Deaths of Despair: Interview with an Expert on Mental Health in the U.S.

A person may say they have high anxiety because they don’t have a job or a place to sleep. When it comes to the individual clinical level, we need to have a holistic view of a person. This means coordinating with resources that may be able to help with other pieces.

Tyler Case, Licensed Professional Counselor & Certified Alcohol and Drug Counselor in McMinnville, Oregon

The American Dream is integral to the moral and ethical fiber of the United States. As the “Land of Promise,” all citizens are told that with hard work, gumption, and good old-fashioned American ingenuity, anyone can be successful.

Programs like the New Deal put this dream in reach for many, especially veterans. The American Dream was the ultimate means of ensuring the continuation of democracy and capitalism during the Cold War. Who could be swayed by communism when the American Dream promised a twenty-year mortgage, car, and family with access to higher education? The “Greatest Generation” could promise their children far more economic security than they’d had. In a country transitioning out of the Depression and the horrors of two world wars, this paradigm meant securing a future that promised opportunity and access to a bigger, brighter future.

This national consciousness not only extends to a work ethic (notably, Americans are among the most overworked when compared internationally) but also to social welfare programs where the ability to access services is tied to work requirements. Americans are supposed to “pull themselves up by their bootstraps.” But what happens when you have no boots in the first place?

The Uneven Impact of the War on Drugs

This reality has plagued people of color, indigenous peoples, immigrants and refugees, and low-income households. Racism, discrimination, and limited economic mobility are just a few of the many issues that limit non-white and low-income folks from being able to access the American Dream.

This is exacerbated when the very programs designed to help poor Americans are instead conditioned on their ability to work. This is an issue well-known to urban areas, where jobs and economic opportunities are limited for Black and Latinx Americans. Segregation, redlining, and white flight diminished investment and employment in these areas, making them ripe for the proliferation of drugs such as crack and heroin from the 1960s to 1990s.

This severe public health crisis was instead treated as a crime issue, where it became the “the War on Drugs.” The results of this approach led to tougher sentencing requirements for low-level drug offenders such as increased mandatory minimums and “three strikes” laws, as well as increased racial profiling codified through policies like “broken windows” policing and “stop-and-frisk”.

On the other hand, the impacts of heroin and opioids since the mid-1990s have largely impacted white Americans. This increase in addiction is concurrent with decreased economic mobility for white Americans who primarily live in rural and suburban areas. Many of these communities previously had natural resource-based economies, such as timber harvesting or coal mining, that are now restricted due to their environmental impacts.

Others have seen decreased economic mobility due to the globalization of manufacturing jobs or automation. Overwhelmingly, this group is far more economically insecure than their parents, going against the promises that the American Dream set forward.

Consequently, the current face of the drug epidemic is now White Americans in suburban and rural areas rather than Black Americans in the inner city. Counter to previous policy and programmatic approaches to substance abuse and addiction, public agencies and law enforcement officials carry Naloxone, the prescription nasal spray that counteracts the effects of an overdose. Multiple states have passed emergency legislation to fund behavioral health services and increase access to treatment.

“Diseases of Despair”

New York Times columnist and Oregon resident, Nicholas Kristoff, wrote Tightrope with his wife and frequent collaborator Sheryl WuDunn. Focusing on the farming town of Yamhill in rural Northcentral Oregon, their recently published book chronicles an “unfolding humanitarian crisis” in rural Oregon—one that is mired in economic hardship, addiction, substance abuse, and lack of health care. Suicide, drug and alcohol overdose, alcoholic liver disease have increased among middle-aged white Americans with less than a college education and who live in rural and suburban areas. This crisis has been coined as “diseases of despair.”

While the term is new, the impacts of economic hardship on substance abuse, overdoses, and suicides is not. These issues have long afflicted Black and Latinx Americans whose public health needs were criminalized instead of holistically treated.

As the understanding of addiction and substance abuse as a public health crisis evolves with further research and a shift in the public mindset, there is hope that one day Americans will see the diseases of despair as an epidemic that impacts all Americans.

A Holistic Approach to Addiction

Tyler Case is a licensed professional counselor and certified alcohol and drug counselor in McMinnville, Oregon. The largest city in Yamhill County, McMinnville is a modest town of 40,000 people just twenty minutes south of the town profiled by Kristoff. Case was born and raised in Oregon and has worked in mental health for over 15 years, including stints at the local mental health clinic and psychiatric hospitals. He recently opened his own private practice in downtown McMinnville.

“I see a wide variety of people socioeconomically—everyone from entrepreneurs to manual laborers,” he said. “I look at addiction as part of mental health treatments.”

