Things I May Have Been Wrong About

Ace of Spades writes, in response to a NYT article on the death of a homeless woman:

In Sunday’s NYT there is a long article about a homeless woman who lived on a grate near Grand Central Terminal. She was seemingly intelligent, a Williams grad, and had a promising future snuffed out by mental illness....

What is ironic is that the majority (probably all) of the people involved and interviewed probably support the deinstitutionalization craze that has gripped America since the 1970s. I wonder whether a firm public policy of forced commitment would have helped this woman. My suspicion is that it would have. That is not to say that our institutions were wonderful, but an all-or-nothing approach makes no sense. We have moved the mentally ill out of sometimes awful psychiatric facilities into the revolving door of the street, prison and an early death.

I was among those who has opposed forced institutionalization.  The practice used to be rife with abuse, and when it was really being challenged in the 1970's it was with recent knowledge of how institutionalization for supposed mental health issues had been used in the Soviet Union as a tool against dissent.  And in a world where political partisans still routinely assign negative mental health diagnoses to their political enemies and have even suggested using mental health diagnosis-from-a-distance to unseat the current President, there is still a lot of possibility for abuse.  But seeing that most of those who would have been in state mental hospitals are now in prison or living (and dying) on the streets, I am open to having made a mistake.   I am still not sure, though, who advocates for such people who are without friends and family and would help guard against their abuse.

  • me

    Anything with "forced" in the title usually doesn't end well - fundamentally it's an expression of "I know better what you ought to do than you do".

    What we lack in the US is frequently the option of access to help - you need a place to sleep tonight but have neither cash nor ID? You need food, water, a shower, basic medical care? Tough luck. There are programs that'll help you but navigating the funnel of finding access to care and applying correctly will be quite the hurdle.

    Let's fix that last part and discover how much of a real problem homelessness really is after all that, especially before we talk about forced institutionalization.

  • Bistro

    One of the things I regret was not ordering a petty officer to psychiatric counseling when she lost her mind, literally overnight. She was an outstanding Petty Officer and then one day she lost it all. It was like 40 points were shaved off her IQ. I didn't order her to a psych hold because the closest base was Travis and the Air Force had a long and troubled history of using Psych to the maximum disadvantage of the people who needed help or who were burned by the USAF Psych service. I didn't want that.
    She finally lost it to the point of danger and then went over the line. She ended up at Captain's Mast and then out of the service but something went very very wrong in her brain one night. It was like somebody threw a switch and the personality we knew disappeared.
    I used to see a girl, no more than 19 who was crazy and raving at invisible people under an I-5 overpass in Sacramento. She could be helped I thought but there was no way to encompass that.
    I too was against the forced institutionalization of the damaged but surely we could have open campus for people like that who could come and go and be dropped off by concerned people, treated for 48 hours and then come and go. Anything is better than what we have now.

  • Bistro

    We have so many closed colleges that died for lack of students and yet they have student housing that could be used if taken over by the state. We had, after the BRAC any number of bases with housing on a massive scale that could be used for the same purpose. Not to imprison or lock up but to leave a viable option for people who lack them.

  • Bram

    The Florida school shooter was recommended for institutionalization - but nothing came of it and 17 people died.

  • Stephen Maturin

    Who should advocate for people who are without friends and family and help guard against their abuse? People voluntarily providing private charity in a lost, gentler, but still recoverable Judeo-Christian culture in which people haven't been conditioned to believe their involvement with the needy ends with the high taxes they pay to governments at every level that assure us they're going to take care of and protect everyone -- but either do nothing or else do it mostly badly.
    But even in the best of cultures, not every human problem is solvable.
    My sister obtained a PhD, raised two daughters, and had grandchildren before she developed paranoid-schizophrenia in her middle age and became homeless. At times, she has lived with my mother and me. But she is extremely difficult to deal with. She constantly makes scenes with people she believes are stalking her or whom she images are sexual predators. She calls the police routinely to report being rendered unconscious remotely via a microchip in her brain and raped. We tried having her committed, unsuccessfully, because she doesn't appear to pose a physical danger to herself or others. She prefers the street to the restrictions we place on her in our homes. It's the wrong choice, but, at some level, it's a rational choice.
    We had a younger brother who also developed schizophrenia, but as a young adult. In contrast to my sister, he was institutionalized, mostly in private facilities but occasionally, after a violent outburst, in a state facility. We didn't learn until long after the fact that he had been sexually and physically abused over a long period at several facilities, adding to his psychological problems. He was also perpetually sedated, to make him more easily manageable to staff. But it also made him easier prey. He eventually developed brain damage and severe palsy, we believe from being overmedicated over many years. My mother did what she could to protect him. But, unless you have some experience dealing with largely unaccountable, largely understaffed, mostly mediocre mental-health facilities, it's probably hard to imagine how helpless one is.
    In short, in our family, we've experienced both -- institutionalization and private charity. Neither worked well. I've come to believe that in trying to solve many human problems we simply hide them, mostly only changing them from one form to another. It doesn't mean we shouldn't try to solve them. But it does suggest caution. One can confiscate a lot of wealth from some ostensibly to help others -- and render those who would help with less means and inclination to do so and those who need help with only a different set of problems.

