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>Since we find the idea of involuntarily committing psychiatric patients to be unpalatable these days We closed the asylums, because the long-term detention of

>Since we find the idea of involuntarily committing psychiatric patients to be unpalatable these days We closed the asylums, because the long-term detention of the mentally ill is costly and inhumane. We can do better than just warehousing people in pseudo-prisons. We completely failed to provide 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. Most of these people aren't "incompatible with peaceful society", they just need help and can't get it. If any one factor is to blame, it's the systematic defunding of social work and community mental health. If your local library is full of mentally ill homeless people, 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?.

germinalphrase 8y ago
In complete agreement. Consider also the historical uniqueness of public libraries: if they didn't already exist in the fabric of civic life, would we really have the political ability to build them? We have little imagination or desire to build civic institutions any more; we only know how to build commercial ones.
- eru 8y ago
  It's not just civic institutions. Manhattan would be illegal to build these days in Manhattan. I'm glad that incapacity hasn't affected the whole world, yet. But it's seems to be spreading.
  - freehunter 8y ago
    >Manhattan would be illegal to build these days in Manhattan I don't really view that particularly to be a problem. Manhattan was already built in Manhattan, it doesn't need to be built there again. Now that it exists, it needs to be managed with the new problems that have arisen since the building of Manhattan. Problems change when you scale, things that were not a problem when you were growing are now a problem after you achieve massive success "Do things that don't scale" is great advice for a growing startup, and for a very good reason. Because once you get to Manhattan size, you have to start doing things that do scale. If Manhattan hadn't changed its building codes, it would be unlivable today.
    - AnthonyMouse 8y ago
      Nobody is really talking about building codes. Building a skyscraper without fire sprinklers is a bad idea, but requiring fire sprinklers is not a thing that prevents you from building skyscrapers. On the other hand, a rule restricting building height or imposing minimum parking requirements or the like does exactly that, and has no benefit other than to enrich the existing landlords when it prevents housing supply from responding to increased demand.
- dreamcompiler 8y ago
  Probably not. It would be easy to paint public libraries as "socialist" which is a dirty word nowadays.
  - dictum 8y ago
    There was a window of time (roughly from the eighties until about 2016) when "socialist" wouldn't be used because it was perceived as outdated, too linked with the Cold War and Red Scare... so it would be painted as "entitlement" or "lack of personal responsibility": if you wanted to read, you should have bought your own damn books. (I think the discourse is being revamped in light of the rise of democratic socialism in US politics)
ascar 8y ago
> Most of these people aren't "incompatible with peaceful society", they just need help and can't get it Do you have any source that most of these people can't get it? With a father who outright refused any medical help unless basically forced on him, in a country where it's completely free, I can absolutely relate to the argument that not having involuntary psychatric treatment plays a big part here. And his mental state was only a minor part of his health issues. It's not nice to be in stationary psychatric treatment. These are horrible places you want to leave as soon as possible. But it sometimes can't be helped. I can even relate to the point that it's better for (some/most of) these people to live on the streets than in a psychatric facility, while it's probably worse for society as a whole.
- jdietrich 8y ago
  There's a world of difference between "having access to medical care" and "having access to appropriate care for a disorder that presents particular obstacles in accessing conventional care pathways". Access to care in the US is highly inconsistent, because there's a patchwork of providers and funders. Effective care for people with severe and enduring mental illness needs to be patient-led but assertive - we're not going to lock you up unless it's genuinely in your best interests, but we're not going to let you slip through the cracks either. Compulsory inpatient treatment is a necessary last resort where people pose a clear and immediate risk, but it should not be the basis of care for severe and enduring mental illness. The issues regarding involuntary treatment in the US are highly complex, but the evidence indicates that involuntary community treatment does not make a significant difference in clinical outcomes. Forcing people to attend appointments or take medication doesn't seem to result in any long-term benefit on aggregate. Some people do benefit (at least in the short term) from being treated against their will, but compulsion undermines the relationship of trust between care providers and service users and discourages people from engaging with care. https://kaiserfamilyfoundation.files.wordpress.com/2013/01/8182.pdf https://kaiserfamilyfoundation.files.wordpress.com/2013/01/8... https://en.wikipedia.org/wiki/Assertive_community_treatment https://en.wikipedia.org/wiki/Assertive_community_treatment https://www.cochrane.org/CD004408/SCHIZ_compulsory-community-and-involuntary-outpatient-treatment-people-severe-mental-disorders https://www.cochrane.org/CD004408/SCHIZ_compulsory-community...
raverbashing 8y ago
> 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.
- jdietrich 8y ago
  >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.
  - overkill28 8y ago
    > 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?
krapht 8y ago
