4 ms·

What we should do about the mentally ill homeless

50 points by inglor_cz 2y ago

inglor_cz 2y ago
A very long title, didn't fit the limit, sorry. This is a good example of a really hard problem.
- argimenes 2y ago
  Alternative title: "What we should do about the mentally ill homeless".
  - inglor_cz 2y ago
    OK, I edited that.
al_borland 2y ago
>in practice it’s all vibes Vibes matter. When walking down the street, a person isn't going to do a full evaluation on a homeless person. They are going off vibes, and if the vibe is unsafe, it makes the city feel unsafe. People with money to spend tend not to go to cities and areas that feel unsafe, which over time will cause a city to die, which is bad for everyone. >Best-case scenario, they’re completely sane. Now what? Do you keep a completely sane person locked in the mental institution forever? .... >the social workers can’t show up at their door, because these patients are homeless and hard to track down. ... >Okay, sounds like you need to get them homes. But there’s not enough government-subsidized housing. Why does the mental institutions have to be "lock up"? It seems like there could be levels to this. Lockup for those who are still potentially dangerous out in society, and have something more akin to a halfway house where someone can live and are free to go and do stuff, but have a place to come back to to keep tabs on them and make sure they are taking their meds. Provide a path to full independence, but with some guardrails to make sure they are doing it in a way where they have a place to live and are taking their meds, and not just throwing them back on the street and expecting things to be different than when they were picked up off the street. This will probably be expensive, but looking at what the homeless problem has cost some very expensive cities, it seems like it would be worth it.
- inglor_cz 2y ago
  Indeed one of the phenomena that surprises me is just how much do cities like San Francisco spend on homelessness without visible success. It is something like 50 000 dollars per homeless person per year.
  - mrguyorama 2y ago
    That's just the base cost of a human being using the absolute ragged edge of what remains of our "safety net", primarily ambulance calls and unpayable hospital bills for very basic and unnecessary things. The homeless people in my small (60k people) city have an ambulance called about once per day because they get heat stroke, because if they try to stand somewhere they wont get heat stroke, they will be arrested. Those wasteful usages of our absurdly BS priced medical system balloons how much a "homeless" person "costs". It doesn't matter that the only actual resources used where a hospital bed and some OTC medication, the hospital will claim that expense as 10k and bitch and moan that they can't afford it. Then you have the secondary effect that a 100 bed shelter in California will be absurdly expensive to operate simply due to rent, like disproportionately so.
- beardyw 2y ago
  > Lockup for those who are still potentially dangerous out in society, and have something more akin to a halfway house where someone can live and are free to go and do stuff. There are a lot inbetween those where people will wander off and then get confused.
  - al_borland 2y ago
    If someone isn't stable enough to not wander off and get confused/lost, then they shouldn't be let out on their own.
- worldvoyageur 2y ago
  I am not an expert but it seems that many of the real challenges outlined in this blog are handled with what my city (Ottawa, Canada) calls 'supportive housing'. Basically, a purpose built building with 30-50 small apartments and social services co-located. Residents have to meet conditions to get in, to remain in and progress to the point that they can function in more regular market housing, thus freeing the slot for another resident. https://ottawainnercityhealth.ca/programs-services/supportive-living-programs/ https://ottawainnercityhealth.ca/programs-services/supportiv... ' Our supportive living units are run in partnership with other organizations and provide specialized supports for individuals exiting homelessness. This includes substance use support, mental health care, and peer support. Our programs are designed to be client-centred with a harm-reduction-focus. [...] Carruthers is a supported housing program operated in partnership with the John Howard Society with 46 units. Originally, the substance use treatment available focused strongly on Injectable Opiate Substitution (IOAT) with 20 of the available apartments being reserved for people who were enrolled in that program. Many of the original residents have now migrated to other forms of treatment and to different lives where volunteering, work and time spent with family and friends are a priority. [..] The Richcraft Residence was the first OICH housing program which offered all available substance use, physical health and mental health treatments in one location providing a full menu of care options for residents. ' Upstream of supportive housing you need good street facing services with social workers and police well coordinated and tracking clients. Downstream of supportive housing you need to help people maintain the progress they made at living more indepently as a functional part of their wider community. Remaining problems include: - keeping clients alive long enough to recover before they die from opiod poisoning - having enough of supportive housing capacity to meet the need. - the candidates who do not want to participate, even space was available.
