Establishing a Comprehensive System of Care for Persons with Mental Illnesses


While the definitions and terms are varied, we here refer to both persons defined as having a diagnosable mental disorder and those with a serious mental illness, as well as those with co-occurring substance-abuse disorders, when using the term "persons with mental illnesses."

Mental illness can shatter lives. It is a condition often lacking explicit physical manifestations and thus is both easily hidden and easily denied. Like physical illnesses and perhaps even more so, mental illnesses and their ramifications are experienced in every sector of life. Treatment-or the lack thereof-of persons with mental illnesses is therefore best considered not only as a medical issue but also as an important social one, with far-reaching economic and human welfare implications.

Judaism concerns itself with the health and well-being of the mind and the soul as well as of the body. Maimonides wrote:

When someone is overpowered by imagination, prolonged meditation, and avoidance of social contact, which he never exhibited before, or when he avoids pleasant experiences that were in him before, the physician should do nothing before he improves the soul by removing the extreme emotions.

The reality is that mental illness continues to be stigmatized in our society. While people with physical illness are usually treated with solicitude and concern, persons with mental illness are frequently the objects of ridicule, contempt, or fear. While we often go to great lengths to accommodate and include people with physical illness, the mentally ill are frequently marginalized and excluded.

In this context, we examine the issue of mental illness and its multiple and far-reaching manifestations for individuals from all walks of life.

Mental illness strikes often, affecting millions of men, women, and children across America in both our communities and our synagogues. Approximately 23 percent of American and Canadian adults (ages 18 and older) suffer from a diagnosable mental disorder at some point during their lives, but only half of those report impairment of their daily functioning due to the mental disorder. Of this number, approximately 5 percent are diagnosed as having a serious mental illness, such as schizophrenia, major depression, or bipolar disorder. In addition, between 25 percent and 50 percent of all people with mental illnesses are believed to have a substance-abuse disorder.

Almost 20 percent of the U.S. population age 55 and older experience specific mental illnesses that are not part of the normal aging process. This population is also the U.S. demographic group most likely to commit suicide.

Mental illness is also prevalent among children and teenagers in North America. Approximately 20 percent of children and adolescents-11 million in all-are believed to have mental health problems that can be identified and treated. At least 1 in 20 children-3 million in all-may have a serious emotional disturbance, defined as a mental health problem that severely disrupts a juvenile's ability to function socially, academically, and emotionally. Each year, almost 5,000 young people age 15 to 24 commit suicide in this country.

An important issue facing North America today is the lack of availability of and access for individuals to mental health treatment, exacerbated by the need for mental health insurance parity, defined as the requirement that health plans provide the same annual and lifetime limits for mental health benefits as they do for other health care benefits. The UAHC has consistently supported health care for all, declaring in 1975, for example: "In the United States there should be made available national, comprehensive, prepaid, single-benefit standard health insurance with no deductible to cover prevention, treatment, and rehabilitation in all fields of health care." Currently, however, great disparities exist between coverage of mental health care and physical health care.

Employment and Mental Illness
According to a report by the Association for Health Services Research and the National Alliance for the Mentally Ill, employers bear significant costs due to mental disorders of their employees, probably more than they realize since many costs are difficult to measure or are not easily recognizable as being caused by mental illness. Depression, for example, results in $30 billion a year in direct and indirect costs to employers.Depressed employees use 1.5 to 3.2 more sick days per month than other employees-lost time that costs employers $182 to $395 per worker per month, according to a study by the U.S. Centers for Disease Control and Prevention (CDC). Mental illness also takes many potential workers out of the labor force. Of disabled workers, more than 22 percent of those who receive Social Security Disability Insurance (SSDI) benefits and 30 percent of those who receive Social Security Insurance (SSI) qualify because of mental illness. Yet research has shown that people with mental illness have high productivity potential and that they can work and remain in the labor market for significant periods of time. It is thus vital to advocate for increased attention to ways in which persons with mental illnesses can continue to serve as productive members of the workforce and to advocate for protections of these persons once they are in the workplace.

