Mental illness and the broken system intended to address it are among this nation’s dark secrets. Each year, tens of millions of Americans and their families struggle with mental health challenges ranging from anxiety and depression to bipolar disorder and schizophrenia. Mental illness disrupts education and employment. It challenges family relationships. It tests our criminal justice system. It costs business and the health industry billions of dollars. And tragically, far too often, it costs people their lives.
And if you are Black or brown, the disparities in access to treatment and treatment itself are unconscionable and compound other system failures.
In this challenging moment, we are grappling with two unprecedented realities: the pandemic that has upended society as we know it, and the potential for serious reckoning with our history of racial injustice spurred by the massive, widespread protests following George Floyd’s murder. It is in these moments that philanthropy has a unique responsibility to do two things at once: respond to the immediate challenges and catalyze systemic change, particularly in long-overlooked areas critical to creating a “new normal.”
So that prompts a question about mental health that was serious before COVID-19 and imperative now: Where is the philanthropic community?
Those of us who have held senior positions in philanthropy are aware of its power and blind spots. We know that it can, and should, take on the greatest challenges facing society. At times, it has, albeit slowly and unevenly. We’ve seen this in historic efforts to support civil rights, marriage equality and the response to AIDS, and current efforts to make climate change and structural racism the priorities they should be.
So what can philanthropy do to address the nation’s vast mental health challenges at this moment? And with more funders stepping up to help undo systemic racism, as well as deep economic disparities spotlighted by the pandemic, how should philanthropy think about mental health as a leverage point for advancing a broader equity agenda?
Vital Yet Neglected
These questions are personal for me. Motivated in part by personal tragedy after my young-adult son developed and died from a serious mental illness, I spent time exploring the question after I left my position as director of U.S. Programs at the Open Society Foundations. I learned about a profound and wide-reaching domain that has all the ingredients to be a top philanthropic priority. But it is not. According to data from CANDID developed by the Center for High Impact Philanthropy, mental health accounted for 1.3% of overall foundation investments from 2015 to 2018, and, even more strikingly, only 5% of foundation spending on healthcare.
On one level, this is surprising. Mental health has huge implications for all Americans, one in five of whom experience such challenges each year. The implications are especially notable for African-Americans, LGBTQ youth, veterans and rural Americans facing marginalization and added stigma. Moreover, as a result of COVID’s impact, recent reports suggest a staggering rise in the suicide rate, along with lesser forms of mental health and substance use disorders (collectively referred to as behavioral health). One study suggests upwards of 150,000 additional deaths in coming years.
Further, for philanthropy, mental health is integral to the success of many key priorities. Notably, criminal justice reform has risen to the top of philanthropy’s agenda, with a keen focus on reversing this nation’s historic treatment of Black and brown people. But the connection here to mental health has not received equal philanthropic attention. The biggest mental health institutions in the United States are our prisons and jails, with the L.A. County Jail the nation’s largest. Incarceration is both a cause of, and a failed response to, mental health issues.
Similarly, mental health is one critical part of the long overdue conversation about policing in the United States. Simply put, we need responses to mental health emergencies that do not center law enforcement. By prioritizing effective and culturally competent mental health supports, we can end the faulty overreliance on police in this area.
So it is with other top priorities for funders—like expanding life opportunities for low-income families and empowering girls and women. Whether a funder’s approach focuses on individuals and families or the systems intended to support them, mental health ranks high on any rational assessment of what matters for resilience and progress.
The good news is that this is an area ripe for dramatic progress. There are promising seedlings for change that could lead to systemic transformation—if appropriately assessed, adapted and scaled. By philanthropy’s own criteria, it’s time to recognize the potential of high-leverage grantmaking in this space.
Let’s take a closer look at the logic of stepped-up philanthropic funding for mental health.
The Almighty ROI
First, there’s the compelling economic case. According to a recent study by McKinsey & Co. that analyzed national insurance claims data, 60% of total medical expenditure is driven by the 23% of members who have mental health or substance use disorders. The study estimates that every dollar spent on scaling up treatment for common mental disorders generates four times the return through improved health and productivity. For this reason, we are starting to see significant initiatives involving the business community, such as One Mind at Work, which has organized Fortune 100 companies around a set of principles and action steps that prioritize and highlight behavioral health treatment and reform.
Further, there are huge savings to be obtained by investing in prevention and early intervention. According to a joint analysis by the National Academies of Sciences, Engineering and Medicine, every $1 investment in prevention and early intervention for mental illness and addiction programs yields $2 to $10 in savings. These interventions include an increased focus on screening and targeted responses when mental health challenges first arise. Especially at a time when fiscal constraints threaten so many philanthropic priorities, we simply cannot afford not to advance mental health reform.
Strengthening the Racial Equity Agenda
Second, there’s the explicit racial and social justice case, readily evidenced by the arc of criminal justice reform.
