I'm in the US. I was homeless as a teenager (not by choice). I live adjacent to a major homeless community (not by design). My ex left our family to join the homeless community (she struggles with mh issues). I have some observations.
We could sharply reduce homeless numbers here if we had in-patient mental health facilities (for non-wealthy), comprehensive housing aid and politically powerful job placement programs.
I just looked up our jail budget and inmate population; we pay ~$25k/inmate/year (excluding court & police costs). That money gets us a pretty solid guarantee that arrested mentally ill people will reoffend, given how many entrenched systems there are to make sure that convicted people are locked out of most jobs and housing.
Inpatient mental hospitals used to be in every state. They housed not only the mentally ill but also the chronically homeless and other outcasts. As the advent of antipsychotics and antidepressants reduced their population, these hospitals were an obvious target for budget cuts throughout the 80s and 90s. They money for the community health centers that were supposed to replace them never materialized, and thousands of patients were left without access to their medication. Some estimate that over 50% of the homeless population is mentally ill.
Ironically prison systems now provide these services (and sometimes paying more for them!!), but in a much worse environment for the patients.
I would add that you are missing a major component for why mental hospitals went away-- public opinion changed. The public was made aware of abuses and such abuses were also dramatized in One Flew Over The Cuckoos Nest. There was pressure to shut these down.
Separately, I will add that we need these hospitals back desperately. I don't know who will sign up for this tough job, but we need a place for the mentally ill to reside that is not the middle of the street.
Pennhurst and Bridgewater State Hospitals and the resulting exposes on these facilities were the start of the abandonment of most state run mental health services and facilities.
added: Also search "Titicut Follies" for temporal context
Those calls to action lead to defunding and closing of many facilities on mass regardless of the services they provided or the conditions. From orphanages up to mental health institutions.
That period was followed up by a small influential group of individuals that lobbied very hard to have state schools for the handicapped and severe development delays closed in preference of services provided by local schools culminating in Title 1, which was eventually federally mandated regardless of the level of care and support a child might need.
Both of these large changes led to significant changes in the cultural acceptance of institutionalization of any individual young or old, even to the detriment of those individuals in some cases.
Odd that "One Flew Over the Cuckoos Nest" could have such an effect, but we have all kinds of movies and TV shows now depicting how terrible prison is and that doesn't seem to have a similar (but opposite) effect.
"One Flew Over the Cuckoo's Nest" is about how forcing someone into a mental hospital just because they don't fit into society is evil and dehumanizing.
There's lots of movies and shows that take place in prisons, but th prison itself is usually just the setting. The film is rarely making a statement about incarceration itself. Also, we have a much more fragmented high volume media culture, so it's not clear that film and TV can effect cultural change like they used to be able to.
I'll never forget this fact because there is a King of the Hill episode (10:13) where a mentally-ill, homeless man named Spongy exclaims "Ronald Reagan kicked me out of my mental hospital!" and Hank bashfully tries to justify it as part of winning the cold war.
I remember that episode, seen them all at least twice. I was just a kid when they all were closing but thinking back it seemed like a good thing. I do wonder now where people thought all those people in there would go. I think a lot of people believed they did not need to be there and were getting a free ride as strange as that sounds.
Hard to source this claim exactly but after many discussions on the topic, my view is that people across the political spectrum believed that there were adequate outpatient mental health resources for the newly released individuals.
Either they imagined it was already available or that the money saved on running the institutions would instantly create it (with some left over).
There was a massive underestimation of the scope of the problem.
> As the advent of antipsychotics and antidepressants reduced their population, these hospitals were an obvious target for budget cuts throughout the 80s and 90s
Do you have a source that shows that public funding for hospitals and treatments for mental health declined during this time period?
From a quick search is seems it has risen considerably throughout the 80s to today.
Just an observation. The mental health system doesn’t have much capacity to begin with. Even for middle-class folk with insurance it can be very hard to get treatment. There is a shortage of mental health professionals which is projected to get worse. Psychiatrists are mostly doing medication management because that’s where they’re most effective. Following the path of getting treatment—everything including diagnosis, therapy, medication, and accommodation requests—requires a shocking amount of initiative on the part of the patient.
I would love to see the country dig itself out of the hole. I think the mental health crisis itself is huge. Both in-patient and out-patient. We need more psychiatrists and psychiatrist PAs.
> Psychiatrists are mostly doing medication management because that’s where they’re most effective.
I think it's money: insurance will shell a lot more $/hour if they do 15 minute medication appointments instead of hour therapy + medication appointments.
Going to dissent here—we need psychiatrists doing medication management because there are so many medications today, and so many previously untreatable conditions which are treatable with modern medications.
If we switched to one-stop therapy + meds, the psychiatrist shortage would be worse.
the problem with this approach is there's not an obvious person to consult with to decide whether to start with therapy, medication, or both. I find that therapists tend to consider themselves unqualified to even suggest that their clients look into medication (or perhaps they are explicitly prohibited from doing so, idk). psychiatrists can either give you drugs or say no, but they tend to offer you something if there's at least a chance it could help.