  • Matthew Slyfield

    It wasn't just the process of involuntary commitment that was rife with abuse. There is a long history of horrific abuse of patients by the institutions to which they were committed.

  • ErikTheRed

    There are a couple of factors:

    1) Public spaces have been declared more or less fair game for the homeless by various court decisions. This creates a classic "tragedy of the commons" where these areas now become ad-hoc homeless encampments. This makes it easy for mentally challenged or disturbed people who have no other support structure to avoid being institutionalized. Without this issue, institutionalization becomes voluntary - at a certain point people need a place to eat and sleep and whatnot.

    2) I'd love to think that the abuses from back in the day would not repeat themselves in the age of the Internet and social media, but prison conditions being what they are now gives me little faith here.

    3) Somebody needs to be responsible for people with mental health problems, and wherever even remotely possible that someone needs to be the parents. As long as people are able to externalize the costs of their children onto society, we'll continue to see these problems grow.

  • Elam Bend

    I knew a woman who's son was schizophrenic and lived on the streets for years, getting in trouble with the law. It took her decade before she found a sympathetic judge who would agree to institutionalization. By the time I met her, the son lived with her, but under the condition that he'd go back if he didn't follow the household regime (which was basically they ate breakfast and dinner together and she watched him take his med.

  • Matthew Slyfield

    Also, look into the tiny house movement. Tiny houses, fixed locations or on trailers, can be produced at very low costs.

  • John Moore

    The causes of de-institutionalization were complex. Here are a few factors:

    1) The belief by psychiatrists that many patients could be so well managed with medication (or, cough) therapy that they need no longer be institutionalized. This required a substantial increase in community mental health care (certainly a benefit to psychiatrists and psychologists, which may have influenced their optimism). There certainly may have been some people institutionalized who shouldn't have been there - but nothing is perfect.

    2) The anti-psychiatry movement, led by Thomas Szasz, who was a radical and claimed that there was no such thing as insanity.

    3) The belief that institutionalization violated civil rights. This is also tied into the false equivalence with Soviet political institutionalization.

    4) A desire to reduce the cost to the government of institutions.

    De-institutionalization certainly went too far. On the other hand, it is not clear that all the people who choose to be homeless need to be institutionalized - many of them would probably not be better off.

  • There is where having a government class that's not composed of people unemployable in the productive half of society, matters. This is why most libertarians are against the death penalty. If you don't want a government this corrupt and incompetent having the power of life and death, why would anyone want them to have the power to institutionalize people?

    Can you see the IRS or the FBI having this kind of power, to wield against political enemies?

  • irandom419

    Maybe institutionalization might be a good thing, at least temporarily. If Popeye from South Caroline was, she might still have binocular vision. But then again freshly minted lawyers(3 years = associates degree?) trying to prove themselves will try to get them all out again. I think the worst thing is granting free side walk camping.

  • Mercury

    "I am still not sure, though, who advocates for such people who are without friends and family and would help guard against their abuse."
    -------------------------------------------------------------------------------
    If SJWs actually cared about social justice they could make a far more substantial impact on society by sinking their teeth into something like this instead of running around trying to make us all say "Nanu-Nanu" to each other.

    But of course, the don't. See previous post.

  • jdgalt

    That's Monday morning quarterbacking. Allow precautionary incarceration and millions of innocent people will be victims of it. Even VAWA does more about pre-crime than any law has business doing.

  • jdgalt

    Most of those who want treatment would go willingly, if the institutions were still open to them; and letting them keep the choice to leave is the only way to prevent abuses. So let us reopen them, but never bring back involuntary commitment to them.

