Poverty & Mental Illness: You Can’t Have One Without the Other

If you’ve spent any time in the public mental health system, you know that folks diagnosed or labeled as having serious mental illnesses are poor. If you’ve been poor or worked with poor folks, you know that many poor folks suffer from affective and cognitive disorders or, to quote Bentall, “complaints” (1,2). But what comes first, the poverty or the presumed mental illness? Does poverty play a role in causing a person’s mental illness or does a person become ill and simply drift down the socioeconomic ladder into poverty? And how many people are we talking about?.

According to the U.S. Bureau of the Census (3), 4.1 million persons aged 18-64 that live below the Federal poverty line reported having a disability of some kind in 2010. An additional 10.9 million persons in that age group also reported a disability, but presumably did not live in poverty. It’s not clear from the data how many persons among that 15 million-person total have diagnosed serious mental illnesses. It’s also not clear how accurately their self-reports reflect the respondents’ actual situation. In 2008, after all, the NIMH estimated that persons with serious mental illnesses comprised approximately 5% of the U.S. population (4). That’s about 15 million persons. It always comes down to who’s asking what questions and who’s analyzing the answers.

FYI … the poverty line as per the U.S. Department of Health and Human Services for a single person in 2011 was $10, 890 (5). To put that sum into context, the National Technical Assistance Center, or PEERLINK, reports that the national average annual rent for a one bedroom apartment in that same year was $12,197 and for a studio apartment $10, 781. By way of further comparison, the 8.1 million persons eligible for SSI in January, 2012, because of disability will receive an average annual payment of $8064, which is $2826 or 26% below the Federal poverty line (6).

Of all SSI recipients, 34% or 2.7 million, as per the Office of Retirement and Disability Policy of the Social Security Administration, have been diagnosed or labeled as suffering from severe mental illnesses (7). Unless these folks have other sources of income – only 11% of all persons receiving Federal disability benefits receive both SSI and SSD (8), and only 2.8% report work-related income (3) – or live with family members – as an estimated 50% still do – they will officially be living below the Federal poverty line. And we’ve seen how much – or little – that can buy.

Ultimately, there are no discrete data that clearly enumerate the persons who are poor and have a presumed serious mental illness. While it is undoubtedly substantial, the precise number appears highly variable, ranging from as few as 2.7 million persons to as many as 15 million. This wide variability should not be surprising since many folks eligible for governmental social welfare benefits often don’t apply for them, and the public mental health system itself is a porous system, with service recipients moving in and out of it in haphazard fashion. It’s also indicative of how little attention has been paid to poverty as a causative agent of presumed serious mental illness that the scope of the problem, the number of persons affected, is so uncertain.

So how did the folks presumed to have serious mental illnesses – who are also the same folks caught up in the country’s public mental health systems – get into the financial fix they’re in and how can they get out of it? Perhaps more importantly, what’s the nature of the problem that needs to be addressed … clinical or economic and political or all of the above? The answer and its import, in this post-recession economy, with many economists defining income inequality, social class and unemployment as structural or immutable and fixed, and with Romney and Santorum referring to poor folks as members of a caste (9), again immutable and fixed, will affect every working person in this country, including all those who want to work but can’t find a job. To paraphrase Randy Bosin, a peer/survivor advocate and NAMI member … “no economic recovery for peer/survivors, no wellness!” To which I would add that the problem is one of economics and the social stigma that’s attached to unemployed and poor people; accordingly, the solution is political. More on this below.

That a relationship exists between poverty and mental illness was first established in the landmark New Haven study conducted by Hollingshead and Redlich (10), whose findings were published in 1958. Their principal conclusion was that there is a significant relationship between social class (SES or socio-economic status) and mental illness as regards the type and severity of the illness suffered as well as the type and quality of the treatment provided. Specifically, persons who were members of the lowest social stratum were the poorest, had a higher incidence of presumed serious mental illness and received the least adequate forms of treatment if they received any treatment at all. What was not clear was the direction of their findings, i.e., which phenomenon, mental illness or poverty, preceded which.

