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"The one institution that can never say no to anybody is jail."
April 1, 2012 8:52 AM   Subscribe

"If you think health care in America is bad, you should look at mental health care," says Steve Leifman, who works as a special advisor on criminal justice and mental health for the Florida Supreme Co " Fifty years ago, the U.S. had nearly 600,000 state hospital beds for people suffering from mental illness. Today, because of federal and state funding cuts, that number has dwindled to 40,000. When the government began closing state-run hospitals in the 1980s, people suffering from mental illness had nowhere to go. Without proper treatment and care, many ended up in the last place anyone wants to be." Of course, it's not just a problem confined to the US.
posted by dave78981 (69 comments total) 52 users marked this as a favorite

 
I don't know why (as there are so many horrible abuses in this society of its weak members) but this neglect of the mentally ill irks me so fearsome. Shame on its enablers & on those who tolerate & excuse it
posted by growabrain at 9:20 AM on April 1, 2012 [3 favorites]


This is what you get when you ask for "smaller government." Shame on us.
posted by haltingproblemsolved at 9:46 AM on April 1, 2012 [13 favorites]


They've changed their platform over the years, so the formatting is pretty cruddy, but Bernard Harcourt did a pretty interesting (to me anyway) series of posts on the Volokh Conspiracy blog a few years ago about the shift from institutionalization to incarceration in America over the last half century. The graph combining the mental hospital and prison incarceration rates is particularly striking (and, as an aside, doesn't totally support the view laying the whole story, or even the bulk of it, on the 1980s).
posted by dsfan at 9:47 AM on April 1, 2012 [3 favorites]


The highly visible mentally ill homeless population has grown dramatically within my lifetime. I'd always assumed it was mostly from the deinstitutionalization, but the graph dsfan linked makes it look like that happened earlier, so the story must be more complicated.
posted by Forktine at 9:57 AM on April 1, 2012 [1 favorite]


Mental illness is one of the more pernicious stigmas around. I feel we will become a post-racial (ha ha ha), gender neutral, marriage equity society before we become tolerant of those with Serious and Persistent Mental Illnesses. It is so built into our everyday language very few people care.

At it's core, Deinstitutionalisation is not a bad idea, but in reality it was just an excuse to cut funding. Fuck Reagan and the Reagan model of thinking. The 1980 presidential election was more important than most people realize and all we got is decades of social service cuts and the cult of Reagan.
posted by edgeways at 10:06 AM on April 1, 2012 [16 favorites]


See, the free market is more efficient!
posted by bradbane at 10:19 AM on April 1, 2012 [3 favorites]


At it's core, Deinstitutionalisation is not a bad idea, but in reality it was just an excuse to cut funding

I'm not sure that Deinstitutionalisation was just an excuse to cut funding. There were some real horror stories revolving around institutions that went a long ways to perpetrating those same stigmas and undoubtedly the system needed major reform or to be completely scrapped. The problem was that the broken institutional system was scrapped without an adequate substitute being developed.
posted by dave78981 at 10:22 AM on April 1, 2012 [5 favorites]


The 1980 presidential election was more important than most people realize and all we got is decades of social service cuts and the cult of Reagan.

To the endless decades of social service cuts, I would add the war on unions and, by extension, the working and middle classes in general, starting with PATCO.
posted by scody at 10:22 AM on April 1, 2012 [3 favorites]


I was a Parole Officer in Washington state from 1982 to 1997. I watched the criminalization of mental illness throughout that time. It is one of the saddest occurences that I have seen in my lifetime.
posted by Crackerbelly at 10:24 AM on April 1, 2012 [26 favorites]


That's fascinating, dsfan. I vaguely remember a book (I think it had "madness" in the title) arguing that we're right in the middle of a mental illness epidemic, but it had no plausible theories as to why. Can't seem to locate it at the moment.
posted by Melismata at 10:26 AM on April 1, 2012


If you live in Los Angeles, particularly in places like Hollywood, as I do, you know what its like to have the streets be the new institution. It serves nobody well. Mentally ill people are extremely likely to be victims of crime. Those with behavior problems resulting from their mental illness are likely to be criminalized for it. Shelters are ill-equipped to deal with the mentally ill, and there aren't enough of them anyway. Neighborhood suffers as they turn into skid rows. And there is an awful sense of everybody simply having given up, or it not even occurring to anybody that this is a problem.

We are failing the people who need us most. We are failing as a society.
posted by Bunny Ultramod at 10:35 AM on April 1, 2012 [14 favorites]


Thanks for posting this dave. I'm a person who has reoccurent major depressive disorder.

I live in a big city, with solid infrastructure. I had an issue this very week and was denied admittance (just yesterday)-- I was 'not sick' enough to merit a bed. My MD 'might' have an opening tomorrow.

This issue doesn't get enough visibility. I'm not a scary homeless guy with incredible facial hair. I'm a senior engineer at a big software company-- and we have good insurance-- but there's just no room. I was literally turned away at the door.

Have I been incarcerated for having mental illness? In two states.

Do I feel at a total loss? My MD has a huge patient load. The local hospitals have no room for you-- unless you are a threat to yourself or others.

Thanks for posting this. I do not know what I will do in my specific situation-- but I hope that the failure of the psychiatric machine will get into the public eye.
posted by mrdaneri at 10:40 AM on April 1, 2012 [23 favorites]


dsfan: "The graph combining the mental hospital and prison incarceration rates is particularly striking "

Indeed. Though I think the steep uptick starting in 1982 has more to do with the war on drugs and other Conservative hard line policy than anything.
posted by stbalbach at 10:52 AM on April 1, 2012 [1 favorite]


Worth popping this in here as well. A deleted FPP about the impending New Orleans' mental health crisis
posted by edgeways at 10:59 AM on April 1, 2012


This is a huge problem in SF. So much loud crazy on the streets here. I know involuntary commitment is a fraught issue, but is it really that much more humane to make these people sleep on the streets and eat from trash cans? For everyone else, it's a serious quality-of-life issue, especially on public transportation.