Can we? The severely mentally ill, those with willful medication noncompliace and/or violent psychotic episodes, what do you propose we do with them? It's well known that many of them lack the self-awareness to even realize they are ill. Some sort of involuntary commitment is necessary. Frankly I believe the asylum would be a better place for many of them rather than taking dumps on the streets of San Francisco. Closing them was a mistake; rather what was needed was more oversight. It would be like shuttering all nursing homes and sending the elderly back onto the streets or into their children's homes, because the cheapest ones are run like deathbed holding warehouses. In fact they've all but reappeared, we just call them prisons today, or sometimes a long-term residential psychiatric care facility. Historically the severely mentally ill were either put to death, or placed under the custody of their immediate relatives, with the family being punished if said ill person were to cause trouble in society. This is not really an option in modern society. The severely psychotic need inpatient care, and it should be an option. Today they're getting it in jail, this is not ideal.
- alsetmusic 8y ago
  Bi-polar can be treated with medication and people can often lead a normal life as a result.
  - krapht 8y ago
    Yes, but in particular I'm referring to the problem of the mentally ill not taking their medication.
  - alecco 8y ago
    I’ve heard many times of bipolar people committing crime because they either decided to stop medicating (it does make you feel not good) or they lost them or something. There is a point between individual freedom and public safety. We can’t just sigh and throw up our hands in the air.
  - maxlamb 8y ago
    I think schizophrenia is the much bigger problem regarding the homeless.
village-idiot 8y ago
> We closed the asylums, because the long-term detention of the mentally ill is costly and inhumane. We can do better than just warehousing people in pseudo-prisons. Apparently not, because we just kicked them out onto the streets to starve and freeze to death.
vkou 8y ago
> We closed the asylums, because the long-term detention of the mentally ill is costly and inhumane. We can do better than just warehousing people in pseudo-prisons. How? This is a serious question. Right now, we are housing them in open-air prisons - the various homeless ghettos in Vancouver, San Francisco, Seattle, etc. What exactly do you propose we do for someone who is unable to, due to mental illness: 1. Maintain their living space, or themselves in a remotely neighborly manner. (All the problems the librarian faces? Imagine living in a shelter/state housing, next door to that.) 2. Take their medicine. 3. (Bonus). Do anything, or consent to do anything about their substance abuse problem. These are not traits that most homeless people have. Most homeless people can be immediately helped by housing first, etc, etc. But these are traits that some homeless people have. And since you're hand-wringing about institutionalization, I would like to hear what you propose, as an alternative for them.
- jdietrich 8y ago
  >I would like to hear what you propose, as an alternative for them. https://en.wikipedia.org/wiki/Assertive_community_treatment https://en.wikipedia.org/wiki/Assertive_community_treatment
  - vkou 8y ago
    So, "Medical professionals should spend more time helping their patients." That's great. I fully endorse that. That's an improvement over them spending less time helping their patients. How does this help someone who refuses to be treated? What do you do until they are willing to be treated? Keep them on the streets?
    - DanBC 8y ago
      If someone is a danger to themselves or others you can detain them and force them to take medication against their will. If they're not a danger to themselves or others you can't do either of this because they're both significant interferences with human rights. But it's important to recogise that forced hospitalisation doesn't always work, and that keeping someone banged up in hospital for two years is an expensive injustice. So you provide assertive outreach - teams that maintain contact with people who deny their illness, and who aim to work with the patient until they're ready to engage with services. https://www.theguardian.com/healthcare-network/views-from-the-nhs-frontline/2017/aug/21/assertive-outreach-team-community-care-mental-illness https://www.theguardian.com/healthcare-network/views-from-th...
criddell 8y ago
Is there a state or country that you think is doing an excellent job of taking care of their mentally ill citizens?
- jdietrich 8y ago
  There's no one system I'd point to as being ideal, but there are plenty of excellent examples of best practice. The UK does many things badly wrong, but one crucially important programme is Early Intervention in Psychosis. EIP works with young people experiencing a first episode of psychotic symptoms, with the goal of preventing that episode from developing into an enduring psychotic illness. A majority of patients should be treated within two weeks of being referred. A care co-ordinator provides a single point of contact for the service user, guiding them to access clinical, behavioural and psychosocial treatment. The service provides integrated care for comorbid physical conditions and support for social issues such as social isolation, unemployment and homelessness. The available evidence suggests a 90% reduction in premature death and cost savings of £15 for every £1 spent. https://www.england.nhs.uk/mentalhealth/wp-content/uploads/sites/29/2016/04/eip-guidance.pdf https://www.england.nhs.uk/mentalhealth/wp-content/uploads/s...
BeetleB 8y ago
>We can do better than just warehousing people in pseudo-prisons. Interestingly, some years ago I watched a documentary (Frontline, most likely) on mentally ill people in jails/prisons. If true, it was eye opening, and changed my perception on a lot of things. They followed some of the patients around, including when they were released. The general takeaways were: 1. The mental asylums that were shut down were truly horrible places. 2. Currently the only reliable place these people get medical help for their mental issues is in prisons. And it's a much better experience than those asylums. 3. For a number of prisoners/former prisoners, life in prison was better than life outside and homeless - not because of shelter/food, but because they got treatment. Regression rates are high once they are released. 4. Providing voluntary mental health help on the outside will help some, but not many. It's just one of the problems with a number of mental illnesses that if you regress a little, you likely are not going to voluntarily seek help. The key is not to regress. When you have no family support and no help in job, housing, etc, the likelihood of regression is much higher.