The pioneering Judge Leifman of Miami-Dade County emphasizes that we have replaced the deeply damaging over-institutionalization of people with mental illnesses in psychiatric hospitals by institutionalizing them in our jails and prisons—at least those who are people of color. Today, in New York City at the notorious Rikers Island jail complex, more than 50% of the individuals have mental health needs, nearly 20% have a serious mental illness, and 90% are Black or brown. These figures are consistent with national statistics. While the hard-fought effort to get New York City to agree to close Rikers is a significant breakthrough, it also reinforces that we must remake our behavioral health system, even as we fight to end mass incarceration.
Of course, the social justice case goes much further. It includes addressing racial disparities in access to mental healthcare and the need for cultural competency within the mental health sector—all areas in which philanthropy’s increasing focus on racial equity in other fields can be brought to bear. It extends to the growing philanthropic commitment to confront the “social determinants of health”—the non-health system factors closely aligned with racial equity goals that impact mental (and physical) health, such as unsafe housing, dangerous neighborhoods and poor educational experiences. In this regard, one notes the social justice relevance of trauma-informed care and interventions to reduce adverse childhood experiences (ACEs).
All told, mental health is deeply intertwined with philanthropic social justice efforts to advance economic opportunity, education, housing, criminal justice, civic engagement and more.
Capitalizing on Momentum
A third case for prioritizing mental health in philanthropy rests on the clear potential to elevate a critical societal challenge. At its best, philanthropy can identify “emerging issues of scale” that are ripe for breakthrough progress, but where there’s not yet an adequate private and public sector response.
Mental health is at this tipping point, with youth, celebrities and business groups beginning to prioritize it. On the youth front, as anyone with teenagers or college students knows, part of the promise of the moment is how actively and openly young people are engaging with mental health concerns, issues and discussions, challenging stigma and seeking change. Similarly, we are witnessing prominent celebrities, including NBA stars such as Kevin Love, musicians like Billie Eilish, and prominent cultural icons such as Kenneth Cole speaking publicly to combat mental health stigma and advance a changing narrative.
And, as noted above, the corporate community is starting to act as the business case for addressing mental health and addiction issues has become increasingly clear (even if legal requirements to equalize mental health insurance coverage through the Parity Act are unevenly met). For example, Path Forward, a recently launched partnership between a major employer benefits group, the American Psychiatric Association and Meadows Public Policy Institute, has created a five-point plan to expand behavioral health coverage and effectiveness.
Finally, it is notable that there is bipartisan support for stepped-up efforts on mental health, as reflected in major legislative commitments in both Texas and California (not a pairing that one usually sees). As the nation deals with the mental health fallout from the trauma of COVID-19—a challenge that’s already drawing media attention—the political climate is likely to become more receptive to new action in this area.
Advancing a Growing Ecosystem
A fourth and final case for why philanthropy should prioritize mental health is that this is a field rich with emerging leaders and promising innovations. While still at an early stage, there are important seedlings that suggest the potential and growing capacity of key actors in the field. Some of these are about peer-led networks that are centering people with lived experience, and reorienting approaches that for too long were overly dependent on a disempowering medical model.
Groups such as Active Minds on college campuses and the Foundation for Excellence in Mental Health Care are surfacing the leadership of people who have lived experience with mental health challenges and offering new approaches that force reconsideration of models of practice and intervention. National nonprofits focused on mental health, such as the National Alliance on Mental Illness (NAMI) and Mental Health Association (MHA), are working in new ways with the Kennedy Forum and the guilds, the American Psychiatric Association and the American Psychological Association. And there are new entrants, such as the recently launched Inseparable that is integrating campaign tactics from other advocacy efforts, such as the marriage equality fight.
Finally, there is growing application of institutional reform approaches that recognize how sectors like higher and secondary education must address mental health. For example, the Jed Foundation is engaged with over 300 colleges and universities across the country regarding mental health supports and interventions, drawing on suicide prevention lessons originally piloted by the Air Force.
Why Isn’t Philanthropy Stepping up on Mental Health?
Given these factors, what is the reluctance that accounts for the lack of broad-based philanthropic engagement to date?
In talking to philanthropic and civil society leaders over the past year, what is clear is that some of the traditional reasons for reluctance are diminishing. Historically, of course, our nation has never been good at dealing with issues around mental health. In part, this is due to stigma, which at times rippled out onto funders who sought to engage, and in part because support of people with mental health challenges (like other forms of care) has been undervalued as “women’s work.” From others comes a view that the challenge seemed too large, with insufficient potential for success. Yet in a philanthropic moment when combating stigma is seen as a key objective, and large-scale problems like climate change and criminal justice reform are prioritized, these no longer stand as the barriers they once were.
