“’Give me your tired, your poor, your huddled masses yearning to breathe free, the wretched refuse of your teeming shore. Send these, the homeless, tempest-tost to me, I lift my lamp beside the golden door.” This poem, “The New Colossus” written by Emma Lazarus, is inscribed on the base of the Statue of Liberty. For decades upon decades, this couplet embodied the beacon of the United States. The United States was the place to go to start anew, to build a life from scratch and live “The American Dream.” However, gone are the days where the tired, poor, huddled masses find reprieve in the United States. Gone are the days of a nation that looks to help the sick and the poor. In today’s world of corporatization and privatization, the sick and the weary are no longer those in need, but rather outliers in a consumerist market society that places consumption above all else. They are no longer seen as in need of assistance, rather they drive the profit-hungry pharmaceutical and insurance industries. There is no clearer example of this change in priorities than the treatment of those with mental illness. In a society that lets the market define what behavior is proper and normal, those with mental illness have been commoditized or left behind.

How did we get from a beacon of hope to where we are today? The story goes back almost three-quarters of a century, but the most important changes happened not fifty years ago. Promulgated by the election of Ronald Reagan as President, an era of neoliberal government swept the nation. In this paper, I will present the background of mental health treatment policy in the United States and current issues in the area of mental health treatment. I will then present neoliberalism as a lens to view the development of mental health treatment. Finally, I will use the lens of neoliberalism to argue that mental health treatment in the past half-century has shifted to rehabilitate the mentally ill into what the neoliberal consumerist market society views as socially acceptable.

Treatment for the mentally ill has changed by leaps and bounds over the past century. Burris (2004) notes the evolution of mental health treatment over time, explaining how the burden of taking care of a mentally ill patient has shifted away from families since the mid-nineteenth century. Accordino, Porter and Morse (2001) further explain that one of the greatest developments in mental health treatment came in the 1940’s, after the end of World War Two (WWII). Accordino, Porter and Morse (2001), all specialists in rehabilitation of the mentally ill, add that the influx of American servicemen and women returning from WWII brought widespread attention to treatment for the mentally ill, specifically the inhumane conditions in state mental institutions. Davis et al. (2012) build upon this idea by arguing that the increased psychiatric demand post- WWII made it apparent that the mental health profession lacked sufficient resources to treat those in need. This realization led to a legislative push to depopulate state-run mental hospitals in favor of private community mental health centers, more commonly known as deinstitutionalization. Initially, deinstitutionalization had a positive effect on patients. However, as time went on, it was clear that deinstitutionalization caused more harm than benefit.

Another major development in mental health treatment has been the introduction of pharmaceuticals that treat mental illness. Many attribute the decline in the population of state mental hospitals to the advent of psychiatric medication (Espositio & Perez, 2014). However, Esposito and Perez (2014), both professors of sociology at Barry University, further argue that “the introduction of these drugs represented an extension, and not the cause, of a discharge trend that had been taking place for some time” (p. 424). As the 20th century progressed, as shown later, the use of psychiatric medication to treat mental illness proliferated dramatically.

In the late 1980’s, mental health treatment began to drastically change as neoliberal leaders came into power, slashed hospitals budgets, further privatized mental health care, and commoditized mental health treatment. The 1980’s were a period of devastating inflation in the United States, and this was truer in the health sector than almost anywhere else (Newton, 1982). The result, as Patricia Newton (1982) explains, was the closure of many mental health treatment centers, primarily in the public sector. Furthermore, a commentary by Gary Gottlieb, President and CEO of Partners in Health, Benjamin Liptzin, psychiatry chair at Baystate Health and Paul Summergrad, psychiatrist-in-chief at Tufts medical center (2007), explains that changes in the insurance payment system drastically increased the profitability of psychiatric services in private hospitals, albeit temporarily. The 2007 commentary continues that as a result of the rising profitability of psychiatric treatment, private hospitals’ investment in psychiatric services also proliferated, and therefore, so did the availability of inpatient psychiatric treatment. However, as the insurance industry was consolidated, the profitable repayment plans ceased to profitable (Gottlieb, Liptzin & Summergrad, 2007). Instead of bringing in money, the psychiatric units began to sap the capital out of hospitals, threatening their very existence (Gottlieb, Liptzin & Summergrad, 2007). Because of the threat that psychiatric wards posed to the private hospitals’ bottom line, many downsized their programs and cut their staff, even though they were the primary method of treatment for those on both public and private insurance with severe mental illness (Gottlieb, Liptzin & Summergrad, 2007). These cuts resulted in situations like the one that Baker and Gutheil (2011) use as a case study, where staffs are under-trained, which results in poorer treatment and the possibility of injury due to a patient’s outbursts. What has brought about the major changes in past several decades? The answer boils down to one word: neoliberalism.