germinalphrase 8y ago

In complete agreement. Consider also the historical uniqueness of public libraries: if they didn't already exist in the fabric of civic life, would we really have the political ability to build them? We have little imagination or desire to build civic institutions any more; we only know how to build commercial ones.

eru 8y ago
It's not just civic institutions. Manhattan would be illegal to build these days in Manhattan. I'm glad that incapacity hasn't affected the whole world, yet. But it's seems to be spreading.
- freehunter 8y ago
  >Manhattan would be illegal to build these days in Manhattan I don't really view that particularly to be a problem. Manhattan was already built in Manhattan, it doesn't need to be built there again. Now that it exists, it needs to be managed with the new problems that have arisen since the building of Manhattan. Problems change when you scale, things that were not a problem when you were growing are now a problem after you achieve massive success "Do things that don't scale" is great advice for a growing startup, and for a very good reason. Because once you get to Manhattan size, you have to start doing things that do scale. If Manhattan hadn't changed its building codes, it would be unlivable today.
  - AnthonyMouse 8y ago
    Nobody is really talking about building codes. Building a skyscraper without fire sprinklers is a bad idea, but requiring fire sprinklers is not a thing that prevents you from building skyscrapers. On the other hand, a rule restricting building height or imposing minimum parking requirements or the like does exactly that, and has no benefit other than to enrich the existing landlords when it prevents housing supply from responding to increased demand.
dreamcompiler 8y ago
Probably not. It would be easy to paint public libraries as "socialist" which is a dirty word nowadays.
- dictum 8y ago
  There was a window of time (roughly from the eighties until about 2016) when "socialist" wouldn't be used because it was perceived as outdated, too linked with the Cold War and Red Scare... so it would be painted as "entitlement" or "lack of personal responsibility": if you wanted to read, you should have bought your own damn books. (I think the discourse is being revamped in light of the rise of democratic socialism in US politics)

