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What has the pandemic revealed about the US health care system — and what needs to change?

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With vaccinations for Covid-19 now underway across the nation, MIT SHASS Communications asked seven MIT scholars engaged in health and health care research to share their views on what the pandemic has revealed about the U.S. health care system — and what needs to change. Representing the fields of medicine, anthropology, political science, health economics, science writing, and medical humanities, these researchers articulate a range of opportunities for U.S. health care to become more equitable, more effective and coherent, and more prepared for the next pandemic.

Dwaipayan Banerjee , associate professor of science, technology, and society

On the heels of Ebola, Covid-19 put to rest a persistent, false binary between diseases of the rich and diseases of the poor. For several decades, health care policymakers have labored under the impression of a great epidemiological transition. This theory holds that the developed world has reached a stage in its history that it no longer needs to worry about communicable diseases. These "diseases of the poor" are only supposed to exist in distant places with weak governments and struggling economies. Not here in the United States.

On the surface, Covid-19 made clear that diseases do not respect national boundaries. More subtly, it tested the hypothesis that the global north no longer need concern itself with communicable disease. And in so doing, it undermined our assumptions about global north health-care infrastructures as paradigmatically more evolved. Over the last decades, the United States has been focused on developing increasingly sophisticated drugs. While this effort has ushered in several technological breakthroughs, a preoccupation with magic-bullet cures has distracted from public health fundamentals. The spread of the virus revealed shortages in basic equipment and hospitals beds, the disproportionate effects of disease on the marginalized, the challenge of prevention rather than cure, the limits of insurance-based models to provide equitable care, and our unacknowledged dependence on the labor of underpaid health care workers.

To put it plainly, the pandemic did not create a crisis in U.S. health care. For many in the United States, crisis was already a precondition of care, delivered in emergency rooms and negotiated through denied insurance claims. As we begin to imagine a "new normal," we must ask questions about the old. The pandemic made clear that the "normal" had been a privilege only for a few well-insured citizens. In its wake, can we imagine a health-care system that properly compensates labor and recognizes health care as a right, rather than a privilege only available to the marginalized when an endemic crisis is magnified by a pandemic emergency? 

Andrea Campbell , professor of political science

No doubt, the pandemic reveals the dire need to invest in public-health infrastructure to better monitor and address public-health threats in the future, and to expand insurance coverage and health care access. To my mind, however, the pandemic’s greatest significance is in revealing the racism woven into American social and economic policy.

Public policies helped create geographic and occupational segregation to begin with; inadequate racist and classist public policies do a poor job of mitigating their effects. Structural racism manifests at the individual level, with people of color suffering worse housing and exposure to toxins, less access to education and jobs, greater financial instability, poorer physical and mental health, and higher infant mortality and shorter lifespans than their white counterparts. Residential segregation means many white Americans do not see these harms.

Structural racism also materializes at the societal level, a colossal waste of human capital that undercuts the nation’s economic growth, as social and economic policy expert Heather McGhee shows in her illuminating book, "The Sum of Us." These society-wide costs are hidden as well; it is difficult to comprehend the counterfactual of what growth would look like if all Americans could prosper. My hope is that the pandemic renders this structural inequality visible. There is little point in improving medical or public-health systems if we fail to address the structural drivers of poor health. We must seize the opportunity to improve housing, nutrition, and schools; to enforce regulations on workplace safety, redlining, and environmental hazards; and to implement paid sick leave and paid family leave, among other changes. It has been too easy for healthy, financially stable, often white Americans to think the vulnerable are residual. The pandemic has revealed that they are in fact central. It’s time to invest for a more equitable future.

Jonathan Gruber , Ford Professor of Economics

The Covid-19 pandemic is the single most important health event of the past 100 years, and as such has enormous implications for our health care system. Most significantly, it highlights the importance of universal, non-discriminatory health insurance coverage in the United States. The primary source of health insurance for Americans is their job, and with unemployment reaching its highest level since the Great Depression, tens of millions of workers lost, at least temporarily, their insurance coverage.

Moreover, even once the economy recovers, millions of Americans will have a new preexisting condition, Covid-19. That’s why it is critical to build on the initial successes of the Affordable Care Act to continue to move toward a safety net that provides insurance options for all without discrimination.

The pandemic has also illustrated the power of remote health care. The vast majority of patients in the United States have had their first experience with telehealth during the pandemic and found it surprisingly satisfactory. More use of telehealth can lead to increased efficiency of health care delivery as well as allowing our system to reach underserved areas more effectively.

The pandemic also showed us the value of government sponsorship of innovation in the health sciences. The speed with which the vaccines were developed is breathtaking. But it would not have been possible without decades of National Institute of Health investments such as the Human Genome Project, nor without the large incentives put in place by Operation Warp Speed. Even in peacetime, the government has a critical role to play in promoting health care innovation

The single most important change that we need to make to be prepared for the next pandemic is to recognize that proper preparation is, by definition, overpreparation. Unless we are prepared for the next pandemic that doesn’t happen, we won’t possibly be ready for the next pandemic that does.

This means working now, while the memory is fresh, to set up permanent, mandatorily funded institutions to do global disease surveillance, extensive testing of any at-risk populations when new diseases are detected, and a permanent government effort to finance underdeveloped vaccines and therapeutics.

Jeffrey Harris , professor emeritus of economics and a practicing physician The pandemic has revealed the American health care system to be a non-system. In a genuine system, health care providers would coordinate their services. Yet when Elmhurst Hospital in Queens was overrun with patients, some 3,500 beds remained available in other New York hospitals. In a genuine system, everyone would have a stable source of care at a health maintenance organization (HMO). While our country has struggled to distribute the Covid-19 vaccine efficiently and equitably, Israel, which has just such an HMO-based system, has broken world records for vaccination.

Germany, which has all along had a robust public health care system, was accepting sick patients from Italy, Spain, and France. Meanwhile, U.S. hospitals were in financial shock and fee-for-service-based physician practices were devastated. We need to move toward a genuine health care system that can withstand shocks like the Covid-19 pandemic. There are already models out there to imitate. We need to strengthen our worldwide pandemic and global health crisis alert systems. Despite concerns about China’s early attempts to suppress the bad news about Covid-19, the world was lucky that Chinese investigators posted the full genome of SARS-CoV-2 in January 2020 — the singular event that triggered the search for a vaccine. With the recurrent threat of yet another pandemic — after H1N1, SARS, MERS, Ebola, and now SARS-Cov-2 — along with the anticipated health consequences of global climate change, we can’t simply cross our fingers and hope to get lucky again.

Erica Caple James , associate professor of medical anthropology and urban studies The coronavirus pandemic has revealed some of the limits of the American medical and health care system and demonstrated many of the social determinants of health. Neither the risks of infection nor the probability of suffering severe illness are equal across populations. Each depends on socioeconomic factors such as type of employment, mode of transportation, housing status, environmental vulnerability, and capacity to prevent spatial exposure, as well as “preexisting” health conditions like diabetes, obesity, and chronic respiratory illness.

Such conditions are often determined by race, ethnicity, gender, and “biology,” but also poverty, cultural and linguistic facility, health literacy, and legal status. In terms of mapping the prevalence of infection, it can be difficult to trace contacts among persons who are regular users of medical infrastructure. However, it can be extraordinarily difficult to do so among persons who lack or fear such visibility, especially when a lack of trust can color patient-clinician relationships.

One’s treatment within medical and health care systems may also reflect other health disparities — such as when clinicians discount patient symptom reports because of sociocultural, racial, or gender stereotypes, or when technologies are calibrated to the norm of one segment of the population and fail to account for the severity of disease in others.

The pandemic has also revealed the biopolitics and even the “necropolitics” of care — when policymakers who are aware that disease and death fall disproportionately in marginal populations make public-health decisions that deepen the risks of exposure of these more vulnerable groups. The question becomes, “Whose lives are deemed disposable?” Similarly, which populations — and which regions of the world — are prioritized for treatment and protective technologies like vaccines and to what degree are such decisions politicized or even racialized?

Although no single change will address all of these disparities in health status and access to treatment, municipal, state, and federal policies aimed at improving the American health infrastructure — and especially those that expand the availability and distribution of medical resources to underserved populations — could greatly improve health for all.

Seth Mnookin , professor of science writing

The Covid-19 pandemic adds yet another depressing data point to how the legacy and reality of racism and white supremacy in America is lethal to historically marginalized groups. A number of recent studies have shown that Black, Hispanic, Asian, and Native Americans have a significantly higher risk of infection, hospitalization, and death compared to white Americans.

The reasons are not hard to identify: Minority populations are less likely to have access to healthy food options, clean air and water, high-quality housing, and consistent health care. As a result, they’re more likely to have conditions that have been linked to worse outcomes in Covid patients, including diabetes, hypertension, and obesity.

Marginalized groups are also more likely to be socioeconomically disadvantaged — which means they’re more likely to work in service and manufacturing industries that put them in close contact with others, use public transportation, rely on overcrowded schools and day cares, and live in closer proximity to other households. Even now, more vaccines are going to wealthier people who have the time and technology required to navigate the time-consuming vaccine signup process and fewer to communities with the highest infection rates.

This illustrates why addressing inequalities in Americans’ health requires addressing inequalities that infect every part of society. Moving forward, our health care systems should take a much more active role in advocating for racial and socioeconomic justice — not only because it is the right thing to do, but because it is one of the most effective ways to improve health outcomes for the country as a whole.

On a global level, the pandemic has illustrated that preparedness and economic resources are no match for lies and misinformation. The United States, Brazil, and Mexico have, by almost any metric, handled the pandemic worse than virtually every other country in the world. The main commonality is that all three were led by presidents who actively downplayed the virus and fought against lifesaving public health measures. Without a global commitment to supporting accurate, scientifically based information, there is no amount of planning and preparation that can outflank the spread of lies.

Parag Pathak , Class of 1922 Professor of Economics   The pandemic has revealed the strengths and weaknesses of America’s health care systems in an extreme way. The development and approval of three vaccines in roughly one year after the start of the pandemic is a phenomenal achievement. At the same time, there are many innovations for which there have been clear fumbles, including the deployment of rapid tests and contact tracing.   The other aspect the pandemic has made apparent is the extreme inequality in America’s health systems. Disadvantaged communities have borne the brunt of Covid-19 both in terms of health outcomes and also economically. I’m hopeful that the pandemic will spur renewed focus on protecting the most vulnerable members of society. A pandemic is a textbook situation in economics of externalities, where an individual’s decision has external effects on others. In such situations, there can be major gains to coordination. In the United States, the initial response was poorly coordinated across states. I think the same criticism applies globally. We have not paid enough attention to population health on a global scale. One lesson I take from the relative success of the response of East Asian countries is that centralized and coordinated health systems are more equipped to manage population health, especially during a pandemic. We’re already seeing the need for international cooperation with vaccine supply and monitoring of new variants. It will be imperative that we continue to invest in developing the global infrastructure to facilitate greater cooperation for the next pandemic.

Prepared by MIT SHASS Communications Editor and designer: Emily Hiestand Consulting editor: Kathryn O'Neill

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The Coming Collapse of the U.S. Health Care System

I t’s four in the morning and you awaken with crushing chest pain. Your family calls 911 and paramedics arrive and diagnose a cardiac event. They inform you that they need to transport you forty-five minutes away because your two local hospitals have closed over the last several months. Even when you arrive at the hospital, there is massive overcrowding and they inform you that there are no ICU beds open for you in that fifty percent of the beds in the cardiac unit are “browned out” due to lack of staff. This nightmare is an all too familiar post pandemic reality about the delivery of health care in our country. This is not the expectation that the public expects in the delivery of health care in one of the richest nations in the world that has been at the cutting edge of health care innovation of the last century.

What has led to this post-pandemic nightmare is multifactorial. The pandemic changed how health care professionals are both valued and how they see themselves. During the height of the pandemic they were heroes that were endangering their lives to help the community. But now things look different.

Around 7,000 nurses on strike in New York City nursing strike is emblematic of the dire situation. Nurses, who are essential to the critical functioning of all hospitals, are entitled not only to more equitable compensation and benefits, but ultimately safer staffing ratios in all patient care settings. What’s ironic is that the strike will force these very health care systems to replace employed nurses with temporary nurses from staffing agencies, further compounding their financial woes, and ultimately, their bottom lines. Until we invest in people and their value in healthcare, we won’t be able to see light at the end of the tunnel.

Everyday we read about hospitals throughout the country losing millions if not billions of dollars per year. Hospitals are closing urgent care centers, obstetric, pediatric and other services to try to survive. One of the major factors that has triggered this crisis is the lack of staff. Post-pandemic hospital staffing has massively decreased with a rise in temporary locum staffing dependency. Hospitals and clinicians no longer have regular staff that can build professional and patient relationships; instead, they are dependent on locum staff with short term contracts to provide such services. Those locum providers are at all levels of the professional ladder from physicians, mid-level providers, nurse, respiratory therapists, and radiology technologists. This staffing model has led to many issues both professionally and financially.

On the professional level this massive shortfall of staff and dependency on temporary staff has created a critical issue in the realm of patient care. Hospitals and clinics have shut down services in all vital patient services. It is not uncommon to hear that health care systems have shut down Pediatrics, Psychiatry, Obstetrics, and ICU. Other healthcare systems have gone to the point of closing down entire hospitals because of staffing issues. Another important factor is the crisis is that outpatient services have reduced hours and days. It is obvious that this reduction of services has greatly affected access to health care. Individuals have lost the ability to get timely appointments, x-rays, and tests. In many communities, it is the underserved that have payed the greatest price in terms of getting timely care.

Hospitals have had to also close down operating rooms due to staffing thus delaying both elective and emergent services. Critically ill patients boarded in the emergency department have also spent long hours or days waiting for inpatient beds due to lack of trained staff even when beds become available. Even when they may be ready for hospital discharge patients have long waits to find rehab and skilled nursing facilities because they have also been affected by short staffing. This inability to transfer patients to appropriate facilities only adds to the short fall of inpatient beds.

During the pandemic, it was not uncommon for older providers with health issues to retire than to go into work. Individuals that did go to work worked long hours and had increased levels of stress. Post pandemic, many of these individuals were not financially rewarded: they saw COVID-19 relief money go to upgrade facilities, build new buildings, and other non-employee rewards. This obviously changed the relationship between the bedside providers and hospital leadership.

Adding to this breakdown for many were the city and state vaccine mandates. Many believed that they had worked hard with limited resources and experience against COVID-19 and now the appreciation is losing your job over your own ability to make health care decisions. Another major issue is the shortfall of individuals who wish to be health care providers. Many individuals and families observed how hard healthcare workers were required to work and to work while other professions and jobs could work from home.

One of the most important aspects in the shift was the introduction of massive numbers of temporary workers during the pandemic which continues today. Temporary workers (typically known as Locums) are a major contribution to staffing issues. As regular hospital staff learn about the financial rewards that locum providers receive, it only leads to more individuals questioning, “why do I still work here?”

Locum providers may be receiving two to three times the hourly rate of pay, and in some cases, free housing, rental cars and meal allowances. This is not a good model for worker satisfaction where an individual works through the pandemic with all its stress and is now training an individual who will make many folds their salary with additional perks who has no loyalty to the facilities. In some areas of the country locum health workers may be from the hospital down the street. Employees from hospital A go to hospital B then hospital C without having to travel.

Also integral to this discussion is the high pre-pandemic levels of burnout and attrition among providers that further devastated the supply of available healthcare providers leading into the pandemic. Addressing this issue is integral for the ongoing supply of providers throughout the U.S.

The widespread use of locums also affects the way and quality of the care provided. In the complex environment of health care delivery over the last few decades, we have learned that the best care is provided by individuals who work as teams caring for specific issues or problems. Prime examples of this are operating rooms and ICUs. Here, providers know the individual expertise and skills of each provider and protocols and guidelines needed to care for specific conditions. You can easily see how this would generate the best care. With short term locum providers, use of this system collapses into a world where individuals do not know the guidelines, location of supplies, the needs of individual providers and what each individual brings to the table. What also suffers is the ability to run through simulations and learning scenarios because staff is temporary. Many of us will see a rise in complications and poor outcomes in the next few years because of the breakdown in the healthcare team.

The massive financial drain imposed by staff shortages and use of locums has led to many health care facilities reaching the point of financial instability. Daily reports of massive quarterly losses by both internationally known and local hospitals where billions of dollars are being lost in an industry which was already working on a slim margin will lead to many additional facility closures. This has affected not only rural hospitals with slim operating margins, but larger urban healthcare facilities as well. The loss of such important services in hospitals and associated outpatient facilities will impact care for our communities for future generations.

So, if all of the hospital and healthcare facility close, where will we get our care? The answer is bleak. If we are hit with another pandemic where will the care be delivered, where will the beds be? This critical financial issue is also going to affect other industries. Medical technology companies cannot sell cutting edge ventilators, monitors and imaging devices to facilities that have no cash flow. Aging medical infrastructure cannot be repaired, upgraded or replaced in this financial environment.

As a backdrop to this evolving crisis, we wonder why is this not a major news story. Why are our local and national leaders not addressing these issues?

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Home — Essay Samples — Nursing & Health — Health Care — Healthcare Crisis

Healthcare Crisis Essay Examples

In the realm of academic research and writing, understanding the multifaceted nature of healthcare crises is essential. Our curated selection of healthcare crisis essay samples offers students a diverse array of perspectives on this critical issue. These essays serve as a foundational tool for those aiming to explore the challenges, solutions, and impacts of healthcare crises in various contexts. Whether you are looking for inspiration, detailed case studies, or guidance on how to approach this topic, our collection stands ready to support your academic journey.

Exploring the Healthcare Crisis

A healthcare crisis can manifest in numerous ways, from pandemics to inadequate healthcare infrastructure, affecting populations globally. Essays on this topic dissect the myriad factors contributing to healthcare crises, including political, economic, and social dimensions. By engaging with these essays, students can gain a deeper understanding of how healthcare crises develop, their repercussions on communities, and the strategies implemented to address them. This exploration encourages critical thinking and invites students to consider innovative solutions to complex problems.

Our Collection Highlights

Our assortment of healthcare crisis essays encompasses a broad spectrum of topics, reflecting the complexity of the issue. Essays range from analytical discussions on policy and healthcare system reform to personal narratives capturing the human element of healthcare crises. This variety ensures that every student can find essays that resonate with their specific academic focus and personal interests. By offering a comprehensive overview of the healthcare crisis from multiple angles, our collection aims to enrich your research and provide a solid foundation for your writing.

Utilizing Our Essays Effectively

• Inspiration: Kickstart your essay writing process by exploring topics that capture the breadth and depth of the healthcare crisis.
• Research Foundation: Utilize the essays as a research tool, helping you to frame your own inquiries and gather relevant data.
• Structural Guide: Analyze the composition of our essays to understand effective ways of structuring your arguments and presenting your analysis.
• Referencing: Learn from the citation practices observed in our essays to enhance the credibility of your work through proper sourcing.

Navigating the complexities of a healthcare crisis requires insight, empathy, and a comprehensive understanding of the issue's roots and ramifications. Our collection of healthcare crisis essay samples is designed to empower students with the knowledge and inspiration needed to contribute meaningful essays to the academic dialogue surrounding this pressing global issue. Through careful analysis and reflection on the essays in our collection, students can craft compelling narratives that highlight the urgency of addressing healthcare crises and propose thoughtful solutions.

