By: Gianna Strand
Gianna R. Strand, MS is a doctoral student in research ethics and clinical ethics consultation at Loyola University Chicago. She received a master’s degree in clinical bioethics from Columbia University in the City of New York. Her clinical work focuses on experimental therapeutics in early-phase oncology and transplantation research.
During the 20th century, the American health system experienced rapid decentralization whereby hospitals were no longer the sole hub for receiving care. In its place, a continuum of care model developed requiring patients to navigate increasingly complex, often privatized care in specialty clinics and outpatient centers. (1) Mental health care services also deinstitutionalized as widespread closures of large state asylums forced patients into nursing homes or community-based programming with variable success. (2) Although providers seldom view public libraries as part of the care continuum model, grassroots efforts have demonstrated the feasibility and public support for developing the untapped partnership potential of integrating mental health services into libraries to reduce barriers to accessing and receiving community-based care.
Library-Based Physical Health Interventions
Public libraries are centers for information transfer and community engagement. Alongside a mission to promote literacy, libraries routinely address a wide variety of topics with patrons including educational attainment, job readiness, nutrition, financial skills, and social interaction. These topics are widely acknowledged as intersectional social determinants of health disparities. (3,4)
Comprehensive reviews have previously identified libraries as community-level resources capable of improving the physical domains of health. (5) Libraries routinely serve as a hub or access-point for trained providers to supply patrons with health services like vaccine clinics; blood pressure screenings; nutrition classes; fitness classes; and bins for safe needle disposal. (5,6)
Current Limits to Community-Based Interventions
Public mental health care interventions have not been afforded a similar focus. The community-based programs resulting from deinstitutionalization routinely struggle to meet patient needs as funding for public mental health services has dropped precipitously. (7) The state of Illinois has eliminated $113 million for community mental health treatment services from its operating budget while its largest city, Chicago, has reduced the total number of mental health clinics it operates by half. (8) This leaves many patients with no geographic access to mental health service centers, and the few remaining clinics face care demands in excess of their limited provider capacities.
Where community mental health centers do still exist, individuals do not steadily access office-based services due to barriers in accessibility including transportation and health insurance as well as the expectation of discrimination at care centers. (7,9) This latter notion of approachability is often under-considered in policy attempts to offer community-based mental health services. An estimated half of all inmates in the United States have a mental illness or substance abuse disorder. (10) When these individuals are released, there is a wariness surrounding interactions with community mental health centers and health clinics which are often policed for security. Immigrants, whether lawfully residing or undocumented, are also often fearful that seeking assistance will incur public charge consequences that will compromise their future efforts to secure permanent legal status. (11) These expectations of discrimination affect the approachability of community care centers which negatively impacts mental health treatment maintenance by limiting continuity of care in the outpatient setting.
Libraries as Safe Spaces
Public libraries offer a natural response to these geographic and stigma-based barriers to sustained community-based mental health treatment. The majority of Americans reside less than five miles from a library and consider it easy to access in-person. (12) Unlike hospital emergency rooms or public parks, libraries are not heavily policed nor do patrons need permission, identification, or financing to enter the premises. This allows the more than 17,000 public libraries in the United States to function as one of the few trusted, neutral, and accessible community spaces for those on the margins – including immigrants, the formerly incarcerated, and persons experiencing homelessness – to interact with. (5)
Libraries as a Natural Link
For individuals unable to reach traditional hospital-based resources or fearful of policing in community care centers, libraries offer a unique space to access resources. There is existing overlap in the populations with the highest utilization of library services – women, African-Americans, Hispanics, low-income households, and minor youth (12) – and those at a higher likelihood of experiencing psychiatric disorders and having unmet mental health care needs. (7) Given how these populations often face disproportionate barriers navigating a widening, fractured continuum of services with fewer resources, one ethically justified response would be to introduce novel methods of integrating care.
Small Studies; Big Potential
In the current healthcare system, the onus remains on the individual to know where to locate health information and how to initiate access. Efforts to integrate trained practitioners into a library to shift the burden of seeking care away from patrons has been started by some districts. In San Francisco, where an estimated 15% of patrons experience homelessness, the library system has integrated a full-time clinical social worker alongside the trained homeless outreach team to directly provide patrons case management and housing. (13) This model acknowledges the intersecting burdens of steadily accessing mental health services amid navigating housing insecurities, while still affording patrons their autonomous liberty to accept or reject the offer of engagement at point-of-contact. A community library in the suburbs of New York City has similarly begun offering free sessions with a licensed clinical social worker for those challenged by unemployment or struggling with grief from the loss of a loved one due to COVID. (14) In Connecticut, hundreds of patrons have attended psychologist-run sessions covering topics like depression and addressing hoarding behaviors. (15)
These small examples demonstrate that provider integration, which seeks to transition libraries from solely points of information provision to additional points of access within the care continuum model, is feasible. These points of access, whether for mental or physical health, are generally episodic or short term but create the opportunity for providers to make connections for screening and referral to patrons who may need longer term care. This is similar to historical methods used by community-based health care outreach staff to make contact in existing, familiar community spaces. (7)
Libraries are not immune from the funding cuts faced by public mental health services. Former President Trump notably sought to withdraw funding to library and museum services from multiple federal budgets. (16) What separates libraries from other public works is their near-universal, bipartisan support. Over 95% of Americans believe that their public library is an important, valuable space in the community. (12)
Some patrons have objected that libraries are not the right space for persons with mental health needs. City residents in San Francisco, which launched the program to employ a full-time social worker at the public library, have complained about the "inappropriate use” of library resources such as taking a nap or using the restroom by homeless persons. (13) There are differences, however, underlying objections to use that result in damages to a public resource thereby limiting the benefit others can accrue from that good versus objections to how particular marginalized groups independently use or interact with a public space.
Whether libraries serve as a point in the care continuum for physical health services through a dietician-led nutrition class or mental health services through a psychologist-led group counselling session represents a difference in degree but not in kind. The provision of physical and mental health are both valid and necessary components of a complete health care system. Objections only to the latter reflect the internalized bias and stigmatization of substance use disorders and mental illness. Individuals from all backgrounds and social groups can and do experience mental health care needs. One cannot truly believe that libraries are a valuable public resource to foster community integration and support social and health needs while simultaneously evoking a “not in my backyard”esque objection to mental health care. (4)
In conclusion, ethical public health initiatives must seek to decrease morbidity and mortality in the least restrictive and least burdensome ways. Prior research has evidenced the effectiveness of library-based direct interventions on physical health initiatives. Less research has been afforded to similar library-based mental health interventions, but available information from grassroots efforts by dedicated, localized communities offer the theoretical potential for the value of mental health care integration into libraries. Librarians are not trained healthcare providers, nor should they be conscripted to fill the gaps left by hospital decentralization and deinstitutionalization. Successful integration of libraries into the care continuum model would utilize the intrinsic value of the library as a safe third-space as an opportunity for direct point-of-contact partnering with trained mental health service providers. This partnership allows trained providers to share more responsibility in care delivery rather than leaving patrons to shoulder the demands of navigating how to access an array of possible services. This narrative does not aim to be exhaustive in its review of selected literature but rather to call to action the need to further analyze novel ways in which to assess and define the best practices, benefits, and limits of using library-based interventions to provide ethical community-based mental health care.
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