mensetmanusman 2y ago
Simply answer how would you want to be cared for if you were ill? 1) A comfortable bed 2) Engaging entertainment/task (eg folding laundry is helpful for some disorders) 3) Safe from abuse 4) Basic medical care 5) Place to sit for sunshine 6) Opportunity to hold hands / human touch
- hattmall 2y ago
  We use to have this, self operating mental institutions. Most all patients had jobs that kept the facility running. The US has around ~10 mental health beds per 100k. Most European nations have around 100 and developed Asian countries have ~200. The US had similar or higher numbers decades ago. The pharmaceutical companies however have successfully lobbied to medicate instead of house the mentally ill. As well we have largely replaced those mental health beds with prison beds. The largest expenditure after staffing for most correction departments is inmate medications. We simply need to bring back an intermediary between the streets and jail. As well I would argue we may need something as an intermediary between jail and the military like the pre-ww2 CC camps.
  - lesuorac 2y ago
    Pretty sure the closure of mental institutions was a (bipartisan) budgetary one. https://en.wikipedia.org/wiki/Mental_Health_Systems_Act_of_1980#Consequences_of_the_repeal https://en.wikipedia.org/wiki/Mental_Health_Systems_Act_of_1...
deleted 2y ago
[deleted]
apwheele 2y ago
IMO the long acting drugs + more intensive caseworker intervention is the most feasible way for the very difficult to work with individuals. (Long acting is good for opioids as well, https://healthandjusticejournal.biomedcentral.com/articles/10.1186/s40352-024-00281-w https://healthandjusticejournal.biomedcentral.com/articles/1...). So there is a mixture of types of homeless -- some of the examples Scott gets into for "draconian" are for what I would call transient/short-term -- those folks some welfare type intervention (housing vouchers, cash) to smooth over their instability is all they need. Those are not the homeless people are complaining about! The "pollution" homeless though Scott is mostly talking about are the people who cause public disorder. And those are very hard to deal with. So everything will be difficult, but I think caseworkers being able to help them as much as possible is IMO the best approach I've seen work in some cases.
- readyman 2y ago
  Why do the "pollution" homeless simply not exist in so many other wealthy countries, to even a fraction of the degree that they exist in the United States?
  - financltravsty 2y ago
    Don't know why this -- or a bunch of your other posts -- are dead. But the reason is the rest of the countries that don't have this problem take care of their people (positively and negatively, e.g. social services or prison). For example much of the EU has: - A social safety net that allows people to reintegrate into society if a catastrophic event happens, rather than throwing them out and letting natural selection decide who gets back up on their feet - Better health care (for mental health and addiction, to simply not being a constant drain financially and emotionally on patients) - Housing is more accessible and egalitarian, leading to -- unsurprisingly -- less homeless. The ones that do end up homeless will likely be able to find state-funded housing with reintegration programs (rather than homeless "shelters" and halfway "homes") - Less income inequality and less "otherism." Homogenous populations and a lack of individualism == "that could be me at any point; I should help when I can, so if I ever fall into such straits, others will do the same." Reminds me of how I haven't heard of the "golden rule" (treat others the way you want to he treated) in decades - Notable mentions: homelessness in the U.S. pretty much guarantees you do not have: a permanent address, so you most likely cannot apply for jobs or other programs (which necessitate a permanent address). Bank account? Good luck with the prehistoric KYC laws. Also in most of the country barring massive cities with public transport, you need to own a car for transport to most jobs. Don't? You're automatically disqualified from 95% of jobs that you could be eligible for. Cars are expensive Basically, a lot of systemic problems that culminate in a not insignificant portion of homeless being forever locked out of society
pcthrowaway 2y ago
