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Comment by crooked-v | Hacker News Reader

> Who will write the definitive book on how everything went downhill over the past 10 or so years?

I feel like most of that would just be 200 pages of saying "And then, San Francisco didn't allow enough housing to be built." over and over.

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I figured it would be 200 pages of “and that’s a result of Reagan’s drive to shut down public mental health”

I very much doubt the visible homeless problem is a result of housing - the iceberg is a result of housing. The visible homeliness wouldn’t be solved if rent were half - that doesn’t treat schizophrenia

Becoming homeless through no longer being able to afford rent (a common cause of homelessness) is extremely bad for your mental health.

In this case Housing would be a preventive measure but it doesn’t deal with the problem that everyone truly wants dealt with: the mentally I’ll.

How do we solve the mentally I’ll problem? Is it that involuntary commitment with excessive oversight is incomparable with American values of freedom ?

Involuntary commitment was done away with as in the past the conditions in many facilties were super bad. Rather than reform the system they just shut it down. Now there's just nothing at all.

Leaving humans to rot in the streets seems morally more convenient but not better.

I think Reagan was an absolute disaster responsible for a lot of our problems today, but this isn’t one of them. Mental institutions of Reagan’s era were a humanitarian nightmare. But, I am not sure there is a humane solution to serious mental illness. It requires the attention and care that probably only immediate family members are capable of providing, while simultaneously requiring medical treatment and security that only mental institutions are capable of providing.

The problem we are having today is we’ve excused criminal behavior due to mental illness. I agree prison probably is inappropriate in most cases, but so is just letting them back on the street.

I would note, a bit late on the thread, the nightmare was mostly marketing on the anti mental health front stemming from a Nixon-Reagan continuum in the conservative movement of the time. My father is a phd clinical psychology and spent his early career doing fellowships and residencies in various public inpatient hospitals for the deeply disturbed (the folks you see on the street now). They were not like you believe, by in large, and the people who work in those environments largely work there out of human compassion, not avarice. My great grandmother worked as nurse in a Wild West sanitarium - now that was a different story.

If you dig into news about current inpatient care for the mentally ill, I think you’ll see something white washed but not too dissimilar to the past sanitariums. Heavily medicated patients confined to close quarters without much supervision and that that exists is unskilled providers, with 30 minutes or less of professional care a week. Patients frequently assault each other and because they’re often placed their by the police for criminally insane behavior there’s no recourse or different place to move them to just an upgrade to their charges. Sexual assaults are rampant by staff and patients. It’s barbaric, but even then, there aren’t enough beds so people in crisis have to wait months getting limited care through outpatient if they have find a psychiatrist with an opening- most don’t take insurance, and even then it can be a six month wait.

They were in some, but not all cases. Turning them out into the streets to rot in the gutter while they spiral out in their insanity is certainly morally more convenient, but not, IMO, superior to attempting to build an infrastructure that provides treatment and long term care for people suffering so deeply as this. Freedom that’s a living hell isn’t freedom, it’s just freedom from responsibility for caring.

A lot of seriously mentally ill folks burn their family care due to the extreme burden it places on them, and the fact a lot of mania and schizophrenia accompanies a willful belief in their own sanity and autonomy, and a lack of personal knowledge of their state. This makes keeping them under care and medications extraordinarily difficult.

Prison isn’t the answer. Mental health facilities is. That’s the real alternative to letting them back into the streets. Prisons aren’t equipped to treat anyone.

>”Freedom that’s a living hell isn’t freedom, it’s just freedom from responsibility for caring.”

The problem is that the latter is far too attractive and convenient for a large percentage of this country. Then simply move out of a city center, get some guns, put up some fences, and it’s no longer a problem that you’re directly personally affected by.

And most importantly in “free market”-loving America, lots and lots of funding that no one is willing to provide. When they inevitably break some laws, it’s easier for everyone to swallow their obscene housing costs under the guise of “we’re keeping these criminals away from society”.

> The visible homeliness wouldn’t be solved if rent were half - that doesn’t treat schizophrenia

By itself? No.

But literally every viable path to addressing serious mental illness requires stable housing as a prerequisite. Without it, there's literally no way to manage the problem - just different ways of shifting it around over and over again.

I know. But there’s housing that’s affordable outside of San Francisco and seattle city cores.

Anywhere within an hour drive of SF is extremely expensive, and without a car, extremely difficult to eke out a living outside of a major metro area even if they wanted to.

It’s not difficult to eke out a living in most of the country. Unemployment is 3.5% across the nation, not just in San Francisco.

It feels like so many convos, especially here on HN, start from the false equivalence that homeless == mentally ill. It’s an issue sure, but not even a primary cause.

https://ww2.kqed.org/news/wp-content/uploads/sites/10/2019/0...