  • regularjoeski

    There is a role for mandatory hospitalization in the treatment of the mentally ill. Many families do not have the resources to take care of severely mentally ill. Deinstitutionalization failed because the half way houses and outpatient treatment was never funded. Try and get zoning for a treatment house in an upper middle class/high income neighborhood. Homelessness could be taken care of if the states used eminent domain to open treatment centers next door to every federal and state judge's home. Take a bedroom in the home of every lawyer who objects for treatment along with a room in the home of each of the people who donate to the organization. "Skin in the game" as Taleb puts it. BTW section 8 housing should be limited to homes next to Judges, lawyers, and government workers who administer the program. Skin in the game

  • Bram

    We didn't have kids like him in my public High School. After multiple encounters with the law, he would have been off to reform school or the state hospital depending on how he was assessed.

    School was for students.

  • The problem with the death penalty (at least IMHO) is that, in the event of discovering a mistake in guilt or punishment, the remainder of the sentence cannot be waived. For both prison and institutionalisation, that is not the case.

    Best regards

  • mlhouse

    The answer is yes. She would have been better with electroshock therapy. I get that everyone watched "One Flew Over The Cuckoo's Nest" which was a major driver in the deinstitutionalization trend but electroshock therapy isn't "torture".

    We can see the problems associated with creating a mental health system that is voluntary in nature. Homelessness. Drug abuse. Violence. These are the unintended consequences of allowing people who cannot make rational decisions make their own decisions regarding their mental illnesses.

    It is inarguable that institutionalizing these mentally ill people benefits them as they will, at a minimum, at least be safe. IF they can get the proper treatment and medication that is even better. Some of them may even become better and able to actually function in the world.

    To protect the mentally ill I think the concept of guardianship is what is needed. Upon the recommendation of a mental health professional for institutionalization, a guardian would be appointed for the individual. THis guardian could be a parent, relative, friend, or appointed by the state. The guardian would be responsible for evaluating the recommendation of the mental health professional in the best interest of the person, as well as in charge of their personal matters. Due process rights can be maintained and guardianship challenged, but the benefits of such a system far outweigh the potential abuse.

  • marque2

    Electro shock actually makes severely depressed people feel happy for a few weeks. The electric charge changes brain patterns for abit of time. It wasn't applied for general torture.

  • marque2

    There were also rich people who got two doctors to sign that a spouse was insane and was able to lock em up for life - even though the said doctors didn't see the spouse and the spouse was generally sane. Rich people did this to avoid messy divorce.

  • marque2

    Your first assertion is false. As soon as three day rule was created the assylums almost completely emptied out - so they were closed. The myth is that Reagan hated them - threw them all on the street then shut down the facilities. Totally false notion.

    You could say the same about our empty homeless shelters - that if they exist the homeless.would surely stay there. Not happening.

  • marque2

    Libertarians - the death penalty is only for innocent babies.

  • marque2

    Problem is the mentally ill refuse to go into such homes. Once the supreme court made a ruling that you can't hold a person against their will, all the homes emptied out. No point in building if you can't keep people in them.

    I guess people have forgotten so now we think, if we only built more homes, and more microhouses, whatever, the mentally ill don't stay there, and unless they also have maid service, the places go downhill very fast and become unlivable.

  • mx

    That was the problem. The process was abusive and the institutions were abusive, with little to no effort made to keep people in the least restrictive setting that met their needs. Addressing that was a good thing.

    The problem is that nice places with ample qualified staff are expensive. So we never built anywhere near enough of them when we closed the hellhole institutions. We make outpatient mental health care really hard to access on Medicaid (fun fact: having a mental illness can make it even harder to navigate the health care system by yourself). My city has a couple dozen adult in-patient psych beds, and some of those are reserved for seniors. You can't diagnose from afar, but a walk through downtown will reveal far more people clearly in serious need of mental heath care and/or drug treatment. Patients are turned away at the hospital routinely.

    Is there perhaps room for a bit more coercion to get people into treatment? I'd say so. But so many people aren't getting help not because we ended horrible abuses, but because we never were willing to pay the costs of providing the non-abusive services we needed.