> (Also, even in the best case where you successfully treat somebody, I’m afraid that “1995 - 2024: psychotic homeless person” doesn’t look good on a resume, so they probably won’t be getting high-powered jobs. Meanwhile, cheap apartments in SF are $1000/month. So the connection between “no longer psychotic” and “no longer homeless on the street” is tenuous unless you also have some plan to provide free housing.) I mean, there is so much overlooked here, I'm truly confused by this post. The housing cost is very clearly related to the issues of homelessness. Of course it's not the only thing, but it's a significant factor. Fix housing, provide housing for the mentally ill. Voila! You no longer have mentally ill homeless people. Like, of course the system which doesn't support people until they're able to stand on their own legs results in people repeatedly falling over. Fixing the mental illness epidemic is another problem, one which may require better policy around housing, food, mental health services, and taxation of the wealthy. Even then we may not have the tools to 'fix' all the people who've been broken by the current system, during the lifetime, because the human brain is so complex. But if we fix these issues, the next generation wouldn't have so many mentally ill homeless people in the first place, and we'd have better tools in place to treat people before their mental illness spirals to the point where it's beyond our current mental health care industry's capability to treat.
- loa_in_ 2y ago
  I believe that consensus is that we have all the economic capacity we need. If we can get by without helping those people, why would we? Obviously I do not share this worldview and me myself border on homelessness for past years, but the world is a world of financial incentives and there is none big enough to do that.
  - alan-hn 2y ago
    Perhaps the issue then is the structure of capitalism
- hoseja 2y ago
  Voilà! Now you have mentally ill destroying houses.
- 2y ago
deleted 2y ago
[deleted]
fulafel 2y ago
I'd recommend starting with https://www.astralcodexten.com/p/book-review-san-fransicko https://www.astralcodexten.com/p/book-review-san-fransicko before reading this.
kzurell 2y ago
I love love love that we're having these discussions about housing first and tiny homes, what if the homeless damage them, let's build (new) traditional custodial institutions for the violent, and so on... ...at exactly when architectural Brutalism is having a critical revival, don't tear down the Moriyama Science Centre, look at those beautiful Brutalist churches... We scrounge ratty old buildings for inadequate, dangerous shelters, and haggle and whinge to the point of inaction about housing people in shipping containers or surplus hotels, but laud "jail cell chic". It goes to show that "The cruelty is the point", that "We'll give you the world if only you bow down before [our economic truisms]". Some people have taken into their hearts that human suffering is a renewable resource.
- thatfunkymunki 2y ago
  Agreed. It's interesting how much analysis is given to the outcomes of these less cruel positions, at the same time that one hears calls for "more policing" as if that is not literally advocating for greater rates of incarceration and authoritarian violence without further consideration.
deleted 2y ago
[deleted]
more_corn 2y ago
The housing first program shows that it is way easier to treat the causes of chronic homelessness if you put people in housing. The total cost when counting ER visits and police intervention is 4x less under housing first. The evidence is clear. Believe it or don’t, but reality is the thing that exists even if you don’t believe in it.
floxy 2y ago
It sounds like one potential problem is with all the hurdles around acquiring anti-psychotic meds. Is this something we could loosen up on? As in subsiding the cost completely (i.e. $0 out-of-pocket). And not being very strict on prescriptions? Like the pharmacy could give out a second batch without question, if the first batch was "lost". Or maybe it is something that is almost OTC, but behind the counter like Sudafed? With the goal to make it almost as easy to get actual meds as it is to get fentanyl?
ogou 2y ago
We should differentiate between truly low functioning schizophrenics that are in active psychosis and people who developed psychotic features through years of drug abuse. One is born that way or organically develops the condition, the other makes hundreds of small decisions that lead to destructive consequences that society is left to confront. Both are worthy of compassion. But, the latter has responsibility for their own choices. They should be held to a higher standard of expectations, including managing their own medical path and showing up to appointments. One thing this article avoids, and most other advocacy articles do also, is acknowledgement of the vast numbers of mentally ill people who do prioritise their own care and participate in a structured treatment. It's disrespectful and ableist to group the worst behaviours of people that abandon their own care for street drugs, with the condition itself. Those people need to be held responsible for those decisions. Consequences for destructive behaviour are crucial for a functioning society. Even many low functioning people understand consequences. What we have done is slowly remove the consequences for multiple tiers of progressively worse behaviour. I have seen many freakouts and assaults in large cities and have also seen them act right up to the threshold of a consequence. Then when police show up, suddenly they know exactly what to say to get out of it. That is not someone who doesn't understand what is happening. Involuntary hospitalisation needs to remain a tool, even as a last resort, to prevent escalation of conditions and for the safety of the general public.