I’m sorry I think you misunderstood me. When I talked about visible / invisible and the iceberg of homelessness I referred to this exactly. However the issue in the discussion here is visible homelessness - the stuff that frightens people away from the downtowns of the west coast. Indeed the vast majority of homelessness happens away from your view and is no less tragic.

Reagan’s shutdown of mental hospitals is a big problem, but a distinct lack of housing and space is SF's problem.

California and other warm states, on a long timeframe, absorb a lot of homeless people -- only places you can sleep outside all year and, like, not die. Not an option for NYC or Minneapolis. So inevitably they have all of these people, and no place to put them. Nor the political will to crack down, since California Capitalists want things to be nice while still flogging the NIMBY-isms.

At this point, feces on the sidewalk /is/ part of the SF aesthetic, so in a way, by refusing to allow anything more than two or three stories to be built in many neighborhoods, they’re correct in that they’re preserving it.

Then again, it’s not like the high rises ever end up including a significant amount of affordable housing anyway, so that doesn’t even make a dent in the issue.

I lived in SF in the 1995-2002 time range and feces and used condoms and needles were literally everywhere even then. I’ve only ever seen this in SF in all my travels and places I’ve lived the country and world over, even places with severe homeless problems. It’s definitely a part of the charm - human excrement and Victorians.

> I figured it would be 200 pages of “and that’s a result of Reagan’s drive to shut down public mental health”

Reagan hasn't been Governor of California for nearly 50 years.

But he sure was president of the US, and that's where he pushed to repeal the Mental Health Systems Act of 1980.

He certainly did try to crush it on state level, too, as a governor.

And? 1980 was 43 years ago.

I'm still not seeing why the present-day problems can reasonably be blamed on "Reagan".

Why don't Bush I, Clinton, Bush II, Obama, Trump, and Biden bear any responsibility? Or, in California, Brown, Deukmejian, Wilson, Davis, Schwarzenegger, Brown (again), or Newsom?

Why haven't any of those people undone what "Reagan" supposedly did?

Because of the act mentioned above. They presumably could have undone it, but the real damage was the dismantling of the public mental health infrastructure and the market economic approach to mental health via managed care that has turned out to be so disastrous. With the passage of the 1980 act the hospital networks were shut down and dismantled, and reimbursements via insurance for mental health were hobbled due to industry maneuvering despite many repeated attempts by congress to “fix” the loop holes exploited. The ACA actually did address the issues but by the point of the ACA decades of rot had set in - the hospital networks were long gone, mental health as a profession obliterated due to rapidly declining reimbursement rates (my father is a phd in clinical psychology with professorships and fellowships from Yale with an established private practice and hospital practice and saw his income go from upper middle class to upper lower class in 30 years, so he switched to doing evals for super secret government stuff). Even with the “fixes,” there’s no meaningful professional class in mental health - just a bunch of undergrads with a certificate, and even then not enough by a light year. But worse of all, there aren’t beds in facilities for the acute care people need today. Have bipolar and need inpatient care during a manic episode? It’s a multi month wait for a short term bed in Washington state, and the facilities are frightening and you’ll be co-habitating with criminally insane people. I know someone who was bunked with a serial rapist on trial - across the hall was two women who were gang affiliated schizophrenics on trial for murder and felony assault respectively). My friend was very well off with a well connected family. Doesn’t matter. Even then they could only house him for two weeks before sending him home deeply manic. They needed the bed for a criminally insane schizophrenic who had killed someone.

That’s why it’s Reagan’s fault. He set up the stage so effectively it’s taken this long to turn around the basic issue of payment, and now we have no providers or services or infrastructure left to pay for.

Sorry, no. I'm willing to assume just for the sake of argument that Reagan messed things up.

If things are still messed up 40-50 years later, it's not due to "Reagan". That's just an excuse.

As for the idea that the mental health infrastructure was some kind of wondrous utopia before "Reagan", I draw your attention to this:

https://en.wikipedia.org/wiki/Titicut_Follies

Many other citations are available.

Would you say social security isn’t a part of FDR’s legacy because it passed through the hands of every president over the last 80+ years? Many have reviled it in that time but haven’t been able to dismantle it. It’s harder to build than destroy. The fact that it wasn’t until Obama we reversed coverage for mental health shows how enduring Reagan’s legacy is in mental health. But I would agree every president since carries a guilt for not driving redress, similarly every congress whose really at fault.

I don’t hold it was a utopia. But if you want to see something worse than Bridgewater, look at the streets and see humans rotting in front of your eyes in the depths of untreated, yet easily treated, mental illness. It’s certainly morally convenient to do nothing, and morally wrong to try and get it wrong - but I think trying and failing in some cases and succeeding in others is better than failing in all cases by default. My father and great uncle were both clinical psychologists in the public mental health system, and there were many institutions that were high quality and served a population we let simply decompose on our streets now. If we traded a non utopia, we traded it for a total dystopia.

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