Seriously, what do they do with their mentally ill indigents in other countries? I always hear international visitors talk about how "we don't have this in my country"? Hell, I'd like to know how they deal with this in other CITIES. It was nowhere near this bad in NYC.
posted by Afroblanco at 11:01 AM on April 1, 2012 [6 favorites]


Thanks edgeways. This post was a direct result of trying to comment on the New Orleans post and being frustrated by its deletion. One of the major complaints about the NOLA post was that it was too concerned with local issues, so I expanded it. I even culled a link or two from that post. I really think this is an important, broad spectrum issue that touches on a lot of current hot button issues like health care, the prison system, racial disparity and drug legalization.
posted by dave78981 at 11:05 AM on April 1, 2012 [2 favorites]


I know involuntary commitment is a fraught issue, but is it really that much more humane to make these people sleep on the streets and eat from trash cans?

No, it's more humane to provide them with housing and adequate outpatient services. Long-term in-patient care is rarely necessary. Permanent, stable, affordable housing is. NYC has made significant progress on housing, but still has a long way to go.
posted by Mavri at 11:08 AM on April 1, 2012 [5 favorites]


Mental health in crisis in rural Minnesota
posted by edgeways at 11:10 AM on April 1, 2012 [1 favorite]


Sorry afroblanco for making so much noise. Everyone with mental illness eats out of trashcans and is disruptive, of course. Sorry, got to get back to this rotten Arby's sandwich I just found. Green horsey sauce!

I found your statement of 'loud crazy' deeply distasteful. Yes, I can look out my window and see a man who is clearly suffering from schitzophrenia. I would hope that he gets help-- he is not a figure to mock.

The horrible thing is that there is no room for him, or me, or almost anyone, unless you arrive at your nearest SF hospital in police custody.

(I joke, but your reduction of mental health issues in SF to 'crazy folks screaming in the street' is facetious. As noted above, I have wonderful insurance and a great employer-- and I was turned away just as quickly as that pigeon guy in the Haight. Something is really wrong.
posted by mrdaneri at 11:11 AM on April 1, 2012 [8 favorites]


Here's the thing: we've never had a policy in this country of treating non-wealthy mentally ill people in any way other than locking them away and drugging them into a stupor. Pre-1980s, we locked them away in state mental institutions and claimed to be treating their sickness when we drugged them into a stupor. Now, we lock them away in jails and prisons and claim to be rehabilitating their antisocial behavior when we drug them into a stupor. Same abusive, crappy treatment, just in a different building.

There are definite downsides to criminalizing mental illness. Locking mentally ill people up with dangerous predators puts them at risk of being victimized by their fellow inmates. Prison inmates have little access to medical doctors and are often punished for behaviors, such as self-injury and not following simple instructions, that are non-volitional symptoms of the illness. But it's silly to pretend that 20th century state mental hospitals were much better. "Patients" there victimized each other and were victimized by staff, treatment was often perfunctory at best, and abuse was rampant.

As with most problems of this sort, it comes down to money: unless you have rich relatives who care enough about you to pay for your care when you can't care for yourself, you're going to be stuck with whatever society is willing to pay for. And despite our periodic hand-wringing about the plight of those who can't take care of themselves, we've decided to go with institutionalization in one form or another. It lets us tell ourselves that people who need it are being taken care of, while making it so that us "normal" folks don't have to look at them or interact with them in ways that make us uncomfortable.

I spend a lot of time with mentally ill people who are arrested for crimes like "loitering" and "disturbing the peace," and it's clear to me that our real goal is not to make sure that mentally ill people are well cared for; it's to make sure that they don't bother us. And until that goal shifts, we're always going to come up with public policy solutions that are basically a form of abusive warehousing.
posted by decathecting at 11:14 AM on April 1, 2012 [27 favorites]


This is what you get when you ask for "smaller government." Shame on us.

Deinstitutionaliztion has more to do with the advent of thorazine and with legal decisions such as O'Connor v. Donaldson and Addington v. Texas. One Flew Over the Cuckoo's Nest, written in 1962, remains a vivid reminder that institutional mental health treatment was often more coercive than caring. The government began closing many hospitals in the 1980s because legal cases such as those above made it much more difficult to confine patients 'for their own good.'

It's hard to have your cake (maximum legal autonomy for the individual) and eat it (streets free of crazy behavior). Many mentally ill people do not present a sufficiently imminent or severe danger to themselves or others that can justify involuntary confinement, but are nevertheless dysfunctional to the point of helplessness. Attempts to remedy this are inevitably going to result in conflict with ptients' liberty rights and a risk of institutional abuse.

I care deeply about this issue, but the FPP and the comments here are only looking at half the picture.
posted by anigbrowl at 11:18 AM on April 1, 2012 [10 favorites]


mrdaneri : I don't mean to further stigmatize a segment of the population that already has enough problems. I'm just coming at this from the perspective of a long-time city-dweller whose girlfriend is afraid to take the bus because of jabbering lunatics on buses and at stations. To be honest, some of these people are more threatening than actual criminals because they're COMPLETELY UNPREDICTABLE, and oftentimes like to get up in your face.

Yes, they have a real problem, and yes, they deserve help and humane treatment. But what about the rest of us that just want to get by? In NYC, you see all kinds of people from all strata of society taking the subway. Why? Because the subway is safe. Here in SF, it's more like the rest of the country where there's this perception that "buses are for poor people". I don't think I'm being horribly inhumane in suggesting that, in failing to provide for the indigent mentally ill, my city has done a disservice both to that segment of the population as well as to innocent taxpayers such as me and my girlfriend.

Anyway, you seem to have zeroed in on one part of my comment to the exclusion of everything else. My main question is this -- why is it so much worse here than everywhere else? What do other cities and countries do that they don't have the same problem? Also, while I realize that involuntary commitment has its own share of problems, I don't necessarily think it's worse than letting people sleep on the street. Some people just CANNOT handle their shit.
posted by Afroblanco at 11:21 AM on April 1, 2012 [2 favorites]


I found your statement of 'loud crazy' deeply distasteful. Yes, I can look out my window and see a man who is clearly suffering from schitzophrenia. I would hope that he gets help-- he is not a figure to mock.