This was a time of hope in America. Researchers and advocates like Oscar Lewis (Children of Sanchez, 1961)[11] and Michael Harrington (The Other America, 1962)[12] succeeded in focusing attention on poverty as a social problem that could be addressed and resolved. The estimated U.S. poverty rate in 1959 was 22.4%, with 40 million individuals living in poverty (compared to today’s 16% and 49 million persons)[13]. From 1966, or two years after President Johnson declared a “war on poverty” and the Economic Opportunity Act was passed, until 1982, or a year after Ronald Reagan assumed the presidency, the official poverty rate never exceeded 15%, and for the ten-year period 1968-78, the number of persons living in poverty remained below 25 million [3]. It should be noted that the income maintenance programs that today attract the most controversy – Medicare, Medicaid and SSI – all were enacted into law as amendments to the Social Security Act between 1965 and 1977[14,15]. As a young man, I got caught up in the fervor and sense of mission. Animated by Harrington and his Catholic Worker anarchist ethic, I joined the Peace Corps in 1964 and lived the next three years in poor urban barrios in Colombia. When I returned to the U.S., I became a social worker and community organizer and essentially spent 1969 to 1976 doing welfare rights organizing. From then until the present, I’ve worked principally with poor folks presumed to have serious mental illnesses.

In the early 1960’s, policy makers watched the first persons released from the large state hospitals, the first wave of the thousands subsequently deinstitutionalized, migrate back to their families, largely working class or poor, or to poor communities. They simply assumed they were witnessing mentally ill persons drift downward into poverty, their appropriate social stratum. During my many years in the field, that appeared to be the intuitive or reflexive response of most mental health professionals with whom I interacted. The Midtown Manhattan Study [16], conducted by Srole and colleagues and published in two volumes in 1961 and 1963, confirmed the relationship between socio-economic status and mental illness; identified economic stress as an exacerbative variable resulting in intra-family alienation and social disconnection; and viewed physical and mental health as intertwined, but did not definitively clarify the issue of direction or precedence. Ten years later, in 1973, a Harvard researcher, M. Harvey Brenner, tipped the scales in favor of social causation when his study, Impact of Unemployment on Rates of Psychiatric Hospitalization [17], identified unemployment as a causative agent of mental illness, particularly in men.

Most recently, Christopher Hudson, in a longitudinal study conducted between 1994 and 2000 in Massachusetts [18], published in 2005 and apparently not widely known or discussed, confirmed the social causation hypothesis. Starting with the indexed acute psychiatric hospitalizations of his 34,000 study subjects, each of whom was a Medicaid recipient and, by definition, poor, he tracked their employment status and place of residence over the course of the study and found the following:
• Increased economic hardship across a community resulted in increased rates of mental illness and psychiatric hospitalizations for that community;
• Socio-economic status accounted for four-fifths of the rates of mental illness in a community;
• There was a negligible rate of economic drift, regardless of an individual’s diagnosis, with the exception of schizophrenia. Two-thirds of individuals diagnosed with schizophrenia showed no change in
their socio-economic status and geographic location, but 15% evidenced an improvement in one or both areas, while 17.2% showed a decline; which, comparatively, was quite modest;
• Between study subjects’ first and last hospitalizations, 79.3% showed no change in employment status, 14.3% became employed and 6.3% lost their jobs.

Hudson concluded that there was “a remarkably strong and consistent negative correlation between socio-economic conditions and mental illness, one that supports the role of social causation in mental illness and cannot be accounted for by geographic or economic downward mobility …” He closed with the following recommendation: “… continued development of preventive and early intervention strategies of the major mental illnesses that pay particular attention to the devastating impacts of unemployment, economic displacement, and housing dislocation, including homelessness.”

No wonder no one talks about Hudson’s study. Both his findings and his recommendations are prescient and beyond the scope and competence of the public mental health system; they’re also beyond the political will of the elected and presumptive leaders of the country. The social and economic consequences of the so-called recession of 2008-10 would seem to predict a large scale and nationwide upsurge in the incidence of mental disorders and in psychiatric hospitalizations. Again, there’s no clean and neat table of data detailing that information for the recession period and its immediate aftermath, i.e., from 2008 to the present; government researchers are likely to be compiling it, but are probably nowhere ready to release it to the public. In the interim, Joseph Blader [19], a researcher at Stony Brook in New York State, was able to compile and analyze psychiatric hospitalization data for the period 1997-2007, just prior to the country’s near-economic collapse. His findings – a near-doubling in hospitalizations for children ages 5-19, and a small, 8% increase for adults 20-64 – don’t sync with Hudson’s pre-figurings, but they are startling. So many kids being hospitalized! What’s that all about?