  • cc

    A contributing factor has been the closing down of SROs (Single Room Occupancy) hotels. This was a crusade to "clean up" cities because this was where all the winos and crazy people lived (as well as prostitutes). These hotels were minimal, just a single room with shared bathrooms. They gave crazies a place to stay. I can remember the campaign in Chicago to tear them down, and now they are gone. But getting rid of them put those people on the street. They could afford to live there on a social security check or military pension or pan-handling. The idea that we make a city better by outlawing poverty is a grand progressive idea, but wrong.

  • Matthew Slyfield

    "at a minimum, at least be safe."

    This completely ignores the very well documented historical abuse of patients, by mental institutions.

    Current mental institutions might be better quality, but there aren't enough beds to significantly increase involuntary commitments. The necessary increase in capacity will also necessarily reduce aggregate quality of care and weaken government oversight of care providers.

  • Matthew Slyfield

    "To protect the mentally ill I think the concept of guardianship is what is needed."

    There was a scandal that came out last year where Texas law was allowing corporate guardianship companies to move to have elderly persons declared incompetent and placed in their guardianship, without any request to do so by the family.

    It came out that the top companies were going after mentally competent but well-off couples and using the guardianship to steal their assets.

  • mlhouse

    The problem with arguments like yours is that even if they are true, you are basing your policy decisions on exceptions and ignoring the masses that clearly need to be institutionalized even against their will.

  • Bistro

    I know.

    A campus. A place where they are free to come and go. A place with a thousand benches and people who come by and just drop a blanket aggressively because they can.

  • Matthew Slyfield

    "The problem with arguments like yours is that even if they are true, you are basing your policy decisions on exceptions"

    You are wrong, the well documented history of mental institutions clearly shows that abuse of patients was the rule, not a rare exception.

    "masses that clearly need to be institutionalized even against their will."

    Perhaps, but don't pretend that you want to institutionalize them for their safety rather than for your own.

  • Bart Hall

    I had a very close friend, now deceased, who was head of mental health for an eastern state. When the orders came down from Washington -- was that even constitutional ?? -- to de-institutionalize an arbitrary 80 percent of the patients in his state Bob wept in frustration. I was there. "Maybe 10 or 20 percent will be okay outside." he said, "But that 60 percent in the middle? They need to be here. They're not really stupid, but they're just too fucked up to make it on their own. They'll end up living on the street.Our whole purpose has been to prevent that," He was a 5th-generation Democrat, and this particular Carter-administration idiocy was more than enough to drive him away from that party forever.

    His predictions were depressingly accurate. The "de-institutionalized" about which Bob cared so much were the very first casualties of the prototype Social Justice Warriors. But he and his colleagues had (under threat of federal lawsuit) no available choice but than to comply. Forty-some years have demonstrated he was completely correct.

  • b w

    It wasn't necessarily wrong to oppose involuntary commitment; what was wrong was to do so under the assumption that ending involuntary commitment would be a panacea without any tradeoffs. Under involuntary commitment, there were abuses, and mentally ill people suffered. Under the current system, there is homelessness, and mentally ill people suffer. There is no magic way to eliminate human suffering, but at least, under the current system, people have a choice. Liberty is not antiseptically utopian, and even mentally healthy people, when free, make sub-optimal choices to their own detriment. Mental illness has often been defined as behavior that is inconvenient for those in power, and what constitutes mental illness will always be a political football as long as mental illness is a criteria for stripping people of liberty, livelihood, or property; it's an intrinsic perverse incentive.

    Someone suggested that all the SJW's shift their energy from policing pronouns to setting up a charity to offer the homeless safe places to live and voluntarily get treatment. Conservatives have already done this - the Salvation Army is one of the largest charities in the country working to help the homeless, and one of the largest sponsors of AA programs. One of the reasons their programs are successful is that, as a private organization, lacking the government's coercive power, they offer help conditioned on the recipient's willingness to hear and hopefully embrace their message of philosophical and behavioral change. Just because helping the mentally ill is a good thing to do doesn't mean it's a good thing for the government, forcibly, to do.

    Finally, the impulse to give more power to social scientists is misguided. There is no problem that social scientists claim to address which has not increased in lockstep with the number of social scientists and the policy-setting power given to them. There is no other endeavor labeled a science with a worse track record. The social sciences are more religion than science, and have displaced traditional religions as the primary justification for authoritarian suppression of liberty.

  • Milo Galt

    Clayton Cramer wrote an illuminating account of his brother's mental illness and de-institutionalization that I found very interesting. It is a complex issue.

    http://a.co/hGrGhRv