That doesn't strike me as mockery. Loudness is simply factual, and part of what can make psychotic people intimidating or frightening to those without experience or professional training in dealing with psychosis. 'Crazy' is no more than the acknowledgment of psychotic irrationality. I have experience of both caring for and suffering from mental illness, and don't find such a description pejorative in the least.
posted by anigbrowl at 11:28 AM on April 1, 2012 [1 favorite]


I think you are entirely correct afroblanco on the point that things seem worse here than most places. This is both perceptive and accurate. I don't want to monopolize or derail the thead from the OPP's point-- but you are right on. Something seems especially wrong here-- in a city that has a budget larger than Iowa's.

This is clearly a thread derail, so I apologize to the community. But Dave brought up a great issue, and I am looking forwards to reading about solutions.
posted by mrdaneri at 11:29 AM on April 1, 2012


I care deeply about this issue, but the FPP and the comments here are only looking at half the picture.

I also care deeply about this issue and I think that although the FPP may not be perfect, it's a good starting point for a discussion about this issue and its implications. Also, although I didn't offer any links pointing to this hypothesis, I think the current trend of letting the prison system handle the mentally ill is an end run around the right to refuse medication. Many times at my place of employment I hear members of the nursing staff wish we were a prison so that obviously distressed individuals could receive the immediate help they so apparently need. I don't feel this way, but many do.
posted by dave78981 at 11:33 AM on April 1, 2012


"Jabbering lunatics" are more likely to be the victims of crime than the perpetrators. Someone else may be able to provide a link about the misconceptions about violence and mental illness, but if not I'll do it tomorrow when I'm at work. Where I deal with "jabbering lunatics" all the time.

The only choices aren't eating out of garbage cans and institutionalization, and I have no idea why you're acting like they are. The mantra of people who are concerned about the health and safety of people with mental illness: housing, housing, housing. And did I mention the importance of housing?
posted by Mavri at 11:33 AM on April 1, 2012 [5 favorites]


As for why it's different in SF, perhaps it's a shortage of affordable housing? Maybe you and your girlfriend can contact your local NAMI chapter and see what kind of grass roots efforts are going on in SF to rectify the issue and get involved.
posted by Mavri at 11:38 AM on April 1, 2012


Why is it a problem in SF? I haven't been to SF, but hey I'll take a stab. Because the city and state doesn't give a shit. And people would rather see them thrown into warehouses than invest the time and attention to establish a costly but humane and effective system of housing and treatment. Out of sight out of mind. They are not us.
posted by edgeways at 11:38 AM on April 1, 2012 [1 favorite]


Knowing how hard it was for me - a well-paid, financially secure professional with great health insurance - to get treated for depression/GAD in one of the wealthiest cities in the country, I can't imagine what it's like for those with less means and/or more serious conditions.
posted by downing street memo at 11:42 AM on April 1, 2012 [8 favorites]


Mavri : Perhaps it is a false dichotomy. Can you point me to examples of programs that have worked? I don't doubt these programs exist, I'm just interested in how they solved what appears to be an intractable problem for my city.

And yes, "jabbering lunatics" is pejorative. It's a lot easier to be dispassionate about an issue when it doesn't confront you every day. And maybe the scary, deranged homeless guy ranting about invisible adversaries and insulting everybody on bus may not actually be prone to violence. But to people who don't have a hardened shell from living in cities for 10+ years, he's still scary. And for a city whose built environment discourages automobile use, this is a serious problem.
posted by Afroblanco at 11:42 AM on April 1, 2012 [2 favorites]


The populations housed by large state institutions were supposed to be cared for in smaller, community-based housing that was going to automagically spring up when the state hospitals closed. That mostly didn't happen, in part because it's hard to make a profit running housing like that and when the bottom line of your healthcare system is profit, not health, well...

And in places where halfway houses and the like did come into being, there often isn't enough in the local or state budget for oversight. There was a series in the NYT last year that laid out the horrendous abuses perpetrated in housing like this, and how it continues because there's no oversight and not much regulation.
posted by rtha at 11:43 AM on April 1, 2012 [1 favorite]


And for the record, I'm a longtime donor to SF Homeless Connect, although I'm thinking of supporting GLIDE instead. I used to donate to a variety of charities, but since moving here, it's pretty much all been homeless causes. To see some of these people ... some of them literally look half-dead. It's horrible.
posted by Afroblanco at 11:43 AM on April 1, 2012 [1 favorite]


It's hard to have your cake (maximum legal autonomy for the individual) and eat it (streets free of crazy behavior). Many mentally ill people do not present a sufficiently imminent or severe danger to themselves or others that can justify involuntary confinement, but are nevertheless dysfunctional to the point of helplessness. Attempts to remedy this are inevitably going to result in conflict with ptients' liberty rights and a risk of institutional abuse.

Well, yes. It's been made more difficult to force mentally ill people into care against their will, and that's in many ways a good thing.

But it's also been made much more difficult for mentally ill people who want help to get it. And that seems to me like an unambiguously bad thing.

The two are potentially independent. We could, if we wanted to, respect patients' liberty and still provide funding for voluntary treatment, and it's a damn shame that we don't.
posted by nebulawindphone at 11:43 AM on April 1, 2012 [3 favorites]


But it's also been made much more difficult for mentally ill people who want help to get it.

See, that's the problem with mental illness. It feeds itself, and doesn't want to be cured. See I Am Not Sick, and I Don't Need Help!
posted by Melismata at 11:49 AM on April 1, 2012 [2 favorites]


Check out Pathways to Housing and any provider following the "housing first" model. There are also more intrusive/supportive (some might say paternalistic) models like Common Ground. Supportive housing isn't new, it works well, it comes in all different shapes and sizes for people who need varying levels of support and assistance, and it's cheaper than, literally, everything else--shelter, jail, institutionalization, hospital, ER--except leaving people on the street to scare the taxpayers.
posted by Mavri at 11:50 AM on April 1, 2012 [2 favorites]


It's not as simple as 'more housing'. People get thrown out of housing units for being disruptive or for allowing their unit to fall into disrepair. However, while California law provides for administering treatment to those who are unable to properly care for themselves, it also confers many rights on patients, making it very hard to deliver care over the long or even medium term to anyone who is unwilling to accept it in the short term. The cost of treating people who are truly unable to care for themselves is very high, and there's an additional hidden burden from the cost of litigation. Courts do not like handling mental health problems, nor are they competent to do so, but the legal environment is such that disputes frequently end up there because there is no administrative alternative. Litigating detention or other liberty issue cases (eg the right to own guns contemporary with eligibility for involuntary administration of treatment) costs a lot of money that might otherwise be used for clinical resources.

