Out with the old?
How designing solutions for the future will force us to reconcile with our past
This week I have been reflecting a lot on how we got to where we are for mental health in our country. It’s a theme that seemingly haunts me at every turn of my work in this space. In fact, if you have been with me on this Substack journey since the beginning you know that I have both gone into the history as well as outlined ways that we keep getting stuck in advancing sound public policy for mental health.
There’s a reason that change is hard. When I was actively involved in clinical care, routinely I would be called in to help work with a patient on changing some aspect of their health. Being that I mainly worked in primary care settings, most of the requests were for things like quitting smoking or losing weight. These behaviors, while seemingly simple on the surface, are in fact quite complex. You probably have your own stories and experiences in this space. Change at an individual level is hard enough - changing systems is even harder.
For mental health, we have inherited imperfect systems and structures that at one time was someone’s best idea. There’s no finger pointing here, no one name to blame. What we have in this moment is what we must work with. It does, however, force us to take a look back and understand a bit more about the historical context in which the decisions were made. When we do this - sometimes, just sometimes, we get clues that can be used to inform our thinking today.
The most classic example is our community mental health centers. Started as a solution to individuals with mental illness languishing in institutions, it never really received the attention, funding, or support that it needed to be successful. But this topic has been written about extensively elsewhere. What I want to focus on is how that system and those structures are still with us today. Sure, there have been some subtle shifts in how these centers operate and the funding they receive, but for all intents and purposes it is the same structure. We haven’t really broken ourself from the clinic mentality yet, which means that most care is still predicated on a “you come to me” model.
These structures are reinforced by culture, policy, and financing mechanisms. It’s a daunting complex set of pieces held together by glue. And to truly get to a new system and structure we are going to have to do a few things at once.
Follow the data: We have known for years that most people who need mental health don’t get the help they need. This is in large part because they show up in other places where mental health is nowhere to be found e.g. schools, primary care. In 2023, we should take advantage of our amazing technology and actually look at the data to determine where people seek care. Why would we not map out mental health utilization and gaps to better determine where services are needed and for whom? I am firmly convinced that without these data we run the risk of putting money into places or programs no one is using for their mental health. This analysis can also be used to help identify areas where we could mitigate disparities. Being more informed, we could design a system in which people get care where they are instead of the places we keep telling them to be.
Listen to the people: Designing a system without the end user in mind makes no sense and is bound to fail. Ford Motor Company is one of many businesses who learned this the hard way. Despite putting over $250 million into its development, an absolute fortune in 1957, the Ford Edsel landed with a resounding thud. No one liked the car, and if Ford had listened to their own polling data, they would have known that before creating a car whose name is now synonymous with failure. Listening to the people goes far beyond the obligatory patient advisory boards and actually gets into true engagement. Going into the homes, the bars, the places where people are and asking them for their solutions is a road that more leaders need to take. If we want a better structure, we need to ask the people who have to navigate and use the system as we have it now.
Be bold and take risk: Mental health is too often left as an afterthought. It usually is the first item on any spreadsheet that gets cut, and receives much less air time than other issues of health. This means that if we want to do something meaningful for mental health we have to be bold, be unafraid to take risk, and be prepared to learn and grow when we fail (which we will).
I have written about this topic a bit before so you can tell this is something I am feeling deeply right now; but, when the data and trends show how poorly we are doing for mental health and addiction, I cannot simply stand by and support the status quo.
Every conversation on redesigning mental health should consider how much it changes our current structures. If it doesn’t, I worry that we are simply tinkering at the edges expecting that the outcomes will be different when in reality they will stay the same.