This comes back to what I mentioned earlier in the thread that it “requires a shocking amount of initiative on the part of the patient.”
There are also easy and hard paths through the system. If you are motivated to get a diagnosis, you can talk to a psychologist or psychiatrist and get a diagnosis. You can look for a therapist who specializes in those issues. You can take this diagnosis to a psychiatrist and say “I have diagnosis X and symptoms Y.”
If you go into the hospital with a broken leg, you can just check into the hospital and you will come out with a cast and an appointment to have it removed. If you have mental health issues, unless they are severe enough to require hospitalization, you are in charge of your own treatment.
The problems with this approach are probably even bigger than that, but given they're already stretched this thin and there are years long waiting lists for new patients it will probably be some time before we can really address the more nuanced issues of phychiatry.
Integrating counselling and medical doctoring is a strange idea, and it's somewhat weird that it's even as much of a thing as it is. Drug-focused psychiatrists are certainly going to be a thing so long as med school is so costly and med schools conspire to keep the supply of doctors low.
Right, and a surgeon doesn't serve as your physical therapist just like the psychiatrist doesn't serve as your talk therapist. They're different roles, even though they're both addressing the same part of your health.
Under the US system, the surgeon has to press the patient to learn what operation they're going to perform, because the physical therapist / primary care doc / specialist doc isn't paid to communicate with the surgeon, but they're willing to guess the operation if the patient doesn't take great notes.
Increased secularization is also probably a factor. I presume going to your clergy for assistance was previously more common. I'm sure that kind of care had mixed effectiveness, but suspect it less available and norms are bit different for initiating that kind of conversation.
It's weird even when the medical doctor is trying to alleviate the same symptoms as the counselor? I think the way you put it simply sounds weird because a psychiatrist isn't the first doctor you think of. The concept isn't strange at all, especially considering the huge overlap in training.
Yes it is. Psychologists get paid about $120k/yr with the same amount of schooling and expense as an actual doctor.
It's not as intense as med school is and their internships are normal hours instead of the official hazing ritual that is residency, but the expense is very high unless you get lucky and get a publicly funded PhD program, and then half of your education is research instead of therapy.
Insurance defines the financial demand which determines the pay of psychologists and the amount hired.
Recently, here in Denver, I could not find a psychiatrist that accepted insurance. And the minimum out-of-pocket hourly fee I came across was $250/hour. One was $450.
The psyches that did accept insurance had wait times with March being the soonest.
A stark, stark contrast to seeing a cardiologist, for example. The shortage of mental health professionals is real.
A psychiatrist is a medical doctor who specialized in mental health meds.
A psychologist can diagnose your with mental illnesses and help you via therapy and testing.
Very different. A psychiatrist makes significantly more than a psychologist and needs to go to actual med school, do residency and so on.
My pet theory as to why not is how it's less profitable usually than 15m doctor visits or large do-or-die surgeries and is more objective than once a week 1 hr therapy sessions, thus easier to make money as a professional from insurance providers.
The mentally ill also have a harder time holding a job and so the ones that need it the most are often the ones most ignored for it, while the ones who need physical medicine the most are old and have retirements to suck out.
An ex of mine worked with the homeless through a training program attached to a shelter. Maybe 2 or 3 out of 10 took the training seriously and were stable enough to actually put it to any use. The rest were just there for free bus passes and meals, or were too unstable to hold even an unskilled job for a month.
The hardest part was that those who needed help the most could have gotten it through the program, but were so untrusting of seeing a doctor that they flat out refused- most thought they would be locked up in a ward or some similar conspiracy fear.
Winter around here is no joke, and it is hard to see them and not want to help, but the truth is that the visibly homeless don't want it enough to change. The invisible homeless- the people who don't look like a living stereotype- usually make it out because they still have hope.
>most thought they would be locked up in a ward or some similar conspiracy fear.
This fear is quite legitimate though. Search around online forums for involuntary commitment and you'll see lots of horror stories. There are even news articles about it.[0]
If a homeless person can get back on their feet, then they are a full member of society with all the same rights as everyone else. If they get institutionalized, whether voluntarily or involuntarily, then that'll be a mark that follows them around. They will be denied some rights.[1] A patient at such a facility often has fewer rights than even people in prison. At least in prison if your time is up then you'll be released.
The problems don't stop there either. Misdiagnoses are common. Even when they aren't, it's likely that the treatment they offer has no or minimal effect. It's also possible that the trauma of being in such a facility causes issues of its own.
I can completely understand why people would prefer to struggle with their problems as homeless, but free, rather than go to such a facility.
People who are seriously helped by the program will not return, but those who were not helped will come back. Over the long run the program will be full of people who cannot be helped and a small number who will do well. So seeing 2 out of 10 doing well does not shed light on the program's success.
As someone who had the unfortunate experience of being locked in a psych ward, there’s nothing “conspiracy” related about the fear of being involuntary committed, where you get stripped of all basic rights with no trial.
In-patient services for mental health were decimated in the 80's. Reagan cut the funding and cities were flooded with homeless + mentally ill people. I was at UC Berkeley at the time this happened. There were so many seriously mentally ill folks on the street. It was sad.