Blader did not consider any possible social causes – the period of time he examined precedes the economic dislocation which is certain to have occurred since – but he does offer as speculations the increase in the diagnosis of bi-polar disorder of kids whom adults finds problematic and the concomitant increase in polypharmacy to treat them. We should only expect that purely biological explanations will be offered when the data about mental illness and hospitalizations for the post-2008 era come in. That’s what the struggle about the DSM5 is all about [20] … to put an end to what John Read has called the colonization of the psychosocial by the biological [21]. Further, purely biological explanations maintain the public mental health system, its professional practitioners and the peer/surviviors caught up in it trapped in a bubble of denial about the larger reality of the eco-political system of which the public mental health system is but a small part. Put conversely, the inability of the public mental health system to acknowledge no less address the psychosocial reality of the individuals it purports to help mirrors the failure of the larger system to grapple effectively with the problems delineated by Hudson, principally economic displacement, including unemployment, and housing dislocation. Specifically, the individuals caught up in the public mental health system are poor: in December, 2009, almost 80% of persons considered disabled who possibly could work were unemployed (22); in the more than two years since, there are no data to indicate those numbers have improved.

In the larger social system, the official unemployment rate was 8.3% as of January, 2012 (23); when the Bureau of Labor Statistics adds “short-term discouraged and marginally-attached workers as well as those forced to work part-time because they cannot find full-time employment,” the rate nearly doubles to 15% (24). Perhaps a more telling statistic, put forward by the Labor Center of the University of California, Berkeley, is that in February, 2011, only 67% of all men 20 years and older who could work were working; that number dropped to 55% of all women 20 and older, 57% of all black men and 55% of all black women (25). And remember … in December, 2009, only 21.6% of all persons 16 and older who had a disability of some kind were working (18). Why is the unemployment rate remaining high and intractable? What can be done about it? Has it become a structural problem, immutable and permanent?

Paul Krugman (26), the Nobel-winning economist and NY Times columnist, has argued since the day Obama took office for a large Federal financial stimulus to get the economy moving. He’s also argued that the original Obama stimulus was insufficient, that another stimulus package should be put together aimed at enabling State governments to re-hire the teachers and first responders they’ve been obliged to lay off and to initiate the infra-structure projects they’ve put on hold. Krugman’s approach has been denigrated by conservative economists and politicians as a classic “tax and spend” liberal solution that serves only to increase the Federal government’s budget deficit. The resulting political paralysis has prompted centrist and conservative economists to characterize the unemployment rate and resulting income inequality as structural or essentially permanent, a position that Krugman and other “liberal” economists have denounced.

In mid-February, the NY Times published an article by Tom Edsall, a Columbia journalism professor, entitled “Is this the End of Market Democracy?” (27), which sought to address issues that Edsall characterized as “making some politicians and political thinkers uneasy.” A series of questions were posed to several economists employed at elite American universities, who e-mailed their responses to Edsall for publication in his article. The questions included the following:
• Are millions of American workers at a structural disadvantage in the face of global competition and technological advances and is this situation permanent?
• Will the share of profits flowing to shareholders and high-earning CEO’s continue to grow, while the income of wage earners stagnates?
• Has the surging wealth of the top 1% and 0.1% reached a point at which the political influence of the affluent outweighs that of the electorate at large?
• Is it possible that in the U.S. and Europe democratic free market capitalism is no longer capable of providing broadly shared benefits to a solid majority of workers?
In short, is the world as we know it about to change forever?