The neoliberal ideology, explained further in the section below, has led to a health system that has become corporatized, commercialized and profit hungry. This system of “treatment” is no longer about treating those who need it; it is about maximizing profits and rehabilitating the consumer in patients. Esposito and Perez (2014) argue that the perfect example of the system’s new priorities is the increase of pharmaceutical treatment and the way that that treatment is presented and marketed to patients and the public at large.

Neoliberalism is an ideology that came to prominence and power in the United States during the 1980’s with the election of Ronald Reagan. Terry Carney (2000), a member of the University of Sydney’s law faculty and a past president of the International Academy of Law and Health, explains that neoliberalism focuses on outsourcing government responsibility for programs, especially social programs, to the private sector. Esposito and Perez (2014) continue to say that neoliberalism goes beyond simply deregulation and privatization; neoliberalism is an all-encompassing ideology that evaluates an individual’s actions based on “what is deemed as valuable, acceptable, or desirable by ‘the market’” (p. 416). The key portion of Esposito and Perez’s (2014) explanation of neoliberalism is that the neoliberal ideology is based on the market and market perceptions of individual behavior. The market then prescribes a certain set of behaviors that are deemed “normal,” with any deviance from normal being seen as a “social deviance and/or pathology” (Esposito & Perez, 2014;; p. 416).

In order to illustrate neoliberalism, I will use President Ronald Reagan’s policies as a case study of sort, specifically with regard to mental illness, to show the connection between the neoliberalism and cuts for mental health funding. The Reagan administration came into office riding a wave of conservative fervor. Incredibly pro-business, like all neoliberals, Reagan justified decreasing corporate taxes by reducing government expenditures on social-welfare programs, though budget deficits actually ballooned under his presidency according to the Congressional Budget Office (Thomas, 1998; Congressional Budget Office, 2014). To summarize Alexander Thomas (1998), a professor of sociology at SUNY Oneonta, social-welfare programs like mental health treatment were seen as “big government,” and as such were detrimental to the well being of our nation. Those who utilized them, as Thomas (1998) asserts, were “stigmatized as lazy or even criminal” (p. 4). This example returns to the idea above suggested by Esposito and Perez (2014): those who do not fit into the market norm are stigmatized. As a result, mental health funding was cut throughout the 1980’s, or was outsourced to the private sector, which has been a complete disaster (Thomas, 1998). However, using neoliberalism as a lens to analyze the commercialization of health care provides us interesting insights.

Esposito and Perez (2014) discuss in depth the consequences of neoliberalism on mental healthcare; however, this paper will build upon their work by using the neoliberal idea of maximizing private profit and the idea of individuals as consumers to explain why mental healthcare has become commoditized and commercialized. Esposito and Perez (2014) summarize articulately that “neoliberalism supports… a type of health care system in which health care delivery becomes a commodity as opposed to a right” (p. 416). Dissecting this statement through the lens of neoliberalism shows us something intriguing about the health care system and provides an explanation as to why health care has become so commercialized.

