What American Mental Health Care Is Missing
theatlantic.com
theatlantic.com
I'm not going to pretend like I know what the solution is, but it starts by actually addressing it as a serious problem, which the U.S has not done. I guess politicians thinks it's normal for mentally insane homeless people to be shouting to people on sidewalks everywhere, and assaulting and even murdering random pedestrians? [1] For anyone who hasn't left the U.S - this isn't normal anywhere else in the world. What a shame that the wealthiest country can't manage its cities.
[1] https://nypost.com/2022/02/13/woman-stabbed-to-death-inside-...
Thanks Reagan...
Problem is instead of reform they just shut down the entire system. Now we have loads of people on the street who really do need continuous professional help.
Reagan was governor. Governors sign bills. Legislatures pass them. This was a bipartisan effort and was viewed as a civil rights issue, to not hold people in confinement against their will. Lanterman was a Republican, Petris and Short were Democrats. Reagan could have vetoed it, so he shares in the responsibility, but it was a bipartisan, popular bill.
> removed all funding for Mental Health at the State and Federal level.
Do you really believe that all funding was removed? What is your basis for this shocking claim? It's very hard to cut government spending, and Reagan wasn't known for doing that (spending in almost every area increased under Reagan). Reagan was known for tax cuts, and since spending went up, Reagan was also known for big budget deficits (not like today, where Reagan would be viewed as a model of restraint, but compared to his predecessors the peacetime deficits were shocking). What you are saying is just wildly false.
From 1983-1992, Government spending on mental health grew an average of 6.5% annually in real terms.[1] "Cost-cutting" -- really a slowing down of spending increases, happened in the 2000s, where spending on mental health grew only by 4.7% annually in real terms. This was the slowest spending growth in history for mental health. The U.S. spends an enormous amount on mental health, with dubious results.
Here are two good rules of thumb when thinking about these issues if you are honestly trying to understand our history, rather than trying to score a political point and blame things on your enemies. These two should be your null hypothesis:
1. social spending always goes up. It never goes down. It does not matter who is President. Presidents don't cut social spending in any area.
2. Nothing in America happens because of one person. We have separation of powers and divided government. Everything is always a compromise reached by those in power at the time. This is a good explanation for 1, since the best way to get agreement is to buy people off with more spending.
[1] https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta...
Well it should really start at the county or state level, IMO. There are plenty of US states/cities outside of California that don't have the huge mental illness/homeless problem that SF has. So really SF County or the state of California needs to declare an emergency first before it is escalated to the national level.
Early on in the pandemic, I saw some people saying things like "Housing is healthcare." And it's true.
I just don't know how to get anywhere harping overly much on that, so instead I'm making sketches and notes and if I don't end up homeless again and dying on the streets, maybe I can do a pilot project.
Probably not, but we all need an occupation (as was said in The importance of being Earnest).
I'm quite confident that doubling down on going draconian on people who have no means to fix their own problems absolutely won't make anything better. If you take that far enough, the logical conclusion is something inane like "we should just shoot all homeless people" or something.
People have to be given a path back. Cutting them off will not magically cure what ails them.
I'm all for affordable housing. But when a homeless man commits murder, the answer to that isn't a one liner about the importance of affordable housing which is always the first and only thing that's mentioned when it comes to the homeless. There is nothing draconian about Kendra's Law by the way. It is far more humane to make sure treatment, psych beds are used, especially for people that do not have the capability of knowing when they need help.
I know a whole lot about homelessness and have left many comments on the subject over the years. If you want to have a meaty discussion about it, I'm capable of doing so, though this approach to engaging me isn't a good way to get that.
I write less about homelessness than I used to. These days, I try to focus on community development.
I think that's the best antidote we have and one that gets too little attention.
There comes a point where we need to stop just pulling people out of the river. We need to go upstream and find out why they're falling in. ― Desmond Tutu.
Some stats I pulled up: - Minimum wage in NYC is $15/hr, coming out to ~$30k/yr pre-tax @ 40hrs/week and 50 weeks/year, or $22,752 yearly after tax.
- At 30% of income rule for rent, that comes out to $568/month for rent. At 80 hrs/week that's ~$1k
- "The Bronx neighborhood of Bedford Park has the lowest median rent in the city—$1,558 for a one bedroom"
Forgive me if I'm misunderstanding something, but how is this not a problem of lack of affordable housing?
Those people exist. Not a huge number of them, but they have an outsized effect.