Embark on your academic exploration of the healthcare crisis by delving into our essay samples today. Let these essays be your guide as you uncover the nuances of healthcare crises and craft an essay that not only meets academic standards but also adds valuable insights to the ongoing conversation.

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What's Really Causing America's Mental Health Crisis?

A man wears a face mask as he walks on Pier 45 in Hudson River Park in New York. The coronavirus pandemic has taken a harsh toll on the mental health of young Americans, according to a new poll that finds adults under 35 especially likely to report negative feelings or experience physical or emotional symptoms associated with stress and anxiety. (AP Photo/Mark Lennihan, File) Mark Lennihan/AP hide caption

A man wears a face mask as he walks on Pier 45 in Hudson River Park in New York. The coronavirus pandemic has taken a harsh toll on the mental health of young Americans, according to a new poll that finds adults under 35 especially likely to report negative feelings or experience physical or emotional symptoms associated with stress and anxiety. (AP Photo/Mark Lennihan, File)

This week the U.S. Preventive Services Task Force announced recommendations that doctors screen all patients under 65 for anxiety. Since the beginning of the pandemic, we've heard about sharp increases in the number of people suffering from mental health problems. With a health care system already overburdened and seemingly unable to deal with the rise in mental health issues, America is facing what is being called a mental health crisis. But are we losing sight of another crisis - the political and social issues causing increased anxiety and depression in Americans? Host Michel Martin speaks with Dr. Danielle Carr about her recent essay in the New York Times, Mental Health Is Political .

In participating regions, you'll also hear a local news segment to help you make sense of what's going on in your community.

Email us at [email protected] .

This episode was produced by Robert Baldwin III. It was edited by Jeanette Woods. Our executive producer is Natalie Winston.

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Impact of COVID-19 on people's livelihoods, their health and our food systems

Joint statement by ilo, fao, ifad and who.

The COVID-19 pandemic has led to a dramatic loss of human life worldwide and presents an unprecedented challenge to public health, food systems and the world of work. The economic and social disruption caused by the pandemic is devastating: tens of millions of people are at risk of falling into extreme poverty, while the number of undernourished people, currently estimated at nearly 690 million, could increase by up to 132 million by the end of the year.

Millions of enterprises face an existential threat. Nearly half of the world’s 3.3 billion global workforce are at risk of losing their livelihoods. Informal economy workers are particularly vulnerable because the majority lack social protection and access to quality health care and have lost access to productive assets. Without the means to earn an income during lockdowns, many are unable to feed themselves and their families. For most, no income means no food, or, at best, less food and less nutritious food. 

The pandemic has been affecting the entire food system and has laid bare its fragility. Border closures, trade restrictions and confinement measures have been preventing farmers from accessing markets, including for buying inputs and selling their produce, and agricultural workers from harvesting crops, thus disrupting domestic and international food supply chains and reducing access to healthy, safe and diverse diets. The pandemic has decimated jobs and placed millions of livelihoods at risk. As breadwinners lose jobs, fall ill and die, the food security and nutrition of millions of women and men are under threat, with those in low-income countries, particularly the most marginalized populations, which include small-scale farmers and indigenous peoples, being hardest hit.

Millions of agricultural workers – waged and self-employed – while feeding the world, regularly face high levels of working poverty, malnutrition and poor health, and suffer from a lack of safety and labour protection as well as other types of abuse. With low and irregular incomes and a lack of social support, many of them are spurred to continue working, often in unsafe conditions, thus exposing themselves and their families to additional risks. Further, when experiencing income losses, they may resort to negative coping strategies, such as distress sale of assets, predatory loans or child labour. Migrant agricultural workers are particularly vulnerable, because they face risks in their transport, working and living conditions and struggle to access support measures put in place by governments. Guaranteeing the safety and health of all agri-food workers – from primary producers to those involved in food processing, transport and retail, including street food vendors – as well as better incomes and protection, will be critical to saving lives and protecting public health, people’s livelihoods and food security.

In the COVID-19 crisis food security, public health, and employment and labour issues, in particular workers’ health and safety, converge. Adhering to workplace safety and health practices and ensuring access to decent work and the protection of labour rights in all industries will be crucial in addressing the human dimension of the crisis. Immediate and purposeful action to save lives and livelihoods should include extending social protection towards universal health coverage and income support for those most affected. These include workers in the informal economy and in poorly protected and low-paid jobs, including youth, older workers, and migrants. Particular attention must be paid to the situation of women, who are over-represented in low-paid jobs and care roles. Different forms of support are key, including cash transfers, child allowances and healthy school meals, shelter and food relief initiatives, support for employment retention and recovery, and financial relief for businesses, including micro, small and medium-sized enterprises. In designing and implementing such measures it is essential that governments work closely with employers and workers.

Countries dealing with existing humanitarian crises or emergencies are particularly exposed to the effects of COVID-19. Responding swiftly to the pandemic, while ensuring that humanitarian and recovery assistance reaches those most in need, is critical.

Now is the time for global solidarity and support, especially with the most vulnerable in our societies, particularly in the emerging and developing world. Only together can we overcome the intertwined health and social and economic impacts of the pandemic and prevent its escalation into a protracted humanitarian and food security catastrophe, with the potential loss of already achieved development gains.

We must recognize this opportunity to build back better, as noted in the Policy Brief issued by the United Nations Secretary-General. We are committed to pooling our expertise and experience to support countries in their crisis response measures and efforts to achieve the Sustainable Development Goals. We need to develop long-term sustainable strategies to address the challenges facing the health and agri-food sectors. Priority should be given to addressing underlying food security and malnutrition challenges, tackling rural poverty, in particular through more and better jobs in the rural economy, extending social protection to all, facilitating safe migration pathways and promoting the formalization of the informal economy.

We must rethink the future of our environment and tackle climate change and environmental degradation with ambition and urgency. Only then can we protect the health, livelihoods, food security and nutrition of all people, and ensure that our ‘new normal’ is a better one.

Media Contacts

Kimberly Chriscaden

Communications Officer World Health Organization

Nutrition and Food Safety (NFS) and COVID-19

Failing Economy, Failing Health

The great recession’s toll on mind and body.

Five years after the Great Recession officially came to an end, the United States has yet to fully recover from the economic devastation sparked by the collapse of an $8 trillion housing bubble and the ensuing turmoil that saw global financial systems teetering on the brink of collapse. But while the economic costs of the downturn have drawn the lion’s share of attention, the damage to our bodies could end up far surpassing the damage to our bank accounts.

“It’s quite stunning we haven’t been hearing more about this,” says Kasisomayajula “Vish” Viswanath , professor of health communication at Harvard School of Public Health. “We talk about poverty and inequality resulting from the recession, but we do not take the next step. We do not extend that logic to the effects on health.”

If the issue is largely invisible in the nation’s news outlets, it is drawing the attention of a growing number of public health researchers, some of whom are beginning to identify possible links between the Great Recession—the worst economic downturn in the U.S. since the Great Depression of the 1930s—and a growing list of physical and mental health ills, from heart attacks to obesity to depression. In addition to cataloging the health harms resulting directly from stress [see below: “The Biology of Chronic Stress,”], many studies suggest that economic pressures may also give rise to a host of unhealthy behaviors —such as bingeing on sugary or high-fat comfort foods, smoking, and drinking to escape worries—as well as to widening economic disparities, which exact a documented toll on people’s health.

Joblessness, the foreclosure crisis, the growing gap between rich and poor: these are not solely economic issues. Yet the full tally of public health costs linked to the Great Recession—at levels ranging from our cells to our health care systems—will not be apparent for many years. “Health is a long-run thing, but the methods we use to analyze current data only estimate short-term effects,” says SV Subramanian , HSPH professor of population health and geography. “It may take awhile for the health impact of the Great Recession to kick in, but once it does, it could be dramatic.”

HOW UNEMPLOYMENT MAKES US SICK

There has long been substantial evidence linking job loss to shorter lives and more health-related problems. A 2009 study on the impact of the 1980s oil crisis and subsequent recession in Pennsylvania, published by economists Daniel Sullivan and Till von Wachter in the Quarterly Journal of Economics , found that in the year after men lost their jobs in mass layoffs, their chances of dying doubled. And though the heightened risk tapered off over the years, it was still significantly higher 20 years later. If such trends were sustained indefinitely, the authors wrote, it would mean a loss in life expectancy of 1–1.5 years for a worker displaced at age 40.

Today, a new generation of researchers is building on this scientific foundation. Sociologist Clemens Noelke , David E. Bell Postdoctoral Fellow at the Harvard Center for Population and Development Studies (Pop Center), is in the final stretch of a study of the health impact of job loss during recessions and the extent to which unemployment benefits may cushion potential harms. Noelke’s research, which draws on data from a massive biannual study, focuses on U.S. workers ages 50 and older between 1992 and 2010—years that include the downturns of the early 1990s and the early 2000s, as well as the Great Recession (2007–2009). Among the health indicators he is looking at: mortality rates, cardiovascular disease, cognition, depression, and unhealthy behaviors such as smoking and drinking.

Why target an older population? “It’s harder for an older person to find a new job, and older individuals have more health conditions to begin with,” Noelke explains. “They’re also becoming a larger proportion of the workforce.” By 2016, one-third of the U.S. workforce will be age 50 and up.

While Noelke is not yet talking publicly in detail about his findings (currently under peer review), he expects the results to be in line with existing studies from European countries and the U.S. The studies have consistently tied unemployment to elevated death rates . A 2011 meta-analysis of international research—published in Social Science & Medicine by David Roelfs, Eran Shor, Karina Davidson, and Joseph Schwartz—found that the risk of death was 63 percent higher during the study periods among those who experienced unemployment than among those who did not, after adjusting for age and other variables.

Some argue that this can be explained by the fact that sicker people are more likely to end up unemployed. But studies focusing on workplace closures—where all employees are let go—suggest otherwise. A 2009 report by University of Albany sociologist Kate W. Strully in the journal Demography found that losing a job when a business closes increased the odds of fair or poor health by 54 percent among workers with no preexisting health conditions, and increased by 83 percent the odds of new health conditions likely triggered by job loss—stress-related conditions such as stroke, hypertension, heart disease, arthritis, diabetes, and emotional and psychiatric problems.

Such findings would come as no surprise to those who responded to a 2010 poll, conducted jointly by Knowledge Networks and investigators at HSPH led by Gillian SteelFisher , a research scientist in the Department of Health Policy and Management . The survey found that many people with heart disease, diabetes, or cancer believed that the downturn was hurting their health and that these negative impacts would only worsen over time. Among the facts unearthed by the poll: About a third of those with heart disease or diabetes and a fifth of those with cancer blame the economic downturn for forcing them to use up their savings to deal with medical bills, co-payments, and other expenses related to their illnesses. More broadly, according to the poll, some 4 in 10 Americans with heart disease or diabetes and 1 in 5 with cancer said the downturn had made it more stressful for them to manage their illnesses, a scenario that in itself may have exacerbated existing health problems.

CASCADE OF CATASTROPHE

The United States is unique among developed countries in its historic reliance on employers to provide health insurance—leaving those who lose their jobs not only without an income but also without health care. While passage of the Affordable Care Act (ACA) in 2010 set the stage for a different scenario, it is not yet clear that the law will result in better health outcomes for the unemployed or underemployed. Katherine Baicker , professor of health economics, co-authored a 2011 paper published by the National Bureau of Economic Research that showed that the improved access to Medicaid resulting from the act raised rather than cut costs; yet while the price of care increased, people reported better health and fewer financial strains associated with health care costs.

The United States is unique among developed countries in its historic reliance on employers to provide health insurance—leaving those who lose their jobs not only without an income but also without health care.

Although joblessness has been a major problem in Europe, the unemployed face special challenges in the United States. “Earnings loss because of job loss seems to be larger in the United States, because after unemployment benefits run out, people are often forced to take jobs that don’t match well with their skills,” says Noelke.

Others agree. “If you look at countries with strong social safety nets, it’s not as dire for people who are out of work,” says Laura Kubzansky , professor of social and behavioral sciences. “It’s unpleasant, but it doesn’t set up this cascade of catastrophe in the way that it can in this country, where the only net people have once unemployment runs out is frequently their family and savings.”

Foreclosure is equally traumatic. As a result of the subprime mortgage crisis that led to the Great Recession, more than 13 million American households were foreclosed between 2008 and 2013. That sprawling calamity yielded “a stressful life event of prolonged duration, with multiple phases of variable intensity,” wrote HSPH assistant professor of social and behavioral science Reginald Tucker-Seeley and co-authors Gary G. Bennett and Melissa Scharoun-Lee, both of Duke University, in a June 2009 essay titled “ Will the Public’s Health Fall Victim to the Foreclosure Epidemic? ”

FORECLOSING ON HEALTH

First the birds started dying—falling out of trees, found floating in backyard swimming pools. Then humans began to develop strange and frightening symptoms: tremors, confusion, and occasionally paralysis.

It was May 2007 in Bakersfield, California—a city hard hit by the nation’s foreclosure crisis—when the first cases appeared of what was ultimately determined to be West Nile virus infection, a mosquito-borne disease that sometimes leads to fatal brain damage. But if the diagnosis was clear, the cause was anything but, especially given that public health experts had considered this to be an unusually low-risk year.

The answer finally came in the form of aerial photos of Bakersfield. The images revealed hundreds of swimming pools, birdbaths, and Jacuzzis—an estimated one out of six—covered in green fuzz. Almost all of their owners had decamped, leaving empty homes and signs that said “For Sale” or “Bank-Owned Foreclosure.” Ultimately, investigators found more than 4,000 mosquito larvae infected with West Nile strains in 31 neglected pools. What began as a foreclosure crisis had become a public health menace, wrote sociologist David Stuckler, a former HSPH faculty member now at Oxford University, and Sanjay Basu, an assistant professor of medicine and epidemiologist at Stanford University, in their 2013 book The Body Economic: Why Austerity Kills .

Losing a home, in other words, may endanger not only the home dweller’s health but also the health of neighbors.

At HSPH, Mariana Arcaya , Yerby Postdoctoral Research Fellow at Harvard’s Pop Center, is also tackling the issue. Lead author of a 2013 report in the American Journal of Public Health , she discovered that people who live near foreclosed homes may be at greater risk of being overweight than those who don’t have such properties in their immediate neighborhoods.

Arcaya’s interest was in demonstrating the “spillover effect” of the foreclosure crisis—that is, its impact on those whose own homes did not fall prey to foreclosure. Because Americans so often view health outcomes as reflecting individual choices, Arcaya explains, it was important to show that even those who do everything “right” could be affected. “It’s easy to think ‘You’re the kind of person who let your home go into foreclosure, so you are also more likely to be the kind of person who gains weight. You’re irresponsible!’” she says. “Spillover effect reveals harmful structural forces in the larger economy.”

Arcaya and her colleagues analyzed housing and medical data from 2,078 study participants in Massachusetts from 1987 to 2008, looking at foreclosure records as well as the volunteers’ proximity to foreclosed homes and their body mass index (BMI) levels. They found that living within 100 meters of a foreclosed home was associated with a higher BMI of .2 units—the equivalent of a 1.3-pound weight gain in a 5-foot-6-inch person.

Some 4 in 10 Americans with heart disease or diabetes and 1 in 5 with cancer say the downturn had made it more stressful for them to manage their illness.

What accounts for higher obesity rates among those living near foreclosed homes? Perhaps people are less likely to be physically active when they live in places hit by foreclosure. “You may not want to walk your dog, go running, or garden as much when the physical environment is less appealing,” says Arcaya. “There may be houses boarded up. It may not feel as safe.”

Even more likely, Arcaya suspects, is that weight gain could stem from added stress fueled by factors that include anxiety over declining property values in the neighborhood. “Real estate is location, location, location, and zoning is such that if my house is 2,000 square feet, a foreclosed house is also probably 2,000 square feet. Why should someone buy my house when they don’t want to buy that house? Who would put faith in my neighborhood right now?”

Whatever the pathways turn out to be, HSPH experts believe that the nation’s foreclosure crisis will be leaving its imprint on public health far into the future. “Health is not something that can be miraculously revived overnight,” Vish Viswanath says. “Even if foreclosures go down, even if people manage to regain a foothold in mainstream society, the consequences will be long-lasting.”

TOXIC INEQUALITY

At the beginning of his bestselling book Outliers , Malcolm Gladwell tells the story of Roseto, Pennsylvania, a town settled by Italian immigrants that in the 1950s was found to have astonishingly low rates of heart disease and other leading killers of the era. For men over 65, the death rate from heart disease was roughly half that of neighboring towns and the nation as a whole. More broadly, the death rate from all causes was roughly a third lower than what would have been expected.

After ruling out the obvious causes—genetics, diet, and exercise—medical researchers came to a remarkable conclusion: The source of residents’ unusual good health was the community’s rich social ties and egalitarian ethos.

While not focused on the wealth divide per se, the Roseto follow-up study is in line with a growing body of research suggesting that extreme income inequality may also be bad for health. Such findings are of particular concern, given the ever-widening gap between rich and poor in the United States—a trend that began during the 1970s and has deepened since the Great Recession.

What began as a foreclosure crisis became a public health crisis in one community when West Nile virus spread through neglected pools on foreclosed properties.

According to Emmanuel Saez, an economist at the University of California, Berkeley, the U.S. economic recovery since 2009 has mostly benefited the rich. From 2009 to 2012, he wrote in a 2013 report, the average income of the top 1 percent of Americans grew by 31.4 percent, while for the bottom 99 percent income grew by only 0.4 percent. Put another way, the top 1 percent captured 95 percent of income gains.

To be sure, the question of how—or if—inequality harms health is fiercely debated. One hypothesis is known as social comparison—what most of us think of as “keeping up with the Joneses.” A seminal 2008 study in the Journal of Human Resources found an association between “relative deprivation”—a calculation that takes into account both the incomes of the individuals being studied and that of the people with whom they are likely to compare themselves—and risk of death. They reported that each 1.0 standard deviation increase in the index used to calculate relative deprivation was associated with a 57 percent higher risk of death population-wide, as well as with other stress-related health outcomes such as increased risks of smoking, obesity, and use of mental health services.

As Kawachi sees it, the United States is an especially fertile breeding ground for stress-related discontent and shame. “Americans think you can just be like Bill Gates or Warren Buffett, but data on social mobility say just the opposite,” he says. “When people try hard and fail—which happens a lot during economic recessions—they end up blaming themselves.” He adds: “We were already one of the most unequal societies—and we just became more unequal, thanks to the Great Recession. And the more unequal a society is, the worse its average health measures tend to be.”

This fact is borne out in statistics showing that the U.S. lags far behind peer countries in the Organization for Economic Cooperation and Development, in measures ranging from life expectancy to anxiety to homicide and drug abuse deaths. “We don’t have to wait another 10 or 15 years to see the smoking gun of the 2008 recession,” Kawachi observes. “Just look at the current statistics. The Great Recession made everything much worse, but we were coming from a pretty bad place.”

PAINTING THE BIG PICTURE

“If the data are not there, you don’t know the problem exists,” says Nancy Krieger , professor of social epidemiology. She admires the example of public health statistician and economist Edgar Sydenstricker, who in 1933 led an unprecedented 10-city study in the U.S. to evaluate the health impact of the Great Depression. His survey included fine-grained details not only about health outcomes, but also about wages, unemployment, diet, food insecurity, alcohol consumption, state of mind, and other facts. “What they found was very interesting,” Krieger says. “Some of the people who did psychologically worst were those who had previously been OK, if not somewhat affluent, and ended up suddenly being poor; they didn’t know how to handle it.”