ascar 8y ago

> Most of these people aren't "incompatible with peaceful society", they just need help and can't get it Do you have any source that most of these people can't get it? With a father who outright refused any medical help unless basically forced on him, in a country where it's completely free, I can absolutely relate to the argument that not having involuntary psychatric treatment plays a big part here. And his mental state was only a minor part of his health issues. It's not nice to be in stationary psychatric treatment. These are horrible places you want to leave as soon as possible. But it sometimes can't be helped. I can even relate to the point that it's better for (some/most of) these people to live on the streets than in a psychatric facility, while it's probably worse for society as a whole.

jdietrich 8y ago
There's a world of difference between "having access to medical care" and "having access to appropriate care for a disorder that presents particular obstacles in accessing conventional care pathways". Access to care in the US is highly inconsistent, because there's a patchwork of providers and funders. Effective care for people with severe and enduring mental illness needs to be patient-led but assertive - we're not going to lock you up unless it's genuinely in your best interests, but we're not going to let you slip through the cracks either. Compulsory inpatient treatment is a necessary last resort where people pose a clear and immediate risk, but it should not be the basis of care for severe and enduring mental illness. The issues regarding involuntary treatment in the US are highly complex, but the evidence indicates that involuntary community treatment does not make a significant difference in clinical outcomes. Forcing people to attend appointments or take medication doesn't seem to result in any long-term benefit on aggregate. Some people do benefit (at least in the short term) from being treated against their will, but compulsion undermines the relationship of trust between care providers and service users and discourages people from engaging with care. https://kaiserfamilyfoundation.files.wordpress.com/2013/01/8182.pdf https://kaiserfamilyfoundation.files.wordpress.com/2013/01/8... https://en.wikipedia.org/wiki/Assertive_community_treatment https://en.wikipedia.org/wiki/Assertive_community_treatment https://www.cochrane.org/CD004408/SCHIZ_compulsory-community-and-involuntary-outpatient-treatment-people-severe-mental-disorders https://www.cochrane.org/CD004408/SCHIZ_compulsory-community...

raverbashing 8y ago

> 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.

jdietrich 8y ago
>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.
- overkill28 8y ago
  > 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?

krapht 8y ago

Can we? The severely mentally ill, those with willful medication noncompliace and/or violent psychotic episodes, what do you propose we do with them? It's well known that many of them lack the self-awareness to even realize they are ill. Some sort of involuntary commitment is necessary. Frankly I believe the asylum would be a better place for many of them rather than taking dumps on the streets of San Francisco. Closing them was a mistake; rather what was needed was more oversight. It would be like shuttering all nursing homes and sending the elderly back onto the streets or into their children's homes, because the cheapest ones are run like deathbed holding warehouses. In fact they've all but reappeared, we just call them prisons today, or sometimes a long-term residential psychiatric care facility. Historically the severely mentally ill were either put to death, or placed under the custody of their immediate relatives, with the family being punished if said ill person were to cause trouble in society. This is not really an option in modern society. The severely psychotic need inpatient care, and it should be an option. Today they're getting it in jail, this is not ideal.

alsetmusic 8y ago
Bi-polar can be treated with medication and people can often lead a normal life as a result.
- krapht 8y ago
  Yes, but in particular I'm referring to the problem of the mentally ill not taking their medication.
- alecco 8y ago
  I’ve heard many times of bipolar people committing crime because they either decided to stop medicating (it does make you feel not good) or they lost them or something. There is a point between individual freedom and public safety. We can’t just sigh and throw up our hands in the air.
- maxlamb 8y ago
  I think schizophrenia is the much bigger problem regarding the homeless.

village-idiot 8y ago

> We closed the asylums, because the long-term detention of the mentally ill is costly and inhumane. We can do better than just warehousing people in pseudo-prisons. Apparently not, because we just kicked them out onto the streets to starve and freeze to death.

