Dungeons and Back Alleys: The Fate of the Mentally Ill in America(psychiatrictimes.com)
psychiatrictimes.com
Dungeons and Back Alleys: The Fate of the Mentally Ill in America
https://www.psychiatrictimes.com/couch-crisis/dungeons-and-back-alleys-fate-mentally-ill-america
36 comments
>> The human brain is the most complicated thing in the known universe
Really? It is more complicated than the Orca brain? We aren't magic. The differences between our's and the brains of similarly-sized animals are slight. I'd say our brain isn't fundamentally any more complex than an ape's or a dogs. But if you want to compare numbers, Sperm Whales have 18-20lb brains, far larger and more complex than ours by every measurement.
https://en.wikipedia.org/wiki/File:Figure_35_03_05_Brain_siz...
Really? It is more complicated than the Orca brain? We aren't magic. The differences between our's and the brains of similarly-sized animals are slight. I'd say our brain isn't fundamentally any more complex than an ape's or a dogs. But if you want to compare numbers, Sperm Whales have 18-20lb brains, far larger and more complex than ours by every measurement.
https://en.wikipedia.org/wiki/File:Figure_35_03_05_Brain_siz...
Correlating brain size to intelligence or complexity is a common amateur mistake. Let’s for a second pretend all animal’s brains are black boxes, and we can neither see nor measure them. Instead, let us say we can only judge brains by their impact on the world. Would you then not put humans so far above the other animals as to make it almost silly to compare?
>> can only judge brains by their impact on the world.
So bacteria? Plankton has a massive impact on the world too. Insects ... the planet is arguably dominated by insects.
Mammalian brains are, plus or minus a few percent, equally as dense/complex. There are aspects of dolphin brains that are far more complex than ours. A dog's brain has far more connections dedicated to smell than ours. There is some evidence that Orca brains have similarly more connections dedicated to emotions. Each brain is tuned slightly differently, ours perhaps more to vision and problem solving, but our biology isn't any more evolved or complicated.
So bacteria? Plankton has a massive impact on the world too. Insects ... the planet is arguably dominated by insects.
Mammalian brains are, plus or minus a few percent, equally as dense/complex. There are aspects of dolphin brains that are far more complex than ours. A dog's brain has far more connections dedicated to smell than ours. There is some evidence that Orca brains have similarly more connections dedicated to emotions. Each brain is tuned slightly differently, ours perhaps more to vision and problem solving, but our biology isn't any more evolved or complicated.
Our culture if toxic masculinity that equates mental illness with weakness and personal moral failure
This. Our culture says that if you don’t work you’re a drag on society and frowned upon. If you don’t work you don’t deserve insurance. If you don’t have insurance you don’t deserve to be healthy. Certain politicians would get rid of Medicaid and Medicare in a heartbeat if they could.
It’s truly disgusting.
It’s truly disgusting.
An observation.
On the micro scale these aren't mean or bad people. A lot of people I know back home (Missouri, middle class, many of them baby boomers) follow this brand of logic and the accompanied tough-guy/cult-of-the-dollar ethos.
Not one of them applies this ruthless logic in their daily life. They are compassionate with the people in their lives, some to the point of enabling people with substance abuse problems as opposed to letting the authorities 'deal' with them.
The complexity and scale of these problems out-strips the empathy required to solve them for many people. The experiences(no health care, mental health issues, prejudice) do not match their own experiences which makes those dealing with them the 'other'.
The way to getting some traction with these problems probably lies more in bridging the empathy gap than in the solution space.
On the micro scale these aren't mean or bad people. A lot of people I know back home (Missouri, middle class, many of them baby boomers) follow this brand of logic and the accompanied tough-guy/cult-of-the-dollar ethos.
Not one of them applies this ruthless logic in their daily life. They are compassionate with the people in their lives, some to the point of enabling people with substance abuse problems as opposed to letting the authorities 'deal' with them.
The complexity and scale of these problems out-strips the empathy required to solve them for many people. The experiences(no health care, mental health issues, prejudice) do not match their own experiences which makes those dealing with them the 'other'.