Homelessness and Mental Illness
According to the National Coalition for the Homeless, approximately 20 to 25 percent of the single adult homeless population in the United States suffer from some form of severe and persistent mental illness. In Canada, it is estimated that approximately one-third of the homeless in major Canadian cities suffer from a mental illness. The problems of homelessness and mental illness exacerbate each other. Without proper treatment, mental illnesses prevent people from carrying out essential functions of daily life, thus pushing individuals out of mainstream society, out of jobs, and ultimately out of homes. Mental illness and lack of medical treatment also lead to the use of drugs and alcohol as forms of self-medication, increasing the inability of individuals to function within society. At the same time, homelessness prevents recovery or worsens mental illness: A mentally ill individual will often slip through the cracks of conventional programs and treatments, never obtaining the treatment and medication necessary to regain wellness. Many of these homeless, mentally ill individuals then end up in the criminal justice system, as discussed in the next section. According to the U.S. Department of Justice, mentally ill state-prison inmates in the United States were more than twice as likely as other inmates to report living on the street or in a shelter in the twelve months prior to their arrest (20 percent compared to 9 percent).

A shortage of affordable housing also exists, compounding the problem. Between 1973 and 1993, 2.2 million low-rent units disappeared from the market. These units were either abandoned, were converted into condominiums or expensive apartments, or became unaffordable because of cost increases. Between 1991 and 1995, median rental costs paid by low-income renters rose 21 percent; at the same time, the number of low-income renters increased. In the past, Single Room Occupancy (SRO) housing served to house many poor individuals, especially poor persons suffering from mental illness or substance abuse. From 1970 to the mid-1980s, an estimated one million SRO units were demolished.

Mental Illness and the Criminal Justice System
An additional area of concern is the intersection between mental illness and the criminal and civil justice systems. In 1998, some 283,800 people with mental illnesses were incarcerated in American prisons and jails. This is four times the number of people in state mental hospitals throughout the country. Sixteen percent (179,200) of state inmates, 7 percent (7,900) of federal inmates, 16 percent (96,700) of people in local jails, and 16 percent (547,800) of probationers have reported a mental illness. According to a 1999 U.S. Department of Justice study, approximately 53 percent of mentally ill inmates were in prison for a violent offense, compared to 46 percent of other inmates.While many believe that these mentally ill offenders must be held in jail because of the serious, violent nature of their offenses, it is vital that they receive treatment while incarcerated.

We must be concerned as well with the civil-liberties consequences of some forms of treatment for mental illness within the criminal justice system, especially the use of physical restraints and the imposition of mandatory treatments. It is equally important that nonviolent offenders receive proper medical treatment and that noncustodial treatment programs be explored and made accessible to offenders with mental illnesses, who are often turned away from community treatment programs because of reluctance to treat them.

Notwithstanding our existing policy of opposition to the death penalty in all circumstances, we take special note of the number of persons with mental illness who have been executed in the United States.

The prevalence of youth with mental illnesses within the juvenile justice system is astounding. Approximately 50 to 75 percent of those in juvenile-detention facilities suffer from mental illnesses, and approximately half of these suffer from co-occurring substance-abuse disorders. Each year approximately 11,000 youths make 17,000 suicide attempts while living within juvenile facilities. According to the Department of Justice's Office of Juvenile Justice and Delinquency Prevention, however, 75 percent of juvenile facilities do not meet basic suicide-prevention guidelines, and many detention-facility staff are never trained to recognize and respond appropriately to the symptoms of mental health disorders.

Coordinated Systems of Care
The absence of a coordinated system of care for individuals with mental illnesses has resulted in a dangerous dispersal of responsibility for their care and treatment. This is especially true for individuals with co-occurring substance-abuse disorders, who are often turned away from mental illness treatment facilities. The U.S. government has begun to draw attention to the situation of the mentally ill in America today. In 1999, President Clinton hosted the first White House Conference on Mental Health, calling for a national campaign against stigmatizing the mentally ill. The Surgeon General issued a Call to Action on Suicide Prevention in 1999, and the Surgeon General's first "Report on Mental Health" was also issued in 1999. For decades, private and nonprofit organizations have worked tirelessly to establish access to services, to protect the rights of persons with mental illness, and to call for a comprehensive system of care for those who are in need.