We used to have sanitariums, or locked folks up in jail if they got that bad. They suck, it's expensive, they are ripe for abuse.
But having random insane people wandering the streets accosting people, or in rare cases even murdering them, isn't working either.
I'm not interested in investing more of my time in crisis management for this problem space. I'm looking to find ways to actually shrink the problem.
I'm not saying we should stop doing any crisis management and I'm baffled that multiple people are reacting as if I had.
I'm saying one key piece is we need to resolve our housing supply issues. It's one piece. It's not a comprehensive solution but I think it's really important and far too many people seem to think lack of housing is somehow wholly unrelated to homelessness, which also baffles me.
I don't see how anyone can assert that but I run into pretty frequently.
Better housing will help some. Better accessible care will help some. Better other things will help some.
But there is no fall through default option here being exercised if those options don't help those who aren't helped enough by those options they stop being a repeated danger to themselves or others. In theory it's possible to still get committed. It's almost impossible to actually get committed (as in persistently kept away from society in a controlled institution), and those places are so underfunded and terrible, the street might actually produce better outcomes for everyone.
'Crisis management' is about taking a crisis and not making it a crisis anymore.
But it's generally about a short term emergency intervention, not about long term control of a situation that is fundamentally unstable, unsound, and not 'resolvable' due to a persons own actions. There are people who cannot and will not do what is necessary to stay sane. There are not a lot of them. But they do exist.
We can reduce the overall size of the problem through housing reform. But it doesn't remove the need for some kind of not-a-humanitarian-disaster institutionalization in a non trivial number of cases
Yes yes people don't always know what they need it can be complex. But the majority of homeless people I know and have known needed and wanted help, but were unable to accept the terms of the help offered by the state, or various charities.
I have been homeless and not some cute "living in my car for six months after college" but open sores untreated addiction rotting teeth in the subway station homeless. People I love are still out there dying those deaths and it hurts so so much to hear the way you talk about them in comments today. Not just this one either.
"These people" need anything but more carceral violence directed at them. I've spent time both in jail and institutionalized. Jail is worse but the difference is more a matter of degree than type.
What you want is to have them removed. You're entitled to your wants of course and even to pursue them. But don't use helping homeless people as part of your justification. It is very hard to read these comments and believe you have ever known or cared about someone who was homeless in your city.
This is a tautology. You are essentially defining the word "help" as whatever homeless people define help to be, yet you give some credence to the fact that homeless people might not actually know what is actually helpful for them. What is good for homeless people that are on drugs, that don't want to go to a homeless shelter, that don't want psychiatric help are very often bad for everyone else around them. So maybe we should stop making decisions that put the liberties of homeless people first.
In NYC where I live, two Asian women were killed by black, homeless men in this past month. I'm frankly not interested in making my language any more flowery for your taste with homeless people. I'm only interested in real policy solutions. Until you actually acknowledge the violence, the degeneration of our subway, streets, and city, then we're not going to be able to talk any further.
I spent nearly six years homeless. I spent a lot of years suicidal. I have an incurable medical condition.
I'm back in housing. I'm healthier. I'm rarely suicidal these days.
But when you look at the path that people took to being chronically visibly homeless on the street the pre-cursor in general isn't affordable housing.
> Roger’s parents wondered why, with so many advances in the science of mental health, their brilliant son was talking to voices and eating out of garbage cans.
Their family members may care about them and still be part of the problem. It's really common for people to want to save face and swear it's not their fault, it's something else. In such cases, they won't change. They won't take responsibility for their role. They will blame something else, anything else.
I think it's a mistake to just take the word of a relative as to what went wrong in a case where they might be part of what went wrong. But I usually don't say that because I know that's likely to get really negative reactions from people.
Suffice it to say I still don't agree with you and there's probably nothing to be gained from discussing this further.
If it were feasible for someone to rent a room for not much money and live decently without a car in a walkable neighborhood such that working part-time with decent wages or full-time minimum wage allowed a person their independence, then people with impairments wouldn't be prisoners of dysfunctional and stressed families who are often doing all the wrong things because their scared to death and don't know how to fix anything.
We've built a world in which only a small number of people can possibly keep up the rat race. We've torn down more than a million SROs which used to be normal housing and we now think of that as only housing for homeless people, not housing for young, single adults or childless couples or seniors or students.
(SRO stands for single room occupancy. Copy-paste isn't working for me at the moment, so I can't provide a link.)
