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Comment by nullwasamistake | Hacker News Reader

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

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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).

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.

>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.

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.

"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.

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.

> 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...

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.

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.

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

> 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.

There should be more cheap single room occupancy apartments where the mentally ill can live with state support.

> 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.

>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

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