In the same vein, says Krieger, we need to pose similarly nuanced questions to understand what’s driving disease trends and health inequities in the wake of the Great Recession. And such investigations, she cautions, take time. “One of the dangerous things when researchers conduct these kinds of studies is to expect fast results—and if they don’t get them, to claim there is no harm.”

Adds Viswanath: “The impact of stress, lack of treatment, lack of capacity to manage one’s life, increased smoking or drinking, eating unhealthy foods, family breakups: those consequences are long-lasting.”

PROTECTING HEALTH IN BAD ECONOMIC TIMES

Along with collecting data and pushing for better safety nets, HSPH faculty are exploring ways to buffer people from the health impacts of economic downturns. Laura Kubzansky, for example, is looking at the biology of resilience. “What are the resources that would mitigate the impact of stress?” she asks. “What are the assets that enable people to meet life’s demands in a hardier way? Wouldn’t it be great if we knew the answers and put some proven protections in place before the next recession?”

More specifically, Kubzansky and other researchers are seeking to determine whether positive psychological factors and emotional states shield people from coronary heart disease (CHD). Several studies have found that optimistic people have about half as much risk of developing CHD as their more pessimistic peers. Another study has linked optimism to a slower rate of atherosclerotic progression over a three-year period. And decades of health psychology research have demonstrated the positive impact of social support—such as family, friends, neighbors, co-workers, pets, and governments and organizations that can lend assistance—on physical well-being and longevity. As researchers identify individual-level factors that promote resilience, they also want to understand the structural and social arrangements that promote or hinder these advantages.

“What drives resilience in some individuals? What leaves others more vulnerable?” asks Williams. “Those are the public health questions we need to answer.”

A NEW PUBLIC HEALTH AGENDA

In essence, all of us who lived through the recent recession are part of a massive experiment that is still under way. “Thank you for participating in this clinical trial. You might not recall signing up for it, but you were enrolled in December 2007, at the start of the Great Recession. This experiment was not governed by the rules of informed consent or medical safety. Your treatment was not administered by doctors or nurses. It was directed by politicians, economists, and ministers of finance.” So wrote David Stuckler and Sanjay Basu in The Body Economic , making the case that economic policies can have profoundly toxic public health impacts —or profoundly restorative effects when nations increase spending during economic downturns for programs such as health care, food stamps, and housing.

But in American culture, this broad social perspective is a hard sell. “The idea that people can collectively act to change things cuts against the American myth of self-sufficient individuals who pull themselves up by their bootstraps,” says Krieger. “Linking economics to health, and suggesting that there’s a social production of disease, is not the mainstream analysis—even as it’s very common in other countries.”

In essence, all of us who lived through the Great Recession are part of a massive experiment still underway.

Another argument for a broader frame of reference is the fact that public health and economic prosperity is a two-way street. It’s not surprising that President Franklin Roosevelt’s New Deal—the panoply of social and economic programs enacted between 1933 and 1938 and credited with pulling the country out of the Great Depression—has been described as a massive public health program. And as David Bloom , the Clarence James Gamble Professor of Economics and Demography, has shown, not only does wealth make health, but health makes wealth—in part because healthier people are more productive and less likely to cost health care dollars. These findings suggest that a national focus on improving Americans’ health even in economic downtimes can be part of an overall economic stimulus.

For public health practitioners, acting on lessons from the Great Recession will require both energy and ingenuity. “There has to be an activist agenda,” says Viswanath, with academics translating the evidence in ways that inform public discourse—and, in turn, national programs and policies. “We are fixated on the upstream factors—the recession and its direct economic costs. But the downstream factors—the terrible impact on health—are already far along.”

Amy Gutman is a senior writer for Harvard Public Health.

Spring 2014

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Psychiatric Crisis Care and the More is Less Paradox

Robert e. drake.

Westat, IPS Employment Center, 85 Mechanic Street, Lebanon, NH 03766 USA

Gary R. Bond

Psychiatric crisis care in the U.S. exemplifies the “more is less paradox” of U.S. health care. We spend more for health care than any other high-income country, yet our outcomes are typically poor compared to these other countries (OECD in OECD health statistics. Retrieved from https://www.oced.org/health/health-data.html , 2020). We do this, in part, by emphasizing medical treatments for problems that are inherently social, rather than addressing social determinants of health. Medical interventions for socio-economic problems are usually expensive and ineffective. For mental health crisis care, adding unfunded, untested, medical interventions to the current mélange of poorly funded, disorganized arrangements will not help. Instead, the U.S. should address social determinants, emphasize research-based interventions, and emphasize prevention—proven strategies that decrease costs and improve outcomes.

Introduction

U.S. health care exemplifies the “more is less paradox” of health care. The U.S. spends far more on health care than any of the other 36 high-income country in the Organization for Economic Co-operation and Development (OECD) (Papanicolas et al., 2019 ), but our health outcomes, e.g., maternal health, serious infectious disease, and longevity, are typically in the lowest tenth (OECD, 2020 ; Roser, 2020 ). The U.S. does this by emphasizing high-technology medical treatments, pharmaceuticals, and higher costs for fewer professional services, rather than providing social services (Bradley et al., 2011 ; Squires & Anderson, 2015 ), even though health outcomes for chronic illnesses are predominantly (80–90%) related to social determinants rather than to medical care (Magnan, 2017 ). People who are poor, unemployed, and living in unstable housing in problem-ridden neighborhoods inevitably experience distress, develop psychiatric symptoms, and use alcohol and other substances excessively. Moreover, they die prematurely due to “diseases of despair,” such as alcohol and drug poisoning, alcohol-related liver disease, and depression/suicide (Case & Deaton, 2020 ). The COVID-19 pandemic has amplified these relationships between stress and mental health conditions (Czeisler et al., 2020 ; Gifford et al., 2020 ).

The U.S. spends about the same proportion of its health budget as other high-income countries on mental health care but has a much higher overall health budget and therefore spends more on mental health care (OECD, 2020 ). But what about outcomes? Countries do not report mental health outcomes using the same metrics, but compared to European countries, the U.S. has very high rates of suicide (OECD, 2020 ), homelessness (Fazel et al., 2014 ) and imprisonment (Duffin, 2020 )—all of which are symptoms of an inadequate systemic response to behavioral health problems.

Psychiatric interventions, such as involuntary hospitalizations, brain imaging, expensive medications, and polypharmacy, are neither what patients want nor solutions to these social problems (Drake, 2017 ; Drake & Wallach, 2019 ). Although the pharmaceutical and other industries, professional guilds, hospital associations, insurance companies, and private providers benefit from medicalizing social problems, most of the people who bear the distress do not.

The “more is less paradox” should be at the forefront of discussion among mental health policy makers now because, as we struggle with the COVID-19 pandemic and its related employment and mental health problems, state and federal mental health budgets are likely to be cut significantly rather than increased (Gifford et al., 2020 ). Providers will of course continue to advocate for more psychiatric hospitals, emergency services, medications, and other medical interventions, but more medical treatment is unlikely to solve the problems.

The U.S. needs a new paradigm for mental health services. The crisis care model presents one opportunity to change from a “more is less” mental health approach to a “less is more” approach. Current crisis care is emblematic of the current, expensive, dysfunctional behavioral health system in the U.S. In this essay, we consider the current crisis care system and examine several alternatives.

Current Crisis Care

Consider the following example of a common mental health crisis (actually an amalgam of several patients we have interviewed in recent years), which occurs every day in numerous towns and cities across the U.S. Someone calls 911 in distress reporting suicidal thoughts and is subsequently transported to a hospital emergency room, often by ambulance and in restraints. The precipitant for this episode is likely to be a situational stressor rather than an illness: for example, a father’s alcoholic relapse and violent outburst precipitates an adolescent’s mental health crisis. Once in the emergency department, however, the individual experiencing stress becomes a patient with a medical issue in a medical system that insists on evaluation by a highly trained professional. Even worse, the crisis may involve police who are unprepared to deal with a mental health crisis and escalate the situation to a traumatic, dangerous, and sometimes deadly encounter. The professional in the emergency room often has limited time because the emergency department is overwhelmed and may have little information for a variety of reasons: the patient may be traumatized and uncooperative after having been restrained, a local treatment provider who knows the patient may not be available, medical records may be difficult to access, the patient may deny permission to make contact with family, and so on. Thus, the professional may have little opportunity to explore the sources of the crisis, talk with the family and local mental health provider, or consider alternatives to hospitalization. Nevertheless, once the individual becomes a patient in the emergency room, the professional, with minimal information about the patient and the relevant environmental issues, has medical and legal responsibility. The easiest and safest decision is to insist on hospitalization, even if the patient disagrees vehemently. The patient may now be legally committed to be transported to the hospital but may be housed in the emergency room until a bed in the public hospital is available. After a few hours or days in the emergency room, an ambulance or police car takes the patient, in restraints again, for a lengthy drive to the public hospital. In the hospital, a court hearing, further assessments, daily evaluations, medication trials, and other medical and legal procedures ensue. After several days or weeks of hospitalization, the patient returns home, usually with new medications but without resolution of the social precipitant that led to hospitalization, setting the stage for cyclical crises and hospitalizations in the future.

Note that there are no malign professionals in this typical scenario. The emergency medical technicians, police, emergency room doctor, and hospital staff are trying to be helpful, doing their jobs to the best of their ability, following legal procedures. This is how our system is set up; this is how it works—or doesn’t work.

Every day this type of crisis care occurs in states across the U.S. People with a behavioral health crisis receive interventions from the legal system, medical emergency systems, and psychiatric hospitals. The situation is worse in some states where untrained police turn a psychiatric crisis into a tragedy and in some states where an individual may be kept in jail without treatment while waiting for a psychiatric bed. The system is expensive, legalized, medicalized, hospital-based, doctor-oriented, and, most important, ineffective. Moreover, the interventions create more trauma and a revolving-door system of care that reinforces a chronic patient identity.

Some people do receive help, but this system neither prevents suicides, many of which actually occur in the hospital (Pompili et al., 2004 ), nor leads to functional recovery. The evidence shows instead that crisis interventions and waiting for inpatient care in the hospital are often harmful (Clarke et al., 2007 ), in part because transport to the hospital handcuffed in a police car and being held involuntarily in the hospital add trauma to the individual’s problems. Some suicide experts consider hospitalization a risk factor for suicide (Pompili et al., 2004 ). Even more disturbing, news articles every week report that police interventions for mental health crises can end tragically with a patient’s death. The call for more hospital beds to relieve crowded emergency rooms and bolster an ineffective system rings hollow. Current crisis care in the U.S. is largely ineffective and often harmful. But what are the alternatives?

A New System of Crisis Care

Imagine that the U.S. could create a comprehensive crisis response system that would deliver crisis services to “anyone, anywhere, and any time” without so much reliance on hospitals, emergency medical teams, and police. This is the promise of the substance abuse and mental health services administration’s (SAMHSA) national guidelines for behavioral health crisis care—A best practice toolkit ( https://www.samhsa.gov/find-help/implementing-behavioral-health-crisis-care ). The SAMHSA plan proposes three major new services that would be available in every community: crisis telephone lines linked to a national GPS network available 24/7 to assess needs and dispatch supports, mobile crisis teams to deliver supports outside of hospital settings 24/7, and stabilization facilities outside of hospitals that would provide crisis residences 24/7. Well trained clinicians in teams led by psychiatrists and psychiatric nurse practitioners would oversee triage and care 24/7. The system would provide credentialed peer supports, follow national suicide prevention guidelines, coordinate overflow coverage, dispatch mobile crisis teams as needed, use modern technologies, be trauma-informed, and connect individuals to facility-based care provided by trained clinicians when needed. The system would not involve police, except in special circumstances of dangerousness, and would avoid coercion, except as a last resort. Supervisory staff, a national registry, and staffed stabilization facilities would be available 24/7. This new system sounds ideal.

The SAMHSA proposal offers several components that have been advocated and sometimes provided for decades. For example, various residential alternatives to hospitalization have been used for many years in Europe and the U.S. (Lloyd-Evans & Johnson, 2019 ). Similarly, crisis call lines and outreach teams have been used in the U.S. for over 40 years (Guo et al., 2001 ; Stein & Test, 1980 ). These recommendations are reasonable and practical, and some reflect common sense. For example, a family calling for help with a psychiatric crisis should be able to access an empathic behavioral health worker rather than a police response (the switch to a 988 number promises such a change).

But the SAMHSA proposal also has serious weaknesses. First, SAMHSA terms the proposed system “best practices” rather than “evidence-based practices” because little rigorous scientific evidence exists to support such a system and many of its components. For example, only one randomized controlled study has addressed the central service, mobile crisis teams, and this single study found improved connections to outpatient care (a presumed mediator of outcomes) but no advantages in terms of actual social and symptom outcomes (Currier et al., 2010 ). The problem is that best practices count heavily on expert opinion, which is unreliable, unscientific, and often incorrect (Sackett et al., 2000 ). Second, many of the proposed best practices exist or have existed in the recent past. For example, 39 states reported having mobile crisis teams as far back as 1993 (Geller et al., 1995 ). Similarly, many states have provided crisis call lines, suicide prevention interventions, and residential diversion services over the years. Yet lack of funding has prevented sustaining any of these services on more than a minimal level (Lloyd-Evans & Johnson, 2019 ). Third, although the proposal suggests that a new crisis system would be integrated with the current fragmented system, the evidence shows that government has been consistently unable to engineer such major changes in mental health (Goldman & Grob, 2006 ; Goldman & Morrissey, 2020 ). For example, the federal government has been trying to combine mental health and substance use services into integrated treatment programs for over 30 years (Ridgely et al., 1990 ), but such services remain rare (McGovern et al., 2014 ). Fourth, the financial plan to fund an extensive new crisis care system makes little sense in light of government’s historical failure to fund its mental health policies (Goldman & Grob, 2006 ). Fifth, large government mental health policies have typically produced unintended, adverse consequences for states, providers, and patients (Frank et al., 2003 ). Finally, the 80-page SAMHSA document fails to mention, much less address, prevention.

Evidence-Based Interventions

Before relying on expert opinion, which is notoriously fallible, what about using existing evidence-based practices? Numerous well studied interventions can reduce hospital admissions (Drake & Wallach, 2019 ). Some of these are proximal—that is, they activate at the time of a potential crisis to avert an unnecessary hospitalization. For example, assertive community treatment teams follow high-risk patients in the community over time, meet with them in the community, and are available to patients, families, and landlords 24/7 to resolve potential problems that may lead to a crisis (Dieterich et al., 2010 ).

Most evidence-based practices that reduce hospitalizations are more distal, meaning that they prevent hospitalizations by helping people with mental health conditions to build skills and supports that avert crises weeks or months ahead. Examples include a set of non-medical interventions such as family psychoeducation (Murray-Swank & Dixon, 2004 ), peer supports (Bouchery et al., 2018 ; O’Connell et al., 2018 ), supported housing (Ly & Latimer, 2015 ; Woodhall-Melnik & Dunn, 2015 ), and supported employment (Knapp et al., 2013 ). Importantly, these evidence-based practices address social determinants and involve intervening before people are in acute crisis. Randomized controlled trials have shown that some of these interventions can reduce hospitalizations by 40–50% (Drake & Wallach, 2019 ), especially among high-risk patients with extensive histories of psychiatric hospitalizations (Burns et al., 2007 ).

Despite the potential to prevent crises, these non-medical, evidence-based practices are rarely available to the great majority of people with a serious mental health condition in the U.S. For example, after 40 years of dissemination, only 13% of mental health agencies provide assertive community treatment (Spivak et al., 2019 ). Recent SAMHSA surveys have found that less than 3% of patients in mental health treatment settings were able to access any one of several evidence-based practices (Bruns et al., 2016 ). The profound shortage of affordable housing persists (Anacker, 2019 ).

Why do mental health centers not provide interventions that we know would help people avoid crises and reduce hospitalizations? The crux of the problem is that evidence-based practices require financing to support infrastructure, training of staff, and high-fidelity implementation to achieve the desired outcomes (Bond & Drake, 2020 ). Lack of public financing renders these components rare or impossible to achieve over time. Public and private health insurers in the U.S. generally define these interventions as “social services” and do not consider them “medically necessary,” even though they are arguably the most effective mental health interventions currently available (Drake & Wallach, 2020 ). Moreover, the organizations that save money when these evidence-based practices are available are emergency and inpatient departments of hospitals, not the community agencies that would provide the effective services. At the federal, state, and local levels, organizations rarely collaborate and share funding for psychosocial services; instead, they protect their budgets fiercely. Further, states are currently expecting cuts to Medicaid at a time of rapidly increasing need (Aron-Dine et al., 2020 ).

Meanwhile, excessive mental health dollars in the U.S. continue to go to the pharmaceutical industry for new medications. For example, spending on medications for mental illness increased from $2.8 billion in 1987 to $18 billion in 2001, even before the opioid epidemic (Frank et al., 2005 ). These increases have occurred despite evidence that the pharmaceutical industry’s promises of more effective medications have repeatedly failed (Harrington, 2019 ).

A Prevention Approach

Financing an expensive new crisis care system or many existing evidence-based practices may ignore the underlying causes of mental health crises. Although many mental health disorders have a biomedical substrate, crises are often due to social factors. People with mental health conditions enter crisis mode when they lose or fear losing their housing, jobs, relationships, or other important supports.

Current crisis care overlooks the long-standing, consistent, public health finding that prevention is generally more effective and less expensive than treatment. Just as clean water rather than medical treatments historically stopped cholera epidemics, we now need healthy nutrition to combat the obesity epidemic more than additional weight reduction programs, bariatric surgeries, diabetes medications, and heart surgeries. Similarly, we need more smoking prevention rather than more oxygen tanks, cancer treatments, and lung transplants for smoking-related illnesses. The same principle applies to mental health crises: prevention is always the best medicine.

Primary prevention can reduce the prevalence of mental illness. The literature on evidence-based prevention of mental health conditions, e.g., by providing perinatal maternal care, pre-school education, family supports, and numerous other interventions, is voluminous (Saxena et al., 2006 ). Although primary prevention may prevent mental health crises years into the future, secondary and tertiary preventions can reduce crises in current time. Early intervention for psychosis patients (secondary prevention) can ameliorate social deterioration and prevent hospitalizations (McGorry, 2015 ). Increasing access to affordable housing (Tsemberis et al., 2004 ) and supported employment (Drake et al., 2012 ) for those with established serious mental disorders (tertiary prevention) can also prevent crises and hospitalizations. Yet these services are rarely available in the U.S.A number of the evidence-based services identified earlier in this essay can prevent crises, institutional care, and the attendant traumas that characterize the crisis care system in the U.S. Yet we rarely provide these services. Instead, we spend enormous amounts on medications, hospitals, emergency services, and criminal justice system costs.

To avoid crises, people with mental health conditions need the same conditions that everyone needs: food security, safe housing, employment opportunities, health insurance, and social supports. In the U.S. these individuals languish in their homes, apartments, homelessness settings, hospitals, jails, and emergency rooms because they lack modest social supports and meaningful employment that would help them to avoid crises, relapses, and expensive service use. Most of these people want to work, have friends, and be self-sufficient; and when they are helped to develop meaningful activities and supports, they experience better health and fewer crises (Drake et al., 2012 ).