In the US, it's nigh impossible to live without a car. It's nigh impossible to find someplace really cheap in a walkable neighborhood that's suitable for a household of one to three people.
Parents who know their child can't function well enough to work all the damn time and afford an expensive home and expensive car etc know this is a nightmare from which the entire family has no escape route.
The escape route for everyone is to make affordable housing in walkable neighborhoods the norm again so ordinary people who can function some of the time but can't run full throttle all of the time can protect their own agency, establish their independence and not be driven crazy by other people freaking out about the burden of caring for them forever with no hope of a solution.
I can work part-time. I can't work a regular job.
I currently live someplace cheap in a walkable setting. I've grown healthier and more functional because of it.
I would like to replicate that and make it more the norm in this country, like it once was.
That's a thing that works but it's a thing you aren't going to find plausible if your focus is on how to deal with people after everything has gone wrong and it looks unfixable. It's fixable. It's also very much preventable in many cases.
We just refuse to work on that. We are too busy screaming about how the sky is falling.
I was asking specifically about the person that is dealing with schizophrenia in the example that you provided. What are the next steps in resolution.
To whatever degree a mental illness is treatable with medication, it can be viewed as a physical ailment with somatopsychic symptoms.
I've already said that, elsewhere in this article discussion:
https://news.ycombinator.com/item?id=30334409
If that isn't computing for you, it isn't going to get better to keep telling me I'm wrong and you don't agree.
Your mental models of this problem space and mine clearly aren't jibing. This form of engagement isn't likely to bridge the gap between where you are on this and where I am.
I've spent years talking about this stuff online, including on HN a whole lot. It's not been a waste of time but there's only so far that goes.
At this point, my focus is on trying to flesh out a potential pilot project -- like I said in my first comment.
Sometimes words get in the way. Sometimes the best thing to do is do it and show people.
That's what I hope to do though I may not be able to. I'm not wealthy. I'm not connected. Most of the world does not see what I see.
(Shrug)
Repeatedly mentioning that you spent years talking about this has absolutely no bearing on me. It's not my mental model that isn't working with yours. It's really your language and how you are approaching basic questions that are asking for a clarification on your insight.
It definitely seems like words are getting in the way for you then if you can't do the simplest of explanations. Have a good day.
You've obviously thought about this a lot more than I have so I'd like to gain some insight from you. I won't ask you about what the solution should look like since you didn't claim to know what it would be, but I'd like to learn more about what you think it would look like to actually address it as a serious problem?
Honestly I don't even claim to understand what the problem actually is, just that there seems to be some sort of problem and it seems to be growing rather than getting better. Could you write a little more about this? I'm curious about your thoughts here.
Here are some contrasting viewpoints I consider:
- Some believe that the US does not have much of a social safety net; some believe this to be by design; some believe this to be beneficial
- Some believe the US to be an individualistic society; some believe this to be beneficial in that it promotes the strong, the efficient, the productive, etc, to outcompete the weak, the wasteful, the lazy, etc.
- Some in the US believe that everyone should get therapy, psychiatry, etc under the guidance of a licensed professional; some in the US believe that psychiatric issues are just excuses made by the lazy to avoid work; some in the US believe that religion will save you and it's all the work of the devil; in some well-to-do places in the US, waiting lists for psychiatric care are months-long even with really good insurance; some believe that we are also in a worldwide pandemic that has had deleterious mental health consequences for everyone, and that many have been pushed to the brink
- Some believe we should increase taxes and have the government do things for people, or force people into doing things for themselves; some believe in reducing taxes and government interference; some believe people should fend for themselves and if they are losers, so be it; some believe in charity and doing good deeds; some people donate to virtue signal, some use donations for tax write-offs, and some people donate anonymously and never tell anyone and nobody else ever knows of what they did
- According to some studies, the US ranks #1 in charitable giving, or generosity towards strangers; contrast this with other countries that some believe have better safety nets and more direct government action, though perhaps higher taxes
- There's a saying that goes something like "charity begins at home"--some take this to be a call-to-action for your daily interactions with others you come across, including strangers since that would have the most immediate impact; some believe in a utilitarian mode of action where energy/time/money should be directed where they'd have the most effect or return the greatest value; some believe charities to be scams; some believe charities to be ineffective
Lee's death, along with Michelle Go, is a spectacular failure by NYC in so many ways. We are living in this city pretending like Penn station isn't literally a homeless camp now with addicts shooting up heroin openly in the streets. These are people that are refusing treatment or help and destroying this city and the subway.
