Hacker News Reader

Comment by raverbashing | Hacker News Reader

> adequate support in the community for people with severe and enduring mental illness, which is why so many people are trapped in a cycle of homelessness and incarceration.

The level of "adequate support" needed for (some of) those people are much higher than what you're probably imagining

> they just need help and can't get it

And even when they get one day they just say "I'm not taking the meds anymore" and then what? It's back on the streets or homeless hostels.

Sure, they might not be aggressive per se, but that doesn't mean they are "compatible" with society.

> the fundamental questions are why do these people have nowhere else to go? and why is nobody here who actually has the training to help these people?

You're just pointing out problems without pointing up the solutions. And I'm afraid the best solution would be something much similar to what's described in your 1st paragraph.

View on HN

>And even when they get one day they just say "I'm not taking the meds anymore" and then what? It's back on the streets or homeless hostels.

If someone goes off their meds, you don't just abandon them to the streets. You send a trained mental health nurse and/or social worker to talk to them, several times a day if necessary. If they don't want to engage, you work with them to build a relationship of trust. You work with that person to get them back on a suitable course of medication, or to help them manage their symptoms and manage their life while unmedicated. You provide supported housing and supported employment or work-related activity wherever it would prove beneficial. You keep working with them again and again and again unless you're damned certain that they're truly beyond help.

Of course that's expensive, but it's also remarkably good value for money compared to the alternative. The net difference between a borderline functional person and a completely dysfunctional person can exceed a million dollars per year in policing, incarceration, ER visits and other costs.

This model of community care isn't new and it's proven to work and to be cost effective. There are plenty of places in the world that don't rely on mass institutionalisation and have remarkably low rates of homelessness.

> You send a trained mental health nurse and/or social worker to talk to them, several times a day if necessary. If they don't want to engage, you work with them to build a relationship of trust. You work with that person to get them back on a suitable course of medication, or to help them manage their symptoms and manage their life while unmedicated.

Serious question, would you be willing to do that job? For what price? For how long?

It is exactly what happens in most countries here in Europe

It already exists, you don't have to invent it.

If I were a trained mental health professional who had also been trained on emotional regulation capable of doing this job in a society where mental health professionals are equal to nurses and doctors I would definitely do this job for the salary equivalent to a nurse or a doctor. I’d be contributing to the greater good much more than my current position writing software that will never change/save lives.

You make it sound like those professionals have some magical training to withstand the abuse, the stress, the bad situations of the job.

While they do have some training, it is not possible to shake some things off easily and it does get old quick. One of the reasons why drug abuse is so prevalent in some medical communities.

The median physician salary is $217,000, and the average family doctor oversees a panel of 2,300 people, who see him or her about 20 minutes, two or three times a year.

There is not a sustainable system where workers pay taxes sufficient to afford a specially trained nurse or doctor for full time, personal care for everyone who could benefit from it.

If we don’t have social networks that shoulder burdens at what looks like an economic loss, there’s not enough paid care to go around at the levels of empathy we want.

The 2300 number is commonly cited, but more recent surveys suggest average panel size is much lower.

Recent studies of various practice settings in the United States and abroad found current panel sizes ranging from 1200 to 1900 patients per physician. For example, Kaiser Permanente reported a mean per-physician panel size of 1751 patients, and Group Health Cooperative of Puget Sound reported a panel size of 1490 patients per physician.18 The US Department of Veterans Affairs reported a mean panel size of 1266 patients per full-time equivalent physician.19 One study in Canada found a panel size of 1400 patients per PCP.20 A study in Denmark found a maximum level of 1600 patients per physician,21 and a study in England found 2033 patients per solo physician.22

https://www.jabfm.org/content/29/4/496.full

You seem to imply that I'm proposing something new and radical, whereas I'm actually just describing how community mental health is practised in a lot of places, including some parts of the US.

I wouldn't be willing to work as a psychiatric nurse or a social worker, but clearly plenty of people are. There are all sorts of jobs I wouldn't want that other people love and vice-versa.

I would need some firm data showing plenty of people are willing to work with people who may pose a danger to them. Retail work is considered to be bottom of the barrel because you have to deal with the general public, I don’t see people lining up to spend years of their education to deal with mentally ill customers.

At least not without significant compensation, which we as a society don’t want to pay for, considering the piss poor pay for social workers and lack of mental institutions.

A large number of people have the job title "mental health nurse" or "psychiatric nurse". A majority of those people spend a majority of their time working with the most seriously ill people. For a high-income country, the US has an unusually low number of mental health nurses relative to the overall population; there are more than five times as many mental health nurses per capita in the UK, Scandinavia, New Zealand or Japan.

https://www.who.int/mental_health/evidence/nursing_atlas_200...

True, but this shouldn't be done on the streets. At some point they need to be "taken" to a safe facility.

At some point, sure. But don't dismiss the persuasive power of free food, shelter from the elements, a bed, laundry service, etc. (especially if those are being provided by the same place! ZOMG, what a concept!) to voluntarily entice most of the homeless population to a safe facility.

What happens when this entices someone who is screaming at imaginary aliens between the hours of 3 am to 5 am, uses the hallway as a toilet, and is convinced that his neighbour wants to kill him in his sleep?

Do you force-medicate them? Restrain them? Kick them out? Or just let them ruin it for everyone else? What exactly are you proposing the institution should do?

What about someone overdosing twice a week? Do you just keep sending ambulances to drive them to the ER, until they finally die, and we can feel smug and superior that, well, at least their human rights weren't infringed?

People don't need to be "taken" if they actually expect the facility to be helpful. Too often there are very legitimate reasons that people expect the opposite (e.g. having experienced psych hospitals that are basically just soul-sucking money farms optimized for "processing" patients).

Reply on news.ycombinator.com