To begin, it is important to define a commodity. For the purposes of this paper, a commodity is a good or service that can be traded for a set value of currency. Yet, just in defining a commodity, it is obvious why health care has become commercialized. When a service takes on value in relation to a currency in order to be traded, providers are motivated to maximize their profits; the bottom-line becomes the top priority. It certainly explains why out of Fortune’s 500 largest companies in 2013, 39 deal primarily in the healthcare or insurance industry (Fortune, n.d.). The massive nature of these businesses would also explain the proliferation of mental health insurance and care provision in the early 1980’s and their collapse once reimbursement declined. Insurance has become a business, and mental healthcare provision is now a costly enterprise. Gottlieb, Liptzin and Summergrad (2007) cite a statistic saying that private general hospitals that provided psychiatric care were only being reimbursed 61 cents on the dollar by 2002. Their commentary continues to say, “Financial losses from inpatient psychiatric units threatened the viability of the entire hospital” (p. 1469). There is huge profit to be made in providing healthcare insurance and services, but very little in providing mental healthcare insurance and services.

It is fairly easy to see that there is the huge ability to make profits in the field of mental health treatment. Take for example the way that pharmaceuticals are presented to consumers. In the past several decades, the direct advertisement of pharmaceutical drugs has proliferated at an unprecedented rate. The United States is one of the two countries in the world that allows for the advertisement of pharmaceuticals directly to consumers, and as a result, Esposito and Perez (2014) report that there has been an increase in patients being treated for mental illness. However, I differ partially in my reasoning for this increase in treatment. Esposito and Perez (2014) argue that the proliferation of diagnoses of mental illness is due to “the failure of medicalization as the primary way to deal with mental distress,” and the pressure that neoliberal society puts on people to perform in a way that is deemed normal (p. 427). Though latter seems to be compelling, I argue that the proliferation of mental illness is equal parts difficulty conforming to the neoliberal’s idea of normal and the corporatization of mental healthcare.

With the advent of psychiatric medicines to treat illnesses like minor and major depression, anxiety, and bipolar disorder, there is great profit to be made in making, marketing and prescribing these drugs. This is not to say that more people are not suffering from mental illness; such an assertion would make perfect sense. Kohn et al (2004) cite a statistic saying that almost half of all adults have experienced mental disorders. I argue that this can be attributed to the narrowing of what is considered acceptable by neoliberal society. The societal norm is continually shifting, and as it becomes more and more difficult to conform to the neoliberal idea of normal people face enormous amounts of mental stress. It is no longer good enough to simply have a job, a house and a family. A college education has become expected, in addition to having a family, a well paying job, a home with a white picket fence, etc. The finish line is continuously being moved, increasing the number of those who do not fit the societal norm and are stigmatized for it. However, by moving the finish line, creating that stigma, and increasing those who become mentally ill because of it, pharmaceutical companies profit through selling more Prozac.

What is interesting, however, is that not only does the prescription of psychiatric medication increase profits for pharmaceutical companies, but it also reinforces the consumerist ideals of neoliberalism. Take, for example, Fluoxetine, more commonly known as Prozac. The United States National Library of Health explains that Prozac is what is known as a selective serotonin reuptake inhibitor (SSRI), which is used to treat mental illnesses like depression, obsessive– compulsive disorder, anxiety disorders, and even eating disorders. Peter Wehewein (2011), a contributor to Harvard Health Publications, cites a government report that found that one in ten Americans is prescribed an antidepressant, with the prescription of Prozac up 400% since it was introduced in the 1980’s. While it is helpful to analyze this massive increase for its face value, which is that many more people are receiving treatment for their illness, looking just beneath the surface provides an enlightening insight into the use of prescription drug treatment for mental health issues.