Currently, federal funding for twenty-two statewide family organizations is provided through the Child and Family Branch, Center for Mental Health Services, and Substance Abuse and Mental Health Services Administration. Support and technical assistance are also provided by government agencies as well as by consumer groups via family-support groups and respite-care services. An emphasis on the development of a coordinated system of care has also drawn attention to the needs of caregivers of individuals with mental illnesses. Over the past several decades, there has been a growing awareness of the difficulties families face because services are provided by so many different public and private sources. In addition to problems with coordination, parents and caregivers encounter conflicting requirements, different atmospheres and expectations, and contradictory messages from system to system, office to office, and provider to provider.

THEREFORE, the Union of American Hebrew Congregations resolves to:

  1. Prepare materials to be used for training synagogue, religious school, camp, and youth-program personnel to recognize and deal appropriately with members and participants with mental illnesses;
  2. Call upon all member congregations to:
    1. Participate in communal efforts aimed at destigmatizing mental illness and work with the entire Jewish community to develop resources and programming aimed at addressing the stigmatization of mental illness;
    2. Work with persons with mental illness and their families so that they feel welcome within our synagogues;
    3. Make use of the materials prepared by the UAHC to train personnel to recognize and deal appropriately with members and participants with mental illness; and
    4. Work with other groups performing mental health outreach within the Jewish community to persons with mental illness.
  3. Call for increased governmental and community support and development of programming for caregivers of persons with mental illnesses;
  4. Call on the U.S. and Canadian governments to maintain and increase funding for federal programs aimed at treating persons with mental illness and assisting them to live healthy and independent lives;
  5. Call on the U.S. and Canadian governments to increase funding for mental health research and the development and testing of innovative mental health programs, including those focusing on the co-occurrence of mental health disorders and substance-abuse disorders;
  6. Encourage governmental integration and coordination of quality housing and mental health systems to provide comprehensive assistance, with special attention paid to persons with mental illness who live on our streets and in our shelters;
  7. Call for federal and state legislation in the United States to require parity between physical and mental health coverage by health insurance carriers, both private and public, similar to the system of universal comprehensive mental health coverage in Canada;
  8. Call for state legislation in the United States to provide the necessary funding to fully implement the Olmstead Supreme Court decision to provide community-based treatment for those persons with mental illness when such placement in a less restrictive setting is appropriate.
  9. Call on member congregations and the UAHC to provide health coverage for employees that guarantees parity in mental health coverage;
  10. Call for increased attention to the many inmates in our nations' prisons with mental illnesses, focusing on the need to:
    1. Place nonviolent, mentally ill criminal offenders into community-based mental health programs and also work to ensure that persons with mental illness who are sentenced to prison receive appropriate and humane treatment, including access to appropriate medication;
    2. Limit the use of involuntary physical restraints and the imposition of mandatory treatment solely to cases that are not otherwise manageable.
    3. Limit civil commitment and mandatory treatment to circumstances where it is used only with due-process protections;
    4. Call upon law-enforcement agencies to develop policies, practices, and specialized training for police officers and corrections officers to recognize and deal appropriately with persons with mental illnesses;
    5. Call for increased governmental attention to the youth within the justice system and the need for increased funding for community-based treatment programs for mentally ill juvenile offenders;
    6. Call on state and federal jurisdictions in the United States that retain the death penalty to exclude from consideration for the death penalty persons with mental illness; and
    7. Work to find common ground with all groups-including those who otherwise support the death penalty-who oppose the execution of persons with mental illnesses.
  11. Encourage an end to workplace discrimination against persons with mental illness in fact as well as in law, encourage governmental development of further programs to assist persons with mental illness in returning to the workplace, and assist employers in working with them;
  12. Call for an increased focus on the mental health needs of children, including teenagers, by advocating for:
    1. A coordinated system of care for children and teenagers with mental health problems;
    2. An emphasis on early recognition, prevention, and intervention, especially focusing on the prevention of suicide;
    3. Increased research on the mental health problems of juveniles; and
    4. Increased attention toward mental health needs within the schools and among professionals dealing with children in child care facilities and schools, as well as toward the development and implementation of training programs for these individuals; and
  13. Call for an increased focus on the recognition, prevention, intervention, and treatment of depression and other mental illnesses in the adult population.