> In-patient services for mental health were decimated in the 80's. Reagan cut the funding and cities were flooded with homeless
Deinstitutionalization was a broadly supported policy, especially by advocates of the mentally ill; conditions of the widespread institutionalization were horrible.
The failure to create substitute systems to address the easily forseeable consequences of deinstitutionalization was obviously a problem, but not a uniquely Republican one (though certainly Republicans were more opposed to fixing the problems once they materialized.)
This is about as inaccurate a take as one could possibly imagine and is a great example of seeing the world through political bias.
Reagan did not lead the charge. The ACLU was actively involved in shutting down inpatient psychiatric facilities because of the abuse that was occurring.[1]
With the advent of antipsychotics, our-patient treatment became an option and was regarded as more humane.
Now I remember: pushed the funding from federal to state responsibility, which caused many states to empty out the institutions.
And where do you think many of those people ended up? Berkeley, CA. Because they were sometimes put on buses there, and sometimes it was just the most friendly place to be.
The institutions were being emptied out because organizations like the ACLU brought cases to court to have them emptied.
People were being held against their will in conditions that were causing a stir in the media. It was regarded as a human rights issue that they not be confined unless there was no other option. Hence the shift to outpatient care in the community.
Pining it all on Reagan’s cuts is grossly inaccurate.
You seem to have an axe to grind. What you say is not supported by the evidence. It's definitely true in some cases, but not the main reason for the changes.
Yeah, well, that's great. But I read many articles about police departments in other states putting homeless people on a bus for the Bay Area. That's is not cool of them. It overwhelmed the social services in the Bay Area.
It worked out great for Republicans. The spike in crime rates made their "tough on crime" message resonate. When you're homeless and mentally ill it's basically guaranteed that you're going to have fights with the police.
Tough on crime isn't purely a republican stance though. Democrats worked hand-in-hand with republicans in the late 1980s to push through many tough on crime policies. This was due to crime skyrocketing in the 1980s due to cheap and abundant crack cocaine flooding America's streets.
If you replace Republican with Conservative it works. Hell, our current President is debt-hating Conservative if you view it by the bills he's authored/supported as Senator in the past 30 years.
Not to mention if a night in jail or fine (which itself is not warranted if the person is only mentally ill and not a danger to anyone or themselves), turns into a criminal charge that is then prosecuted and leads to a conviction, you've just made their path to rejoining society so much harder. Likely, their mental health predispositions will also be made much worse due to the strain of prison.
The system keeps trotting along because there's money to be made by prisons. People reflexively want the homeless off the streets and will tolerate, even reward heavy handed prosecutors. I've fallen in that category of punitive nearby residents - I live in a place near what has become a runaway encampment. When I drive by it and think how close my place is, I get angry at the homeless, the blight and trash. I have to force myself to think of the humanity, the suffering and lack of options these folks have. But to be honest, other than try to support local action to help these people, I don't do much either. I take pride in not joining the rest of the NIMBYs but you wouldn't believe the shit fit people around here threw because mobile showers were coming to the encampment once a week. Some of the people who threw the biggest shit fit also have political yard signs supporting anti-poverty measures, but as they say, talk is cheap; yard sign, sure - build cheap community housing near me or allow people to camp - hold your horses...
I was taken political prisoner three times in the Broadlawns facility ran by Polk County Iowa - currently helping Federal Medicaid claw back the fraudulent $20k hospital bill. Lynchpins of the rampant political corruption is nepotism between Chief Justice Susan Larson Christensen/ brother 4th District Chief Judge Jeff Larson and Hon Mary Tabor/brother Chief Deputy Attorney General Eric Tabor.
What you speak of does exist, it's Medicaid - the issue is only in states like Iowa do you have such due process free statutes like Iowa Code 125/229 that magistrates can lock you up without solid evidence that the person is a true threat to themselves or others.
I can't say that in-patient mental health care (for non-wealthy) is available nowhere in the US. But it is scarce enough that you may have the only example.
I am excluding 72hour-hold facilities because they are more like an extended Dr.s visit, than any sort of rehabilitation.
No questions asked monastic living without any Jesus down your throat is rare. Only the homeless and wealthy can afford to walk from their apartment/mortgage for weeks without income.
I saw several women that were domestic abuse victims - their family labeled them as crazy because Iowa doesn't really have any emergency shelters to speak of.
From what I have seen, job placement programs flounder due to lack of strong, consistent interest from elected officials. Without sticks or carrots from local Govs, area employers ignore employer services in favor of whatever hiring practices they're already using.
source: Five years as employment service specialist and another five years trying to help my kids get jobs in spite of first-time hires being algorithmically blackballed by default.
We could sharply reduce homeless numbers here if we had in-patient mental health facilities (for non-wealthy), comprehensive housing aid and politically powerful job placement programs.
I just looked up our jail budget and inmate population; we pay ~$25k/inmate/year (excluding court & police costs). That money gets us a pretty solid guarantee that arrested mentally ill people will reoffend, given how many entrenched systems there are to make sure that convicted people are locked out of most jobs and housing.