As of 2023, about 137,000 homeless people were identified as being seriously mentally ill in the US. Some thoughts from Charles Lehman on how to deal with this crisis, in response to Scott Alexander. Even though this is US centric, it’s applicable to the whole world.
My grandmother was in an institution for a while after a miscarriage and a grandfather after the Korean war. The abuse of patients / inmates in those days was very bad.
There was never really a moment where we stopped as a society and demanded a full account of all the things (sexual abuse, drugging people into compliance, electroshock as punishment, etc) that happened back then, the abusers by and large got away scott free as we quietly shut down the "hospitals".
>There was never really a moment where we stopped as a society and demanded a full account of all the things ... that happened back then, the abusers by and large got away scott free
Isn't this generally the norm historically for everything? It seems extremely rare that there's ever a full accounting of atrocities committed by a state and justice administered. The Nuremberg Trials are one case where such an attempt was made, but even here it fell far short of real justice as only the people at the very top were prosecuted, which apparently led Winston Churchill to set up a "death squad" of assassins to find the lower-ranking Germans who were involved and murder them extra-judicially. And this is for an action (the Holocaust) where it was so infamous and horrible there's a special word for it, and the trials were conducted by the victors after a brutal world war in which the Germans suffered a humiliating and utter defeat. With things done by the US government to its own citizens, they're lucky if they get an apology before they die, many decades later, probably from some President who wasn't even alive when it happened.
> Note how in Scott's argument it's taken for granted that the US can't possibly build such facilities to hold and help "tens of thousands of people", but not acknowleding how US prisons hold an order of magnitude more people - 1,230,100 people as of 2022, per Bureau of Justice Statistics.
And a nontrivial number of those people are there as a result (to some degree or another) of their mental illness. We're already paying the cost, we're just doing it in a particularly ineffective, inefficient, and cruel way.
> But the fact that Alexander is a practitioner in this space—that he has a micro view—does not mean that he has any particular grasp on the macro realities of mental health policy.
This is a drop in the bucket to me. People comment on things they have no expertise in all the time, sometimes with language loaded to brim with vitriol.
It's strange to me that the author doesn't mention the primary cause of all homelessness, which is housing insecurity. By the numbers in the article, something like 99% of people with "severe mental illness" are not homeless, suggesting there are workable options for people with mental illness that don't require mass institutionalization.
I'm not sure if it's an objective of the "Manhattan Institute" to spin up these institutions for indefinite detention, but I will point out that providing housing universally is definitionally cheaper than institutionalization, which is housing with paid orderlies, guards, service workers, etc. If providing housing is too big-government, eviction protections were seen to curb homelessness during the pandemic. And for these right-wing think-tankers, housing affordability also has an available "market" solution which just requires the loosening of zoning restrictions with little other public investment.
> 99% of people with "severe mental illness" are not homeless, suggesting there are workable options for people with mental illness
How homeless is homeless? Crashing on a friend's couch? Staying with their mom for a few weeks? Living with eight other people in a building nobody's sure who owns? That 99% doesn't imply they're holding down a mortgage or even leasing an apartment.
1. The Mental Health Systems Act of 1980 that closed all Federal mental health institutions, leaving the community of psychiatrists to wrestle with the tough border cases while still tenuously mingling with the locals: totally dismantling the 1946—P.L. 79-487, the National Mental Health Act.
2. The FDA authorized take-home of SSRI and SNRI medicine in 1981 and 1982 respectively. This also marked the rise of mass-shooting in psychopharmacology profiles of such deceased shooters.
This subject affects me directly; I know someone who needs more dramatic intervention than he will accept. Is there a "cookbook" or list of escalation pathways, up to and including legal avenues for relatives, to get help?
For extreme example, how do you get someone committed to an IMD, given that that person genuinely needs it? What can be done less drastic than that, by people who care and are willing to turn the crank on a slow legal system?
In Florida it is actually extremely easy to get someone locked up in a mental hospital for 72 hours. You go to a courthouse and fill out a two-sided paper. It is called an ex Parte order. Then a judge rubber stamps it. Then the police go to the person's house and have the authority from the judge to do whatever it takes to put the person into custody and bring them to a mental hospital. I have been a victim of this paper terrorism style attack. Someone filled out the form with complete fabricated stories and I was locked in a mental hospital for 3 days. I had no ability to see a judge to defend myself. I requested a writ of habeas corpus from the court while in the mental hospital and was never brought to a judge. Now it is on my record in the databases police use for the rest of my life and I will likely never be able to get a security clearance.
