What Centrist Democrats Get Wrong on Mental Health Policy

M.K. Anderson

Content Warning: this article deals with the material conditions of the oppression of mentally ill people, and as such describes specific instances of suicide and graphic violence. Links pertaining to the Willowbrook State School contain disturbing and graphic video of child neglect.


[Ed. note: Kamala Harris has dropped out of the race as of publication. However, policy criticism remains relevant to Buttigieg and Klobuchar.]

When Amy Klobuchar announced her bid for the Democratic nomination for president, her platform included a mental health policy: a repeal of the Institutions for Mental Disease (IMD) funding exclusion. In August, Pete Buttigieg added the same policy to his platform following the twin mass shootings in El Paso, Texas and Dayton, Ohio. Kamala Harris followed suit in late November. Ostensibly, the removal of this exception would allow re-institutionalization as a means of treating the mental health epidemic. Now that three major candidates have added this policy to their platforms, disability activists from across the political spectrum are alarmed. We, as Marxists, should be as well. We must oppose this policy for what it is: a proposal to sacrifice even more mentally ill people to state violence in order to cover up violence wrought by capitalism.

First, let me explain what the IMD funding exclusion is and why it exists. ‘Institutions for Mental Disease’ are mental facilities with more than sixteen beds. Medicaid used to cover long-term stays in mental institutions. They no longer do so following a 1965 law delegating responsibility for mental health funding to the states. Despite this, some blame deinstitutionalization solely on Reagan-era austerity. Though it’s not fully attributable to Reagan, asylums did shut down in the 1980s, their clients pushed out the door with a bus ticket to, if they were lucky, somewhere warm.

Indeed, all three candidates’ mental health platforms cite mental illness as a leading cause of homelessness. This correlation is presented as causation without further reflection. Their mental health platforms supposedly address the damage wrought by arrest and incarceration. Curiously absent in the Democrats’ reasoning—implied only by timing and the occasional nudge and wink—is the widely accepted “correlation” between mental illness and violence. It’s a savvy move on their part to avoid invoking this myth, because the link between mental illness and violence is weak to non-existent. Let’s not pretend they live in a vacuum, though. Donald Trump was happy to explicitly blame mental illness for the August shootings, as were media outlets. Re-institutionalization isn’t being proposed outside of that scapegoating, but as part of the same conversation.

Perversely, Klobuchar presents re-institutionalization as part of the mental health parity movement. The disability community has long fought for legal protections requiring insurance companies to cover mental health treatments at the same rate as other healthcare. But that same community strongly and nigh-universally opposes a repeal of the IMD funding exemption because it would mean the return of institutionalization. Deinstitutionalization was a movement by and for disabled people. Together with the 1963 Community Mental Health Act, the 1965 IMD funding exemption represented deinstitutionalization’s greatest legislative victory. Deinstitutionalization was itself a milestone in disability liberation.

To preserve itself, liberalism creates classes of people who are acceptable targets of violence.

Liberation from what, though? In any discussion of mental illness, the first, frustrating hurdle is always establishing that the mentally ill are oppressed at all. Perhaps mentally ill people really are violent! Maybe they love crime and hate living in houses. I first heard the term “triggered” around 2006, in an outpatient support group that met at the local mental hospital. The word was a survival tool. Pay close attention to whatever caused bad days, days of physical and emotional pain, the kind of days that cost us work and friends. That term, one that probably saved my life, is now a tired joke about oversensitivity told by rosy-cheeked blowhards. It’s divorced from the smell of disinfectant and the empty seats from recent suicides.

Being labeled oversensitive—which is nothing more than an out-of-hand dismissal—is by far the most common reaction I receive when I get political about mental illness. Some fellow Marxists can become suspicious that a material analysis that focuses on factors related to (but not the same as) economic class is bad Marxism. If history is (economic) class struggle, then an analysis of (non-economic) class might be a distraction. Perhaps even liberalism!

It’s not.

To understand how liberalism—the political support for capitalism—functions, we must first understand that it promises equality and freedom… but with exceptions. That’s not a flaw. Capitalism is inherently contradictory, and if all of society bears equally the violence of capitalism’s internal contradictions, capitalism wouldn’t last long. To preserve itself, liberalism creates classes of people who are acceptable targets of violence. It is not itself liberalism to recognize material conditions created by liberalism. The Marxist solution—to unite along class lines—does not mean we stick our fingers in our ears and ask our comrades to stop being so divisive. Solidarity takes work.

In 2011, I was working at a facility for developmentally disabled people. At one point, a client’s mouth was washed out with acid. They inhaled it; they swallowed it. They were, for a long time, fed via a tube thrust down their nose and into their stomach, the same procedure used to torture detainees at Guantanamo Bay. These details are available in a 2011 article in the Austin American Statesman. I will not provide further details beyond saying the suffering this person went through did not begin or end there.