Are 400% more people being diagnosed with mental illnesses like depression, anxiety and eating disorders than when Prozac was introduced? It is quite possible, but Samuel Zuvekas (2005) of the Agency for Healthcare Research and Quality has found that the prescriptions of other pharmaceuticals that treat mental illness are up as well. In fact, and perhaps most interestingly, Zuvekas (2005) found that consumer spending on prescriptions for drugs that treat mental illness increased at a rate of nearly 20% per year between 1996 and 2001. I argue that this increase in consumption is a symptom of the consumerist market ideals of neoliberalism. As implied above, one of the pinnacles of neoliberalism is that individuals first and foremost are consumers. Behavior that is seen as disruptive to an individual’s ability to consume is outside the realm of what is characterized as normal. They are, therefore, are prescribed medication that alters their behavior in a way that allows them to become good consumers again. What is more is that the prescription of these medications is part of their rehabilitation, both in the sense that it minimizes their symptoms and that they are becoming consumers again through the purchase of their prescription. In a way, being prescribed a medication that alters their behavior to rehabilitate them into the neoliberal consumerist market society is the first step in once again becoming good consumers.

Counseling, of course, is an option as well. The Bureau of Labor and Statistics (2014) projects that the job growth rate for mental health counselors will grow faster than average over the next decade, while psychologists are projected to grow at an average rate. However, counseling is similar to the prescription treatment of mental illness. While it does not physically alter a person’s brain chemistry like medication does, the goal is still to rewire the person’s mental state so that they fit into the neat mold of “consumer” that neoliberalism calls for. Furthermore, counseling requires consumption similar to that of being prescribed to purchase pharmaceuticals. The United States is one of the few industrialized nations in the world that does not provide healthcare for its citizens (Bell et al., 2008). Because healthcare is not a right provided to all people of this nation, people who need treatment are forced to purchase healthcare, further enabling the commercialization of the healthcare system. The sad truth of the matter is that mental healthcare has been commercialized beyond reason. The system no longer exists to heal those that are ill, rather it exists to create profits and rehabilitate the consumer mentality that is required to be considered a normal member of the neoliberal society.

Further research should compare in greater depth the diagnosis of certain mental illnesses linked with behavior, like mood disorders, anxiety disorders, and attention deficit disorders with data regarding the prescription of relevant pharmaceutical drugs. Further research may also find interest in comparing the prescription of certain pharmaceuticals with consumption habits in the United States. More quantitative research would be helpful to sustain the theoretical arguments made in this paper, as such is a limit to the arguments.

An analysis of mental health treatment in the United States through the lens of neoliberalism has provided several interesting conclusions. As long as the United States continues to be governed by the neoliberal model, both in the sense of actual government as well as societal governance, the issues plaguing the mental healthcare system will only get worse. It would not be surprising to see an even greater proliferation in the diagnoses of mental illness in the next several decades, as the provision of pharmaceutical treatment becomes more profitable. We can already see this in the increasing diagnoses of attention deficit disorders (Center for Disease Control and Prevention, 2014).

As the neoliberal mold of normal continues to shrink, fewer and fewer people will be able to fit into it. As a result, those who are stigmatized for not fitting in will be characterized as different and will be asked by society to change their behavior in a way that is more conducive to the consumerist society that they live in. As mentioned in the paragraph above, this will lead to the diagnoses of new mental illnesses, or increased diagnoses in known mental illnesses that can be treated by counseling and pharmaceuticals. Coupled with the fact that patents will eventually expire, and the cost of producing of these drugs will inevitably fall, the system of mental health treatment only stands to become more profitable as time goes on. As the system becomes more profitable the issue is exacerbated, creating a sort of feedback loop where profits drive what is considered normal, which further drives up profits. The real victims of this terrible cycle are those who are actually suffering from the pain of mental illness. These people that struggle to get out of bed in the morning are told that their illness makes them different; they are stigmatized, ostracized, and then they are commoditized.

The quote inscribed on the base of the Statue of Liberty embodies what was once great about the United States. Yet, those days are gone. As long as the healthcare system is one based on profit, a system where healthcare is a commodity rather than a right, mental health treatment will continue to put profits over patients. It does not have to be like this, though. The United States can join the rest of the industrialized world in the way that it provides healthcare, or can reject the neoliberal model altogether. For now, however, consume or be left behind.