50 points by inglor_cz 2y ago

inglor_cz 2y ago

A very long title, didn't fit the limit, sorry. This is a good example of a really hard problem.

argimenes 2y ago
Alternative title: "What we should do about the mentally ill homeless".
- inglor_cz 2y ago
  OK, I edited that.

al_borland 2y ago

>in practice it’s all vibes Vibes matter. When walking down the street, a person isn't going to do a full evaluation on a homeless person. They are going off vibes, and if the vibe is unsafe, it makes the city feel unsafe. People with money to spend tend not to go to cities and areas that feel unsafe, which over time will cause a city to die, which is bad for everyone. >Best-case scenario, they’re completely sane. Now what? Do you keep a completely sane person locked in the mental institution forever? .... >the social workers can’t show up at their door, because these patients are homeless and hard to track down. ... >Okay, sounds like you need to get them homes. But there’s not enough government-subsidized housing. Why does the mental institutions have to be "lock up"? It seems like there could be levels to this. Lockup for those who are still potentially dangerous out in society, and have something more akin to a halfway house where someone can live and are free to go and do stuff, but have a place to come back to to keep tabs on them and make sure they are taking their meds. Provide a path to full independence, but with some guardrails to make sure they are doing it in a way where they have a place to live and are taking their meds, and not just throwing them back on the street and expecting things to be different than when they were picked up off the street. This will probably be expensive, but looking at what the homeless problem has cost some very expensive cities, it seems like it would be worth it.

inglor_cz 2y ago
Indeed one of the phenomena that surprises me is just how much do cities like San Francisco spend on homelessness without visible success. It is something like 50 000 dollars per homeless person per year.
- mrguyorama 2y ago
  That's just the base cost of a human being using the absolute ragged edge of what remains of our "safety net", primarily ambulance calls and unpayable hospital bills for very basic and unnecessary things. The homeless people in my small (60k people) city have an ambulance called about once per day because they get heat stroke, because if they try to stand somewhere they wont get heat stroke, they will be arrested. Those wasteful usages of our absurdly BS priced medical system balloons how much a "homeless" person "costs". It doesn't matter that the only actual resources used where a hospital bed and some OTC medication, the hospital will claim that expense as 10k and bitch and moan that they can't afford it. Then you have the secondary effect that a 100 bed shelter in California will be absurdly expensive to operate simply due to rent, like disproportionately so.
beardyw 2y ago
> Lockup for those who are still potentially dangerous out in society, and have something more akin to a halfway house where someone can live and are free to go and do stuff. There are a lot inbetween those where people will wander off and then get confused.
- al_borland 2y ago
  If someone isn't stable enough to not wander off and get confused/lost, then they shouldn't be let out on their own.
worldvoyageur 2y ago
I am not an expert but it seems that many of the real challenges outlined in this blog are handled with what my city (Ottawa, Canada) calls 'supportive housing'. Basically, a purpose built building with 30-50 small apartments and social services co-located. Residents have to meet conditions to get in, to remain in and progress to the point that they can function in more regular market housing, thus freeing the slot for another resident. https://ottawainnercityhealth.ca/programs-services/supportive-living-programs/ https://ottawainnercityhealth.ca/programs-services/supportiv... ' Our supportive living units are run in partnership with other organizations and provide specialized supports for individuals exiting homelessness. This includes substance use support, mental health care, and peer support. Our programs are designed to be client-centred with a harm-reduction-focus. [...] Carruthers is a supported housing program operated in partnership with the John Howard Society with 46 units. Originally, the substance use treatment available focused strongly on Injectable Opiate Substitution (IOAT) with 20 of the available apartments being reserved for people who were enrolled in that program. Many of the original residents have now migrated to other forms of treatment and to different lives where volunteering, work and time spent with family and friends are a priority. [..] The Richcraft Residence was the first OICH housing program which offered all available substance use, physical health and mental health treatments in one location providing a full menu of care options for residents. ' Upstream of supportive housing you need good street facing services with social workers and police well coordinated and tracking clients. Downstream of supportive housing you need to help people maintain the progress they made at living more indepently as a functional part of their wider community. Remaining problems include: - keeping clients alive long enough to recover before they die from opiod poisoning - having enough of supportive housing capacity to meet the need. - the candidates who do not want to participate, even space was available.