I haven't been to SF, but hey I'll take a stab. Because the city and state doesn't give a shit.

That's not true. If you've never even been here, then I don't think your opinion has any value.
posted by anigbrowl at 11:58 AM on April 1, 2012 [3 favorites]


Housing, although definitely part of the solution, is not a magic bullet. Eventually, people will stop taking their medications and wander out in to the world and exhibit strange or threatening behavior and then what? They wind up in prison or in a dwindling number of state or private psych beds.
posted by dave78981 at 11:59 AM on April 1, 2012 [1 favorite]


See, that's the problem with mental illness. It feeds itself, and doesn't want to be cured. See I Am Not Sick, and I Don't Need Help!

I'm not buying this generalization — not as a blanket statement, not without an awful lot of qualifiers.

It's true, there are mentally ill people who resist treatment. But there are also plenty who genuinely want treatment and can't afford it — yes, even people with "real," "serious" mental illnesses like bipolar disorder and schizophrenia.

What's more, most mental illnesses are progressive. Someone who is now totally out of touch with reality — and totally resistant to treatment as a result — is likely to have passed through a period earlier in their life when they knew something was wrong and wanted to get better. If we didn't offer them affordable treatment when they wanted it then, it's a little disingenuous to throw up our hands and say "See, they don't want it anymore!"

And on the other hand, people whose mental illness has progressed pretty far can still have relapses and periods of lucidity. If someone wakes up one morning and says "Shit, I need help," it's in our best interest to make that help easily available to him. If getting a hospital bed takes months of waiting and phone calls and string-pulling, we run the risk that the window of opportunity for getting him into voluntary treatment will close before he actually gets the help he needs.
posted by nebulawindphone at 12:03 PM on April 1, 2012 [21 favorites]


I should clarify that treatment resistance is a serious problem, and I don't think better mental health funding would be a complete solution. There may be no complete solution — or at least, none that's consistent with liberal ideals like personal autonomy. But we shouldn't let the perfect be the enemy of the good, and there are an awful lot of people for whom a properly funded voluntary care system would do an awful lot of good.
posted by nebulawindphone at 12:09 PM on April 1, 2012 [3 favorites]


Involuntary confinement isn't the first thing I think of whenever problems like this are brought up.

I think of all the houses and buildings left empty just because nobody worked and paid to live in them, and of all the food that rots just because nobody worked and paid to eat it.

I've heard it said that you can judge the character of a man by how he treats those who can do nothing for him, and it seems the same measure can be applied to the character of communities.
posted by edguardo at 12:16 PM on April 1, 2012 [2 favorites]


I sympathize with Afroblanco, however he expressed himself. Living in a city is living with negotiation, as a neighborhood consists of not one community, but multiple communities, whose needs rarely dovetail with each other. And the homeless, in particular, isn't one community, but multiple, each with their own needs and their own desires, and different groups of homeless are often at odds with each other.

It is possible, to an extent, to negotiate these sorts of neighborhood conflicts with good organization. Predatory landlords can be forced out. Bad businesses can be closed. People who don't clean up after their dogs can be discouraged and ticketed. The homeless can be encouraged to panhandle or sleep in places where they are relatively safe and undisruptive.

But with the mentally ill, these negotiations can be quite a bit harder -- especially if they are self-medicating and chronically homeless. From a tenant's position, their behavior is often indistinguishable from criminal behavior -- and sometimes it is unambiguously criminal. Tenants have their own needs, and safety is high on that list. And so they call the cops.

I do. I don't feel good about it -- I myself have been homeless in Hollywood. But I am offered no other choice to make sure my environment is safe. (By the way, at this moment, Hollywood has been spectacularly bad at any of the negotiations I have mentioned.) If there was a number I could call instead of 911, I would call it. But if somebody is having a psychotic episode in the street outside my apartment, I will call the police, as crummy an option as that is. If somebody is urinating on the side of the building I live in, I will ask the cops to tell them to move along, because this neighborhood has enough problems without becoming a cesspool.

I want there to be better options. I don't like that our infrastructure has given me no options, and has put me in conflict with the neighborhood homeless, who I would rather consider neighbors with specific needs than nuisances. But there is very literally no other option. I always give warning before calling 911, but that's literally the best I can offer right now.
posted by Bunny Ultramod at 12:18 PM on April 1, 2012 [5 favorites]


I will chime in again to ask that the discussion includes a broader definition of the mentally ill. It is reductive to assume all of us are shambling around and screaming Jabberwock.

Some of us wear 3 piece suits and work for Stanford. Our suffering is equivalent. I have a four week wait to see a shrink in SF. I cannot imagine what Pigeon guy endures.

It does bother me though-- the persistant othering going on in this thread. We are your friends, we are your neighbors. It is not just screaming hobos. (they are so lovely in B#)

I can assure you-- it is so hard to get a psych bed in the US right now. I operate from a position of extreme priviliege-- and I cannot be admitted. What the homeless guy-- who I am watching right now-- goes through-- I will never know. Something is really wrong.
posted by mrdaneri at 12:26 PM on April 1, 2012 [14 favorites]


I forgot to mention that one big factor in SF's particular problem is that when California passed Laura's Law - allowing court-ordered outpatient treatment, ie 'take your meds and attend your clinical sessions or be placed in hospital' - in 2002, it was left to each county to pass their own version, or not. San Francisco never has, citing things like cost and civil rights issues. Some of the opposition (purely on civil rights grounds, you understand) comes from organizations like the Church of Scientology, which just happens to have a large and profitable outpost in SF.