Richard Freeman of Harvard responded that the danger is “a move to economic feudalism, in which a small set of wealthy masters dominate markets and the state and subvert or outsmart efforts to regulate their behavior …”

Michael Spence, a Nobel Prize winner, contended “that the employment problems of the U.S. do not result from market failure … the problems arise from an exceptionally efficient global marketplace … many in the U.S., particularly those holding mid-level skill jobs that can be performed at lower cost overseas, are paying the costs of efficiency … We now appear at a crossroads …”

Francis Fukuyama, a senior fellow at Stanford’s conservative Center on Democracy, expressed the belief that “there are a lot of reasons to think that inequality will continue to worsen. The current concentration of wealth in the U.S. has already become self-reinforcing … Schools for the well-off are better than ever; those for everyone else continue to deteriorate …”

David Autor of M.I.T. viewed the job market as “polarized” … “There is growth at the high and low ends, but the middle collapses…”

Jeffrey Sachs of Columbia and Lawrence Katz of Harvard are described by Edsall as “somewhat more hopeful, but their optimism is based on the politically problematic proposition that the U.S. can adopt wage and income policies similar to those in Scandinavian countries…”

Edsall ends the article on an equivocal yet surprisingly optimistic note; he writes “The debate over the workings of democracy, the market, technology and globalization remains unresolved. The political system instinctively avoids this debate, despite its salience and centrality, because the political costs of engagement are likely to substantially outweigh any potential gains. At an undetermined point in the not too distant future, as the ‘gale of creative destruction’ blows through the heartland, the debate will become inescapable.”

I’m not an economist, but I do understand, particularly from Edsall’s closing comments, that our elite academics and equivocating politicians cannot be trusted to devise and carry out needed solutions. My distrust of their leadership is identical to the skepticism that psychiatrists and most mental health professionals evoke in me when I witness their disdain for the hopes and aspirations of the peer/survivors whom they’ve committed to help. The behavior of both sets of individuals serves only to maintain the status quo and to benefit those whose interests are served by the status quo. It appears to me that the Occupy Movement has understood from its beginnings that the answers to the problems we face must come from those most affected. To quote Kalle Lasn, the Canadian editor of “Adbusters”, the on-line magazine that gave “Occupy Wall Street” its name and initial direction: “… the most powerful, personal and collective feeling of people in the Occupy Movement … is a feeling of gloom and doom, that they’re looking toward a black hole future”(28).

When faced with such a realization, when all illusions of your true circumstances have been stripped away, when you can no longer rely on denial to comfort you, you are faced with a stark choice – give in and accept your fate or keep on and devise strategies to continue your struggle. How else could young Spaniards, faced with an official unemployment rate approaching 23%, occupy in protest the central plazas of several Spanish cities for months at a time (29)? How could the Occupy folks erect tent cities in virtually every large city in the U.S. and Canada and maintain them as going concerns during this past summer, or until the winter chill settled upon them? They had no choice other than to be determined and creative, and they devised a strategy, viz., to pinpoint growing income inequality as the fundamental issue to be addressed, that galvanized nationwide support for their efforts. As good democratic anarchists, they disdained a centralized command and left local tactics and local issues to local people to address.

They constituted a model for all of us to follow, including peer/surviviors, who must look beyond their self-contained public mental health system to the larger macrosystem for the resources they need and the opportunities they desire. Peer/survivors must ally themselves with the Occupy Movement even while they set about organizing their own Civil Rights Movement, identifying their unique issues and devising unique strategies. For example, why can’t peers/survivors who are employed as peer specialists by local government and private agencies unionize and demand salaries and benefits commensurate with the work they do? Why can’t they demand affirmative action programs that will promote their integration into the mainstream workforce and vocational schools and universities?

Faced with the enormity of the task before them and before those of us who would be their allies and provide support, it’s tempting to despair and accept what is. Just remember what my old friend Joe Hill would tell you – Don’t mourn, organize!