The way to getting some traction with these problems probably lies more in bridging the empathy gap than in the solution space.
> The experiences(no health care, mental health issues, prejudice) do not match their own experiences which makes those dealing with them the 'other'.
If things keep going the way they are, those experiences will only become more relatable; not less.
I have a good, high-paying job with good benefits and even I am considering going without health insurance because I get so little from the premiums I pay. Most of my providers are out of network because all of the ones in network have 3-12 month waiting lists for new patients.
And that’s on top of the $5000 deductible — plus the fact I know if anything serious happens I’d likely have to fight with the insurance company for years and have to take out a loan to cover the treatment in the meantime (I’ve had to do this before, and conversations with others in my situation taught me I was far from alone).
Our health insurance system is officially non-functional in my eyes.
If things keep going the way they are, those experiences will only become more relatable; not less.
I have a good, high-paying job with good benefits and even I am considering going without health insurance because I get so little from the premiums I pay. Most of my providers are out of network because all of the ones in network have 3-12 month waiting lists for new patients.
And that’s on top of the $5000 deductible — plus the fact I know if anything serious happens I’d likely have to fight with the insurance company for years and have to take out a loan to cover the treatment in the meantime (I’ve had to do this before, and conversations with others in my situation taught me I was far from alone).
Our health insurance system is officially non-functional in my eyes.
100%
These situations will have to become more pervasive because we're talking about shattering identity to adopt change.
The other thing most Americans don’t realize is that many people would be financially better off paying out of pocket and taking a deduction on your tax returns.
Trump made that harder for lower and middle class workers with his “tax cut”, but it’s still viable in certain tax brackets. But something tells me that ending risk-pooling in favor of individual tax deductions is the endgame the current GOP has in mind...
Trump made that harder for lower and middle class workers with his “tax cut”, but it’s still viable in certain tax brackets. But something tells me that ending risk-pooling in favor of individual tax deductions is the endgame the current GOP has in mind...
given that you do not consider these good-to-ingroup-bad-to-outgroup people "mean or bad people", who do you reserve and apply that descriptor for? any examples?
A middle class dad that's anxious about not having enough cash being told consistently for years that 'others' want more of his money may be a bit selfish or lack perspective but he's not a "bad" person. The same way a substance abuser isn't a "bad" person.
Those who feed toxic beliefs/prey on folks' insecurities for personal gain, range from misguided/unscrupulous to bad.
Those who feed toxic beliefs/prey on folks' insecurities for personal gain, range from misguided/unscrupulous to bad.
The problem with deinstitutionalization and modern therapy is the assumption everyone can be treated. While that's more true than ever, a significant proportion of the mentally ill do not respond to medicine or therapy.
We need to bring institutions back for those we cannot cure. Jail has become the treatment center of last resort for those too dangerous to themselves or others, because we closed all the secure psychiatric centers. There's not enough room in jail either, and judges aren't keen on incarcerating people long term to protect them from themselves. So these people end up on the street.
Besides the drug addicts, of which treatment is also a problem in the US, this is why you see so many crazy homeless people.
Institutions might not be a "nice" place to live your life, but it's a hell of a lot better than living on the streets
We need to bring institutions back for those we cannot cure. Jail has become the treatment center of last resort for those too dangerous to themselves or others, because we closed all the secure psychiatric centers. There's not enough room in jail either, and judges aren't keen on incarcerating people long term to protect them from themselves. So these people end up on the street.
Besides the drug addicts, of which treatment is also a problem in the US, this is why you see so many crazy homeless people.
Institutions might not be a "nice" place to live your life, but it's a hell of a lot better than living on the streets
>Institutions might not be a "nice" place to live your life, but it's a hell of a lot better than living on the streets
That's just your opinion. Many prefer the freedom of the streets over the imprisonment and forced drugging of mental institutions
That's just your opinion. Many prefer the freedom of the streets over the imprisonment and forced drugging of mental institutions
There should be more cheap single room occupancy apartments where the mentally ill can live with state support.
