To the Editor: We are pleased that our paper in the May issue (1) prompted Dr. Nelson (2) and Ms. Severson and Dr. Lieberman (3) to write commentaries. Their divergence in opinion about the status of the issues addressed in the paper reinforces our perception that there is a need for mental health service providers, researchers, and policy makers to discuss these issues.
On one hand, Dr. Nelson rejects our contention that poverty and other factors play an important role in the social problems experienced by persons with serious mental illness. He argues that mental illness is the root of social problems experienced by persons with mental illness and that treatment for the illness will ameliorate these social problems. On the other hand, Ms. Severson and Dr. Lieberman contend that our arguments are old, and they imply that these arguments are so widely accepted in the mental health community that they deserve little additional comment. The authors argue that action, rather than continued reflection, is needed.
The central thesis of our paper is that poverty has a profound impact on homelessness, employment, and involvement in the criminal justice system independent of the presence of a mental illness. We do not ignore mental illness as an important factor in the experience of poverty, but we note that focusing on aggressive treatment of the illness will not bring persons with serious mental illness out of poverty. Continued impoverishment is what keeps them at high risk of experiencing the aforementioned social problems.
Thinking about policy or program interventions is not an academic sidebar; it is at the center of action. We would argue that this approach is not reinventing the wheel but that understanding the contemporary social and political contexts in which mental health services are embedded is essential to understanding where the mental health wheel fits, and what it can and cannot do. Vigilance is required in understanding changing contexts and changing times. Ideas for new interventions do not exist in the context of early 20th century Europe, which is the context for the historic Penrose study (published in 1939) mentioned by Ms. Severson and Dr. Lieberman, but in the contemporary U.S. context in which the rate of adult incarceration is currently more than four times the 1975 rate (4).
Perhaps it is discomforting when the implications suggested by our analysis seem at odds with our conceptions of our roles as mental health professionals, whether we are social workers, psychologists, nurses, or psychiatrists. Perhaps that discomfort is a starting point from which to face the challenge of developing truly new directions and new ideas.
We hope that readers of the journal will examine the literature we cited in our paper along with related studies and that they will apply our basic criticism to their reading. The comparisons that would most validly support connections between serious mental illness and these social problems are rarely made. For example, in both commentaries on our paper, the authors note that most people with mental illness who are in jails are there for misdemeanors, which they assert supports the criminalization hypothesis. They offer no evidence that this is any different than for the general jail population. The number of misdemeanors among the jail population with mental illness might seem high, but high compared with what? Do these differences remain after the proper controls are used? (5). Even if people with mental illness are more likely to be arrested for misdemeanors, such a simple comparison may not take into account the factors that typically explain arrest.
We hope this conversation continues, and we join in proposing and encouraging more action—but action based on reflection. Actions based on a misunderstanding of the problem can be ineffective at best—leading to misallocation of resources—and may even have an adverse effect. Painstaking effort to understand the work of mental health professionals and its impact, especially when the impact is complicated, is ultimately in the best interest of our clients.