Insurance companies in the United States are notorious for their poor mental health coverage. It’s gotten to the point that mental health parity laws have been passed, demanding that insurance companies handle mental health benefits in a manner consistent with benefits related to ‘medical and surgical’ needs[1. Apparently mental health is not a medical need?]. Several recent suits in California and elsewhere have highlighted this issue, both making people more aware of mental health parity laws, and underscoring that insurance companies continue to discriminate against mentally ill patients.
The divide in coverage between what I’ll call, for our purposes, mental and physical health[2. Obviously this is an extremely simplistic split. Some mental health conditions cause physical symptoms and vice versa, mental and physical health interact, etc.] illustrates a larger cultural divide in the way people think about illness and disability. Disability is often framed as something embodied; the very name implies this. A disability is something physical, not mental. The brain is something different. The mind/body divide is stark, when it comes to the way people talk about disablility; many people with serious mental illness do not consider themselves disabled because this thing is in their minds, not their bodies, and they don’t ‘count.’
This is not to say that all people with mental illness should identify as disabled. Clearly there are some people who have considered it and don’t feel comfortable with that identity, and there are others who don’t experience mental illness as disabling, and I am not interested in forcing labels on people. But I sometimes encounter discussions about mental illness and mental health conditions that people describe in ways that sound disabling to me: ‘I can’t work,’ ‘I have trouble sleeping,’ ‘I can’t complete basic tasks,’ ‘people in my workplace discriminate against me.’ Yet, they declare that they are not disabled. They say they don’t need accommodations, although if you say ‘would it help if you could go to work two hours later,’ and they say ‘yes, it would,’ and you say ‘well, that would be an accommodation,’ a little lightbulb goes on.
In the hierarchy of disability enforced both within and without the disability community, there’s a clear divide between physical disabilities and mental illness, along with cognitive and intellectual disabilities. But it’s mental illness in particular that is often declared not to be a disability—mentally ill people don’t need accommodations, they don’t experience discrimination, they don’t experience disabling events. As some people with moderate to severe mental illness know, none of these claims are actually true, but they’re often internalised, making it difficult to identify mental illness as something that may potentially be disabling for some people, who could potentially benefit from accommodations.
Which brings us back to mental health parity laws. Through such legislation, insurance companies are being asked to consider mental health conditions as equivalent to physical health problems. If you have bipolar disorder, the coverage limits must be the same as those if you have breast cancer. Insurance companies cannot deny coverage to anorexic patients who need to be hospitalised, just as they must provide coverage to patients who need feeding tube insertions because they cannot swallow.
There is a small part of me that wonders if this could, perhaps, pave the way to breaking down the brain/body divide when it comes to talking about disability. The brain is part of the body. Things that happen in the brain affect the body, just as things that happen in the body affect the brain. Brains matter too! What about the brains? There’s a lot of resistance in some areas of the mentally ill community to identify with the disability community, a reminder that many people still consider disability a bad thing; ‘I may be mentally ill, but I’m not disabled.’ This really leaves people who have both mental illness and physical or other disabilities out in the cold.
I find it increasingly hard to define, to pin down, to identify disability, because it is a complex social and cultural identity. But this I know: Disability is not a bad thing. It’s just a thing, that is, that can result in incredibly varied lived experiences. And, often, it can be a thing that requires accommodation for people to achieve their full potential.
All people deserve accommodations. And when you frame disability in terms of accommodations, suddenly it starts to apply to some mental health conditions, in some cases, which is precisely why mental health needs to be thoroughly covered by insurance companies, to ensure that people with mental illness can receive adequate coverage through their insurance plans. And it is precisely why discrimination against people with mental illness matters, because it is a form of ableism, and a civil rights issue.
I know firsthand how disabling mental illness can be, and how interconnected my mind and body are; as someone a mixture of disabling conditions, I am familiar with both sides of this coin, and sometimes I have trouble differentiating between them. There’s not a point where my mind ends and my body begins, there are no parts of me I can turn off and on. I am a whole organism, a complete entity, and to deny that sometimes my brain harms me, and sometimes people harm me because of my brain, would be a disservice to myself.
Again, this is not about demanding that everybody with mental illness instantly start identifying as disabled, not least because many people do not experience mental health conditions as disabling. A disability identity is not something that should be forced on anyone, ever. But it is a question—where does the mind end and the body begin? Why do we keep reinforcing the hierarchy of disability with claims that some disabling conditions are more ‘real’ than others? Why is it that cerebral palsy, for example, is widely socially accepted as a disabling condition even though people with CP experience a wide range of symptoms, and some necessarily don’t experience disability or identify themselves as disabled, while depression is socially often not considered a disability, even though some people with depression find it disabling?
The stigma against mental illness plays into the same stigma that surrounds disability, and yet the two communities sometimes seem deeply divided. Mental health parity laws are a small chip at the armor, there, and they make me wonder where else we could chip away; can we start talking, for example, about employment discrimination against people with mental health conditions?