>Institutions might not be a "nice" place to live your life, but it's a hell of a lot better than living on the streets
Given the choice between being locked up indefinitely in a quasi-jail with a bunch of crazy people or taking your chances on the streets, what would you choose for yourself? Are you certain?
We don't need institutions, we don't want institutions, we need properly funded community care. People with severe and enduring mental health problems do far better when they have a stable home, meaningful activity and a sense of autonomy. We can provide those things far better in the community. Long-term institutions only offer "out of sight, out of mind" for the rest of us.
Given the choice between being locked up indefinitely in a quasi-jail with a bunch of crazy people or taking your chances on the streets, what would you choose for yourself? Are you certain?
We don't need institutions, we don't want institutions, we need properly funded community care. People with severe and enduring mental health problems do far better when they have a stable home, meaningful activity and a sense of autonomy. We can provide those things far better in the community. Long-term institutions only offer "out of sight, out of mind" for the rest of us.
By labeling the solution as "community care" you are really not proposing a solution: what are the implementation steps for your solution?
We don't need more money, we don't need more programs. We need an implementation checklist.
You see, we as a society need to take it step by step and adopt a scientifical method in dealing with this problem. The first step is to prevent the mentally ill and drug-addicted from being a danger to the community and to themselves. So bring back the institutions as that first step.
Then a second step, we need to identify groups of people that we decide to re-introduce with "community care", monitor their results and keep them accountable. Each one of them will most likely respond differently to different implementations of what you call "community care". Give it a time duration too, and observe the behavior. And so on.
Finally, there will be individuals fully re-introduced into society. There will also be individuals that need a little bit of extra effort to make that happen. But like with any group, statistically there will be individuals too dangerous that must stay in the institutions for their own health.
We don't need more money, we don't need more programs. We need an implementation checklist.
You see, we as a society need to take it step by step and adopt a scientifical method in dealing with this problem. The first step is to prevent the mentally ill and drug-addicted from being a danger to the community and to themselves. So bring back the institutions as that first step.
Then a second step, we need to identify groups of people that we decide to re-introduce with "community care", monitor their results and keep them accountable. Each one of them will most likely respond differently to different implementations of what you call "community care". Give it a time duration too, and observe the behavior. And so on.
Finally, there will be individuals fully re-introduced into society. There will also be individuals that need a little bit of extra effort to make that happen. But like with any group, statistically there will be individuals too dangerous that must stay in the institutions for their own health.
"Community Care" is a bit of jargon that has a well established meaning.
I think you're suggesting that we lock up everyone who has a mental illness, and then release the ones who aren't dangerous.
About 1% of the population has schizophrenia. About 1% of the population has bipolar. Let's say about 1% of the population has a severe personality disorder. If there are about 320m people in the US you're calling for the incarceration of 9,600,000 innocent people.
The vast majority of those people are not a danger to others, or themselves.
What we need to do is invest in community care, have short hospital stays available if needed, and have forensic "secure units" available for the small numbers of people who pose a serious risk of harm to other people or who have committed criminal acts while mentally ill. We do this because it is cheaper; it is more effective; it is safer; and it respects people's human rights.
I think you're suggesting that we lock up everyone who has a mental illness, and then release the ones who aren't dangerous.
About 1% of the population has schizophrenia. About 1% of the population has bipolar. Let's say about 1% of the population has a severe personality disorder. If there are about 320m people in the US you're calling for the incarceration of 9,600,000 innocent people.
The vast majority of those people are not a danger to others, or themselves.
What we need to do is invest in community care, have short hospital stays available if needed, and have forensic "secure units" available for the small numbers of people who pose a serious risk of harm to other people or who have committed criminal acts while mentally ill. We do this because it is cheaper; it is more effective; it is safer; and it respects people's human rights.
There are two extremes: lock everybody up or let everybody be on the street.
Both are wrong, and today the latter is being implemented. We need a balanced solution, but what we have today is not working (as a short walk around San Francisco - for example - will demonstrate).
What I want is not “hopes” or “more funding”. What I want is a plan. Saying that all we need is “community care” is too generic and broad which means things will never change.
I want 1-2-3 steps on how we are going to be dealing with these issues.