Even a modest effort to boost prevention services could avert many psychiatric crises and lead to better outcomes. Nevertheless, problems with the prevention approach are significant. The chief barrier is political. After numerous cycles of failure for more than a century, the U.S. continues to fund biomedical treatments advocated by industry and professional guilds rather than social services desired by patients (Drake & Wallach, 2020 ). Further, many politicians continue to assert that providing social safety net services will undermine motivation for employment, despite extensive economics research to the contrary (Banerjee & Duflo, 2019 ). The reality is that people who have food security and health care insurance are more able to work (Hall et al., 2018 ), and employment reduces crises. A second problem is the extreme fragmentation of federal agencies, programs, budgets, and goals. As just one example, providing supported employment to everyone with a mental illness who wants to work seems an obvious improvement to our mental health system because it is cost-effective and would have numerous positive outcomes, not least of which is reducing crises and hospitalizations (Bond et al., 2020 ; Drake & Wallach, 2020 ). But because no single entity pays for supported employment, providers must bill multiple sources and combine, or braid, funds—a difficult task for individual agencies. Meanwhile, the hospitals that save money when patients are employed do not support the mental health centers that provide the preventive services. Third, as income disparities become greater and greater in the U.S., government has not redistributed wealth by expanding basic supports to disadvantaged populations (Schaefer, 2020 ). Instead, psychiatric hospital advocates increasingly pressure states to provide more hospital beds (O’Reilly et al., 2019 ).

Discussion and Conclusions

The current mental health crisis system in the U.S. provides an expensive, non-evidence-based hodge-podge of services that are largely ineffective and often harmful. As an alternative, SAMHSA has proposed to expand the current system substantially by adding expensive new services—a national call-in system of triage, mobile crisis teams in every community, and regional crisis residential centers—interventions that for the most part are neither evidence-based nor funded. A second alternative would be to fund existing evidence-based practices that prevent hospitalizations. Services with strong scientific evidence do exist but are unavailable in most communities because they lack funding, infrastructure, and trained staff. A third alternative would be to address social determinants by following public health guidelines for prevention, which are largely ignored in the U.S. None of these alternatives—creating a new crisis care system, using evidence-based practices, or addressing social determinants for prevention—would be easy to implement. Vested interests, bureaucracies, resistance to change, and lack of funding will contravene efforts to reform the current system.

How should government policy makers decide what would be the most effective combination of strategies? We believe that health care and social service systems should follow several basic principles of science. Consilience requires that new approaches must be consistent with past evidence from all of science (Wilson, 1998 ). Parsimony means that policy makers should choose the simplest approach that fits the evidence (Sober, 2009 ). Hierarchy of evidence dictates the use rigorous evidence in a descending order: for example, meta-analyses are superior to single experiments, randomized controlled trials are better than studies with non-experimental comparison groups, observational studies provide weak evidence, and expert opinion is extremely weak and unreliable (Jenicek, 2019 ). Public health science proves that prevention helps more people more efficiently than treatments for illnesses (Goetzel, 2009 ). Incrementalism shows that stepwise changes in health care have been more successful than radical health care reforms (Goldman & Grob, 2006 ; Goldman & Morrissey, 2020 ).

Considering all of these principles leads to the conclusion that the U.S. should do whatever is possible to prevent mental health crises (consilience and public health), use the best available science (hierarchy of evidence), and make simple, straightforward changes (parsimony and incrementalism). We therefore recommend a combination of providing some of the known evidence-based practices that can alleviate crises, such as assertive community treatment; preventing crises proximally, for example, by providing psychoeducation and support to families and patients; and expanding some evidence-based social services that could prevent crises more distally, such as supported housing and supported employment. These proposed changes are realistic steps based on current science and current commitments, but they will require shifting away from the usual “more is less” direction of American health care.

Government leaders must resist the demands of vested interests to fund every new medication and polypharmacy, build more hospitals, and provide unproven medical systems of crisis care. These interventions will only layer additional, expensive, ineffective medical solutions to solve social problems. Policy makers should instead redirect funds to the fundamental, evidence-based, social supports that people need and want. People who have safe housing, a meaningful job, and regular contacts with peers, family, or a supportive care manager will experience fewer crises and need fewer hospitalizations.

Government should avoid paying for new medications, new medical services, and new systems of care until research demonstrates that these interventions are clearly more effective than what currently exists. Changes that seem obvious (for example, day treatment and promising new medications) are often instituted prematurely and turn out to be unhelpful or even harmful—that is the history of psychiatry (Harrington, 2019 ). Developing effective changes should proceed in scientific steps. Small observational studies should precede efficacy experiments, which should precede large effectiveness demonstrations, which should precede national policy changes. Moreover, government should pay for infrastructure and training before trying to implement complex interventions, should align provider incentives with desired outcomes of patients rather than those of vested interests, and should demand that data be used to monitor implementations and outcomes. Most important, the mental health system should shift emphasis to address basic social needs before additional medical interventions. Together, these strategies could convert our “more is less” crisis care and overall mental health system to a “less is more” system that would be simpler, less medically oriented, less expensive, and more effective.

Author Contributions

RED and GRB conceptualized and wrote this essay.

The authors received no funding to write this essay.

Declarations

The authors have no financial disclosures to declare.

This essay does not involve human subjects.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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‘It’s Life or Death’: The Mental Health Crisis Among U.S. Teens

Depression, self-harm and suicide are rising among American adolescents. For one 13-year-old, the despair was almost too much to take.

By Matt Richtel

Photographs by Annie Flanagan

Matt Richtel spent more than a year interviewing adolescents and their families for this series on the mental health crisis.

One evening last April, an anxious and free-spirited 13-year-old girl in suburban Minneapolis sprang furious from a chair in the living room and ran from the house — out a sliding door, across the patio, through the backyard and into the woods.

Moments earlier, the girl’s mother, Linda, had stolen a look at her daughter’s smartphone. The teenager, incensed by the intrusion, had grabbed the phone and fled. (The adolescent is being identified by an initial, M, and the parents by first name only, to protect the family’s privacy.)

Linda was alarmed by photos she had seen on the phone. Some showed blood on M’s ankles from intentional self-harm. Others were close-ups of M’s romantic obsession, the anime character Genocide Jack — a brunette girl with a long red tongue who, in a video series, kills high school classmates with scissors.

In the preceding two years, Linda had watched M spiral downward: severe depression, self-harm, a suicide attempt. Now, she followed M into the woods, frantic. “Please tell me where u r,” she texted. “I’m not mad.”

American adolescence is undergoing a drastic change. Three decades ago, the gravest public health threats to teenagers in the United States came from binge drinking, drunken driving, teenage pregnancy and smoking. These have since fallen sharply, replaced by a new public health concern: soaring rates of mental health disorders.

In 2019, 13 percent of adolescents reported having a major depressive episode , a 60 percent increase from 2007 . Emergency room visits by children and adolescents in that period also rose sharply for anxiety, mood disorders and self-harm. And for people ages 10 to 24, suicide rates, stable from 2000 to 2007, leaped nearly 60 percent by 2018, according to the Centers for Disease Control and Prevention.

Emergency room visits for self-harm by children and adolescents rose sharply over the last decade, particularly among young women.

600 E.R. visits

per 100,000

Emergency room visits

for self-inflicted injuries

Ages 10–19

Emergency room visits for self-harm by children and adolescents rose sharply over the last decade, particularly for young women.

room visits

for self-harm

Rates of smoking, drugs, alcohol and sex declined among high school students over the last decade, continuing trends that started over two decades ago.

One notable exception was a rise in excessive smartphone and computer use over the last decade.

Use a smartphone ,

tablet, computer or

game console at least

3 hours a day, not

including school work

Recently drank

Watch television

3 hours a day

Last sex was

unprotected

Get at least

8 hours of sleep

Feelings of sadness and hopelessness rose over the same decade, and suicidal thoughts increased.

Persistently felt

sad or hopeless

Made a suicide plan

Attempted suicide

Injured in a suicide

attempt and needed

medical treatment

Feelings of sadness and hopelessness rose, and suicidal thoughts increased.

How Matt Richtel spoke to adolescents and their parents for this series

In mid-April, I was speaking to the mother of a suicidal teenager whose struggles I’ve been closely following. I asked how her daughter was doing.

Not well, the mother said: “If we can’t find something drastic to help this kid, this kid will not be here long term.” She started to cry. “It’s out of our hands, it’s out of our control,” she said. “We’re trying everything.”

She added: “It’s like waiting for the end.”

Over nearly 18 months of reporting, I got to know many adolescents and their families and interviewed dozens of doctors, therapists and experts in the science of adolescence. I heard wrenching stories of pain and uncertainty. From the outset, my editors and I discussed how best to handle the identities of people in crisis.

The Times sets a high bar for granting sources anonymity; our stylebook calls it “a last resort” for situations where important information can’t be published any other way. Often, the sources might face a threat to their career or even their safety, whether from a vindictive boss or a hostile government.

In this case, the need for anonymity had a different imperative: to protect the privacy of young, vulnerable adolescents. They have harmed themselves and attempted suicide, and some have threatened to try again. In recounting their stories, we had to be mindful that our first duty was to their safety.

If The Times published the names of these adolescents, they could be easily identified years later. Would that harm their employment opportunities? Would a teen — a legal minor — later regret having exposed his or her identity during a period of pain and struggle? Would seeing the story published amplify ongoing crises?

As a result, some teenagers are identified by first initial only; some of their parents are identified by first name or initial. Over months, I got to know M, J and C, and in Kentucky, I came to know struggling adolescents I identified only by their ages, 12, 13 and 15. In some stories, we did not publish precisely where the families lived.

Everyone I interviewed gave their own consent, and parents were typically present for the interviews with their adolescents. On a few occasions, a parent offered to leave the room, or an adolescent asked for privacy and the parent agreed.

In these articles, I heard grief, confusion and a desperate search for answers. The voices of adolescents and their parents, while shielded by anonymity, deepen an understanding of this mental health crisis.

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This study aims to explore the perspectives of community leaders (CL) on trusted sources of health information, examine their roles, challenges, and needs in disseminating COVID-19 health information, and identify opportunities to improve public health reach and access for underserved communities. This qualitative study included seven focus groups conducted via online video conferencing from April-June 2021. The participants ( n  = 9) were CL recruited from the Texas C ommunity E ngagement Al liance (CEAL) for their experience working with underserved communities in Dallas, Texas. Data were coded deductively and analyzed thematically. The analysis resulted in three themes: (1) Information fatigue, mistrust, and desensitization were experienced by community members and leaders; (2) CL were expected to process, verify, and share accurate and timely COVID-19 health information; (3) CL identified potential strategies to improve COVID-19 health info access and reach. CLs were critical in addressing mis/disinformation and fostering trust in public health communication, particularly in underserved communities. They acted as vital intermediaries for health information, striving to debunk mis/disinformation and disseminate accurate health information. Public health strategies could benefit from prioritizing the integration of CL in communicating health information during crises and rebuilding trust within historically and racially marginalized and underserved communities. Supporting CLs, for example, through resources and training programs to counter misinformation and provide access to culturally and linguistically tailored health resources, may significantly enhance the access and reach of evidence-based health communication during health crises.

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Introduction.

Rapid and effective communication of clear, concise health information during adverse public health crises is important in protecting public health and safety (Desborough et al. 2021 ). The rapid dissemination of scientific advancements, health advisories, resources, and safety protocols can help the public make informed decisions, mitigate risk factors, and support those affected (Desborough et al. 2021 ). During the COVID-19 outbreak, governments worldwide implemented health and safety directives, while media outlets and social media were used to share health information and resources (Desborough et al. 2021 ).

Despite these widespread efforts, there were challenges in reaching and resonating with all population segments, particularly in medically underserved communities (Shearn and Krockow 2023 ). In this context, the role of Community Leaders (CL) in health information dissemination became pivotal because they were trusted within their communities. For instance, one study found that CL were uniquely positioned to understand local challenges and they played a central role in public health response during the COVID-19 pandemic, including serving as trusted sources of health information and communicating risk and harm reduction strategies (Michener 2020 ).

During adverse public health events, keeping up with the latest developments can be challenging, even for medical professionals and researchers (Dubé et al. 2022 ). The influx of data, with varied interpretations, can lead to confusion and conflicting messages (Dubé et al. 2022 ); (Wild et al. 2021 ). During the COVID-19 outbreak, mask mandates, lockdown policies and vaccine processes changed rapidly due to political pressures, logistical constraints and new research evidence (Lyu and Wehby 2020 ; Rains et al. 2022 ). To combat the disease outbreak different prevention and treatment strategies were implemented, but these were not always accurately or effectively communicated, especially to marginalized communities (e.g., rural, minority, low socioeconomic).

Furthermore, the rapid advancements in digital communication platforms (e.g., websites, social media) have resulted in an infodemic – an overabundance of information, some of which is false or misleading, especially during a disease outbreak, when there is a higher need for health information (Mheidly and Fares 2020 ; World Health Organization 2022 ). In 2014, less than 10% of people reported using traditional media (e.g., books, newspapers) to seek health information, whereas 10–15% used a healthcare professional, 10–15% talked to a friend or coworker, and greater than 45% used the internet (Jacobs et al. 2017 ). Internet use to find health information has also increased access to mis/disinformation (Jacobs et al. 2017 ). A systematic review found that the prevalence of social media posts with health misinformation was up to 87% and about 1 in every 2.5 social media posts about vaccines contained misinformation (Suarez-Lledo and Alvarez-Galvez 2021 ). Mis/disinformation results in distortion of scientific evidence, opinion polarization, decreasing credibility of circulating information, erosion of confidence in health initiatives and increasing mental and physical fatigue, all of which may lead to adverse health outcomes and economic consequences (Borges do Nascimento et al. 2022 ); (Clemente-Suárez et al. 2022 ). For instance, at the peak of the COVID-19 pandemic, misinformation significantly influenced public behavior including reduced acceptance of preventative measures like mask-wearing, social distancing and vaccine uptake, and in some cases the misinformation about the efficacy of certain medications led to their shortage for patients who needed them for other conditions (Romano et al. 2021 ). Thus, effective methods for disseminating accurate health information during public health crises are needed.

BIPOC (Black, Indigenous, and other People of Color) communities face significant healthcare access and reach disparities, including inadequate insurance coverage, language disparities, and lack of access to culturally competent healthcare providers, resulting in many seeking alternative avenues for health information outside of their healthcare providers (Fiscella et al. 2000 ; Nair and Adetayo 2019 ; National Academies of Sciences et al. 2017 ).

During the COVID-19 pandemic, leaders within different organizations played a critical role in disseminating health information and resources to communities. Many people (e.g., pharmacists, trained school administrators, military personnel) that would not typically administer vaccines to the public stepped up to increase capacity (Merks et al. 2021 ; Pillay 2020 ). These leaders became sources of health information. Thus, by understanding how community leaders obtained, communicated, and distributed COVID-19 health information, we can create more effective public health models to better reach and serve underserved communities. This study, therefore, aims to (1) uncover perspectives of community leaders on trusted sources of health information, (2) explore the practices, challenges, and needs of community leaders in disseminating COVID-19 health information, and (3) describe opportunities to improve public health communication, reach, and access for underserved communities.

Study design and setting

This qualitative study utilized semi-structured focus group discussions ( n  = 7) with community leaders ( n  = 9) from Dallas, TX, USA, from April–June 2021. A focus group (FG) guide (Supplementary Table 1 ) was developed to align with research questions, informed by literature (Higashi et al. 2021 ; Schoch-Spana et al. 2021 ). The FG domains centered around COVID-19, online sources of information, mis/disinformation, suggestions for adapting and disseminating information, and rationale for web content. An initial draft of the guide was produced as part of the ‘COVID Communications Resource Hub’ project—one of seven Texas C ommunity- E ngagement Al liance (CEAL) Consortium research projects aimed to enhance education, access, and inclusion of underserved communities in COVID-19 prevention and treatment efforts—and was reviewed by an expert (RASF) in community health interventions.

Participant recruitment and data collection

Participants were conveniently recruited from a COVID-19 community advisory board because of their vast experiences as leaders in underrepresented communities. Ten community leaders were invited to the study, but one dropped off for personal reasons. A series of seven FGs (6 + 1 make-up FG to cater for low turnout in one of the FGs) were conducted via video conferencing. The same community leaders were invited to each session. Two team members trained in qualitative methods conducted each FG. One was the lead moderator who facilitated discussions (MGS). The other (RASF) served as co-moderator who assisted in capturing a detailed account of the discussions. Participants completed a demographic questionnaire before the FGs, which were audio recorded, lasting 60–90 min each.

Data analysis

All FGs were transcribed verbatim and imported into NVivo (QSR Version 12). After reviewing the transcripts, researchers developed a deductive codebook based on the World Health Organization’s (WHO) Strategic Communications Framework for Effective Communications (World Health Organization 2023 ). LJR author initially coded all FG discussions using the deductive codebook and generated quote queries for each content area in the WHO framework. PG read all transcripts, reviewed the quote queries, and iteratively categorized the data using a thematic analysis approach. Once data were categorized, researchers further sought patterns and relationships to continue iteratively categorizing the data and generating initial themes. PG, ALMU, and JS met to discuss the emerging themes, identify key points, and guide additional data organization. Following the meeting, PG reviewed the data and finalized all themes. Finally, all researchers involved in data analysis (PG, LJR, JS, ALMU) and the rest of the research team reviewed and approved the final themes.

Participants were highly educated community leaders from diverse backgrounds (Table 1 ). The following themes emerged from the perspectives of the community leaders: (1) Both members of the community and their leaders experienced information fatigue, mistrust, and desensitization (2) Community leaders were expected to rapidly process and share accurate COVID-19 information (3) Community Leaders identified potential strategies to improve COVID-19 health information access and reach.

Theme 1: Both members of the community and their leaders experienced information fatigue, mistrust, and desensitization.

Community leaders received COVID-19 health information from multiple online sources, including local news stations, county websites, reputable community leaders (e.g., judges and mayors), and national sources like the Centers for Disease Control (CDC) and the World Health Organization (WHO). Information was also distributed through social media, emails, and within Black/African American fraternities, sororities, and faith-based organizations.

“I listened to the online version of the Dallas Morning News, and they have information about COVID-19. Again, I live in the Dallas suburbs , so there’s always information on the city’s website.”

“I followed the Dallas County judge and the Ellis City mayor for COVID-19 health information.”

“I go to my fraternity [meetings]…. Almost two or three times a week, local chapters have a workshop where you can share, ask questions, and receive information .”

Most community leaders expressed that during the COVID-19 pandemic, there was too much information from various sources, and it was often contradictory and unreliable. Several also mentioned seeing contradictory COVID-19 health information in the media, from reputable organizations, and recognizable individuals.

“There is a lot of information that is not helpful that contributes harm to the community, especially around some of the vaccine hesitancy that people may have.”

“You know, I was trying to avoid this, but immediately after we concluded our meeting last week, the [politician] released some ridiculous information about achieving herd immunity with 19% of the people being vaccinated, and he did it on TV, and as soon as he did it, people on Facebook took it and ran with it.”