Laura's law is working quite well in Los Angeles, and I wish more Bay Area counties would just pass the thing already. We shouldn't discount the rights of mentally ill people, but I have no patience for the idea that we should adopt a hands-off approach to the illness itself.
posted by anigbrowl at 12:27 PM on April 1, 2012 [8 favorites]


Societies have to provide housing, food, and other necessaries of life. But equally important is a sense of community. The liberal idea of atomistic individuals who don't owe each other anything except to leave each other alone is destructive. More than ever, we live in societies that allow us to be alone, to associate with the people we want to associate with. We aren't forced to take care of each other, and not just with bureaucratic social programs. People need genuine social interaction. Mental illness is socially isolating and social isolation just makes it worse, which leads to further isolation. There is no solution to this problem, not without large, structural social and economic change.
posted by smorange at 12:30 PM on April 1, 2012 [2 favorites]


I'm reminded of a girl I went to high school with. She was absolutely beautiful and had everything going for her including coming from a wealthy family. Some time in her 20's she developed paranoid schizophrenia. Her parents then declined to support her, and she was left at the mercy of what little state aid was available. I regret that I never heard what happened to her after that.

Also, I feel I must note that, no matter how flawed they were, I voted for Mondale and Dukakis. Fuck Reagan!
posted by InsertNiftyNameHere at 12:33 PM on April 1, 2012 [2 favorites]


Homeless people in general are more visible in warm places because you can live on the street year round. I used to live in Seattle and was in touch with a group of homeless young people and basically they would move up and down the coast with the weather. I know that's not the same population group, but it may contribute to the visibility and numbers.
posted by Belle O'Cosity at 12:56 PM on April 1, 2012 [2 favorites]


I haven't been to SF, but hey I'll take a stab. Because the city and state doesn't give a shit.

You're probably right about the state -- I wasn't yet born when he was elected, but I can remember being told as a child about Reagan, as Governor, massively defunding mental health facilities. But at the local level, I suspect that SF has a magnet effect because of the (comparatively) extensive services that are available from city agencies and non-profit organizations. Add in weather that allows for year-round outdoor living, too, as part of the issue.
posted by Forktine at 1:29 PM on April 1, 2012


Thanks Ronald Reagan! Another one of your shortsighted idiotic policies bears fruit decades later. And you get bonus points for being dead and beyond any reproach.
posted by Renoroc at 1:31 PM on April 1, 2012 [1 favorite]


Not that the US has a mortal lock on brutality. But it seems as though we are trying hard to give people as much to regret - a century from now - as we already regret about a century ago.

To quote from a man who died nearly 200 years ago: The only thing we learn from history is that we learn nothing from history.

The 21st century is mainly teaching me misanthropy.
posted by Twang at 1:59 PM on April 1, 2012 [2 favorites]


In 2003, the Chronicle did an award-winning investigative series on homelessness in San Francisco (right column of page). They've periodically added update stories ever since. For those who are curious about the SF's problems, especially in the Tenderloin and mid-Market, it sheds a lot of light on how conditions here differ from NYC or Los Angeles.
posted by nakedcodemonkey at 2:00 PM on April 1, 2012 [4 favorites]


Not only does mental illness often instill a profound sense of "I don't need treatment, I'm not sick" as mentioned upthread, it's extremely hard to see any point in treating it when you have nothing left to lose but your life (cf. the homeless, abandoned veterans who quickly become homeless, etc).

My attentional and mood problems only really hit me hard when I found myself fully-grown and married with a house and a family of my own, with the immense commitment towards stability that comes with such profound responsibilities. Suddenly shit was very real and I had to take care of it.

I've found that when I'm really depressed, I have a rather scary fearlessness about losing everything, even though I'm also often paralyzed by social anxiety and a total absence of confidence. When I'm more hypomanic / manic I become very anxious about what I have to lose, and become increasingly "OCD" about the simplest things like making sure I didn't leave anything turned on / plugged-in before leaving the house, for example. There's an insight into my struggle that I only found interesting and worthy of investigation once the stakes got really, really, high. My own health is hard to appreciate without others depending on me.
posted by aydeejones at 2:58 PM on April 1, 2012 [2 favorites]


The problem was that the broken institutional system was scrapped without an adequate substitute being developed.

Yes. But...

The populations housed by large state institutions were supposed to be cared for in smaller, community-based housing that was going to automagically spring up when the state hospitals closed. That mostly didn't happen, in part because it's hard to make a profit running housing like that and when the bottom line of your healthcare system is profit, not health, well...

No. At least not exactly.

It's true that when the state hospitals shut down no private sector stepped in to replace them. But there wasn't any real reason the state couldn't have spent the money they were spending on mental health in other ways. They didn't, because the progressive reformers agitating for an end to the hideous abuses at state mental institutions didn't simultaneously present an alternative. They just pointed at a state system that needed to be shut down. And hey, didn't take much arm twisting. Telling the states "You shouldn't be doing this ludicrously unpleasant, expensive thing!" is a great way to get programs axed, but not a great way to encourage a substitute.

This wasn't necessarily a massive failing, in that a lot of what we now think about the humane care and treatment of the mentally ill didn't really exist when the hospitals were closing, at least not in the form they do now. So it wasn't like activists could say "You need to do this and this, not that." Just "Stop doing that!" So the states did.

And yes, that's right around the time incarceration rates really started to take off.
posted by valkyryn at 3:10 PM on April 1, 2012 [4 favorites]


Some of us wear 3 piece suits and work for Stanford. Our suffering is equivalent. I have a four week wait to see a shrink in SF. I cannot imagine what Pigeon guy endures.

And that's the really terrifying thing about this problem. The "obviously crazy" individuals we see on the street in SF are just the tip of a massive iceberg of need that's going unfulfilled. We can't see the hurt and pain inside anyone but those with the most obviously severe mental illnesses, and there's often not a lot we can do for them either. And the sad thing is that helping people like you is frankly a whole lot easier and cheaper than helping some of the people who hang out by my office on Market St. It's a whole lot better for everyone if we help people long before they turn into "Pigeon Guy."
posted by zachlipton at 3:22 PM on April 1, 2012 [4 favorites]


Also, I'm diagnosed with major chronic depression which I self-medicate with St. John's Wort and a pair of housemates who also have issues and drag me out when I start to collapse in (we only halfway-joke that between the three of us, we have the parts of a single functioning person), and I have absolutely nothing I can do about it because I'm unemployed, uninsured (COBRA for me would be $1200/mo) and the public health service here is avoiding adding anyone due to cuts.