Even assuming this isn't abused as in your experience, it would seem sending people with guns to the home of someone in such mental distress that involuntary admission to a psychiatric facility is necessary is probably not the ideal approach.
Depends on the state. Having the cops called at least has a record of the incident. If you’re willing to post a recording sign at your place and get a record of their behavior, it would also be a starting point to clear up any arguments or for further steps.
In some places there is a step where if a person is a danger to them self or others, you can fill out a form for court appointed psych out patient therapy.
You can get an involuntary hold on someone but then getting them out can be difficult and expensive. It may take a doctor, nurse, EMT, cop, and/or judge to agree with you and they see the truly crazy people who really need a bed.
Other than that, trying to barter with the person, or a cop. Depends on the size of the city.
Keep in mind, there could be backlash and failure to get them help. We had to cut a friend and her husband from our circle because all steps failed. We grew tired of the same repeated stories with slightly different plots. The person tried to get other friends fired by making up stories. I feel like we did all we could and needed to move on with our lives.
If memory serves... In the 60s and 70s there was a regular drumbeat of stories of people who had been committed against their will, usually for money-related reasons. So there came a wave of legal reform. Perhaps a bridge too far ?
Most (some?) states allow you to place a 72 hour hold on someone. I was on the receiving end of such a hold around a decade ago and it changed my life dramatically for the better. That being said, I was one of the lucky ones who wanted the help, and did the work to make it work, which took substantially longer than 72 hours.
I also wound up on a 72 hour hold prior to that in the county detox (picked up while drunk by cops) and immediately started drinking the moment I left, so it can take more than one commitment to prompt change, if change is ever prompted.
Do keep in mind that you might irreparably damage a relationship by committing someone against their will, YMMV.
I find this false choice of extremes mindbogglingly strange & blinkered but not unsurprising coming from American culture. From the article:
> they are identified; arrested; committed to a hospital with a psych ward; put on antipsychotics; allowed to stabilize; and released, at which point the entire cycle begins again.
For the author the answer is to never release them, which for the numbers of people involved is a horrifying idea. Incarcerating large numbers of people because statistically a few of them might cause problems for others is not what a free & fair society should aim for.
There are other options, which is to add steps beyond release. Provide sheltered housing & levels of care for these people so that they can try to build meaningful lives in society. It will fail for some and for many it will be long term, but the costs are much less. My wife has worked in mental health in a couple of European countries at several of these levels of care and it's not perfect but it works for enough people that lives are changed and costs to society are reduced. This is also the case for drug abusers, providing the means for those that want to escape the vicious cycle to do so.
In short, other ways are possible, if the culture can be flexible enough to try them.
> For the author the answer is to never release them, which for the numbers of people involved is a horrifying idea
That's western medicine for you... lock them up, pump them full of drugs, and make sure they are a continuous drain of government resources. All to the benefit of pharma companies.
Most acute mental health patients aren't a lifetime problem, unless we make them that way. We barely know what 10 years of diet pills do to people, let alone the magical concoction of drugs we force on other patients.
If you want to say what you think is important about an article, that's fine, but do it by adding a comment to the thread. Then your view will be on a level playing field with everyone else's: https://hn.algolia.com/?dateRange=all&page=0&prefix=false&so...
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[ 4.0 ms ] story [ 56.7 ms ] threadMy grandmother was in an institution for a while after a miscarriage and a grandfather after the Korean war. The abuse of patients / inmates in those days was very bad.
There was never really a moment where we stopped as a society and demanded a full account of all the things (sexual abuse, drugging people into compliance, electroshock as punishment, etc) that happened back then, the abusers by and large got away scott free as we quietly shut down the "hospitals".
Isn't this generally the norm historically for everything? It seems extremely rare that there's ever a full accounting of atrocities committed by a state and justice administered. The Nuremberg Trials are one case where such an attempt was made, but even here it fell far short of real justice as only the people at the very top were prosecuted, which apparently led Winston Churchill to set up a "death squad" of assassins to find the lower-ranking Germans who were involved and murder them extra-judicially. And this is for an action (the Holocaust) where it was so infamous and horrible there's a special word for it, and the trials were conducted by the victors after a brutal world war in which the Germans suffered a humiliating and utter defeat. With things done by the US government to its own citizens, they're lucky if they get an apology before they die, many decades later, probably from some President who wasn't even alive when it happened.
