Responses to the killing of Jordan Neely on a New York City subway train divided along predictable partisan lines: the left framed Neely’s death as a racially motivated murder, while the right defended Daniel Penny as a good Samaritan trying to protect minions from a man with a history of violent assaults. But regardless of their views on Penny’s culpability, liberals and conservatives broadly agreed that Neely’s untreated mental illness was a crucial factor. If only Neely had access to proper mental health services or if only the state had been allowed to hospitalize and medicate him against his will, his downward spiral and his death could have been avoided.
While such discussions acknowledge the complex social factors that shape mental illness in Neely’s case—a traumatic childhood, drug use, and precarious existence—they still assume that mental illness is not fundamentally different from any other illness. . Specifically, the prevailing assumption is that mental illness can, in principle, be cured or at least managed with effective medical intervention. Consequently, it stands to reason that access to mental health services, voluntary or otherwise, is good policy. But the evidence for this hypothesis is tenuous at best.
For more than a century, the United States has led the way in the treatment of mental illness, pioneering many of the therapeutic and pharmacological methods now used around the world. But despite this boon, the country continues to suffer from the highest prevalence of mental illness among developed countries. The National Institutes of Health reports that 1 in 5 U.S. adults live with a mental illness of varying severity, with adults under 49 reporting the highest rate.
Perhaps the problem is that care does not reach those who need it most. In the wake of Neely’s death, many on the left have decried a lack of public funding for mental health services. The reality, however, is that the United States is spending significant resources on the problem. While Republicans remain pickier than Democrats about funding for mental health services, there is, again, a bipartisan consensus that mental health problems are real, that a medical response is needed, and that at least public funding. In 2020, the federal government spent $280 billion tackling mental health, up from $171.7 billion a decade earlier. Spending has increased every year since 1986, with nearly 60% of all behavioral health services paid for by Medicare and Medicaid.
Despite the resources invested in these services, the mental illness rate also appears to have increased slightly to 15.7% today, up from 14.5% in 1990. Other estimates suggest that a quarter of people are dealing with health problems mental. Looking at post-pandemic trends, it would appear that mental health problems are on a steady and linear upward trajectory in younger age groups.
It seems likely that if more and more resources were devoted to treating any other disease, but the incidence of that disease continued to increase, one might begin to question whether the treatments in question are actually effective. But the failure of mental health services to reduce the incidence of mental illness over the decades has not dampened the belief that expanding access to them is the only conceivable answer to the problem.
It may be that the global approach is not only ineffective, but harmful. Many well-intentioned public health approaches have proven harmful in the past, such as isolating the elderly in care homes during the pandemic. But the problem may also be fundamental: that we have misunderstood the nature of mental health, and all our responses to it are therefore doomed to fail. Perhaps, that is, we are assigning the medical profession problems it has no real hope of tackling, be they the anxiety, depression and anomie that afflict people living in an increasingly atomized society, or the thorny question of how society should deal with individuals whose impairments predispose them to seriously antisocial behavior.
The category of mental illness encompasses a wide range of dissimilar conditions, from common depression and anxiety to the much more severe state Jordan Neely was in before his fateful encounter on the subway. Bringing these conditions together has serious policy implications. Expanding access to mental health services, despite weak evidence of efficacy for both therapy and commonly used antidepressants, could offer some relief to those motivated to seek treatment. But the seriously mentally ill, as Neely’s story reveals, often refuse treatment when it’s offered. According to the National Alliance on Mental Illness, 20% of those with bipolar disorder and 30% of those with schizophrenia have experienced a severe lack of awareness of their diagnosis. This is part of the reason why the forced confinement of the seriously mentally ill was a widespread practice until relatively recently. The effectiveness and legitimacy of this practice is fundamentally a political issue, not a medical one.
The ostensible role of mental health professionals is to treat sick individuals, but they are also charged with protecting society at large from those who fall under their care. In liberal democracies, this has always created tension. There is widespread unease with forcing care on autonomous individuals, particularly if that care involves confinement against their will.
One way to resolve this dilemma is to understand mental illness as a loss of autonomy in itself. If people with psychosis and related conditions cannot be held accountable for their actions, involuntary institutionalization could be justified. Yet many still oppose this idea, not unreasonably, given the fundamental tenet of Anglo-American law that people forcibly detained must be charged with a crime. Those with serious mental health problems are mired in legal confusion: They may be considered a danger without having committed a crime, but when they have committed one, they may be held accountable for their actions. What is this?
The mental health category attempts to turn political issues into medical issues.
This confusion stems in part from the fact that the mental health category attempts to transform social and political issues into medical issues. Psychiatry stands out among medical specialties by the impressionistic vagueness of its diagnostic procedures and categories. There are no purely physical signs of mental illness, and a psychiatrist cannot perform an objective test to assess an individual’s mental state. Instead, this must be inferred from individual statements and acts, and the degree to which these are seen as aberrant or pathological will depend on what is considered normal in a given context.
It was easy enough to ridicule the progressive proposals to replace the police with mental health professionals, but such proposals capture one truth: the reality is that mental health services are less about treating and treating illness in the normal medical sense than about doing comply with social norms. . In milder cases, therapy and antidepressants hold the promise of helping individuals continue to function as normal, productive members of society; in severe cases, mental health services should, in theory, keep individuals out of serious trouble.
The debate over expanding or mandating access to mental health services obscures deeper questions about the normative standards of behavior that should be permitted in public life. There is no scientific or medical answer to the question of how society should welcome individuals like Jordan Neely. The question is political and philosophical. It touches on the limits of individual autonomy and what responsibility we have, collectively, in shaping and limiting the behaviors of our fellow citizens, and what level of force is justifiable as a means to that end.
The fundamental value we attach to individual rights makes any coherent conversation on this subject difficult, as there is no longer a shared vision of the kind of society we want. So instead, we take refuge in the seemingly objective statements of medical science to find a basis for shared discussion. But the combined failures of this approach are becoming hard to ignore. If faith in science dissolves, what are we left with?
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