I could be that guy in the street if I was just a little less lucky, which is why things like this make me angry.
posted by mephron at 3:29 PM on April 1, 2012 [6 favorites]


It is reductive to assume all of us are shambling around and screaming Jabberwock.

I completely agree on this point, for the broader issue of access to mental health care.

For the particular issue of the transfer of responsibility for care of the mentally ill from a patchwork community based system to the prison system, I think it's valid to focus on the visibly bizarre, aggressive mentally ill because they are the most likely to wind up in that prison system, on minor charges, for long periods of time in order to receive medication.

That said, I know personally how it feels to want help and need help and be unable to get it. It sucks, this system sucks, and it will probably get worse before it gets better. Please talk to someone and if you feel AT ALL like hurting yourself or others, go to the ER.
posted by dave78981 at 3:37 PM on April 1, 2012 [2 favorites]


I did a little more background research on the legal/policy roots of this sitution, especially as it pertains to California.

In 1957, the state passed the Short-Doyle Act, effectively taking over outpatient funding from local government in order to deal with the rising numbers of patients in full-time care. Then-governor Ronald Reagan signed the Lanterman-Petris-Short Act in 1967; far from cutting off funding, it was hailed at the time as piece of highly progressive legislation that safeguarded the rights of the mentally ill and protected them from involuntary institutionalization.

This law remained the standard until the late 80s, when the ACLU brought suit on behalf of a patient called Eleanor Riese who did not want to take the anti-psychotic medication she had been prescribed because of the deleterious side-effects. Riese won and California requires a Riese hearing for involuntary administration of medication, which can be a complex procedure; in LA county, for example, doctors would go up against patients' legal advocates, being both subject to cross-examination by patient's counsel and also responsible for conducting cross-examination of the patient or his/her expert witnesses. The California Mental Health Patients' Rights Advocates website sums up the current situation.

Though I'm no fan of Ronald Reagan's policies, it seems rather unfair to dump all the blame on him for what is in fact a complex and multidimensional problem with multiple actors. It is very difficult in California to force mental health treatment upon an unwilling recipient, and the Riese hearing remains the standard in places like San Francisco. I have misgivings about the the applicability of an essentially ratiocinative legal process to the essentially irrational ciscumstances of individual mental patients on a case-by-case basis; to the extent that upholding the economic interests of the mentally ill is at odds with the full expression of their liberty interests, the latter is bound to win out but does not necessarily leave anyone better off.
posted by anigbrowl at 3:43 PM on April 1, 2012 [5 favorites]


It is very difficult in California to force mental health treatment upon an unwilling recipient

Thanks for this because I am not really familiar with what the procedure is in other states. In my state (CT), a person can be held for a 15 observation period if he or she is determined to be a threat to themselves or others, but during that 15 day period, the patient may petition the court for a hearing that must occur within three business days. Also, medication can't be forcibly administered unless, again, the person is a threat to himself or others. (Not sure how broadly this can be interpreted, but where I work we pretty much stick to the letter of the law in regards to meds.)

However, the treatment team can and often does petition the court for a longer involuntary admission and administration of medication. This more often than not succeeds because patients who get to this point are exhibiting bizarre psychotic behavior or have threatened their own or others' lives or something of the sort. The few times I've seen patients succeed in leaving and not taking meds, they've wound up back at the facility a few days later in even worse shape.

I'm torn on this personal liberty vs. involuntary commitment issue because I've seen patients who were very psychotic take two weeks of medication and start talking about wanting to finish college again and get that job they always wanted. Then they discharge and smoke a blunt laced with PCP (but won't take their haldol) and then they're back again, worse than ever.

It's frustrating and heartbreaking.
posted by dave78981 at 3:57 PM on April 1, 2012 [2 favorites]


Then-governor Ronald Reagan signed the Lanterman-Petris-Short Act in 1967; far from cutting off funding, it was hailed at the time as piece of highly progressive legislation that safeguarded the rights of the mentally ill and protected them from involuntary institutionalization.

Right. The closing of the institutions was considered progressive. Seriously. It had nothing whatsoever to do with privatization or deregulation. It was all about reducing involuntary and coercive treatments, some of which really were quite horrific, and affirming the civil rights of the mentally ill.

Turns out that if you're mentally ill, exercising your civil rights may be the worst thing you can do, but hey, that's liberty for you.
posted by valkyryn at 4:09 PM on April 1, 2012 [4 favorites]


just wanted to thank everyone who provided CA's historical context. You can't get that sort of detail anywhere, and it continues to prove the blue brings the best. I do, though, wish things were otherwise.
posted by mrdaneri at 4:18 PM on April 1, 2012


Regarding the "...because the city and state doesn't give a shit..." and "...city that has a budget larger than Iowa's..." points:

Please bear in mind that cities and states pay for lots and lots of things with their budgeted funding, and the majority of those things scale with population. That is, a larger city with more people has to pay for maintenance and upkeep on more roadway miles that are more heavily used than a small city or a sparsely-populated state, more miles of water infrastructure and sewer pipes, more police and fire departments, more and more heavily-used parks, etc etc etc. Cities, states, and local governments have to chose which things get prioritized in the budget, because they don't have enough money to do all of it.

Why don't they have enough money to do all of it? Because cities, states, and local governments are funded almost entirely through tax dollars. Property taxes, sales taxes, business taxes, etc go directly to state and local governments, and personal income tax, gas tax, and other Federal tax revenue goes to state and local governments indirectly, via the Federal government. And because we, as a nation, tend not to vote for local tax increases (property, levies, sales, or state/local income taxes) and tend not to elect Federal representatives who vote for Federal tax increases, so state and local governments have dealt with stagnant or decreasing budgets generally for a number of years. Even without cuts, tax rates haven't increased at the same rates as other cost increases-- so that $XX in local tax revenue pays for 1 teacher now, rather than the 1.5 teachers it was able to pay for ten years ago. Why? Because voters won't approve tax increases.

When local governments don't have enough money, they cut the programs that are revenue-negative (that is, have a cost but do not bring in direct revenue), are unpopular, or will not generate a lot of public outrage to reduce or eliminate. Programs that provide cost savings through efficiencies-- like supportive housing programs, which are very costly programs that generate a huge cost savings in other areas--are vulnerable to cuts if it's hard to clearly demonstrate the link between "spend $x here and save $3x in costs that would be spent otherwise".