And a nontrivial number of those people are there as a result (to some degree or another) of their mental illness. We're already paying the cost, we're just doing it in a particularly ineffective, inefficient, and cruel way.
This is a drop in the bucket to me. People comment on things they have no expertise in all the time, sometimes with language loaded to brim with vitriol.
I'm not sure if it's an objective of the "Manhattan Institute" to spin up these institutions for indefinite detention, but I will point out that providing housing universally is definitionally cheaper than institutionalization, which is housing with paid orderlies, guards, service workers, etc. If providing housing is too big-government, eviction protections were seen to curb homelessness during the pandemic. And for these right-wing think-tankers, housing affordability also has an available "market" solution which just requires the loosening of zoning restrictions with little other public investment.
How homeless is homeless? Crashing on a friend's couch? Staying with their mom for a few weeks? Living with eight other people in a building nobody's sure who owns? That 99% doesn't imply they're holding down a mortgage or even leasing an apartment.
1. The Mental Health Systems Act of 1980 that closed all Federal mental health institutions, leaving the community of psychiatrists to wrestle with the tough border cases while still tenuously mingling with the locals: totally dismantling the 1946—P.L. 79-487, the National Mental Health Act.
2. The FDA authorized take-home of SSRI and SNRI medicine in 1981 and 1982 respectively. This also marked the rise of mass-shooting in psychopharmacology profiles of such deceased shooters.
https://www.kff.org/wp-content/uploads/2013/01/7684.pdf
We have come full circle from no psychiatric drugs (1820s) to full anti-psychiatry movement today.
For extreme example, how do you get someone committed to an IMD, given that that person genuinely needs it? What can be done less drastic than that, by people who care and are willing to turn the crank on a slow legal system?
In some places there is a step where if a person is a danger to them self or others, you can fill out a form for court appointed psych out patient therapy.
You can get an involuntary hold on someone but then getting them out can be difficult and expensive. It may take a doctor, nurse, EMT, cop, and/or judge to agree with you and they see the truly crazy people who really need a bed.
Other than that, trying to barter with the person, or a cop. Depends on the size of the city.
Keep in mind, there could be backlash and failure to get them help. We had to cut a friend and her husband from our circle because all steps failed. We grew tired of the same repeated stories with slightly different plots. The person tried to get other friends fired by making up stories. I feel like we did all we could and needed to move on with our lives.
I also wound up on a 72 hour hold prior to that in the county detox (picked up while drunk by cops) and immediately started drinking the moment I left, so it can take more than one commitment to prompt change, if change is ever prompted.
Do keep in mind that you might irreparably damage a relationship by committing someone against their will, YMMV.
> they are identified; arrested; committed to a hospital with a psych ward; put on antipsychotics; allowed to stabilize; and released, at which point the entire cycle begins again.
For the author the answer is to never release them, which for the numbers of people involved is a horrifying idea. Incarcerating large numbers of people because statistically a few of them might cause problems for others is not what a free & fair society should aim for.
There are other options, which is to add steps beyond release. Provide sheltered housing & levels of care for these people so that they can try to build meaningful lives in society. It will fail for some and for many it will be long term, but the costs are much less. My wife has worked in mental health in a couple of European countries at several of these levels of care and it's not perfect but it works for enough people that lives are changed and costs to society are reduced. This is also the case for drug abusers, providing the means for those that want to escape the vicious cycle to do so.
In short, other ways are possible, if the culture can be flexible enough to try them.
That's western medicine for you... lock them up, pump them full of drugs, and make sure they are a continuous drain of government resources. All to the benefit of pharma companies.
Most acute mental health patients aren't a lifetime problem, unless we make them that way. We barely know what 10 years of diet pills do to people, let alone the magical concoction of drugs we force on other patients.
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If you want to say what you think is important about an article, that's fine, but do it by adding a comment to the thread. Then your view will be on a level playing field with everyone else's: https://hn.algolia.com/?dateRange=all&page=0&prefix=false&so...