Christina Yuna Lee's murderer had multiple charges on him, including assault charges. He should never have ever been on the street. We need to stop valuing the life of criminals above normal citizens. And we need to actually enforce Kendra's Law and build mental institutions outside of the city.
A small town with a couple of people living in vans might quietly exceed the per capita homelessness rate of a city with a giant tent city.
Mate, pick a number ...
---
- Highest incarceration rate in the world.
- Highest percentage of obese people.
- Highest divorce rate.
- Highest rate of illegal drug selling.
- Most car thefts per year.
- Highest amount of rapes per year.
- Highest amount of reported murders.
- More police officers than anywhere else.
- Spends more on healthcare than any other place in the world, which is completely bonkers considering what's offered.
- More people taking drugs, for whatever reason, than anywhere else.
- Student loan debt.
- The vast majority of all pornography comes from the US.
- Bad literacy rate.
- A military budget exceeding many countries combined.
- Over 90% of all media owned by a handful of people.
- A military-industrial complex paying politicians to invent lies for war.
- 50% of private and public schools teach Abstinence instead of actual sex education.
---
... and get in line.
(not sure all of those are still accurate, but sadly it's most likely)
I felt the need to fact-check these because I felt they were not accurate. Below are the results of about 2 minutes per bulletpoint.
> Highest incarceration rate in the world.
True
> Highest percentage of obese people.
US is #12
> Highest divorce rate.
US is #3
> Highest rate of illegal drug selling.
Might be true. Not super easy to get numbers on this.
> Most car thefts per year.
US is #11 per capita. Probably #1 in raw cases, but that data was not super easy to find.
> Highest amount of rapes per year.
True, but per capita like #12
> Highest amount of reported murders.
Per capita nowhere close to true. Raw numbers #6
> More police officers than anywhere else.
Not true at all per capita or raw.
> Spends more on healthcare than any other place in the world, which is completely bonkers considering what's offered.
Just true.
> More people taking drugs, for whatever reason, than anywhere else.
See above drug selling. I couldn't actually find stats that specifically distinguish the two.
> Student loan debt.
True
> The vast majority of all pornography comes from the US.
US does about a quarter of all pornography, but has a much higher gdp than other countries producing porn. UK produces about twice as much porn per gdp.
> Bad literacy rate.
US has a literacy rate of 99%. I would not call that bad.
> A military budget exceeding many countries combined.
True
> Over 90% of all media owned by a handful of people.
> A military-industrial complex paying politicians to invent lies for war.
Not sure how to fact check either of these
> 50% of private and public schools teach Abstinence instead of actual sex education.
It's hard to find hard numbers for this. Abstinence is taught as the most effective method of preventing pregnancies and STDs, but other sex ed is present (often in addition to abstinence) in at least 60% of schools.
So I would say this is not true because of the "instead"
Oh and, regarding literacy rate... 88% and that doesn't mean they're all good readers.
https://www.thinkimpact.com/literacy-statistics/#:~:text=The...
You might be disappointed [0].
And that's in a place where they have “Universal” socialized healthcare. I mean, a lot of the people on the streets are natives, so I guess they don’t really count as real citizens anyways.
In any case, the U.S, especially NYC, SF, LA, and Seattle is still worse than anywhere I've been in this regards.
Part of the reason is the “temperate” climate in those coastal cities making it possible to live in an RV or camp most of the year. The other one is that there’s a policy of not preventing the encampments in the first place (check out Santa Monica for instance).
I have a schizophrenic family member. It costs six figures annually to keep them in a facility - which is designed to handle a completely different type of disability - and off the street.
It’s dumb luck that this facility accepts them and cares for them despite a lot of drama and irregularity. Many others have shown them the door.
It’s even dumber luck that the money exists to pay for the care.
If an American or someone they love winds up with a similar affliction, the chances of finding such a disaster-averting outcome are close to nil.
The system is not set up to help people get better.
The medications, which have the "best track record". Have an NNT of 5-10, severe side effects, and are so strong you risk rebound psychosis if you ever stop taking them. I think they really just help the institutions to manage patients in perpetuity.
However, it's really just a subtle ad for a book, which probably just reiterates the same points in greater detail via lots of anecdotal data and case histories, points the finger at the government for not spending more money on programs designed to support the mentally ill within their communities, and doesn't provide any further concrete solutions.
