable lifestyle—just one of many examples of how mentally ill people can thrive with support. SMI does not strip people of a safe, happy life; systems that withhold resources do.
Bly, Nellie. Ten Days in a Mad-House. Ian L. Munro, 1887, UPenn Digital Library, https://digital.library.upenn.edu/women/bly/madhouse/madhouse.html, Accessed 23 Apr. 2022.
Brooks, David. “The NUCLEAR FAMILY Was a MISTAKE.” Atlantic, vol. 325, no. 2, Mar. 2020, pp. 54–69. EBSCOhost, https://search.ebscohost.com/login.aspx?direct=true&db=lkh&AN=141574863&site=ehost-live&scope=site.
Efird, Caroline. Interview with Vijay Ghate. 2 February 2019 (Y-0061). Southern Oral History Program Collection (#4007), Southern History Collection, Wilson Library, University of North Carolina at Chapel Hill.
Efird, Caroline. Interview with Tim Grizzard. 2019 (Y-00062). Southern Oral History Program Collection (#4007), Southern History Collection, Wilson Library, University of North Carolina at Chapel Hill.
Hall, Donna, et al. “Major Mental Illness as a Risk Factor for Incarceration.” Psychiatric Services, vol. 70, no. 12, 2019, pp. 1088–1093., https://doi.org/10.1176/appi.ps.201800425.
O’Sullivan, Maura. “Interview with Kim Martin.” 22 Apr. 2022.
Stefancic, Ana, et al. “‘We Die 25 Years Sooner:’ Addressing Physical Health among Persons with Serious Mental Illness in Supportive Housing.” Community Mental Health Journal, vol. 57, no. 6, 2021, pp. 1195–1207., https://doi.org/10.1007/s10597-020-00752-y.
Wildeman, Christopher, and Emily A Wang. “Mass Incarceration, Public Health, and Widening Inequality in the USA.” The Lancet, vol. 389, no. 10077, 2017, pp. 1464–1474., https://doi.org/10.1016/s0140-6736(17)30259-3.