Both are wrong, and today the latter is being implemented. We need a balanced solution, but what we have today is not working (as a short walk around San Francisco - for example - will demonstrate).
What I want is not “hopes” or “more funding”. What I want is a plan. Saying that all we need is “community care” is too generic and broad which means things will never change.
I want 1-2-3 steps on how we are going to be dealing with these issues.
> By labeling the solution as "community care" you are really not proposing a solution: what are the implementation steps for your solution?
I'm not proposing anything new, I'm proposing the model that is used by most other developed countries and is being successfully used in some parts of the United States. If you think that "community care" is some vague pie-in-the-sky notion rather than an established approach to care with a proven track record, then there's very little point in continuing this discussion.
https://en.wikipedia.org/wiki/Community_mental_health_servic...
I'm not proposing anything new, I'm proposing the model that is used by most other developed countries and is being successfully used in some parts of the United States. If you think that "community care" is some vague pie-in-the-sky notion rather than an established approach to care with a proven track record, then there's very little point in continuing this discussion.
https://en.wikipedia.org/wiki/Community_mental_health_servic...
In the US “community care” sounds like a great way of collecting more tax money while ultimately not implementing any program that works.
I want politicians to establish the rule of law and create a livable community by implementing a program (or community care checklist) with the tax money we are already providing.
Instead we have unaccountability, poverty, illness, misery and high taxes. All at the same time.
We need to abolish Proposition 47.
I want politicians to establish the rule of law and create a livable community by implementing a program (or community care checklist) with the tax money we are already providing.
Instead we have unaccountability, poverty, illness, misery and high taxes. All at the same time.
We need to abolish Proposition 47.
As a resident of the UK, I can state that community care is exactly the same ideologically-driven agenda with exactly the same real-world failings that are being ascribed to the US model. The only difference is that there are still remnants of a benefit system that provide some protection for the least fortunate, although the government is in the process of dismantling those as well.
It's a failure in most of Canada too, every successive provincial government decides to slash it's budget or 'reorganize' community care to the point it's just a weak pill dispensing model with no oversight and thus you get mentally ill in the street at all hours running wild with drug and alcohol addictions.
I think Andrew Yang style UBI is really the only solution, a guaranteed monthly living income that's illegal to take loans against or illegal to withhold because of debts. That or some kind of accountability where we are able to personally sue politicians who have turned our cities into poorly run asylums.
I think Andrew Yang style UBI is really the only solution, a guaranteed monthly living income that's illegal to take loans against or illegal to withhold because of debts. That or some kind of accountability where we are able to personally sue politicians who have turned our cities into poorly run asylums.
We need both. The majority of homeless could be rehabilitated. But there's a significant fraction that are too dangerous for "community care", to themselves and others. Care for both categories is underfunded.
If you think all mentally ill people can be safely cared for in anything not resembling a comfortable prison you've never met a severe schizophrenic
If you think all mentally ill people can be safely cared for in anything not resembling a comfortable prison you've never met a severe schizophrenic
> locked up indefinitely in a quasi-jail with a bunch of crazy people or taking your chances on the streets, what would you choose for yourself?
The institution, 100%. Being on the streets also involves being around crazy people, plus criminals, and not all that much to protect you from them.
And, of course, you'll likely have to head to a homeless shelter during the winter. Talk to people and you'll find that some of them prefer sleeping on the streets, even with hypothermia risk. Usual complaints include noise, drugs, lice, and getting your shoes stolen.
The institution, 100%. Being on the streets also involves being around crazy people, plus criminals, and not all that much to protect you from them.
And, of course, you'll likely have to head to a homeless shelter during the winter. Talk to people and you'll find that some of them prefer sleeping on the streets, even with hypothermia risk. Usual complaints include noise, drugs, lice, and getting your shoes stolen.
This is a bit cartoony. The US never closed "all" of its secure centers.
It also never really effectively tried deinstitutionalization; the funding for community care never reached the anticipated levels and ultimately the whole thing turned into a cost-saving measure (close the snake pits, but then conveniently decide not to build the things that were meant to substitute for them).