Nobody in particular wanted this to happen. It was a systemic failure. An investigation pinned the accident on someone (who, exactly, it was never determined) who had poured the contents of a leaking container of denture cleaner into an empty bottle labeled “sterile water.” A training issue. There were a lot of systemic failures like that. When a client took a fall, it was standard to reassign staff to the kitchen while an outside agency investigated the employees for abuse and neglect. If found culpable, employees were sometimes prosecuted. I couldn’t give you statistics, but I’d say most investigations found systemic issues rather than intentional abuse. Understaffing. Inadequate training. Multiple mandatory double shifts (as in, we were threatened with prosecution for neglect if we left) to relieve understaffing. Fatigue. These problems were outside of the purview of the investigating agency. No manager would ever face consequences for understaffing. No legislator would go to jail for underfunding. Nobody wanted all these accidents, there was never malice. Just the problems that come with facility on a Medicare budget.

But good intentions don’t unbreak bones.

I could be accused of appropriating the struggles of a person with developmental disabilities, which are distinct from mental illness, to gain your sympathy. Here’s the thing: I’m not the one drawing improper analogies between mental illness and developmental disabilities. Rather, the common history of institutionalization has made such associations implicit. Co-housing of these two disparate populations happened often, within living memory. It didn’t matter if you were mentally ill, developmentally disabled, or queer, for that matter. When the solution to the problem of “you” is warehousing, sterilization, and murder, the powers that be get sloppy with labels. We are not an economic class, but we are a class in the sense that we share interests and history.

I could also be accused of using one example to try and prove systemic violence. I do have others. There’s the schizophrenic prison inmate who was locked in a hot shower, left to scream until he died and his muscles fell off of his bones. His murderers didn’t even lose their jobs. There are statistics—roughly half of incarcerated people are mentally ill, a quarter of people shot by cops are mentally ill, a quarter of homeless people are mentally ill. Marxists will generally agree homelessness is caused by capitalist material forces, but some have balked at an analysis that questions why mentally ill people bear the brunt of that violence.

Here’s the problem: we’ve been taught all our lives that some people—certain minorities—deserve violence more than others. This represents a tremendous failure in ethics and education. If violence against mentally ill people strikes you as natural, as it does for many people, then systemic violence against them will also strike you as natural. I could quote you all the statistics in the world. I could tell you about historical landmarks like Buck v. Bell, the killing of institutionalized mentally ill people as the Nazis developed industrialized mass murder, pro-eugenics articles in America well into the late 1960s, Willowbrook in the 1970s, forced sterilizations to this day. But if you’re a fascist eugenicist who believes that mentally ill people deserve violence, then you won’t see a problem. The left must work to inform the public of these historical truths and the ethical boundaries they transgress. Education is the work of many people across time. This is my small contribution.

I don’t wish institutionalization on anyone. Institutionalized mentally ill people are subject to involuntary (and often inappropriate) treatment. They are denied the right to consent to any kind of bodily autonomy, which means consent is sometimes violently coerced. They can be made to work as part of occupational therapy—for pennies per hour. They don’t have a right to legal recourse to secure their freedom or more appropriate care. And this is assuming the facilities are adequately staffed and funded, which, historically, they never have been. Willowbrook, an institution for developmentally disabled and mentally ill children, infamously had a staff ratio of between fifty and a hundred children to one staff member. The children were naked, kept in pitch dark rooms, covered in their own feces. This wasn’t a hundred years ago. Geraldo Rivera, of all people, made his name as a reporter when he broke the Willowbrook story. We can’t pretend there is a Platonic ideal of institutionalization that exists and is, in contrast to every known mental institution, humane. There’s a joke that Foucault saw every institution as a prison. He was right. We will never redress the state mass incarceration of mentally ill people by simply transferring them into mental institutions.

Systemic violence against mentally ill people is not natural; it is a crime, from which certain interests benefit. If you’re unconvinced, if I can’t appeal to your sense of decency, then let me appeal to your Marxism. Illness doesn’t correlate with crime and doesn’t cause incarceration. Capitalists and petit-bourgeois prosecutors cause incarceration. Mental illness doesn’t cause violence. The belief that violence is sometimes justified—as say, a soldier in war or police officer sweeping undesirables from the street corner—causes violence. The capitalist land speculators who fundraise for Klobuchar, Harris, and Buttigieg cause homelessness. Mental illness isn’t the cause of those problems. Perpetrating further violence through mass institutionalization can’t be the solution. On the contrary, the oppression of mentally ill people is a critical means by which capitalism divides the working class. That’s why, when three major political candidates propose a policy like the IMD exclusion repeal, we must find solidarity with our disabled comrades and unite in strident opposition. ♦


M.K. Anderson is a writer with several short fiction credits. She has worked as a direct care provider and a coordinator of care for individuals with dual diagnosis developmental disabilities and mental illness in an ICF/ID institution. Later, she worked as a financial analyst overseeing the administration of Medicaid insurance contracts. She can be found at mk-anderson.com.

Cover image: Willowbrook State School.