Many community leaders shared that mis/disinformation and virus-related fraud schemes contributed to the mistrust of COVID-19 health information, while others shared that their communities were prone to distrust because of historical racial injustices.

“There are a lot of scams connected to registering for the vaccine. People are being asked for their Medicare number or to put down a deposit to get their second shot. Older adults who may be more vulnerable to the virus are more susceptible.”

“ The discussion among people who look like me [Black/African American] is, ‘Here we go again with the Tuskegee study.’ Even though this is something different, and it happened years ago, people still know about it. It’s still in their mind .”

Over time, community leaders and their communities felt desensitized to health information. For example, one participant stated, “ It just feels like a waste of energy to try to fight it sometimes, but what happens if I don’t say something ? ” For community leaders, desensitization to information became a barrier to disseminating up-to-date information to community members.

Theme 2: Community leaders were expected to rapidly process and share accurate COVID-19 information in professional and personal settings.

Community leaders were trusted by their communities to supply or verify accurate health information. They needed to filter through COVID-19 information sources and rapidly disseminate to their communities. This happened in their professional roles and informal settings such as barbershops, Facebook groups, and churches. One participant shared that he provided COVID-19 information to his friends: “I have friends that contact me, especially the guys at the barbershop who tell me COVID-19 information they’ve seen on Facebook. They give me an opportunity to talk to them and convince them since they see me all the time and trust me.”

Some community leaders described their roles as pseudo-experts who, despite not being trained, had been put in a position of authority to offer guidance and solutions to their communities on COVID-19 health information. Several community leaders mentioned feeling overwhelmed and ill-equipped to continually provide accurate COVID-19 health information.

“Being a nurse, I have learned that throughout the years, instead of people calling their doctors, they will call, email, or text me because they trust what I say or my opinions or directions. Since I’ve been a nurse in this town, they recognize me and know how I work; that kind of history is important. So, when they see an update or a story, they tag me on it, and I try to read it, but I think a lot of it is misinformation, so I try to give them my opinion.”

“I do not work for money, and I am not an authority, but I get bombarded with emails and Facebook messages. So, I am considered a go-to person, and l share my experiences with others. I will even do research to help them.”

“It’s a battle that’s hard for many of us who are thrust into being pseudo-experts in a pandemic.”

Community leaders used multiple strategies to avoid spreading misinformation and to disseminate accurate COVID-19 health information. For instance, they relied primarily on local sources of health information, such as county-run websites, and national and internationally reputable sources, such as the CDC and the WHO.

“I get tweets from the Dallas County Public Health Department, and I know the CDC and WHO also have Twitter accounts, where they repetitively put out tweets on coping with COVID-19. I find those to be incredibly helpful.”

However, many community leaders also stated that all sources of information, including information from trusted local and federal organizations, needed to be scrutinized, as they sometimes provided incorrect information. Some also carefully reviewed potential sources of bias among organizations, such as the organization’s funding sources. Most community leaders viewed government and non-profit organizations as less likely to have conflicts of interest than privately-owned organizations.

The community leaders repeatedly expressed that combating misinformation and preserving community trust was exhaustive and often overwhelming. Many believed that proactively building and sustaining trust with the community was the most effective way to fight COVID-19 mis/disinformation. “We want to ensure that we continue to give good and credible information and continue to be a trusted source for the community.”

Theme 3: Community leaders identified potential strategies to improve COVID-19 health information access and reach.

Community leaders proposed various methods to reach people with credible health information, such as using flyers, home visits, radios, schools, churches, videos, and messages on public transit and encouraging people to share with family and friends. They also suggested using social media as the best way to reach many people, plus faith-based organizations and senior centers for those with little to no access to technology.

“I also try to send stuff to my young adult daughters, and I encourage them to share it with their friends.”

“We had a vaccine drive and a huge number of people canceled. So, we put it on social media, and so many people were available. We were packed within the hour.”

“Something helpful for folks who don’t have access to information is working with faith-based communities, senior centers, and other organizations in the community that work with older adults.”

Although many suggestions were aimed at improving health information reach, there was also a recognized need to improve access to COVID-19 health information by tailoring it to specific communities. Several community leaders mentioned it would be helpful if they received information that was already packaged and ready to be disseminated to facilitate quick and prompt sharing. One participant stated, “One of my priorities is looking for a website that has things I can share easily.”

To facilitate easy dissemination of COVID-19 health information, they desired information and materials already translated into different languages and were culturally appropriate for diverse racial and ethnic groups. Another participant shared, “It helps if it’s translated already into Spanish, as that’s a huge thing for us.” In emphasizing the importance of culturally relevant information, another participant stated, “ There is a need to go beyond translation. It’s not just that it is language-appropriate translation but that it is also culturally relevant. It should be respectful, not condescending, and the material, including the pictures, should represent the people you’re trying to reach.”

Community leaders also expressed that written materials should be adapted to ensure readability for people with lower literacy levels. For example, one participant described the importance of information being at the appropriate reading level: “ To our population, we look for things that are not too high level, so something that everybody can read, and everybody can easily understand.”

The community leaders disclosed that the communities’ reliance on them to provide accurate and trusted information would have been easier if the COVID-19 health information had been tailored to specific audiences and packaged in a format that could easily be shared on social media (e.g., an infographic). They also suggested leveraging recognizable, relatable, and trusted community leaders and organizations to build credibility in disseminating COVID-19 health information.

To address having too many competing sources of information, they suggested having a “one-stop shop,” such as a comprehensive website where all qualified health providers and community leaders could obtain accurate COVID-19 health information. As one participant suggested, “I think what we are missing is something universal where people can just see all the information in one place. Something like your website and resource hub.” This resource would ensure that all parties involved with health dissemination have consistent information to build and retain community trust.

Information mistrust was common during the COVID-19 pandemic, especially among BIPOC communities who bore a disproportionate burden of COVID-19 health consequences (Ojikutu et al. 2022 ). Community leaders in this study reported that the need to provide accurate and timely information was high and compounded with a lot of mis/disinformation. Multiple studies show that COVID-19 mis/disinformation often led to mistrust, reduced acceptance of preventative measures, and contributed to vaccine hesitancy (Ojikutu et al. 2022 ). The spread of online mis/disinformation was pervasive during the COVID-19 pandemic, exacerbating this ongoing public health issue, particularly regarding vaccine hesitancy (S. K. Lee et al. 2022 ). However, mis/disinformation negatively influencing disease prevention measures like vaccine uptake is not just for COVID-19, but for other infectious diseases and immunizations efforts (S. K. Lee et al. 2022 ). These study’s findings may apply to other public health issues affected by mis/disinformation.

In this study’s context, the role of CL became increasingly critical. As trusted figures, they were placed in the unique position of debunking misinformation and validating official public health communication. This role was driven by community trust and the urgent need for credible information. The CL expressed a keen awareness of their responsibility in influencing public opinion and behavior, driven primarily by the motivation to provide their communities with the most accurate and helpful information possible. This intention was particularly evident in their proactive strategies to consult reputable sources, combat misinformation, and tailor messages to meet their communities’ needs. However, despite these commendable efforts, the reliance on CLs for information dissemination also highlights a significant vulnerability in the public health system, especially in reaching individuals with low trust. The potential risks associated with this informal dissemination method are noteworthy, particularly the spread of misinformation by well-intentioned individuals who may inadvertently lack accurate information or the skills to debunk mis/disinformation. This concern is also raised by Ecker et al. ( 2022 ) who notes that misinformation can proliferate even in well-meaning networks, leading to public health challenges. Public health authorities may engage more actively with community leaders to mitigate these risks. Such collaboration would empower CLs with the right tools and information and enhance the overall effectiveness of public health campaigns.

The CL highlighted the influence of race on health information-seeking behavior. Drawing on historical injustices, like the Tuskegee experiments, and the tendency of people to trust members of one’s racial group, the community leaders highlighted how their communities expressed doubt and wariness towards traditional healthcare providers. This mistrust is not an isolated sentiment but a reflection of a broader pattern of skepticism that arises from systemic racial discrimination in healthcare (Jaiswal 2019 ). This finding is corroborated by a poll that found that 63% of Black and 45% of Hispanic adults report they have experienced serious incidents of discrimination in their lifetime, and 17% and 14%, respectively, indicating they experienced this discrimination while getting health care for themselves or a family member (Hamel et al. 2020 ). The mention of Tuskegee experiments and distrust in healthcare systems underscore the critical importance of understanding the historical context when addressing health information-seeking behaviors in different racial groups. Prior research has demonstrated that trust in health information sources varies by racial group. For instance, Black and Hispanic individuals have persistently lower rates of health information-seeking behavior when compared to white individuals (Fareed et al. 2021 ). However, Black and Hispanic populations have higher rates of trust in diverse sources of health information, including family, friends, and charitable organizations, as opposed to healthcare providers and internet health information sources (Fareed et al. 2021 ). Our findings add to the evidence of racial differences in health information-seeking behavior and the need for continued efforts to diversify approaches to disseminating health information. It also suggests that health institutions at local, state and national levels need to rebuild trust in communities affected by historical injustices. Additional focus should be on developing strategies for dismantling misinformation while being sensitive to the historical context of racial discrimination in healthcare.

Community leaders in this study had a health background (e.g., nursing); however, others did not, and most were not trained to interpret COVID-19 health information or play a role in debunking mis/disinformation. Despite this, they played an undeniable role as trusted information conduits in their communities, and their perceived authority and trustworthiness were especially crucial given the widespread mistrust in national entities and official channels for public health communication. This often led them to be approached by others, making them pivotal in communicating COVID-19 health information. Still, the community leaders in this study were highly educated and vehement about not wanting to spread COVID-19 misinformation. To circumvent the mis/disinformation, community leaders relied on trusted and reputable sources of health information; some even assessed potential sources of biases among these information sources. However, it remains unclear if the community leaders could debunk mis/disinformation and accurately interpret or translate COVID-19 health information. This underscores the need to provide these community leaders with appropriate resources and training to enhance their capacity to disseminate accurate health information. Furthermore, while CL have shown diligence in trying to circumvent mis/disinformation, there is an evident need for further research to understand their specific methods of discerning credible health information. Previous research has found that community leaders can be trained to provide accurate and reliable health promotion information (e.g., colorectal cancer, physical activity, nutrition) (Cole et al. 2017 ; Wilcox et al. 2013 ). Thus, replicating existing models may be needed for other health outcomes, including a model for health crises like the COVID-19 pandemic.

Another critical issue raised by community leaders was the overload of COVID-19 health information that they and their community members experienced, which contributed to information fatigue and desensitization. The community leaders felt burdened and fatigued with synthesizing and disseminating health information to their local communities. Indeed, other studies have similar findings regarding COVID-19 information fatigue and desensitization (Seale et al. 2022 ). Information overload is a critical concern because it can lead individuals to ignore all information, including guidance from health experts or authoritative sources (C.-J. Lee et al. 2018 ). Additionally, information overload can lead to anxiety, stress, delaying decision-making, and lack of critical evaluation of the information, potentially leading to delaying protective health behaviors or adopting unfounded or dangerous behaviors (Clark et al. 2019 ; C.-J. Lee et al. 2018 ; Nagler 2014 ; Parra-Medina and Álvarez-Cervera 2021 ). The relentless influx of information, coupled with the daunting task of countering misinformation, especially in a public health crisis, can lead to a sense of futility and exhaustion (Stevens et al. 2021 ). Therefore, it is imperative to equip community leaders with comprehensive support mechanisms that bolster their capacity to remain steadfast and effective in their roles. This support should encompass access to accurate and timely information and resources such as resilience training programs, peer support networks, and access to mental health resources.

Another strategy that community leaders suggested would help deal with information overload and mis/disinformation was having a single source of accurate, timely, and culturally appropriate COVID-19 health information. This approach could help streamline the flow of information, reducing the burden on community leaders and enhancing the effectiveness of their communication efforts. It is important to note the community leaders reviewed the Texas CEAL COVID-19 Information and Resource Hub website, which was developed as a tool for finding and relaying trustworthy information and materials on COVID-19.

In addition to having a single source of COVID-19 health information, community leaders shared many other strategies for increasing access and reach of COVID-19-related information based on their experience working with local communities. For instance, they suggested using multiple communication mediums (e.g., radio, schools, churches), encouraging community members to share trusted information with family and friends, and translating information into multiple languages. These strategies are also supported by research that demonstrates that using various mediums of communication can improve reach and timeliness, as individuals may prefer or have access to particular mediums (Ingram and Reed 2016 ). Word-of-mouth is a powerful communication tool that previous research demonstrates to effectively increase health information reach (Bradford et al. 2017 ). Translation of health information into multiple languages—by native speakers and performing a back translation—are effective strategies included in the WHO Strategic Communications Framework to increase the understandability of information (World Health Organization 2023 ). Although these strategies are critical for health communication, there continues to be a lack of consistency and rigor in applying them in practice, an area of study that deserves further investigation (Tan and Cho 2019 ).

Strengths and limitations

The community leaders were highly educated and diverse in age, race, and sex and they were well-informed and could provide multiple perspectives. Future studies should include a broader range of educational backgrounds, such as those without college degrees, to ensure a more comprehensive representation of community leaders. The sample size of this study was small; however, the study’s qualitative nature and ample time with community leaders (7–10.5 h each) allowed for the exploration of rich and in-depth perspectives. The researchers’ distinct backgrounds and experiential differences compared to the participants could have impacted the analysis but were mitigated through researchers’ reflection on potential biases throughout the analysis process. In some cases, the perspectives of community leaders may not have been representative of the individuals or communities they interact with or serve.

Public health implications

This study underscores the critical role of CL in public health communication, especially during health crises like the COVID-19 pandemic. Their unique position of trust within communities highlights the need for targeted public health strategies that leverage their influence. For instance, with the evolving challenges of the COVID-19 pandemic, such as the emergence of new COVID-19 variants and discussions around the need for booster shots, CLs can serve as essential channels for evidence-based public health communication. Their engagement may be instrumental in helping communities understand and adapt to ongoing preventative measures.

To address the pervasive issue of misinformation, which has been shown to exacerbate health crises and contribute to resistance to public health measures, it is imperative to equip CL with the tools and resources necessary for effective communication. This may include training programs that enhance their ability to discern and counteract misinformation, as well as providing them with ready-to-disseminate, culturally appropriate resources suitable for different health literacy levels and strengthening their resilience in navigating public health challenges. Furthermore, policy implications arise from the need to create interventions designed to rebuild trust in public health systems, particularly in communities with a history of healthcare discrimination. Incorporating CL in these efforts may be strategic in creating more effective community-centric public health interventions. For practitioners, there may be a need to diversify the approaches used in disseminating health information to improve the reach and effectiveness of evidence-based health messages.

Data availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request.

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Acknowledgements

The authors would like to acknowledge the community leaders who participated in the study. Without their willingness to share their valuable insights, this work would not be possible. This research was made possible by a grant from the National Institutes of Health (NIH) and the National Heart, Lung, and Blood Institute (NHLBI). The University of North Texas Health Science Center and Texas A&M AgriLife Research received the primary award for this project. All opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the views of these institutions.

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Phrashiah Githinji

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Alexandra L. MacMillan Uribe, Jacob Szeszulski, Chad D. Rethorst, Vi Luong & Lucy Xin

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RASF conceptualized and designed this qualitative research study. RASF, VL, MGS, and LX collected data. PG, ALMU, JS, LJR, and CDR analyzed and interpreted the results. PG, ALMU, and JS drafted the manuscript, and the rest reviewed and validated the themes. All authors contributed to revising the manuscript and gave substantive feedback. All authors read and agreed to the published version of the manuscript.

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Githinji, P., MacMillan Uribe, A.L., Szeszulski, J. et al. Public health communication during the COVID-19 health crisis: sustainable pathways to improve health information access and reach among underserved communities. Humanit Soc Sci Commun 11 , 1218 (2024). https://doi.org/10.1057/s41599-024-03718-7

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8 Overcoming Challenges College Essay Examples

The purpose of the Overcoming Challenges essay is for schools to see how you might handle the difficulties of college. They want to know how you grow, evolve, and learn when you face adversity. For this topic, there are many clichés , such as getting a bad grade or losing a sports game, so be sure to steer clear of those and focus on a topic that’s unique to you. (See our full guide on the Overcoming Challenges Essay for more tips).

These overcoming challenges essay examples were all written by real students. Read through them to get a sense of what makes a strong essay. At the end, we’ll present the revision process for the first essay and share some resources for improving your essay.

Please note: Looking at examples of real essays students have submitted to colleges can be very beneficial to get inspiration for your essays. You should never copy or plagiarize from these examples when writing your own essays. Colleges can tell when an essay isn’t genuine and will not view students favorably if they plagiarized. 

Essay 1: Becoming a Coach

“Advanced females ages 13 to 14 please proceed to staging with your coaches at this time.” Skittering around the room, eyes wide and pleading, I frantically explained my situation to nearby coaches. The seconds ticked away in my head; every polite refusal increased my desperation.

Despair weighed me down. I sank to my knees as a stream of competitors, coaches, and officials flowed around me. My dojang had no coach, and the tournament rules prohibited me from competing without one.

Although I wanted to remain strong, doubts began to cloud my mind. I could not help wondering: what was the point of perfecting my skills if I would never even compete? The other members of my team, who had found coaches minutes earlier, attempted to comfort me, but I barely heard their words. They couldn’t understand my despair at being left on the outside, and I never wanted them to understand.

Since my first lesson 12 years ago, the members of my dojang have become family. I have watched them grow up, finding my own happiness in theirs. Together, we have honed our kicks, blocks, and strikes. We have pushed one another to aim higher and become better martial artists. Although my dojang had searched for a reliable coach for years, we had not found one. When we attended competitions in the past, my teammates and I had always gotten lucky and found a sympathetic coach. Now, I knew this practice was unsustainable. It would devastate me to see the other members of my dojang in my situation, unable to compete and losing hope as a result. My dojang needed a coach, and I decided it was up to me to find one.

I first approached the adults in the dojang – both instructors and members’ parents. However, these attempts only reacquainted me with polite refusals. Everyone I asked told me they couldn’t devote multiple weekends per year to competitions. I soon realized that I would have become the coach myself.

At first, the inner workings of tournaments were a mystery to me. To prepare myself for success as a coach, I spent the next year as an official and took coaching classes on the side. I learned everything from motivational strategies to technical, behind-the-scenes components of Taekwondo competitions. Though I emerged with new knowledge and confidence in my capabilities, others did not share this faith.

Parents threw me disbelieving looks when they learned that their children’s coach was only a child herself. My self-confidence was my armor, deflecting their surly glances. Every armor is penetrable, however, and as the relentless barrage of doubts pounded my resilience, it began to wear down. I grew unsure of my own abilities.

Despite the attack, I refused to give up. When I saw the shining eyes of the youngest students preparing for their first competition, I knew I couldn’t let them down. To quit would be to set them up to be barred from competing like I was. The knowledge that I could solve my dojang’s longtime problem motivated me to overcome my apprehension.

Now that my dojang flourishes at competitions, the attacks on me have weakened, but not ended. I may never win the approval of every parent; at times, I am still tormented by doubts, but I find solace in the fact that members of my dojang now only worry about competing to the best of their abilities.

Now, as I arrive at a tournament with my students, I close my eyes and remember the past. I visualize the frantic search for a coach and the chaos amongst my teammates as we competed with one another to find coaches before the staging calls for our respective divisions. I open my eyes to the exact opposite scene. Lacking a coach hurt my ability to compete, but I am proud to know that no member of my dojang will have to face that problem again.