Claiming that you see crazy homeless people ergo "community care and modern treatment is ineffective" skips over the fact that this treatment is underfunded and hasn't really been tried on most of the US. It should be the first line of defence, and will be way cheaper than locking everyone up again.
There will always be incurables who need to be in institutions, but the current regime is creating way more people who appear this way (often after having been traumatized by prison and homelessness).
It also never really effectively tried deinstitutionalization; the funding for community care never reached the anticipated levels and ultimately the whole thing turned into a cost-saving measure (close the snake pits, but then conveniently decide not to build the things that were meant to substitute for them).
Claiming that you see crazy homeless people ergo "community care and modern treatment is ineffective" skips over the fact that this treatment is underfunded and hasn't really been tried on most of the US. It should be the first line of defence, and will be way cheaper than locking everyone up again.
There will always be incurables who need to be in institutions, but the current regime is creating way more people who appear this way (often after having been traumatized by prison and homelessness).
One thing institutions had going for them is that they were large buildings with many employees, and thus had political weight.
Spending the same money on community care might be more efficient, but doesn't have this weight. So if you trim the budget 20% this year in some crisis, 20% another year, you never have to officially claim to be giving up. Which if I understand right is basically what happened.
I don't claim that proponents of deinstitutionalization had this in mind, I think they were well-intentioned. But it does seem like a factor worth bearing in mind. It's a bit like the trams vs busses debate -- the more flexible system is vulnerable to getting squeezed, the less flexible one is more permanent.
Spending the same money on community care might be more efficient, but doesn't have this weight. So if you trim the budget 20% this year in some crisis, 20% another year, you never have to officially claim to be giving up. Which if I understand right is basically what happened.
I don't claim that proponents of deinstitutionalization had this in mind, I think they were well-intentioned. But it does seem like a factor worth bearing in mind. It's a bit like the trams vs busses debate -- the more flexible system is vulnerable to getting squeezed, the less flexible one is more permanent.
> The problem with deinstitutionalization and modern therapy is the assumption everyone can be treated.
The problem is that places like California tried deinstitutionalization full stop.
The problem is that places like California tried deinstitutionalization full stop.
Large part alcohol and drug abuse can be attributed to self-medication.
Alcohol is the most available tranquilizer and sedative. If you are homeless with mental problem, what else there is?
After the WWII many veterans simply drank themselves into grave because PTSD was not a thing and they could not get other help. https://academic.oup.com/aje/article-abstract/109/6/687/1121...
After the WWII many veterans simply drank themselves into grave because PTSD was not a thing and they could not get other help. https://academic.oup.com/aje/article-abstract/109/6/687/1121...
So... not to undercut the message of anyone who is trying to reform the catastrophically broken mental health system, but - there is a massive elephant in the room in this discussion, and that is trauma.
It is nearly inconceivable to me that a leader in the field, a guy who wrote an earlier version of the DSM aka bible of modern psychiatry, manages to talk about the pros and cons of meds but never mentions the experiences that are known to drastically harm mental health.
We don’t need a “moon shot” as Dr. Frances suggests. At least in terms of expensive research into completely novel technologies or drugs to determine the root cause or treat much of this suffering. We may need a moonshot in terms of getting over our stigma around talking about trauma and abuse, so that trauma-informed care becomes the rule and not the exception.
The closest thing the DSM has to a trauma diagnosis is PTSD and complex PTSD. Dr. Bessel van der Kolk (author of The Body Keeps The Score, incredible resource on trauma) has proposed the diagnosis “Developmental Trauma Disorder” but this has not yet been widely adopted by mainstream psychiatry.
As far as I’m concerned, adding this single diagnosis and training mental health professionals to screen for trauma will do a lot more to help people than writing doomsaying articles like this one.
Source: grew up with developmental trauma from abusive family environment. Lost my little sister to suicide after her severe trauma was not screened for and was misdiagnosed as “bipolar”.
It is nearly inconceivable to me that a leader in the field, a guy who wrote an earlier version of the DSM aka bible of modern psychiatry, manages to talk about the pros and cons of meds but never mentions the experiences that are known to drastically harm mental health.