References:
(1) Bentall, R., Madness Explained: Psychosis and Human Nature, Penguin Books, London, 2004

(2) Bentall, R., “Abandoning the concept of Schizophrenia: the cognitive psychology of hallucinations and delusions,” in Read, J., Mosher, L.R., Bentall, R., eds., Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia, Routledge, London & New York, 2004

(3) U.S. Census Bureau, “Income, Poverty and Health Insurance Coverage in the United Stares: 2010,” September, 2011

(4) National Institute of Mental Health, “Prevalence of Serious Mental Illness Among U.S. Adults by Age, Sex and Race in 2008,” www.nimh.nih.gov/statistics

(5) U.S. Department of Health & Human Services, “The 2011 HHS Poverty Guidelines,” http://aspe.hhs.gov/poverty/11poverty.shtml

(6) Zulich, A., Diamata, D., “Poverty and Mental Illness,” Peerlink: National Technical Assistance Center, powerpoint presentation, February 16, 2012

(7) Office of Retirement and Disability Policy, U.S. Social Security Administration, “SSI Federally Administered Payments, Table 2. Recipients, by eligibility category and age, January 2011 – January 2012,” www.socialsecurity.gov/policy/

(8) U.S. Social Security Administration, “Annual Statistical Report on the Social Security Disability Program, 2010,” www.socialsecurity.gov

(9) Starr, B., “Romney and Santorum Envision a Caste System for America,” Huffington Post, March 5, 2012, www.huffingtonpost.com/bernard-starr/romney-santorum-poverty

(10) Hollingshead, A., Redlich, F., Social Class and Mental Illness: A Community Study,
John Wiley, New York, 1958
Also c.f., Pols, H., “August Hollingshead and Frederick Redlich: Poverty, Socioeconomic Status and Mental Illness,” American Journal of Public Health, October, 2007

(11) Lewis, O., The Children of Sanchez, Alfred A. Knopf, New York, 1961
(12) Harrington, M., The Other America: Poverty in the United States, Simon & Schuster, New York, 1962

(13) Yen, H., “U.S. Poverty: Record 49.1 Million Americans are Poor According to New Census Measures,” November 7, 2011, www.huffingtonp[ost.com/2011/11/07

(14.) Centers for Medicare & Medicaid Services, “History of Medicare & Medicaid,” powerpoint presentation, www.oucom.ohiou.edu/currents

(15) Encyclopedia.com, “Medicare and Medicaid,” www.encyclopedia.com

(16) Srole, L., et al, The Midtown Manhattan Study: Mental Health in the Metropolis, McGraw-Hill, New York, 1962

(17) Brewer, M.H., Mental Illness and the Economy, Harvard U. Press, Cambridge, 1973

(18)Hudson, C.G., “Socioeconomic Status and Mental Illness: Tests of the Social Caudation and Selection Hypotheses,” American Journal of Orthopsychiatry, Vol. 75, No. 1, pp. 3-18, 2005

(19) National Institute of Mental Health, “Survey Assesses Trends in Psychiatric Hospitalization Rates, September, 2011, www.nimh.nih.gov/science-news/2011/

(20) Carney, J., “1984 Revisited: The New DSM,” posted at www.behavioral.net, November, 2011

(21) Read, J., et al, “Childhood Trauma, Loss and Stress,” in Read, J., Mosher, L.R., Bentall, R., eds., Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia, Routledge, London & New York, 2004

(22) Office of Disability Employment Policy, U.S. Department of Labor, “Historical Disability Employment Data, Table 1. Employment Status of the Civilian Noninstitutional Population by Sex, Age and Disability Status …,” Novemner-December, 2009, www.dol.gov/odep/

(23) Bureau of Labor Statistics, U.S. Department of Labor, “The Employment Situation – January, 2012,” www.bls.gov

(24) Shadow Government Statistics, “Alternate Unemployment Charts,” February 3, 2012, www.shadowstats.com

(25) Center for Labor Research and Education, University of California, Berkeley, “Data Brief: Black Employment and Unemployment in February, 2011,” www.laborcenter.berkeley.edu/
(26) Krugman, P., “Economics in the Crisis,” posted March 5, 2012, New York Times http://krugman.blogs.nytoimes.com

(27) Edsall, T.B., “Is This the End of Market Democracy?,” New York Times, posted February 19, 2012, http://campaignstops.blogs.nytimes.com

(28) Roberts, S., ‘The Port Huron Statement at 50,” New York Times, Sunday, March 4, 2012

(29) Minder, R., “Spanish Unemployment Rate Rises to 22.8 Percent,” New York Times, posted January 27, 2012, www.nytimes.com/2012/01/28/