mensetmanusman 2y ago

Simply answer how would you want to be cared for if you were ill? 1) A comfortable bed 2) Engaging entertainment/task (eg folding laundry is helpful for some disorders) 3) Safe from abuse 4) Basic medical care 5) Place to sit for sunshine 6) Opportunity to hold hands / human touch

hattmall 2y ago
We use to have this, self operating mental institutions. Most all patients had jobs that kept the facility running. The US has around ~10 mental health beds per 100k. Most European nations have around 100 and developed Asian countries have ~200. The US had similar or higher numbers decades ago. The pharmaceutical companies however have successfully lobbied to medicate instead of house the mentally ill. As well we have largely replaced those mental health beds with prison beds. The largest expenditure after staffing for most correction departments is inmate medications. We simply need to bring back an intermediary between the streets and jail. As well I would argue we may need something as an intermediary between jail and the military like the pre-ww2 CC camps.
- lesuorac 2y ago
  Pretty sure the closure of mental institutions was a (bipartisan) budgetary one. https://en.wikipedia.org/wiki/Mental_Health_Systems_Act_of_1980#Consequences_of_the_repeal https://en.wikipedia.org/wiki/Mental_Health_Systems_Act_of_1...

deleted 2y ago

[deleted]

apwheele 2y ago

IMO the long acting drugs + more intensive caseworker intervention is the most feasible way for the very difficult to work with individuals. (Long acting is good for opioids as well, https://healthandjusticejournal.biomedcentral.com/articles/10.1186/s40352-024-00281-w https://healthandjusticejournal.biomedcentral.com/articles/1...). So there is a mixture of types of homeless -- some of the examples Scott gets into for "draconian" are for what I would call transient/short-term -- those folks some welfare type intervention (housing vouchers, cash) to smooth over their instability is all they need. Those are not the homeless people are complaining about! The "pollution" homeless though Scott is mostly talking about are the people who cause public disorder. And those are very hard to deal with. So everything will be difficult, but I think caseworkers being able to help them as much as possible is IMO the best approach I've seen work in some cases.

readyman 2y ago
Why do the "pollution" homeless simply not exist in so many other wealthy countries, to even a fraction of the degree that they exist in the United States?
- financltravsty 2y ago
  Don't know why this -- or a bunch of your other posts -- are dead. But the reason is the rest of the countries that don't have this problem take care of their people (positively and negatively, e.g. social services or prison). For example much of the EU has: - A social safety net that allows people to reintegrate into society if a catastrophic event happens, rather than throwing them out and letting natural selection decide who gets back up on their feet - Better health care (for mental health and addiction, to simply not being a constant drain financially and emotionally on patients) - Housing is more accessible and egalitarian, leading to -- unsurprisingly -- less homeless. The ones that do end up homeless will likely be able to find state-funded housing with reintegration programs (rather than homeless "shelters" and halfway "homes") - Less income inequality and less "otherism." Homogenous populations and a lack of individualism == "that could be me at any point; I should help when I can, so if I ever fall into such straits, others will do the same." Reminds me of how I haven't heard of the "golden rule" (treat others the way you want to he treated) in decades - Notable mentions: homelessness in the U.S. pretty much guarantees you do not have: a permanent address, so you most likely cannot apply for jobs or other programs (which necessitate a permanent address). Bank account? Good luck with the prehistoric KYC laws. Also in most of the country barring massive cities with public transport, you need to own a car for transport to most jobs. Don't? You're automatically disqualified from 95% of jobs that you could be eligible for. Cars are expensive Basically, a lot of systemic problems that culminate in a not insignificant portion of homeless being forever locked out of society