Instead, what comes to the fore are two issues—neither of which seems to reflect fully a current read of the field. First, there is a perception that the complex interplay of issues that account for the current system failures do not provide a focus for reform efforts or an easy entry point. Yet, as reflected in the above discussion, there are emerging insights from both new and old actors that suggest this perspective is out-dated. Recent efforts, such as Well-Being Trust’s Healing the Nation framework, point to new strategic frameworks for change. Especially as philanthropy recognizes that virtually all major issues require cross-sectoral approaches that involve an array of tools, it is clear that foundation expertise in realms ranging from (physical) health systems, criminal justice, education and workforce development are, fundamentally, interrelated with behavioral health.
Second, there is a sense that the diverse perspectives of foundations fragment the potential for collective philanthropic action, and thus lead to questions about the potential for change that can occur at scale. Unquestionably, there are complicated and diverse issues to be addressed: the reality that 50% of mental health professionals are not part of insurance networks; the tattered social safety net and fiscal challenges faced by educational and other institutions that hinder prevention and early intervention; the geographic disparities in availability of mental health supports that make the challenges in North Dakota very different from those in New York City.
But this is a question of philanthropic leadership and will, not about the potential and need for change. And this is where one hopes that philanthropy takes seriously the lessons of criminal justice reform, where the multi-faceted approaches foundations are capable of pursuing have supported change in an equally challenging domain.
Areas of Opportunity
So especially in this moment, there is unquestionably opportunity and promise in the face of challenge and turbulence. With new entities such as Mindful Philanthropy identifying specific opportunities of note, and knowing that each foundation brings its own expertise and approach to bear, some of the areas of promise include:
- The intersection of criminal justice and behavioral health as previewed above, including the exceedingly timely public conversation about alternatives to law enforcement’s role in dealing with mental health emergencies.
- The expansion of the philanthropic focus on the social determinants of health and other forms of place-based interventions to specifically incorporate mental health, including how prevention and early responses to ACEs might transform the trajectory of low-income families, particularly those of color.
- The application of philanthropy’s growing focus on racial equity and disparities to the mental health arena, including steps to improve access to quality care that addresses cultural barriers such as those undertaken by Steve’s Fund in its impressive work involving students of color in higher education.
- For those engaged in healthcare system reform, the full incorporation of behavioral health so that it is possible to realize and scale promising efforts including payment reform (e.g., collaborative codes), the promise of tele-health initiatives, the integration of primary care physicians and other basic healthcare providers, and improving outcomes while reducing the spiraling costs of the system.
- For those engaged in education, workforce and other sectors that begin with people as students, teachers or workers, the investment in system adaptations to incorporate mental health as fundamental to success and sustainability.
- For states and localities initiating efforts to rebuild economies post-shutdown, the incorporation of mental and emotional health into these efforts.
Whether in these or other engagements, philanthropy can play a critical role in combating stigma by standing up and speaking out. In doing so, it is vital that philanthropy operate from an aligned playbook based on core values and long-term goals, even as distinct funders play to their respective strengths. In this sense, mental health is no different than other targets of collective impact that prioritize scale rather than go-it-alone approaches.
It is, of course, easy to emphasize the immense costs of not engaging around mental health and substance use disorder, reflected most recently in the concept of “deaths of despair” detailed by Anne Case and Angus Deaton in their recent book. But it is equally important to emphasize the positive potential of making change in the mental health arena. Especially in this time of great uncertainty, a commitment to emotional and mental well-being for all and support for the dignity of every individual, including those with mental or emotional illnesses, is a critical stepping stone toward strengthening our society’s resilience and recognizing our common humanity.
Twenty-five years ago, it was unthinkable that there would be broad bipartisan consensus around criminal justice reform supported by celebrities and politicians, grassroots advocates (from evangelicals to formerly incarcerated people), and law enforcement and other professionals in the field. And even more significantly, that there would be real movement in changing the fundamentals of how the criminal justice system operates, from significant shifts in public policy (e.g., bail reform, three strikes laws, diversion programs) to a significantly expanded set of evidence-based programs and research from America’s most prestigious institutions, such as the National Academy of Sciences. While we still have a long way to go, philanthropy played a significant role in supporting these changes, and should reflect on how it can similarly catalyze transformation elsewhere.
It is time to imagine a similar arc related to mental health. To the extent that philanthropy is first and foremost about the exercise of imagination, this is a future worth considering. And given the potential that exists and the moment we are in, it is worth not just the imagining but the investing.
Ken Zimmerman is a Distinguished Fellow at NYU’s Furman Center and the former Director of U.S. Programs for the Open Society Foundations. He previously served in the Obama and Clinton administrations, as Chief Counsel to New Jersey Governor Corzine, and as the founding Executive Director of the New Jersey Institute for Social Justice. He can be reached at firstname.lastname@example.org.