Hasn't this same book been written over and over again?
I also see these things as endemic to academia, especially in the sciences, and regard them as roots of our current replication crises, alongside capitalistic pressures.
Health care itself explains only a small fraction of health outcomes. Much of what we need for better outcomes is fundamental, but it is not part of health care. Social factors (your zip code, not your genetic code), lifestyle (how you live, not how many medications you take), and livelihood (your work, not just your wealth) are much more important for health outcomes than your specific diagnosis or health-care plan.
I was suicidal for decades. I rarely feel suicidal anymore and it's like a bad habit, a mental tic that occasionally comes back when I'm having an excessively stressful day. Eating and sleeping are usually the way to make that stop.
There are two main components to mental health: physical health and social factors. To whatever degree a mental illness is treatable with medication, it can be viewed as a physical ailment with somatopsychic symptoms.
But even if you can genuinely cure the physical roots, you still need to deal with negative social patterns and "habits" (for lack of a better term) that may remain after the physical roots are resolved. If you can do both things, you can actually resolve it.
It's a better article than a lot I've seen. I find this piece encouraging.
I keep hearing this, but if this move was such an obviously bad thing why hasn’t it been undone yet?
I know the local chapter of the ACLU screams bloody murder whenever the city tries to institutionalize some of the local homeless population. Even if there was substantial bipartisan support for undoing what Regan changed in the 80’s, it seems like a plethora of other challenges stops it.
In which case, it seems unproductive to keep blaming Reagan.
Public perception of mental health facilities were dire in that era. Think of how influential One Flew Over the Cuckoo's Nest was.
Many places actively hide the problem in various ways, or ship folks off to 're-education camps' from which they may not come back, or classify it so it doesn't show up so much.
America seems to be pretty unique in that it lets it all hang out, front and center, and has a bunch of social activists groups running around publicizing the issue without gov't or society telling them to sit down and shut up.
It also has a much worse problem, also due to the socioeconomics of how the country exists (imo), and the legal structures and social disconnectedness of it's various urban and rural areas.
http://thespiritscience.net/2014/06/16/what-a-shaman-sees-in...
What if we have it all wrong? I do love the hopeful perspective this article has.
I've commented somewhat extensively about my friend's struggle with the mental health industry. They've decided she's a chronic psychotic who requires anti-psychotics for the rest of her life.
A year after she was formally misdiagnosed by the mental health industry I found videos on my phone from ~2 weeks before that 2015 hospitalization. I think my videos prove that my friend's supposedly-chronic condition can be entirely explained by substance abuse.
The tragedy of "American Mental Health Care" is the use of palliative drugs, when the various causes of the various diagnoses have actually been figured out by researchers. Science knows exactly how stimulants harm the metabolism [0]. The symptoms of mental illness can usually be explained as a metabolic problem - sometimes caused by substance abuse, sometimes by diet, always exacerbated by 'stress'.
Emotional stress is the most important drain on the body's metabolism. I have a bunch of references from books about stress - went to the ASU science library to read a book referenced in Gabor Maté's In The Realm of Hungry Ghosts [1], and found a discussion of how 'stress' contributes to psychosis.
[0] My comment/quote/submission: https://news.ycombinator.com/item?id=18211048 - "I learned from a Hacker News comment/submission a while ago that cocaine causes its harm by shredding the mitochondria. [searching] Ahh, found it, this one:" https://news.ycombinator.com/item?id=10956058
[1] https://www.google.com/books/edition/In_the_Realm_of_Hungry_...
In 2018, after her treatment center perpetrated fraud on the District Court, my friend got annoyed about how all the new clients at her treatment center were getting cheek-swabbed. She herself had not been cheek-swabbed when she was sent there 2 years before, and asked to have this genetic test. It revealed that she is a poor methylator, who cannot turn the provitamin folic acid (commonly used to fortify food as it is shelf-stable) into Vitamin B-9. She said that adding L-Methy-Folate to her routine was like flipping a switch from "depressed" to "not-depressed" [1].
[1] https://news.ycombinator.com/item?id=27990331 (also some good responses to my comment - search for 'histamine')
The Supreme Court of the United States is going to be considering my petition soon. I'm optimistic that it will be one of the handful that they grant. All I'm asking is for them to order the district court to hold the evidentiary hearing that is required by the case law. (I'm currently working on a write-up of my experience for https://MadInAmerica.com, using some tips from HN moderator dang.)