Because homeless services, mental health services, and supportive housing programs generate savings that very easily become invisible (because they're spread out among emergency services, hospital programs, other housing programs, and other civic maintenance), it's hard to make it crystal clear that spending money on these programs is actually cheaper in the long run (which I personally am totally certain that they do, aside from being humane and decent to vulnerable populations). These programs also serve marginalized populations that don't advocate for themselves very well, and are perceived as 'other' by most voters.

Which leads us back to the fact that voters will not tax themselves to pay for supportive housing, and they sure as hell raise a stink of the city/state prioritizes these programs above services that they use themselves. If you can find me ten voters in most metro areas who would say "well, I'd love to get the potholes in my street taken care of, but it's more important to pay for those supportive housing programs that help keep mentally ill people stable and off the street" rather than "OMFG why is the city spending millions of dollars on lazy homeless bums instead of fixing my potholes I PAY TAXES TO FIX MY STREET DAMMIT", I will give you a unicorn.

It's shameful how we treat our mentally ill and vulnerable residents-- but until we as a society becoming willing to part with some of our own money to do a better job, and start voting for representatives that prioritize human beings above cars and businesses and the generation and retention of capital, and start making it clear to our elected leadership that this is important enough to make a difference in future voting behavior, it's not going to change much.
posted by Kpele at 5:21 PM on April 1, 2012 [9 favorites]


This might be a mini-derail but I went to SF with my family 20 years ago and was shocked by the number of homeless people on the street. My parents let me walk around alone and I ended up giving a Big Mac to one homeless guy and being followed down the street and being called a 'whore' by another. I was 15 at the time.

The same problem definitely does not exist on the streets in Canada (where I'm from) to the same extent at all (facetiously because it's too cold) but probably more accurately because of what the above poster said. Taxes. Taking care of your fellow man, and there but for the grace of god go I sort of thing.

I know live in NYC and get nervous on the subways at times but basically the truth is, society has discarded these people. And if NY and CA would agree to higher taxes to better fund social services, these problems could
probably be lessened greatly.
posted by bquarters at 6:11 PM on April 1, 2012


It's not as simple as 'taxes'. We pay 8.25% sales tax in most bay Area counties; property tax is a moderately low rate, but the real estate is expensive so it it usually thousands of dollars per year; California state income tax is about 8% for the median income; there's a use tax on out-of-state purchases, though not everyone bothers to pay; and there's any number of fees and levies built into prices as well. To be sure, Californians could pay some more tax, especially given the very high levels of wealth in some parts of the state; but on the other hand, California is certainly not a low-tax state. Historically the CA tax burden is a bit larger than the US average, and you need to consider that the higher cost of living (at least in the coastal areas) increases prices and thus sales tax revenues in parallel. There are all sorts of affordable housing mandates, such that if you earn or save too much you can't participate in such schemes. And so on.

I haven't been to NY, but it is certainly not cheap to live in the Bay Area, and to be honest I don't feel like I get very good value for my tax dollars as is - I'd grade local government here between a C and a B-. It's not that I object to taxes as such, but that I see other places with similar or lower taxes which handle this public health issue more efficiently and that seem to deliver rather better value to taxpayers. some costs are higher in urban areas, to be sure, but then you get all sorts of economies of scale as well - in theory.

I'm sick of 'raise taxes and government spending' as the left's reflexive answer to every social problem, and don't think it's much better than the right wing trope of 'cut taxes, increase private charity'. It's a facile way of dismissing problems that are painful to analyze. As Valkyryn says above, maximizing civil rights may not be the best thing for mentally ill people in the aggregate. That's a disturbing policy problem to grapple with, and can't be solved by simply passing the hat around or inaccurately blaming it on Reagan.
posted by anigbrowl at 7:49 PM on April 1, 2012 [4 favorites]


Historically the CA tax burden is a bit larger than the US average, and you need to consider that the higher cost of living (at least in the coastal areas) increases prices and thus sales tax revenues in parallel.

And maybe if some of that money was spent on something other than CalPERS...

Mostly kidding...
posted by valkyryn at 11:35 PM on April 1, 2012


I have a family member who is on the front line of this problem -- she's been working with the mentally ill in the criminal justice system for fifteen years, and says that it's the worst she's ever seen right now - she keeps getting told over and over that there are no beds at clinics for her patients, and "at least they are safe in jail." The stories she comes back with are heartbreaking, and she's seriously burnt out as a result. After she's been driven away, who will be there to help these people? It's terrible.
posted by ukdanae at 4:42 AM on April 2, 2012 [1 favorite]


Things are going to get worse before they get better.

There's a huge over-reliance on beds located in hospitals rather than standalone facilities. Those beds are over-represented at hospitals with already-rotten margins and bad payor mixes. Psych beds are a charity to begin with. An average psych patient is probably well over 10 times less profitable than a high-acuity patient. The patients are not using expensive resources like monitoring equipment, ventilators, lab services, etc. unless they've got something else wrong (many do). Plus, the beds are harder to operate from a staffing standpoint because a nurse in a medical unit can't just fill in for one in a psych unit.

I don't think people quite understand how bad things are for hospitals. When you get a $25,000 bill for a few days stay, you assume they're rolling in cash. The opposite is true. There aren't any good financial trends in the industry. Without reform they were going to get slammed as baby boomers aged into Medicare. With any reform, that pressure ratchets up several notches.

Every small hospital in this country is looking for a savior right now. Every large system is looking to protect its referral base by getting even bigger. The rate of consolidation is nuts and will accelerate with PPACA. Are the big, financially savvy organizations taking over the industry are going to invest in psych care?

Are any of the big prison companies publicly traded?
posted by pjaust at 7:53 AM on April 2, 2012 [1 favorite]


Historically the CA tax burden is a bit larger than the US average, and you need to consider that the higher cost of living (at least in the coastal areas) increases prices and thus sales tax revenues in parallel.