This essay begins with an in-the-moment narrative that really illustrates the chaos of looking for a coach last-minute. We feel the writer’s emotions, particularly their dejectedness, at not being able to compete.

Through this essay, we can see how gutsy and determined the student is in deciding to become a coach themselves. The writer shows us these characteristics through their actions, rather than explicitly telling us: To prepare myself for success as a coach, I spent the next year as an official and took coaching classes on the side.

One area of improvement of this essay would be the “attack” wording. The author likely uses this word as a metaphor for martial arts, but it feels too strong to describe the adults’ doubt of the student’s abilities as a coach, and can even be confusing at first.

Still, we see the student’s resilience as they are able to move past the disbelieving looks to help their team. The essay is kept real and vulnerable, however, as the writer admits having doubts: Every armor is penetrable, however, and as the relentless barrage of doubts pounded my resilience, it began to wear down. I grew unsure of my own abilities.

The essay comes full circle as the author recalls the frantic situations in seeking out a coach, but this is no longer a concern for them and their team. Overall, this essay is extremely effective in painting this student as mature, bold, and compassionate.

Essay 2: Starting a Fire

Was I no longer the beloved daughter of nature, whisperer of trees? Knee-high rubber boots, camouflage, bug spray—I wore the garb and perfume of a proud wild woman, yet there I was, hunched over the pathetic pile of stubborn sticks, utterly stumped, on the verge of tears. As a child, I had considered myself a kind of rustic princess, a cradler of spiders and centipedes, who was serenaded by mourning doves and chickadees, who could glide through tick-infested meadows and emerge Lyme-free. I knew the cracks of the earth like the scars on my own rough palms. Yet here I was, ten years later, incapable of performing the most fundamental outdoor task: I could not, for the life of me, start a fire. 

Furiously I rubbed the twigs together—rubbed and rubbed until shreds of skin flaked from my fingers. No smoke. The twigs were too young, too sticky-green; I tossed them away with a shower of curses, and began tearing through the underbrush in search of a more flammable collection. My efforts were fruitless. Livid, I bit a rejected twig, determined to prove that the forest had spurned me, offering only young, wet bones that would never burn. But the wood cracked like carrots between my teeth—old, brittle, and bitter. Roaring and nursing my aching palms, I retreated to the tent, where I sulked and awaited the jeers of my family. 

Rattling their empty worm cans and reeking of fat fish, my brother and cousins swaggered into the campsite. Immediately, they noticed the minor stick massacre by the fire pit and called to me, their deep voices already sharp with contempt. 

“Where’s the fire, Princess Clara?” they taunted. “Having some trouble?” They prodded me with the ends of the chewed branches and, with a few effortless scrapes of wood on rock, sparked a red and roaring flame. My face burned long after I left the fire pit. The camp stank of salmon and shame. 

In the tent, I pondered my failure. Was I so dainty? Was I that incapable? I thought of my hands, how calloused and capable they had been, how tender and smooth they had become. It had been years since I’d kneaded mud between my fingers; instead of scaling a white pine, I’d practiced scales on my piano, my hands softening into those of a musician—fleshy and sensitive. And I’d gotten glasses, having grown horrifically nearsighted; long nights of dim lighting and thick books had done this. I couldn’t remember the last time I had lain down on a hill, barefaced, and seen the stars without having to squint. Crawling along the edge of the tent, a spider confirmed my transformation—he disgusted me, and I felt an overwhelming urge to squash him. 

Yet, I realized I hadn’t really changed—I had only shifted perspective. I still eagerly explored new worlds, but through poems and prose rather than pastures and puddles. I’d grown to prefer the boom of a bass over that of a bullfrog, learned to coax a different kind of fire from wood, having developed a burn for writing rhymes and scrawling hypotheses. 

That night, I stayed up late with my journal and wrote about the spider I had decided not to kill. I had tolerated him just barely, only shrieking when he jumped—it helped to watch him decorate the corners of the tent with his delicate webs, knowing that he couldn’t start fires, either. When the night grew cold and the embers died, my words still smoked—my hands burned from all that scrawling—and even when I fell asleep, the ideas kept sparking—I was on fire, always on fire.

This essay is an excellent example because the writer turns an everyday challenge—starting a fire—into an exploration of her identity. The writer was once “a kind of rustic princess, a cradler of spiders and centipedes,” but has since traded her love of the outdoors for a love of music, writing, and reading. 

The story begins in media res , or in the middle of the action, allowing readers to feel as if we’re there with the writer. One of the essay’s biggest strengths is its use of imagery. We can easily visualize the writer’s childhood and the present day. For instance, she states that she “rubbed and rubbed [the twigs] until shreds of skin flaked from my fingers.”

The writing has an extremely literary quality, particularly with its wordplay. The writer reappropriates words and meanings, and even appeals to the senses: “My face burned long after I left the fire pit. The camp stank of salmon and shame.” She later uses a parallelism to cleverly juxtapose her changed interests: “instead of scaling a white pine, I’d practiced scales on my piano.”

One of the essay’s main areas of improvement is its overemphasis on the “story” and lack of emphasis on the reflection. The second to last paragraph about changing perspective is crucial to the essay, as it ties the anecdote to larger lessons in the writer’s life. She states that she hasn’t changed, but has only shifted perspective. Yet, we don’t get a good sense of where this realization comes from and how it impacts her life going forward. 

The end of the essay offers a satisfying return to the fire imagery, and highlights the writer’s passion—the one thing that has remained constant in her life.

Essay 3: Last-Minute Switch

The morning of the Model United Nation conference, I walked into Committee feeling confident about my research. We were simulating the Nuremberg Trials – a series of post-World War II proceedings for war crimes – and my portfolio was of the Soviet Judge Major General Iona Nikitchenko. Until that day, the infamous Nazi regime had only been a chapter in my history textbook; however, the conference’s unveiling of each defendant’s crimes brought those horrors to life. The previous night, I had organized my research, proofread my position paper and gone over Judge Nikitchenko’s pertinent statements. I aimed to find the perfect balance between his stance and my own.

As I walked into committee anticipating a battle of wits, my director abruptly called out to me. “I’m afraid we’ve received a late confirmation from another delegate who will be representing Judge Nikitchenko. You, on the other hand, are now the defense attorney, Otto Stahmer.” Everyone around me buzzed around the room in excitement, coordinating with their allies and developing strategies against their enemies, oblivious to the bomb that had just dropped on me. I felt frozen in my tracks, and it seemed that only rage against the careless delegate who had confirmed her presence so late could pull me out of my trance. After having spent a month painstakingly crafting my verdicts and gathering evidence against the Nazis, I now needed to reverse my stance only three hours before the first session.

Gradually, anger gave way to utter panic. My research was fundamental to my performance, and without it, I knew I could add little to the Trials. But confident in my ability, my director optimistically recommended constructing an impromptu defense. Nervously, I began my research anew. Despite feeling hopeless, as I read through the prosecution’s arguments, I uncovered substantial loopholes. I noticed a lack of conclusive evidence against the defendants and certain inconsistencies in testimonies. My discovery energized me, inspiring me to revisit the historical overview in my conference “Background Guide” and to search the web for other relevant articles. Some Nazi prisoners had been treated as “guilty” before their court dates. While I had brushed this information under the carpet while developing my position as a judge, i t now became the focus of my defense. I began scratching out a new argument, centered on the premise that the allied countries had violated the fundamental rule that, a defendant was “not guilty” until proven otherwise.

At the end of the three hours, I felt better prepared. The first session began, and with bravado, I raised my placard to speak. Microphone in hand, I turned to face my audience. “Greetings delegates. I, Otto Stahmer would like to…….” I suddenly blanked. Utter dread permeated my body as I tried to recall my thoughts in vain. “Defence Attorney, Stahmer we’ll come back to you,” my Committee Director broke the silence as I tottered back to my seat, flushed with embarrassment. Despite my shame, I was undeterred. I needed to vindicate my director’s faith in me. I pulled out my notes, refocused, and began outlining my arguments in a more clear and direct manner. Thereafter, I spoke articulately, confidently putting forth my points. I was overjoyed when Secretariat members congratulated me on my fine performance.

Going into the conference, I believed that preparation was the key to success. I wouldn’t say I disagree with that statement now, but I believe adaptability is equally important. My ability to problem-solve in the face of an unforeseen challenge proved advantageous in the art of diplomacy. Not only did this experience transform me into a confident and eloquent delegate at that conference, but it also helped me become a more flexible and creative thinker in a variety of other capacities. Now that I know I can adapt under pressure, I look forward to engaging in activities that will push me to be even quicker on my feet.

This essay is an excellent example because it focuses on a unique challenge and is highly engaging. The writer details their experience reversing their stance in a Model UN trial with only a few hours notice, after having researched and prepared to argue the opposite perspective for a month. 

Their essay is written in media res , or in the middle of the action, allowing readers to feel as if we’re there with the writer. The student openly shares their internal thoughts with us — we feel their anger and panic upon the reversal of roles. We empathize with their emotions of “utter dread” and embarrassment when they’re unable to speak. 

From the essay, we learn that the student believes in thorough preparation, but can also adapt to unforeseen obstacles. They’re able to rise to the challenge and put together an impromptu argument, think critically under pressure, and recover after their initial inability to speak. 

Essay 4: Music as a Coping Mechanism

CW: This essay mentions self-harm.

Sobbing uncontrollably, I parked around the corner from my best friend’s house. As I sat in the driver’s seat, I whispered the most earnest prayer I had ever offered.

Minutes before, I had driven to Colin’s house to pick up a prop for our upcoming spring musical. When I got there, his older brother, Tom, came to the door and informed me that no one else was home. “No,” I corrected, “Colin is here. He’s got a migraine.” Tom shook his head and gently told me where Colin actually was: the psychiatric unit of the local hospital. I felt a weight on my chest as I connected the dots; the terrifying picture rocked my safe little world. Tom’s words blurred as he explained Colin’s self-harm, but all I could think of was whether I could have stopped him. Those cuts on his arms had never been accidents. Colin had lied, very convincingly, many times. How could I have ignored the signs in front of me? Somehow, I managed to ask Tom whether I could see him, but he told me that visiting hours for non-family members were over for the day. I would have to move on with my afternoon.

Once my tears had subsided a little, I drove to the theater, trying to pull myself together and warm up to sing. How would I rehearse? I couldn’t sing three notes without bursting into tears. “I can’t do this,” I thought. But then I realized that the question wasn’t whether I could do it. I knew Colin would want me to push through, and something deep inside told me that music was the best way for me to process my grief. I needed to sing.

I practiced the lyrics throughout my whole drive. The first few times, I broke down in sobs. By the time I reached the theater, however, the music had calmed me. While Colin would never be far from my mind, I had to focus on the task ahead: recording vocals and then producing the video trailer that would be shown to my high school classmates. I fought to channel my worry into my recording. If my voice shook during the particularly heartfelt moments, it only added emotion and depth to my performance. I felt Colin’s absence next to me, but even before I listened to that first take, I knew it was a keeper.

With one of my hurdles behind me, I steeled myself again and prepared for the musical’s trailer. In a floor-length black cape and purple dress, I swept regally down the steps to my director, who waited outside. Under a gloomy sky that threatened to turn stormy, I boldly strode across the street, tossed a dainty yellow bouquet, and flashed confident grins at all those staring. My grief lurched inside, but I felt powerful. Despite my sadness, I could still make art.

To my own surprise, I successfully took back the day. I had felt pain, but I had not let it drown me – making music was a productive way to express my feelings than worrying. Since then, I have been learning to take better care of myself in difficult situations. That day before rehearsal, I found myself in the most troubling circumstances of my life thus far, but they did not sink me because I refused to sink. When my aunt developed cancer several months later, I knew that resolution would not come quickly, but that I could rely on music to cope with the agony, even when it would be easier to fall apart. Thankfully, Colin recovered from his injuries and was home within days. The next week, we stood together on stage at our show’s opening night. As our eyes met and our voices joined in song, I knew that music would always be our greatest mechanism for transforming pain into strength.

This essay is well-written, as we can feel the writer’s emotions through the thoughts they share, and visualize the night of the performance through their rich descriptions. Their varied sentence length also makes the essay more engaging.

That said, this essay is not a great example because of the framing of the topic. The writer can come off as insensitive since they make their friend’s struggle about themself and their emotions (and this is only worsened by the mention of their aunt’s cancer and how it was tough on them ). The essay would’ve been stronger if it focused on their guilt of not recognizing their friend’s struggles and spanned a longer period of time to demonstrate gradual relationship building and reflection. Still, this would’ve been difficult to do well.

In general, you should try to choose a challenge that is undeniably your own, and you should get at least one or two people to read your essay to give you candid feedback.

Essay 5: Dedicating a Track

“Getting beat is one thing – it’s part of competing – but I want no part in losing.” Coach Rob Stark’s motto never fails to remind me of his encouragement on early-morning bus rides to track meets around the state. I’ve always appreciated the phrase, but an experience last June helped me understand its more profound, universal meaning.

Stark, as we affectionately call him, has coached track at my high school for 25 years. His care, dedication, and emphasis on developing good character has left an enduring impact on me and hundreds of other students. Not only did he help me discover my talent and love for running, but he also taught me the importance of commitment and discipline and to approach every endeavor with the passion and intensity that I bring to running. When I learned a neighboring high school had dedicated their track to a longtime coach, I felt that Stark deserved similar honors.

Our school district’s board of education indicated they would only dedicate our track to Stark if I could demonstrate that he was extraordinary. I took charge and mobilized my teammates to distribute petitions, reach out to alumni, and compile statistics on the many team and individual champions Stark had coached over the years. We received astounding support, collecting almost 3,000 signatures and pages of endorsements from across the community. With help from my teammates, I presented this evidence to the board.

They didn’t bite. 

Most members argued that dedicating the track was a low priority. Knowing that we had to act quickly to convince them of its importance, I called a team meeting where we drafted a rebuttal for the next board meeting. To my surprise, they chose me to deliver it. I was far from the best public speaker in the group, and I felt nervous about going before the unsympathetic board again. However, at that second meeting, I discovered that I enjoy articulating and arguing for something that I’m passionate about.

Public speaking resembles a cross country race. Walking to the starting line, you have to trust your training and quell your last minute doubts. When the gun fires, you can’t think too hard about anything; your performance has to be instinctual, natural, even relaxed. At the next board meeting, the podium was my starting line. As I walked up to it, familiar butterflies fluttered in my stomach. Instead of the track stretching out in front of me, I faced the vast audience of teachers, board members, and my teammates. I felt my adrenaline build, and reassured myself: I’ve put in the work, my argument is powerful and sound. As the board president told me to introduce myself, I heard, “runners set” in the back of my mind. She finished speaking, and Bang! The brief silence was the gunshot for me to begin. 

The next few minutes blurred together, but when the dust settled, I knew from the board members’ expressions and the audience’s thunderous approval that I had run quite a race. Unfortunately, it wasn’t enough; the board voted down our proposal. I was disappointed, but proud of myself, my team, and our collaboration off the track. We stood up for a cause we believed in, and I overcame my worries about being a leader. Although I discovered that changing the status quo through an elected body can be a painstakingly difficult process and requires perseverance, I learned that I enjoy the challenges this effort offers. Last month, one of the school board members joked that I had become a “regular” – I now often show up to meetings to advocate for a variety of causes, including better environmental practices in cafeterias and safer equipment for athletes.

Just as Stark taught me, I worked passionately to achieve my goal. I may have been beaten when I appealed to the board, but I certainly didn’t lose, and that would have made Stark proud.

While the writer didn’t succeed in getting the track dedicated to Coach Stark, their essay is certainly successful in showing their willingness to push themselves and take initiative.

The essay opens with a quote from Coach Stark that later comes full circle at the end of the essay. We learn about Stark’s impact and the motivation for trying to get the track dedicated to him.

One of the biggest areas of improvement in the intro, however, is how the essay tells us Stark’s impact rather than showing us: His care, dedication, and emphasis on developing good character has left an enduring impact on me and hundreds of other students. Not only did he help me discover my talent and love for running, but he also taught me the importance of commitment and discipline and to approach every endeavor with the passion and intensity that I bring to running.

The writer could’ve helped us feel a stronger emotional connection to Stark if they had included examples of Stark’s qualities, rather than explicitly stating them. For example, they could’ve written something like: Stark was the kind of person who would give you gas money if you told him your parents couldn’t afford to pick you up from practice. And he actually did that—several times. At track meets, alumni regularly would come talk to him and tell him how he’d changed their lives. Before Stark, I was ambivalent about running and was on the JV team, but his encouragement motivated me to run longer and harder and eventually make varsity. Because of him, I approach every endeavor with the passion and intensity that I bring to running.

The essay goes on to explain how the writer overcame their apprehension of public speaking, and likens the process of submitting an appeal to the school board to running a race. This metaphor makes the writing more engaging and allows us to feel the student’s emotions.

While the student didn’t ultimately succeed in getting the track dedicated, we learn about their resilience and initiative: I now often show up to meetings to advocate for a variety of causes, including better environmental practices in cafeterias and safer equipment for athletes.

Overall, this essay is well-done. It demonstrates growth despite failing to meet a goal, which is a unique essay structure. The running metaphor and full-circle intro/ending also elevate the writing in this essay.

Essay 6: Body Image

CW: This essay mentions eating disorders.

I press the “discover” button on my Instagram app, hoping to find enticing pictures to satisfy my boredom. Scrolling through, I see funny videos and mouth-watering pictures of food. However, one image stops me immediately. A fit teenage girl with a “perfect body” relaxes in a bikini on a beach. Beneath it, I see a slew of flattering comments. I shake with disapproval over the image’s unrealistic quality. However, part of me still wants to have a body like hers so that others will make similar comments to me.

I would like to resolve a silent issue that harms many teenagers and adults: negative self image and low self-esteem in a world where social media shapes how people view each other. When people see the façades others wear to create an “ideal” image, they can develop poor thought patterns rooted in negative self-talk. The constant comparisons to “perfect” others make people feel small. In this new digital age, it is hard to distinguish authentic from artificial representations.

When I was 11, I developed anorexia nervosa. Though I was already thin, I wanted to be skinny like the models that I saw on the magazine covers on the grocery store stands. Little did I know that those models probably also suffered from disorders, and that photoshop erased their flaws. I preferred being underweight to being healthy. No matter how little I ate or how thin I was, I always thought that I was too fat. I became obsessed with the number on the scale and would try to eat the least that I could without my parents urging me to take more. Fortunately, I stopped engaging in anorexic behaviors before middle school. However, my underlying mental habits did not change. The images that had provoked my disorder in the first place were still a constant presence in my life.

By age 15, I was in recovery from anorexia, but suffered from depression. While I used to only compare myself to models, the growth of social media meant I also compared myself to my friends and acquaintances. I felt left out when I saw my friends’ excitement about lake trips they had taken without me. As I scrolled past endless photos of my flawless, thin classmates with hundreds of likes and affirming comments, I felt my jealousy spiral. I wanted to be admired and loved by other people too. However, I felt that I could never be enough. I began to hate the way that I looked, and felt nothing in my life was good enough. I wanted to be called “perfect” and “body goals,” so I tried to only post at certain times of day to maximize my “likes.” When that didn’t work, I started to feel too anxious to post anything at all.  