We don’t need a “moon shot” as Dr. Frances suggests. At least in terms of expensive research into completely novel technologies or drugs to determine the root cause or treat much of this suffering. We may need a moonshot in terms of getting over our stigma around talking about trauma and abuse, so that trauma-informed care becomes the rule and not the exception.
The closest thing the DSM has to a trauma diagnosis is PTSD and complex PTSD. Dr. Bessel van der Kolk (author of The Body Keeps The Score, incredible resource on trauma) has proposed the diagnosis “Developmental Trauma Disorder” but this has not yet been widely adopted by mainstream psychiatry.
As far as I’m concerned, adding this single diagnosis and training mental health professionals to screen for trauma will do a lot more to help people than writing doomsaying articles like this one.
Source: grew up with developmental trauma from abusive family environment. Lost my little sister to suicide after her severe trauma was not screened for and was misdiagnosed as “bipolar”.
> It is hard to be complacent when 600,000 people who should be our patients are instead languishing as prisoners or sleeping on streets.
Any success stories of decriminalizing — or normalizing given it’s pervasiveness — mental illness?
One of the most poignant “policing” incidents I saw was at a Charlotte bus stop where the officer with compassion and humbleness was helping out a gentleman who was going through an episode — my lay person’s interpretation. I don’t know whether the officer had any training, but he was doing the best he could with whatever training he did have, in a way where the person, his meager belongings and his integrity were respected. So why do we depend on the kindness of police rather than mental health givers?
Any success stories of decriminalizing — or normalizing given it’s pervasiveness — mental illness?
One of the most poignant “policing” incidents I saw was at a Charlotte bus stop where the officer with compassion and humbleness was helping out a gentleman who was going through an episode — my lay person’s interpretation. I don’t know whether the officer had any training, but he was doing the best he could with whatever training he did have, in a way where the person, his meager belongings and his integrity were respected. So why do we depend on the kindness of police rather than mental health givers?
Americans don't treat it as a health problem, so the only public force with authority is the police force. There's no fire. There's no car accident. Is not in a national park.
We are cold isolated people.
We are cold isolated people.
[deleted]
I have been a regular visitor to the USA, and lived there for some time in between, and seen it over most of my life as a visitor. A time period of 45 years, almost.
Whenever I'm 'back in Cali', one of my favourite places to visit is Skid Row.
From here, you truly see what is rotten in the state of Kansas.
Of course, we can go to all of the major American cities, but there is nothing more sobering from the glitzy side of downtown than to go work in a soup kitchen, if they still have them, just a few short blocks away from the wealth.
It is a sad memory of America. But always an honest one.
Whenever I'm 'back in Cali', one of my favourite places to visit is Skid Row.
From here, you truly see what is rotten in the state of Kansas.
Of course, we can go to all of the major American cities, but there is nothing more sobering from the glitzy side of downtown than to go work in a soup kitchen, if they still have them, just a few short blocks away from the wealth.
It is a sad memory of America. But always an honest one.
> Why is it that the rest of the developed world gets this and what makes us the laggard outlier?
Has a lot to do with playing world police. A lot of this is tied to veterans with PSD.
Has a lot to do with playing world police. A lot of this is tied to veterans with PSD.
The human brain is the most complicated thing in the known universe and keeps its secrets well hidden. Genetics and neuroimaging have shown how remarkably complex and interacting are the biopsychosocial causes of mental illness and that there will likely never be magic bullets. Drug companies have stopped looking for them.
This paragraph summarizes the issue of mistreatment of the mentally ill in the US perfectly:
Why is it that the rest of the developed world gets this and what makes us the laggard outlier? How can it be that the richest country in the world is most neglectful of its most vulnerable citizens? The simplest answer to this complicated question is the misplaced US faith that market forces are always the most efficient vehicle for solving problems. Adam Smith—the father of modern economics—knew better and strongly supported the role of government in providing vital public services undervalued by the market. Privatization of mental health has resulted in too much treatment for the well; cruel neglect for severely sick.
The path to improvement is a political one, lobbying the ones in power on behalf of our powerless mentally ill. We need to end their silent suffering.