Case always had a knack for counseling: “I was someone that people would seek out to go talk to,” he said. He’s a quiet person who focused on listening and helping people process issues.

His interest in counseling was also encouraged when he had to “deal with family issues on addiction and substance abuse.” He was already pursuing a degree in the field, but he wanted to go further. That meant getting a master’s degree in counseling to fulfill his goal of running his own practice.

Counter to popular narrative, he hesitated to confirm whether there’s an outright increase in addiction and substance abuse among the patients he sees. “I’ve seen more people seek out help for issues that involve addiction,” Case emphasized. “There are more people coming to the forefront. Most of my addiction treatment is court-mandated.”

The Affordable Care Act and Access to Mental Health Services

Perhaps the biggest change he’s seen? “The Affordable Care Act was a huge part of this [increase]. It increased Medicaid [services], especially with the Oregon Health Plan,” he said. He described this change as “revolutionary when it comes to mental health treatment and who is able to access it.” In particular, he noted the requirement for private health insurance to cover mental health care. In other words, there may be a boom in people looking for mental health care because benefits have increased.

However, while healthcare coverage has increased, economic hardship still lingers, especially in rural Oregon where timber was once king, and communities were heavily reliant on profits from timber sales.

Case noted he has observed an increase in substance abuse since he was a kid. While he highlights that this may be the result of “increased awareness”, he emphasized that “it [addiction and substance abuse] came through here and remains like plague.”

He further remarked, “It could also be a symptom of the intergenerational trauma of children in our society—something we have only looked into since the 1970s.” He mentions that American culture also prioritizes quick fits to escape, medication culture, and more. In other words, “we [Americans] are just reaping benefits of the seeds sown over the last hundred years.”

A Holistic Approach: Understanding Co-occurring Risk Factors Among Americans

This deeper understanding of culture has led to a more well-rounded approach to care—one that is perhaps the result of the increase in homelessness that many communities, especially on the west coast, are seeing. Homeless residents not only need access to housing and employment, but may also need access to physical and mental health care.

According to Case, this has expanded our understanding of mental health: “A person may say they have high anxiety because they don’t have a job or a place to sleep,” Case said. “When it comes to the individual clinical level, we need to have a holistic view of a person. This means coordinating with resources that may be able to help with other pieces.”

For example, take an individual that is depressed and anxious because they have no job, insecure housing, and want to go back to school. If they have coverage through the Oregon Health Plan, he would know what resources to share with them. “I could connect them with an employment specialist who can connect with you and help you tackle getting a job as part of your mental health,” he said.

Case is quick to remark that a holistic approach to mental health is only a single part of the solution. “Increasing the minimum wage would be life-changing for a lot of people in that position,” he emphasized. “I have someone trying to start a small business, as well as do DoorDash and drive for Uber because one minimum wage isn’t enough to start a business and survive.”

Similarly, he also cites universal healthcare as another vital policy change. He imagines a world where each health care visit, no matter what time of year, is $5, rather than the $40 copay that is offered by some of the better healthcare plans available on the market.

Moving Toward a Stronger Mental Health System to Prevent Deaths of Despair

As with many policy issues, so much comes down to funding. Despite starting his practice almost seven months ago, he is completely booked with appointments and having to turn away clients: “Funding for mental health workers is necessary … counseling is underfunded and under prioritized everywhere I’ve seen it.” He added, “Whether it’s here [McMinnville], Salem, or Portland, it seems like it’s hard to find a counselor that is available. Part of this could be picked up by county health agencies, but it’s a statewide issue.”

He wondered if it’s the result of the recurring myth that it’s hard to make a living as a counselor. Noting part this myth could be the result of low salaries in government positions and the cost of the required education, in addition to issues with the Public Service Loan Forgiveness Program, he emphasized that private practice is still an option—one that’s been enough for him to support his family and then some.

“Any small business is as successful as your ability to organize, prioritize, and get financially viable,” Case stated. “From the month I started, I was profitable, even before I was on insurance panels. Before I was doing it [his practice] full-time, I was doing it after work for $100. That is still a profit.” He encouraged anyone interested in mental health counseling that it is doable.

“It’s a viable career—it’s about how you choose to put it together.”

Bree Nicolello

Bree Nicolello


Bree is an urban planner and freelance writer based in Seattle, WA. She has worked on land use and housing policy issues throughout the Pacific Northwest. She previously led Run Oregon Run, a nonprofit dedicated to helping Oregonians run for office and apply to boards and commissions. When not writing, she is lovingly tending to her cast iron pans.

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