Body image insecurities and social media comparisons affect thousands of people – men, women, children, and adults – every day. I am lucky – after a few months of my destructive social media habits, I came across a video that pointed out the illusory nature of social media; many Instagram posts only show off good things while people hide their flaws. I began going to therapy, and recovered from my depression. To address the problem of self-image and social media, we can all focus on what matters on the inside and not what is on the surface. As an effort to become healthy internally, I started a club at my school to promote clean eating and radiating beauty from within. It has helped me grow in my confidence, and today I’m not afraid to show others my struggles by sharing my experience with eating disorders. Someday, I hope to make this club a national organization to help teenagers and adults across the country. I support the idea of body positivity and embracing difference, not “perfection.” After all, how can we be ourselves if we all look the same?

This essay covers the difficult topics of eating disorders and mental health. If you’re thinking about covering similar topics in your essay, we recommend reading our post Should You Talk About Mental Health in College Essays?

The short answer is that, yes, you can talk about mental health, but it can be risky. If you do go that route, it’s important to focus on what you learned from the experience.

We can see that the writer of this essay has been through a lot, and a strength of their essay is their vulnerability, in excerpts such as this: I wanted to be admired and loved by other people too. However, I felt that I could never be enough. I began to hate the way that I looked, and felt nothing in my life was good enough. I wanted to be called “perfect” and “body goals,” so I tried to only post at certain times of day to maximize my “likes.”

The student goes on to share how they recovered from their depression through an eye-opening video and therapy sessions, and they’re now helping others find their self-worth as well. It’s great that this essay looks towards the future and shares the writer’s goals of making their club a national organization; we can see their ambition and compassion.

The main weakness of this essay is that it doesn’t focus enough on their recovery process, which is arguably the most important part. They could’ve told us more about the video they watched or the process of starting their club and the interactions they’ve had with other members.

Still, this essay shows us that this student is honest, self-aware, and caring, which are all qualities admissions officer are looking for.

Essay 7: Health Crisis

Tears streamed down my face and my mind was paralyzed with fear. Sirens blared, but the silent panic in my own head was deafening. I was muted by shock. A few hours earlier, I had anticipated a vacation in Washington, D.C., but unexpectedly, I was rushing to the hospital behind an ambulance carrying my mother. As a fourteen-year-old from a single mother household, without a driver’s license, and seven hours from home, I was distraught over the prospect of losing the only parent I had. My fear turned into action as I made some of the bravest decisions of my life. 

Three blood transfusions later, my mother’s condition was stable, but we were still states away from home, so I coordinated with my mother’s doctors in North Carolina to schedule the emergency operation that would save her life. Throughout her surgery, I anxiously awaited any word from her surgeon, but each time I asked, I was told that there had been another complication or delay. Relying on my faith and positive attitude, I remained optimistic that my mother would survive and that I could embrace new responsibilities.

My mother had been a source of strength for me, and now I would be strong for her through her long recovery ahead. As I started high school, everyone thought the crisis was over, but it had really just started to impact my life. My mother was often fatigued, so I assumed more responsibility, juggling family duties, school, athletics, and work. I made countless trips to the neighborhood pharmacy, cooked dinner, biked to the grocery store, supported my concerned sister, and provided the loving care my mother needed to recover. I didn’t know I was capable of such maturity and resourcefulness until it was called upon. Each day was a stage in my gradual transformation from dependence to relative independence.

Throughout my mother’s health crisis, I matured by learning to put others’ needs before my own. As I worried about my mother’s health, I took nothing for granted, cherished what I had, and used my daily activities as motivation to move forward. I now take ownership over small decisions such as scheduling daily appointments and managing my time but also over major decisions involving my future, including the college admissions process. Although I have become more independent, my mother and I are inseparably close, and the realization that I almost lost her affects me daily. Each morning, I wake up ten minutes early simply to eat breakfast with my mother and spend time with her before our busy days begin. I am aware of how quickly life can change. My mother remains a guiding force in my life, but the feeling of empowerment I discovered within myself is the ultimate form of my independence. Though I thought the summer before my freshman year would be a transition from middle school to high school, it was a transformation from childhood to adulthood.

This essay feels real and tells readers a lot about the writer. To start at the beginning, the intro is 10/10. It has drama, it has emotions, and it has the reader wanting more.

And, when you keep going, you get to learn a lot about a very resilient and mature student. Through sentences like “I made countless trips to the neighborhood pharmacy, cooked dinner, biked to the grocery store, supported my concerned sister, and provided the loving care my mother needed to recover” and “Relying on my faith and positive attitude, I remained optimistic that my mother would survive and that I could embrace new responsibilities,” the reader shows us that they are aware of their resilience and maturity, but are not arrogant about it. It is simply a fact that they have proven through their actions!

This essay makes us want to cheer for the writer, and they certainly seem like someone who would thrive in a more independent college environment.

Essay 8: Turned Tables

“You ruined my life!” After months of quiet anger, my brother finally confronted me. To my shame, I had been appallingly ignorant of his pain.

Despite being twins, Max and I are profoundly different. Having intellectual interests from a young age that, well, interested very few of my peers, I often felt out of step in comparison with my highly-social brother. Everything appeared to come effortlessly for Max and, while we share an extremely tight bond, his frequent time away with friends left me feeling more and more alone as we grew older.

When my parents learned about The Green Academy, we hoped it would be an opportunity for me to find not only an academically challenging environment, but also – perhaps more importantly – a community. This meant transferring the family from Drumfield to Kingston. And while there was concern about Max, we all believed that given his sociable nature, moving would be far less impactful on him than staying put might be on me.

As it turned out, Green Academy was everything I’d hoped for. I was ecstatic to discover a group of students with whom I shared interests and could truly engage. Preoccupied with new friends and a rigorous course load, I failed to notice that the tables had turned. Max, lost in the fray and grappling with how to make connections in his enormous new high school, had become withdrawn and lonely. It took me until Christmas time – and a massive argument – to recognize how difficult the transition had been for my brother, let alone that he blamed me for it.

Through my own journey of searching for academic peers, in addition to coming out as gay when I was 12, I had developed deep empathy for those who had trouble fitting in. It was a pain I knew well and could easily relate to. Yet after Max’s outburst, my first response was to protest that our parents – not I – had chosen to move us here. In my heart, though, I knew that regardless of who had made the decision, we ended up in Kingston for my benefit. I was ashamed that, while I saw myself as genuinely compassionate, I had been oblivious to the heartache of the person closest to me. I could no longer ignore it – and I didn’t want to.

We stayed up half the night talking, and the conversation took an unexpected turn. Max opened up and shared that it wasn’t just about the move. He told me how challenging school had always been for him, due to his dyslexia, and that the ever-present comparison to me had only deepened his pain.

We had been in parallel battles the whole time and, yet, I only saw that Max was in distress once he experienced problems with which I directly identified. I’d long thought Max had it so easy – all because he had friends. The truth was, he didn’t need to experience my personal brand of sorrow in order for me to relate – he had felt plenty of his own.

My failure to recognize Max’s suffering brought home for me the profound universality and diversity of personal struggle; everyone has insecurities, everyone has woes, and everyone – most certainly – has pain. I am acutely grateful for the conversations he and I shared around all of this, because I believe our relationship has been fundamentally strengthened by a deeper understanding of one another. Further, this experience has reinforced the value of constantly striving for deeper sensitivity to the hidden struggles of those around me. I won’t make the mistake again of assuming that the surface of someone’s life reflects their underlying story.

Here you can find a prime example that you don’t have to have fabulous imagery or flowery prose to write a successful essay. You just have to be clear and say something that matters. This essay is simple and beautiful. It almost feels like having a conversation with a friend and learning that they are an even better person than you already thought they were.

Through this narrative, readers learn a lot about the writer—where they’re from, what their family life is like, what their challenges were as a kid, and even their sexuality. We also learn a lot about their values—notably, the value they place on awareness, improvement, and consideration of others. Though they never explicitly state it (which is great because it is still crystal clear!), this student’s ending of “I won’t make the mistake again of assuming that the surface of someone’s life reflects their underlying story” shows that they are constantly striving for improvement and finding lessons anywhere they can get them in life.

Where to Get Your Overcoming Challenges Essays Edited

Do you want feedback on your Overcoming Challenges essays? After rereading your essays countless times, it can be difficult to evaluate your writing objectively. That’s why we created our free Peer Essay Review tool , where you can get a free review of your essay from another student. You can also improve your own writing skills by reviewing other students’ essays. 

If you want a college admissions expert to review your essay, advisors on CollegeVine have helped students refine their writing and submit successful applications to top schools. Find the right advisor for you to improve your chances of getting into your dream school!

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Friday essay: Bad therapy or cruel world? How the youth mental health crisis has been sucked into the culture wars

Professor of Psychology, The University of Melbourne

Disclosure statement

Nick Haslam receives funding from the Australian Research Council.

University of Melbourne provides funding as a founding partner of The Conversation AU.

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Rates of mental ill health among young people are on the rise. Between the years 2020 and 2022, 39% of Australians aged 16 to 24 had a mental disorder in the previous year , compared to 26% in that age range in 2007, and 27% of those aged 18–24 in 1997.

The recent Lancet Psychiatry commission on youth mental health documents equally steep increases in mental illness in the United States, UK and Denmark. Governments, mental health services, educational institutions and parents are struggling to respond. But what is behind these trends?

Two accounts seem to be emerging. According to one, which I’ll call the “cruel world” narrative, young people are distressed because the world is in bad shape and getting worse.

Facing climate emergency, unaffordable housing, precarious employment, rising inequality and other dire mega-trends, they are canaries in a societal coalmine. By this account, the mental health crisis is the direct result of systemic adversity.

The alternative, which I’ll call the “cultural trend” narrative, is a little less bleak. Young people are experiencing more mental illness not primarily because the world is grim and getting grimmer, but because cultural shifts have shaped how they perceive and inhabit it.

This narrative suggests a culture preoccupied with harm creates vulnerability and leads people to view life problems through a psychiatric lens. Adversity and social dislocation undoubtedly contribute to young people’s distress, but the way therapeutic culture frames their suffering makes it worse.

The two narratives offer different prescriptions.

From the “cruel world” perspective, the ultimate causes of the mental health crisis are the basic structures of our society, economy and ecology. Only systemic, macro-level changes can arrest them.

For proponents of the “cultural trend” narrative, the focus of intervention is more micro. We should challenge the social practices and technologies that create vulnerability and undermine mental health.

As a social scientist, I take it as self-evident that adverse social environments play a leading role in the creation of mental ill health: that we can’t isolate human misery from its broader context. However, I’m equally certain that culture plays a crucial part.

A range of cultural changes that could plausibly undermine mental health are well underway: increased immersion in the digital world, rising political polarisation and preoccupation with risk and harm, among others. Separating them from the tangled skein of factors that contribute to the youth mental health crisis is a matter of urgency.

Abigail Shrier’s new book Bad Therapy , a forceful exposition of the “cultural trend” narrative, provides a golden opportunity to explore some of them.

Youth mental health and the culture wars

Journalist and cultural critic Soraya Chemaly’s recent book The Resilience Myth exemplifies the first narrative. Young people are distressed “because the world is distressing, and adults have failed them”. Their sensitivity and emotional honesty place them at higher risk of distress than their elders, and the ubiquity of trauma, oppression and existential climate threat tip that risk into illness.

Chemaly’s solutions lean towards the revolutionary. Her targets include individualism, rigid gender ideologies, capitalism and white supremacy.

Social psychologist Jonathan Haidt’s The Anxious Generation presents a version of the second narrative. Haidt does not deny the magnitude of the challenges young people face. However, he questions whether their rising rates of mental ill health directly follow increases in adversity.

This inflection point in the trajectory of young people’s mental ill health appears to have occurred in the early 2010s. However, many of the systemic trends now held responsible for the crisis – like climate change and rising income inequality – have been building over a much longer period, when rates of ill health were relatively stable. By implication, the precipitating causes must be more specific, recent developments.

Haidt identifies two such changes: the advent of smartphones and “safetyism”. His focus on smartphones has been widely reported . But his equally important emphasis on the cultural preoccupation with protecting us from harm has received less attention.

Haidt argues that parental and institutional over-protection hampers the development of young people’s resilience and autonomy. Citing the idea of “anti-fragility” he proposes that risk, challenge and failure are required to build strength.

By now, it should be obvious that the youth mental health crisis has become politicised, sucked into the vortex of the culture wars.

The crisis can be attributed either to an uncaring system that oppresses the most vulnerable, or to emerging social trends that do young minds no favours. It can be addressed either by progressive social change, such as economic redistribution and environmental protection, or by winding back some damaging cultural developments, such as promoting unsupervised play for children and restricting access to smartphones in schools .

Blaming ‘bad therapy’

Whereas Haidt spends much of his book on the damage done by young people’s immersion in the digital world, in Bad Therapy, Shrier castigates mental health experts for contributing to the crisis they claim to be addressing.

Shrier is a controversial figure. Her previous book Irreversible Damage drew protests and bans for critiquing youth gender medicine and arguing that social contagion plays a role in the rise of girls seeking gender transition.

The former lawyer and Wall Street Journal columnist, who has not previously written at length on mental health, is just as fierce in prosecuting the case against the growing influence of mental health expertise.

Bad Therapy begins by arguing that the rise in mental ill health among young people is not merely a response to deepening life challenges. Instead, Shrier writes, it is driven by destructive cultural shifts and misguided experts. She suggests many people who are experiencing ordinary problems in living have been led to believe their unhappiness is psychiatric in nature.

Shrier is quick to clarify that distress often is genuinely severe. There are “two distinct groups of young people”, she argues: those experiencing “profound mental illness” and “the worriers; the fearful; the lonely, lost, and sad”.

This second group is Shrier’s battleground. These “worriers” have fallen victim to shifts in education and parenting, and to the expansionism of the mental health field. On this point, she doesn’t mince her words. “No industry refuses the prospect of exponential growth,” she writes, and “the mental health industry is minting patients faster than it can cure them.” As a result, “we rush to remedy a misdiagnosed condition with the wrong sort of cure”.

Shrier challenges the common view that mental health interventions – therapy for short – are invariably beneficial. She reviews evidence suggesting therapy is less helpful than it is touted to be, and that it can sometimes be actively harmful. For instance, “psychological debriefing” immediately after exposure to traumas can interfere with recovery .

Mental health treatment can undermine recovery, she suggests, by “hijack[ing] our normal processes of resilience” and creating dependency on professionals. It can crystallise illness by applying diagnostic labels too liberally.

Diagnoses may bring relief to anxious and desperate parents, but they can also affect how their children perceive themselves and are perceived by others. Much like therapeutic staples such as trauma and chemical imbalance , diagnostic terms can convey the view that young people are fundamentally damaged and have little control over their predicaments.

Many of these critiques of therapy chime with familiar attacks on medicalisation . But Shrier also advances some newer criticisms. Mental health treatment can induce rumination and a passive focus on feelings: common features of anxiety and depression. “Bad therapy encourages hyperfocus on one’s emotional states, which in turn makes symptoms worse.”

Therapy can also affirm young people’s worries and encourage public sharing of distress in ways that can entrench unhelpful patterns. “A dose of repression,” Shrier counters, “appears to be a fairly useful psychological tool for getting on with life.”

Mental health workers overlook the possibility that talk therapy can have these adverse consequences, Shrier argues – although it is no less plausible that some psychological treatments may do harm than that some medications can have adverse side effects. Without questioning therapists’ desire to help, she takes the hardheaded view that they have incentives not to acknowledge the harm they may be causing.

Should teachers be delivering therapy?

The clear implication of Shrier’s argument is that we should challenge, rather than expand, therapeutic approaches to young people’s mental health. Instead, she finds that American schools are riddled with bad therapy, often under the banner of “social-emotional learning”.

Shrier maintains that social-emotional learning licenses psychologically untrained teachers to work in a therapeutic mode. It encourages excessive self-focus, demands emotional disclosure and can expose children to dual relationships, all out of view of their parents.

Social-emotional learning and related elements of therapeutic schooling don’t just encourage unhelpful inwardness, she argues. She contends they also use questionable teaching methods and draw time and energy away from academic learning.

Of one effort to smuggle emotional learning into a maths class, Shrier writes: “I began to wonder whether this wasn’t some sort of ploy by the Chinese Communist Party to obliterate American mathematical competence.” She concludes that

social-emotional learning turns out to be a lot like the Holy Roman Empire. Neither social, nor good for emotional health, nor something that can be learned.

Schools’ therapeutic missions also undermine how they educate disadvantaged students. Shrier contends that some “trauma-informed” practice prejudges students who have experienced hardship as fragile and in need of blanket mental health interventions, while lowering expectations for their behaviour and academic achievement. Meanwhile, classroom chaos is created by excessive accommodation of disruptive students.

Shrier takes aim at the outsized role “trauma” plays in currently popular accounts of mental ill health. She reserves some of her sharpest criticism for psychiatrist Bessel van der Kolk , whose bestselling book, The Body Keeps the Score, places trauma front and centre in mental ill health, and physician Gabriel Maté , who claims trauma contributes to everything from cancer to ADHD.

Seeing childhood trauma as the buried root of most adult mental health problems conflicts with copious evidence that resilience is the normal response to adversity – and that trauma memories tend to be recalled accurately, rather than locked voiceless in the body. Shrier maintains that the concept of trauma has become trivialised through over-use. She chastises experts for characterising problems ranging from anger outbursts to procrastination as trauma responses.

In the school environment, the consequences of elevating trauma are troubling:

under the banner of “whole child” education and “trauma-informed” care, educators greet every child with the emotional analogue of a gurney, all but begging kids to hop in. They never wait to see who might be injured because every child is encouraged to see herself as overtaxed and worn out. They encourage every child, constantly, to think about herself and her struggles.

Against ‘gentle’ parenting and ‘overmanaged’ kids

Shrier condemns schools for usurping parental authority, but argues that contemporary parenting also subverts itself.

“Gentle” styles of child-rearing end up creating anxious, unresilient children whose demands are endlessly accommodated and whose dependency is reinforced. A strange combination of permissiveness and over-involvement makes for exhausted parents who are unwilling to exercise adult authority or to impose consequences on behaviour, she argues.

Liberal American parents may look askance at earlier styles of parenting, but by placing emotional wellness front and centre in their relationships with their children, they are making their task harder and more thankless.

As Shrier observes:

forty-year-old parents – accomplished, brilliant, and blessed with a spouse – treat the raising of kids like a calculus problem that was put to them in the dead of night: Get it right or I pull this trigger .

Ultimately, the failures of therapeutic parenting are another strike against the mental health experts who advocated for it. Shrier urges parents to cut themselves loose from the advice of parenting sages, for the good of their children: “love means occasionally telling an expert to get lost”.

Concretely, parents should step back, stop compulsively monitoring and over-praising their children, reduce scheduled activities, enforce consequences and encourage independent behaviour. She writes: “if you could do something at their age, let them give it a whirl”.

A parent’s goal should be to set their children free from an “overmanaged, veal-calf life” and ensure they experience “all of the pains of adulthood, in smaller doses, so that they build up immunity to the poison of heartache and loss”.

Not all therapy is bad therapy

Bad Therapy is an unashamedly polemical book. Shrier has strong views on what is wrong with the culture of mental health in the US –  and takes these supposed failings as examples of broader progressive trends she opposes.