pcthrowaway 2y ago

> (Also, even in the best case where you successfully treat somebody, I’m afraid that “1995 - 2024: psychotic homeless person” doesn’t look good on a resume, so they probably won’t be getting high-powered jobs. Meanwhile, cheap apartments in SF are $1000/month. So the connection between “no longer psychotic” and “no longer homeless on the street” is tenuous unless you also have some plan to provide free housing.) I mean, there is so much overlooked here, I'm truly confused by this post. The housing cost is very clearly related to the issues of homelessness. Of course it's not the only thing, but it's a significant factor. Fix housing, provide housing for the mentally ill. Voila! You no longer have mentally ill homeless people. Like, of course the system which doesn't support people until they're able to stand on their own legs results in people repeatedly falling over. Fixing the mental illness epidemic is another problem, one which may require better policy around housing, food, mental health services, and taxation of the wealthy. Even then we may not have the tools to 'fix' all the people who've been broken by the current system, during the lifetime, because the human brain is so complex. But if we fix these issues, the next generation wouldn't have so many mentally ill homeless people in the first place, and we'd have better tools in place to treat people before their mental illness spirals to the point where it's beyond our current mental health care industry's capability to treat.

loa_in_ 2y ago
I believe that consensus is that we have all the economic capacity we need. If we can get by without helping those people, why would we? Obviously I do not share this worldview and me myself border on homelessness for past years, but the world is a world of financial incentives and there is none big enough to do that.
- alan-hn 2y ago
  Perhaps the issue then is the structure of capitalism
hoseja 2y ago
Voilà! Now you have mentally ill destroying houses.
2y ago

deleted 2y ago

[deleted]

fulafel 2y ago

I'd recommend starting with https://www.astralcodexten.com/p/book-review-san-fransicko https://www.astralcodexten.com/p/book-review-san-fransicko before reading this.

kzurell 2y ago

I love love love that we're having these discussions about housing first and tiny homes, what if the homeless damage them, let's build (new) traditional custodial institutions for the violent, and so on... ...at exactly when architectural Brutalism is having a critical revival, don't tear down the Moriyama Science Centre, look at those beautiful Brutalist churches... We scrounge ratty old buildings for inadequate, dangerous shelters, and haggle and whinge to the point of inaction about housing people in shipping containers or surplus hotels, but laud "jail cell chic". It goes to show that "The cruelty is the point", that "We'll give you the world if only you bow down before [our economic truisms]". Some people have taken into their hearts that human suffering is a renewable resource.

thatfunkymunki 2y ago
Agreed. It's interesting how much analysis is given to the outcomes of these less cruel positions, at the same time that one hears calls for "more policing" as if that is not literally advocating for greater rates of incarceration and authoritarian violence without further consideration.

deleted 2y ago

[deleted]

more_corn 2y ago

The housing first program shows that it is way easier to treat the causes of chronic homelessness if you put people in housing. The total cost when counting ER visits and police intervention is 4x less under housing first. The evidence is clear. Believe it or don’t, but reality is the thing that exists even if you don’t believe in it.

floxy 2y ago

It sounds like one potential problem is with all the hurdles around acquiring anti-psychotic meds. Is this something we could loosen up on? As in subsiding the cost completely (i.e. $0 out-of-pocket). And not being very strict on prescriptions? Like the pharmacy could give out a second batch without question, if the first batch was "lost". Or maybe it is something that is almost OTC, but behind the counter like Sudafed? With the goal to make it almost as easy to get actual meds as it is to get fentanyl?

ogou 2y ago

We should differentiate between truly low functioning schizophrenics that are in active psychosis and people who developed psychotic features through years of drug abuse. One is born that way or organically develops the condition, the other makes hundreds of small decisions that lead to destructive consequences that society is left to confront. Both are worthy of compassion. But, the latter has responsibility for their own choices. They should be held to a higher standard of expectations, including managing their own medical path and showing up to appointments. One thing this article avoids, and most other advocacy articles do also, is acknowledgement of the vast numbers of mentally ill people who do prioritise their own care and participate in a structured treatment. It's disrespectful and ableist to group the worst behaviours of people that abandon their own care for street drugs, with the condition itself. Those people need to be held responsible for those decisions. Consequences for destructive behaviour are crucial for a functioning society. Even many low functioning people understand consequences. What we have done is slowly remove the consequences for multiple tiers of progressively worse behaviour. I have seen many freakouts and assaults in large cities and have also seen them act right up to the threshold of a consequence. Then when police show up, suddenly they know exactly what to say to get out of it. That is not someone who doesn't understand what is happening. Involuntary hospitalisation needs to remain a tool, even as a last resort, to prevent escalation of conditions and for the safety of the general public.