California is the third-largest state in the United States in terms of land area, and the largest by population by over ten million people. California has several major metropolitan areas as well as huge swaths of freeway that connect them, tons of bridges and over- and under-passes in an earthquake-prone area, and significant rural land. California, in terms of tax-supported costs, has the worst of all worlds, with all the costs of major urban areas as well as costs of massive rural areas. The cost of maintaining the roadways alone (even at the rather poor level that they are maintained) is probably staggering. I do not live in California, and I do not work for California, but I can make educated guesses about the costs that state bears, and they have got to be enormous. If states that do a better job on this issue on a smaller budget do not also have much lower baseline costs, I will be amazed.

If raising taxes is not the answer you want, then decide what tax-funded services you want to cut to pay for supportive housing and mental health programs. No state, California included, has a big pot of money available to fund new programs-- all those funds are directed to existing programs. Putting money towards new programs or increasing funding to existing programs can only be done by increasing revenue or making cuts elsewhere.

If you want to increase state revenues to pay for services without making cuts to road maintenance, education, public safety, water infrastructure, or other tax-funded existing services, or by taking a tax hit yourself, encourage your elected leaders to increase contributions from those that do have big pots of money sitting around--major corporations and extremely wealthy people.
posted by Kpele at 8:41 AM on April 2, 2012


An average psych patient is probably well over 10 times less profitable than a high-acuity patient.

The homeless, in particular, are often tremendously expensive to treat.
posted by Bunny Ultramod at 11:01 AM on April 2, 2012 [1 favorite]


It's not as simple as 'more housing'. and Housing, although definitely part of the solution, is not a magic bullet.

Housing certainly isn't the only thing (or a simple magic bullet), but I strongly believe it is the first thing, a necessary foundation. How can a person build a stable life if they're on the street or insecurely housed? Is it remotely realistic to expect a homeless person to comply with a treatment regimen or get clean? In order to see doctors and take prescribed medications, a person needs, at the very least, some form of insurance, and money for co-pays and transportation. Being very poor is a lot of work. I've had clients come to my office with a shopping bag full of notices from Medicaid, food stamps, public assistance, clinics, etc. A person without an address won't get these notices. A person who gets mail at a homeless advocacy place or general delivery won't be able to keep track of all of them. And then when their benefits get cut off, it'll be a nightmare to untangle. Getting clean (since there are a lot of people with serious mental illness and co-occuring substance abuse) is even more unlikely. Some can do it on the street, but getting clean is hard for people who have homes, support networks, and awesome insurance. Doing it when you don't have a roof over your head seems almost impossible.

That's why I go on about housing, housing, housing. A lot of supportive housing providers place barriers to entry--being in treatment, being clean--that are unrealistic expectations to place on people coming off the street. The housing first model acknowledges that and gives housing to people who are not in treatment and who are not clean. It seems dead obvious to me that this is the way to go, but it's controversial. If you can't afford housing in this country, then getting it subsidized or free is a reward, not a right, that's doled out to the good mentally ill (or the deserving poor). Housing first programs have been shown to have good outcomes with the most difficult, resource-intensive homeless people. It's not a magic bullet, and some people need more structure, but the goal, in my mind, is to provide a variety of models and try to match people well. It's a pipe dream.

I realize that the person acting bizarre in the street is too often the public face of mental illness, but I've had many, many seriously mentally ill clients who haven't had a pysch hospitalization in years, and you'd never know they're "crazy" if you saw them on the bus. And when I say seriously mentally ill, I mean it. My project is funded by the Dept of Health to provide civil legal services to people with serious and persistent mental illness (SPMI), so all my clients, for the past 7 years, have been SPMI. Some of them have been lucky enough to be stable on the right meds for years. Some are in highly supportive out-patient treatment programs where a case manager will pick up on any problems before they become a crisis. I've also had quite a few who need short in-patient hospitalizations every year or so. Our social worker calls them "tune-ups." Sometimes an involuntary hospitalization is precipitated by noncompliance, but it can also happen when a medication stops being as effective or when psychosocial stressors cause decompensation.

I don't disagree that the mental health system is a disaster, but I do disagree with people who seem to think the solutions aren't out there. I've had clients with histories of noncompliance who'd been through the revolving door of repeat hospitalizations do very well with ACT teams, for example. ACT teams, intensive case managers, housing first, etc. have all shown significant successes in curtailing hospitalizations and homelessness, but the money and political will just aren't there to provide these services to everyone who needs them.
posted by Mavri at 1:48 PM on April 2, 2012 [4 favorites]


If raising taxes is not the answer you want

It needs not to be the only answer. Voters here do in fact vote to raise taxes on a regular basis; and there are other ways to balance budgetws besides just raising taxes and cutting services, such as reducing the cost of delivering those services; it's not as if local government is already maximally efficient. But the point I've been making above is that even when the fiscal resources are available, there are often legal barriers to their deployment. In much of CA, for example, already-underfunded public defenders represent indigents against their own doctors in adversarial hearings. There are a significant first- and second-order economic costs to the defense of people's liberty interests even though the model statutory alternative has not so far led to any kind fo constitutional controversy at the state level.

I heartily agree with the idea that a stitch in time saves nine, as regards the availability of housing and so forth, but proponents of these solutions need to make their economic case more clearly to municipal, county, or state legislative bodies; and as a matter of practical politics, there need to be sanctions as well as incentives. What I'm getting at is a shift in the nature of advocacy: instead of saying 'we need housing first' (a call for resources), the argument is better presented in reverse: we need to reduce the incidence of this social problem and all the associated costs (scary psychotic people, police time, shelters crime) and then offer suitable housing as the most cost-efficient alternative. This means shifting the rhetorical emphasis away from the rights we wish to preserve and towards the undesirable behavior we wish to reduce. This is an unpleasant perspective from which to analyze matters, but arguably a more effective one in terms of getting the necessary political momentum.

There was an interesting segment on a recent PBS Need to Know program about prison reform in Texas; intensive and high-contact parole regimes turned out to have a greater impact on recidivism at lower cost than building additional penal facilities. This bipartisan policy came about partly because the consistent severity of penal policy in Texas was not really in question, so retributivists had more than enough political capital to experiement with post-release diversion.
posted by anigbrowl at 3:17 PM on April 2, 2012 [2 favorites]


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