How Access Became an Afterthought 

Mental illness has existed for as long as humans have, but only in the past century has the concept of ‘accessibility’ been linked to mental health treatment. Unlike water, electricity and transportation systems, mental healthcare was never imagined as something for everyone. It was first built, and has largely stayed, as something meant for the othered, the damaged and the depraved – or, in many cases, something for the rich and the white. Concerns of accessibility have been superimposed on to mental healthcare’s centuries-old roots, long after they had grown unjust. The state of mental health treatment today is the natural end result of relegating access to an afterthought.

Mental healthcare’s access problems can be traced to the very bones of its design. Two specific design features have become especially sticky barriers to building a system that everyone can – and is meant to – benefit from: the problems of vertical and horizontal integration of mental health services. (These terms have roots in the business world, but they’ve been recently repurposed for the healthcare sphere.) In a vertically integrated mental healthcare system, the level of support someone needs links up to the level of care that’s immediately available to them; that level easily ratchets up or down as needs increase or decrease over time. Given vertical integration, a person experiencing a mental health crisis who improves within the first few days of hospitalization would be seamlessly transferred to outpatient and community-based services once ready to leave the hospital; likewise, someone with just-emerging depressive symptoms would receive low-intensity outpatient support, to both alleviate their problems and stop them from getting worse.

The horizontal dimension refers to how well care is integrated across diverse health-related problems and settings – that is, the coupling of care for physical and mental health services. (Mental health supports housed in primary care clinics are a great example of ‘horizontal integration’.) Given horizontal integration, someone reporting mental health needs to their primary care doctor would be quickly transferred to a care navigator or a therapist – depending on their symptoms, wants and needs. Failures in both vertical and horizontal integration of mental healthcare have rendered it virtually inaccessible to those in need of treatment, at the moments they need it most. 

Vertical and horizontal disintegration are modern ways to describe mental healthcare’s problems, but their roots are centuries old. They didn’t happen by accident.

This book stresses the importance of vertical mental healthcare integration (creating easy avenues for ratcheting people’s mental health supports up or down, as needed) and horizontal integration (uniting mental healthcare and other types of medical care) to meet society-wide needs. As I write this book, true integration of mental health treatment along either axis remains theoretical. But many, many people still need help every day. So, what do they do? Who helps them, and how, and when? Answers vary, but together, their stories are stark reminders of the need for new pathways to accessing support. 

When mental healthcare is chronically disintegrated and under-funded, those who need help anyway face several stark realities: crises become the quickest (or only) path to treatment; a two-tiered mental healthcare hierarchy prevails (especially in the United States, and, to a lesser degree, in other countries with insurance-reliant healthcare systems and stark wealth disparities); treatments based on scientific evidence are deprioritised, disincentivised and nearly impossible to get; and even the few who do access treatment are rarely able to complete it.

So, where do we go from here? Are there any promising paths toward helping you, and those you care for, access timely, effective mental health support, short of total overhauls of healthcare systems, insurance coverage and social attitudes toward mental illness? Overhauls will certainly be useful as long-term goals, but people are suffering now. And we can only start from where we are. As a first step, it seems necessary to consider creative solutions that minimise or challenge stigma; are easily embedded within cash- and resource-strapped care systems; are evidence-based and fit within current systems of care; may be accessed outside of formal treatment systems, so that people who would otherwise access nothing might instead access something with potential to help; and respond to the needs, experiences and priorities of service users themselves.

From Little Treatments, Big Effects
by Jessica Schleider, published by Robinson.
Copyright © 2023 by Jesssica Schleider.
Reprinted courtesy of Robinson.


  • Jessica L. Schleider, PhD, is assistant professor of psychology at Northwestern University, where she directs the Lab for Scalable Mental Health. Schleider completed her PhD in clinical psychology at Harvard University, her doctoral internship in clinical and community psychology at Yale School of Medicine, and her BA in psychology at Swarthmore College. Her research on brief, scalable interventions for youth depression and anxiety has been recognized via numerous awards, including a National Institutes of Health Director’s Early Independence Award; the Association for Behavioral and Cognitive Therapies (ABCT) President’s New Researcher Award; and Forbes’s “30 Under 30 in Healthcare.”