Back to the Future

Since the 1970s psychiatrists have focused primarily on clinical concerns and biomedical research while broader sociopolitical forces have typically been viewed as beyond the purview of psychiatric expertise. The latest welfare legislation in tandem with an intensification of corporate restructuring signals an end to the illusion that psychiatrists must eschew involvement in the sociopolitical arena.

It is estimated that the welfare legislation, signed in August 1996, may drop 3.5 million children from the welfare rolls by the year 2001, and 4.9 million by 2005. Funding for food stamps will be cut by $28 billion. This country already has child poverty rates that are two to three times those of other developed nations. Eventually this legislation will be felt deeply in cities such as Detroit, where 67 percent of children receive welfare during the course of a year, or New York City, where the figure is 39 percent. Moreover, the legislation can deny food stamps, Supplemental Security Income, and Medicaid to many legal immigrants; some 900,000 persons nationally may be affected. Finally, the new legislation will surely have an impact on many persons with chronic mental illness because many live near or below the poverty level.

Along with legislation directed at indigent persons and immigrants, corporate restructuring has created job insecurity and stagnant wages for many workers. Wages for high school graduates have been declining for 20 years, and the median wage for all workers fell 3.3 percent between 1992 and 1994. Nearly three-fourths of all households report having had a close encounter with layoffs since 1980.

An extensive body of research has established that poverty, social stress, unemployment, diminished job satisfaction, and powerlessness are causally linked with serious mental illness, suicide, drug and alcohol abuse, domestic violence, physical disease, and the erosion of the social fabric. Furthermore, research also indicates that low socioeconomic status can negatively influence the course and outcome of chronic mental disorders.

Ironically, condemnation of community psychiatrists for transgressing their professional boundaries in the 1960s to become involved in social causes was made more credible because many of the visible linkages between sociopolitics and mental health, such as extreme poverty and racial discrimination, were partly mitigated by the legislation of that period. Regrettably, these causal linkages are again becoming manifest as psychiatrists must deal with the casualties of the new welfare legislation and of the transformation in economic structures. As these linkages become increasingly recognized, good medical practice dictates that psychiatrists must develop clinical, educational, and sociopolitical strategies to explicate and ameliorate them.