vkou 8y ago

> We closed the asylums, because the long-term detention of the mentally ill is costly and inhumane. We can do better than just warehousing people in pseudo-prisons. How? This is a serious question. Right now, we are housing them in open-air prisons - the various homeless ghettos in Vancouver, San Francisco, Seattle, etc. What exactly do you propose we do for someone who is unable to, due to mental illness: 1. Maintain their living space, or themselves in a remotely neighborly manner. (All the problems the librarian faces? Imagine living in a shelter/state housing, next door to that.) 2. Take their medicine. 3. (Bonus). Do anything, or consent to do anything about their substance abuse problem. These are not traits that most homeless people have. Most homeless people can be immediately helped by housing first, etc, etc. But these are traits that some homeless people have. And since you're hand-wringing about institutionalization, I would like to hear what you propose, as an alternative for them.

jdietrich 8y ago
>I would like to hear what you propose, as an alternative for them. https://en.wikipedia.org/wiki/Assertive_community_treatment https://en.wikipedia.org/wiki/Assertive_community_treatment
- vkou 8y ago
  So, "Medical professionals should spend more time helping their patients." That's great. I fully endorse that. That's an improvement over them spending less time helping their patients. How does this help someone who refuses to be treated? What do you do until they are willing to be treated? Keep them on the streets?
  - DanBC 8y ago
    If someone is a danger to themselves or others you can detain them and force them to take medication against their will. If they're not a danger to themselves or others you can't do either of this because they're both significant interferences with human rights. But it's important to recogise that forced hospitalisation doesn't always work, and that keeping someone banged up in hospital for two years is an expensive injustice. So you provide assertive outreach - teams that maintain contact with people who deny their illness, and who aim to work with the patient until they're ready to engage with services. https://www.theguardian.com/healthcare-network/views-from-the-nhs-frontline/2017/aug/21/assertive-outreach-team-community-care-mental-illness https://www.theguardian.com/healthcare-network/views-from-th...

criddell 8y ago

Is there a state or country that you think is doing an excellent job of taking care of their mentally ill citizens?

jdietrich 8y ago
There's no one system I'd point to as being ideal, but there are plenty of excellent examples of best practice. The UK does many things badly wrong, but one crucially important programme is Early Intervention in Psychosis. EIP works with young people experiencing a first episode of psychotic symptoms, with the goal of preventing that episode from developing into an enduring psychotic illness. A majority of patients should be treated within two weeks of being referred. A care co-ordinator provides a single point of contact for the service user, guiding them to access clinical, behavioural and psychosocial treatment. The service provides integrated care for comorbid physical conditions and support for social issues such as social isolation, unemployment and homelessness. The available evidence suggests a 90% reduction in premature death and cost savings of £15 for every £1 spent. https://www.england.nhs.uk/mentalhealth/wp-content/uploads/sites/29/2016/04/eip-guidance.pdf https://www.england.nhs.uk/mentalhealth/wp-content/uploads/s...

BeetleB 8y ago

>We can do better than just warehousing people in pseudo-prisons. Interestingly, some years ago I watched a documentary (Frontline, most likely) on mentally ill people in jails/prisons. If true, it was eye opening, and changed my perception on a lot of things. They followed some of the patients around, including when they were released. The general takeaways were: 1. The mental asylums that were shut down were truly horrible places. 2. Currently the only reliable place these people get medical help for their mental issues is in prisons. And it's a much better experience than those asylums. 3. For a number of prisoners/former prisoners, life in prison was better than life outside and homeless - not because of shelter/food, but because they got treatment. Regression rates are high once they are released. 4. Providing voluntary mental health help on the outside will help some, but not many. It's just one of the problems with a number of mental illnesses that if you regress a little, you likely are not going to voluntarily seek help. The key is not to regress. When you have no family support and no help in job, housing, etc, the likelihood of regression is much higher.