The mental health crisis troubles her not only for its human costs, but because it erodes key conservative values: self-reliance, strength, parental authority and freedom from institutional compulsion.

Shrier’s rhetoric is sharp-elbowed, with a memorable turn of phrase. Some villains are identified and savaged, though the criticised cabal of mental health experts is often a faceless mass. The book is studded with revealing case studies and she interviews many leading scientists, like Paul Bloom, author of Against Empathy , memory expert Elizabeth Loftus , leading trauma psychologist Richard McNally , and generational difference researcher Jean Twenge .

Though she presents herself as defending science against ideology, at times Shrier’s claims run ahead of the data. There is little evidence that mental health interventions are creating ill health on a large scale, for example, or that increases in self-diagnosis among young people account for increases in their levels of distress.

Some schools may implement socio-emotional learning in problematic ways. But studies typically find that they benefit academic achievement . And though there is evidence that today’s young adults are reaching some developmental milestones later than earlier generations, there is little direct evidence that gentle parenting is responsible for the delays.

Shrier tends to present the mental health world as a monolith. But anyone working in it knows it to be criss-crossed with divisions: between researchers and practitioners, consumers and professionals, medical and non-medical workers, and numerous disciplines and therapeutic tribes.

The idea that this Babel of voices is united in a process of crisis creation is hard to credit. Not all therapy is bad therapy. Indeed, many of the positions Shrier espouses – for facing challenges head on and experiencing the consequences of our behaviour, and against safetyism, over-medication and the therapeutic excavation of our childhoods – are gospel for mainstream cognitive behaviour therapists.

Correcting concerning trends

Even so, for all its exaggerations and simplifications, Bad Therapy is a timely corrective to some real and concerning trends. It is increasingly clear that over-diagnosis of mental illness is common, especially among young people, and that diagnostic labelling can have adverse implications .

It now seems likely that campaigns to boost mental health awareness sometimes backfire and pathologise ordinary unhappiness. School-based prevention initiatives are sometimes ineffective and can even reduce wellbeing.

Most of all, it is becoming obvious that although there is a high unmet need for treatment, simply expanding the current mental health system – training more therapists, funding more sessions and services, further boosting awareness of mental health, embedding a therapeutic sensibility in more of our institutions – cannot be relied on to substantially reduce mental ill health.

Research on the so-called “treatment-prevalence paradox” demonstrates that large increases in service provision have failed to reduce rates of mental illness. Current treatment practices have only modest efficacy in real-world settings. Reasons likely include the complexity and recurring nature of many mental health problems, and the low quality implementation and short-lived benefit of many treatments.

Some treatments also clearly do more harm than good, for some patients. A recent evaluation of Australia’s Better Access program, which gives Medicare rebates to help people access mental health care, found that patients who sought help for relatively mild distress were three times more likely to deteriorate than to improve (patients in more severe distress typically improved).

In this context, Shrier has some grounds to be sceptical that doing more of the same will turn around the mental health crisis. There is no question that more needs to be done – but believing that the solution is to scale up current practice seems, as Samuel Johnson said of a second marriage, a triumph of hope over experience.

Shrier addresses her concluding chapters to parents, urging them to reclaim the confidence that they know what’s right for their child. The trouble is, parents rarely know to which of Shrier’s “two distinct groups of young people” their child belongs.

How could they know? No bright line separates the supposed victims of therapy culture from the profoundly ill. Faced with a loved one’s distress, what can parents do but seek the forms of help that are currently available?

Our young people will continue to be funnelled toward mental health treatment in alarming numbers. We can only hope it will become more effective and less necessary.

Correction: Nick Haslam is not registered as a health care practitioner in Australia, so his job description in this article has been amended to “social scientist”.

• Overdiagnosis
• Gentle parenting
• Friday essay
• Youth mental health crisis

Professor of Indigenous Cultural and Creative Industries (Identified)

Communications Director

Associate Director, Post-Award, RGCF

University Relations Manager

2024 Vice-Chancellor's Research Fellowships

Children’s mental health is in crisis

As pandemic stressors continue, kids’ mental health needs to be addressed in schools

Vol. 53 No. 1 Print version: page 69

• Mental Health
• Schools and Classrooms

As the United States approaches 2 full years of the COVID-19 pandemic, mental illness and the demand for psychological services are at all-time highs—especially among children. While some children benefited from changes like remote learning , others are facing a mental health crisis. Prior to COVID-19, Centers for Disease Control and Prevention ( CDC ) data found 1 in 5 children had a mental disorder, but only about 20% of those children received care from a mental health provider. Whether kids are facing trauma because of child abuse or loss of a family member or everyday anxiety about the virus and unpredictable routines, they need even more support now—all amid a more significant shortage of children’s mental health resources.

In a 2020 survey of 1,000 parents around the country facilitated by the Ann & Robert H. Lurie Children’s Hospital of Chicago , 71% of parents said the pandemic had taken a toll on their child’s mental health, and 69% said the pandemic was the worst thing to happen to their child. A national survey of 3,300 high schoolers conducted in spring 2020 found close to a third of students felt unhappy and depressed much more than usual.

Mental health crises are also on the rise. From March 2020 to October 2020, mental health–related emergency department visits increased 24% for children ages 5 to 11 and 31% for those ages 12 to 17 compared with 2019 emergency department visits, according to CDC data (Leeb, R. T., et al., Morbidity and Mortality Weekly Report , Vol. 69, No. 45, 2020).

Emergency visits could be mitigated with more widespread outpatient care, but even before the pandemic, kids often had to wait months for appointments (Cama, S., et al., International Journal of Health Services , Vol. 47, No. 4, 2017). Only 4,000 out of more than 100,000 U.S. clinical psychologists are child and adolescent clinicians, according to APA data. School psychologists are also in short supply, leaving kids without enough support at school. The National Association of School Psychologists (NASP) recommends a ratio of 1 school psychologist per 500 students; current NASP data estimate a ratio of 1 per 1,211 students.

The pandemic has also exacerbated existing disparities in mental health services. A 2020 technical report from the University of Massachusetts Boston and the University of Massachusetts Amherst found that students who needed access to school-based services the most, particularly those with lower socioeconomic backgrounds, had lower rates of counselors and school psychologists in their districts.

While federal funding has provided schools with money to support students’ well-being, psychologists have been seeking additional long-term solutions to address the mental health problems revealed and exacerbated by the pandemic, from building mental health into school curricula to training teachers in prevention strategies to support students based on psychological science.

Here are some of the most notable ways psychologists have worked to address students’ mental health and what’s ahead.

Bringing mental health into the classroom

The American Rescue Plan Act, passed in March 2021, included $170 billion for school funding, and many schools used the funding to hire mental health workers, including psychologists. Other federal and state funding is being allocated toward training more psychologists. For example, in Nevada, which has historically ranked last in U.S. mental health, the University of Nevada, Las Vegas, received a grant to train school clinicians in urban diversity and social justice, and Nevada State College received funding to create a new program to train school mental health clinicians, including psychologists.

While the field of psychology recognizes a shortage of mental health services for kids, addressing those needs may not be a realistic solution until the workforce grows. Relying on temporary funding to hire permanent staff isn’t financially sustainable for lower-income districts, said Kenneth Polishchuk, APA’s senior director for congressional and federal relations. As a result, Polishchuk said, many schools are hiring mental health providers on a short-term basis, as well as taking a preventative approach focused on training teachers in psychological principles .

Psychologists in some districts are training teachers in basic social and emotional skills to help students cope with stress and anxiety in real time, said Kathryn H. Howell , PhD, an associate professor of child and family psychology at the University of Memphis and chair-elect of APA’s Committee on Children, Youth and Families. Howell said equipping kids with coping skills in the classroom can prevent strain on school psychologists while also improving students’ ability to learn.

“As psychologists, we don’t just want to bring in interventions that only we as experts can deliver,” Howell said. “We need to make it sustainable by teaching those on the front lines how to equip kids with the skills they need to thrive.”

Some teachers are incorporating formal mental health lessons into their curriculum with help from psychologists. New York state requires basic mental health education in health classes, and Peter Faustino, PsyD, a school psychologist in Scarsdale, New York, said he’s been receiving requests from teachers for help incorporating pandemic-relevant topics like anxiety, trauma, and warning signs of suicide into their classes. Other schools, he said, are investing in social and emotional health training programs for staff, such as Yale University’s RULER program , which teaches school leaders and teachers how to equip students with emotional intelligence skills.

Training teachers to address trauma

Along with more minor mental and behavioral health concerns, teachers are facing an unprecedented number of students with trauma, said Laurie McGarry Klose, PhD, president of NASP and director of the School Psychology Program at Trinity University in San Antonio, Texas. And many teachers don’t feel equipped to handle their students’ struggles: A 2020 survey by the New York Life Foundation and American Federation of Teachers found that only 15% of educators said they felt comfortable addressing grief or trauma tied to the pandemic.

As a result, psychologists are finding new ways to share their expertise with school personnel. For example, Samuel Song , PhD, a professor of school psychology at the University of Nevada, Las Vegas, and president of APA’s Div. 16 (School Psychology), is working on a grant with colleagues to deliver a four-part web-based curriculum on trauma-informed practices. Such programs can help teachers identify signs of trauma in students and also cope with their own trauma, which Klose says are equally important. Teachers are more likely to dismiss trauma-driven behaviors as belligerence when they’re under strain, so with proper resources and training, they can better identify kids who are struggling and route them to appropriate support services within the school system.

Mental Health Primers , developed by the Coalition for Psychology in Schools and Education, also provide information for teachers to identify behaviors in the classroom that are symptomatic of mental health and other psychological issues, with the goal of directing teachers to appropriate resources for their students.

“We know one-on-one therapy won’t be possible for every kid who’s struggling, so we need a multipronged approach to help build the capacity of teachers and staff to support kids in the classroom setting,” said Melissa Pearrow , PhD, a professor of counseling and school psychology at the University of Massachusetts Boston.

Resilience is built outside the classroom, too. Howell said psychologists and graduate students from her department at the University of Memphis are also working with local community centers to train leaders in emotional health principles. “We want to help provide mentors that can be present in kids’ lives beyond their parents, who are already dealing with a lot,” she said. “We have the expertise and scientific background, and they have expertise in working directly with families and systems, so how can we pair our expertise and learn from each other?”

Ensuring long-term resilience

While short-term crisis funding has helped many communities and schools hire mental health professionals and develop related programs, psychologists and policymakers continue to advocate for more permanent solutions. In a September 2021 address to the House Energy and Commerce Subcommittee on Oversight and Investigations , APA CEO Arthur C. Evans Jr., PhD, encouraged Congress to consider long-term investments in states’ and school systems’ mental health workforces and infrastructures. In October 2021, the Biden administration and U.S. Department of Education released new guidance for schools to better help students’ mental health needs.

Several bills could help protect kids’ mental health in the long term. President Biden proposed an additional billion dollars to procure health care professionals—including mental health professionals—in schools. As of November 2021, the bill has passed in the House and will soon go before the Senate.

Also as of November 2021, bipartisan lawmakers are working to pass the Student Mental Health Helpline Act , which would create a grant program to support existing and promote new statewide student mental health and safety helplines. The Comprehensive Mental Health in Schools Pilot Program Act, a bill referred to the House Committee on Education and Labor in May 2021, would provide resources for low-income schools to integrate social and emotional learning and evidence-based, trauma-informed practices into all aspects of the school environment. Also in May 2021, the House passed the bipartisan Mental Health Services for Students Act, which would build partnerships between schools and community-based organizations to provide school-based mental health care for students. It now awaits consideration by the Senate.

Until new laws go into effect, psychologists are committed to finding new ways to address children’s mental health, not only for their own well-being but for the common good. “It’s not only the right thing to do to make sure people can have as full a life as they possibly can,” said Alan Leshner, PhD, the former director of the National Institute on Drug Abuse and former deputy and acting director of the National Institute of Mental Health, who has recently turned his attention to student mental health as a member of the National Academies of Sciences, Engineering, and Medicine Committee on Mental Health, Substance Use, and Wellbeing in STEMM Undergraduate and Graduate Education. “Young people are critical to the future of society, so it’s in society’s interest to make sure we don’t lose the talent youth could contribute to a set of problems that can be alleviated.”

Additional resource

• Applauding the surgeon general’s December 7 advisory on ‘Protecting Youth Mental Health’  (APA Services, Inc.)

2022 trends report

• This article is part of our 14 emerging trends special report. Explore our full coverage on how the pandemic era is changing attitudes toward science and mental health .

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• Read the complete 2022 trends report .

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Main page content, connected and strong compendium: 10 technical assistance briefs to foster unity and strengthen continuity across crisis response and treatment systems.

Together, these papers lay out recommendations and highlight specific strategies to connect the oftentimes fragmented crisis care system, and strengthen America’s approach to providing behavioral healthcare overall, in accordance with President Biden’s Unity Agenda.

The papers are:

• Connected and Strong: Strategies for Accessible and Effective Crisis and Mental Health Services
• Peer Support Services Across the Crisis Continuum
• Growing and Strengthening the Behavioral Health Crisis Response Workforce
• Crisis Services: General Medical and Psychiatric Approaches to Care Delivery
• Innovative Uses of Technology to Enhance Access to Services Within the Crisis Continuum
• Crisis Systems Coordination and Collaboration: Leveraging Strengths and Opportunity of 988 and 911
• Facilitating Rapid Access to Outpatient Mental Health and Substance Use Care
• Increasing Equitable Access to Care for Co-Occurring Mental Health and Substance Use Disorders
• Intersectionality: Faith, Mental Health, and Community Partnerships
• Long COVID and High-risk Populations

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Connected and Strong Compendium File Type: PDF File Size: 6.38 MB

Connected and Strong: Strategies for Accessible and Effective Crisis and Mental Health Services File Type: PDF File Size: 924 KB

Peer Support Services Across the Crisis Continuum File Type: PDF File Size: 730 KB

Growing and Strengthening the Behavioral Health Crisis Response Workforce File Type: PDF File Size: 786 KB

Crisis Services: General Medical and Psychiatric Approaches to Care Delivery File Type: PDF File Size: 656 KB

Innovative Uses of Technology to Enhance Access to Services Within the Crisis Continuum File Type: PDF File Size: 1.33 MB

Crisis Systems Coordination and Collaboration: Leveraging Strengths and Opportunities of 988 and 911 File Type: PDF File Size: 987 KB

Facilitating Rapid Access to Outpatient Mental Health and Substance Use Care File Type: PDF File Size: 682 KB

Increasing Equitable Access to Care for Co-Occurring Mental Health and Substance Use Disorders File Type: PDF File Size: 985 KB

Intersectionality: Faith, Mental Health, and Community Partnerships File Type: PDF File Size: 1.82 MB

Long-COVID and High-Risk Populations File Type: PDF File Size: 797 KB

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Audience: Prevention Professionals , Professional Care Providers , Public Health Professionals

Issues, Conditions and Disorders: Mental Illness , Suicide

Language: English

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America’s mental health treatment crisis demands action | Editorial

The plight of people struggling with mental illness and homelessness, and the murder of a patient in a Pennsylvania psychiatric hospital, point to a strained system that fails those who need help.

The death earlier this summer of a mentally ill Scranton man who authorities said was killed by his roommate at Norristown State Hospital is yet another sad symptom of this nation’s woefully inadequate system to help people whose medical conditions have made them a danger to both themselves and others.

Jacob Gonzalez, 25, diagnosed with schizophrenia, bipolar disorder, and depression, was killed the day before a scheduled July 15 court hearing to determine his competence to leave the state-run psychiatric hospital and stand trial for breaking into a doctor’s office in November to seek shelter from the cold.

Authorities said another patient, Kyle Samuels-Robey, went to nurses to ask for ice for a swollen hand and told them he had choked Gonzalez. Samuels-Robey, 34, of West Philadelphia, was also diagnosed with schizophrenia, bipolar disorder, and depression. He had been committed to mental institutions for more than a decade.

The most egregious aspect of the state hospital’s failure to ensure Gonzalez’s safety was its staff’s apparent disregard for rules requiring room checks every 15 minutes. Video surveillance showed no one checked on Gonzalez and Samuels-Robey between 8 and 9:15 p.m. Shortly before 9:30, Samuels-Robey made his confession to nurses.

This was not the first time Norristown State Hospital has been in trouble.

» READ MORE: Trump shooter’s history underscores the need for more mental health resources in schools | Editorial

The 144-year-old mental institution was cited in 2018 for having beds, doorknobs, and shower grab bars that inmates might use to take their own lives. Two years ago, its employees accused the hospital of abusing patients and encouraging their violent outbursts.

That type of patient neglect and mistreatment sparked the national movement more than 50 years ago to deinstitutionalize mental health patients. As a result, the more than a half-million patients in mental hospitals in 1955 were reduced to less than 60,000 by 1998. By 2020, however, that number had risen to 125,000 patients , and thousands more need institutional help.

Based on wait lists and other demographics, researchers say 60 psychiatric beds per 100,000 persons are optimal , and 30 beds should be the minimum. But America falls woefully short of either goal, with only 18 beds per 100,000, including beds in general hospitals. Pennsylvania has 29 beds per 100,000, and New Jersey has 22.

Hospital emergency rooms with too few psychiatric beds are routinely overwhelmed by people experiencing a mental crisis. Too often those patients are “treated and streeted” prematurely, which may lead to violent behavior aimed at others or themselves after their discharge, including suicide.

In fact, the Treatment Advocacy Center points out that a person with a severe mental illness is more likely to be a victim of violence than a perpetrator. While they admit the statistic is hard to calculate with precision, experts estimate that up to 56% of people with severe mental illness have experienced violent victimization within the last year, including theft, emotional abuse, sexual assault, and homicide.

Many of these victims were part of what experts 20 years ago called a “new generation of severely mentally ill persons” who instead of being committed to institutions were too often left on the street. Today, there’s nothing new about people who are mentally ill being homeless. Both their plight and the inexcusable murder of a patient in a Pennsylvania psychiatric hospital suggest America’s mental health system needs better attention.

» READ MORE: Mobile crisis units are a key resource for vulnerable Philadelphians | Opinion

“[W]e know today that the community is not necessarily the most benign treatment site for all mentally ill people at all times and that access to hospital care for those who need it, for as long as they need it, is absolutely essential to the success of deinstitutionalization.” That spot-on assessment — made 20 years ago by psychiatrists Leona L. Bacharach and H. Richard Lamb — remains an unheeded call for action.

Several fronts must be addressed to produce a more effective mental health system.

Institutions cannot be allowed to operate under the same inadequate standards that led to their mass closure decades ago. More institutional settings are needed for people on waiting lists who too often end up homeless or in jail. Better programs must be developed, and housing provided for people who, with the right intervention, can avoid commitment.

The nation’s mental health system seems to only get attention after a mass shooting. Gun rights proponents, in particular, are quick to blame the perpetrator’s mental state rather than the easy availability of a rapid-firing weapon as the problem. Even so, their lip service never leads to measures that dramatically improve the likelihood of a mentally unstable person getting help before a mass murder occurs.

In the long course of the current presidential election, little is being said about America being on track for its fifth year in a row with more than 600 mass shootings in which four or more people were killed. Many of those crimes were likely carried out by someone who never got the mental health assistance they needed.

It’s time to stop talking about a more effective mental health system. Let’s create it.