The over-medication of hospitalized patients resulted, years ago, in an abhorrence for forcing people to be medicated against their will. As someone who has worked in short-term involuntary psych hospital units, I have seen how difficult it is to give meds to someone who doesn't want to take them--it is a legal and bureaucratic nightmare. Someone who is in a floridly psychotic state does not have the ability to make informed consent, but many hearings must be held and hoops jumped through before the Dr's judgement that they need meds can be accepted. The pendulum swung so far in the diretion of patients' rights, that patients sometimes need to be restrained, or in seclusion to keep them from harming themselves or others, when a shot or a pill will return them to a semblance of reality. The pendulum has to swing back to the middle. Freedom is a very elusive concept when you are trying to help, or manage the symptoms of someone who has no internal capacity for self-control.
Your analysis of how end-stage capitalism has fueled the crisis of homelessness is excellent, but there's more to it, that stems from the closing of state mental hospitals during the Reagan administration. Not only were the community resources for medical care and housing never funded as promised. The entire premise was based on the belief that people with chonic, severe mental illness would be willing to voluntarily take medication, and live in situations where they would be required to follow rules of behavior. As a retired psychiatric social worker, I can tell you that this whole model is a fallacy. A huge percentage of the unhoused and also those housed in prison are not willing to take medications to control the symptoms of their illnesss that cause them to be unable to manage their lives, or who often turn to alcohol or street drugs instead. Nor do they want to live anywhere that requires them to take meds, abstain from alcohol or street drugs, or follow basic rules. To solve a big part of the homeless problem, and the reality that our streets and jails have become de facto psychiatric facilities, mostly unmedicated, we need to re-establish state hospitals--hopefully more humane than those of the past. If the laws were changed to make it easier for a court to require a chronic miscreant to take meds, it might be possible for some to live in the community with adequate support services, and if they refuse, they live in the hospital. Some are simply too sick or disorganized to care for themselves and need to be mandated to live in a state facility. It is less cruel to make sure that the chronic, severely mentally ill are adequately housed, fed, clothed --and required to take medication--than it is to allow them to continue to live in bedlam and befoul the streets of our communities, even if that is what they prefer to do.
I agree with you 100% about the de-institutionalization of care, which began under Kennedy. I think Kennedy was well-intended and his vision was altruistic and probably a response to his sister, Rosemary who was developmentally disabled and required care. But the idea was that families would care for their people, with support from care centers stationed around all around the US. When those care centres never materialized.... well, you know what happened. I agree about the complexity of all this. I think supported residences could be an alternative to psychiatric confinement though, particularly in places where homelessness is not rampant and entrenched yet. UnityHouse in Troy, NY runs a very successful program that houses schizophrenic adults with the goal of living in the community, although many never make it and stay in supported housing. I really appreciate this comment because you really dig into why this is so hard to manage. But I do believe part of the equation is for people to not other people into seclusion outside our communities. I am intrigued by this hospitialization idea because I wonder if we could ever get facilities to be as humane as we need them to be. I wonder if there are examples of this..... Thanks for this great comment! I so appreciate your perspective.
There are other facilities like the one you reference in Troy, NY. They presume a willingness to accept treatment . The bigger problem can only be tackled if psychiatry courts were established that were able to mandate medication to those unwilling to take them voluntarily, and the re-establishment of long-term involuntary treatment facilities, i.e. state hospitals, for those who cannot or will not comply.
Do you feel like it would be a hard sell for the public to embrace committing people back into institutions? Are there any models of this kind of institution that would work? (I can think of none) What are the ethics of force-medicating people? (We do that routinely for the incarcerated mentally ill so they can stand trial and there is a lot of shady ethics there. I'm going to be thinking about this for awhile.... Thanks for raising it as a discussion point.
So difficult. In particular, I remember one homeless person I called Rabbit Woman. She was tall, beautiful, dirty, walking constantly, and usually moaning. She was prey, and from what I heard raped too many times. A chef friend said Rabbit would come into her restaurant sometimes, relatively early. They'd sit her away from anyone else there because she did smell. After ordering and eating she'd pull out a wad of money and pay, tipping well. Another friend said Rabbit came from a wealthy family, who'd had her involuntarily institutionalized through the years. She'd get on meds in the facility, and her mind would get to a right place. She'd then sue to get out, winning every time. Once out, she'd stop the meds, end up on the streets striding and moaning. The family finally gave up, finding good people in my city who'd watch out for her, hand her a wad of money periodically. I have a few other similar tales like that. What to do? Oliver Sacks in one of his books talked about the old institutions with farms and other work attached. He said many enjoyed the work and liked getting outside but still in a safe, enclosed space. The fans were shut down after lawsuits stating the people were forced to work. Sacks said that was not true; all work was voluntary. I don't know, but I could see someone - not all - liking a place where the schedule remained the same, and they had something to do each day, not just sit in a room with a t.v. on, or old magazines, or even books (as much as I like to read). We really need to figure this out, how to help those mentally challenged, who might benefit from a facility of kind people.
Agree. We have to get this right. And love the Oliver Sacks mention. I like this idea of an enclosed village that would be built to provide a sense of purpose and leisure and community and context. But it's still incarceration right? It's still guards and gates even if they are nice guards and gates. It is a big deal to take someone's freedom away even if we think it's the best thing for them. I mean Esme Weijung Wang writes in her book (The Collected Schizophrenias) that the most terrifying moments of her life happened when she was involuntarily committed. I suspect that the answer partially has to come from communities impacted by this kind of confinement and what alternatives might be.
Agree, but in we're confined in so many ways in society. Some people cannot adjust (I think of one homeless "neighbor" a women's group helped, but showed up later saying he'd been on the street too long, it was home). I think a fair amount want it, it's almost like coddling - or would welcome it if it didn't feel institutional. Then there are degrees of mental issues, and times when it is worse, times almost non-existent. There are people who just had a bad economic time, and homelessness is temporary. What are the statistics? I think it's that the majority of those homeless are housed again after two to four months, or that was so in the past. It's mainly the mentally ill who need some permanent solution, or semi-permanent. New York City lost around 2000 psychiatric beds in the last two years. Texas has not quite 2300; the whole state! (It would be around 2900 but staff shortages reduced it by 700.) We need to look to other nations, see how they handle it. The US is 29th in ranking out of 167 countries in the category of living conditions (prosperity.com should be seen by all; we're number . . 19 overall). I've had homeless as neighbors; both cities where I've lived had too many. I was acquaintances with a fair amount in my home city, but not here. Hurts my heart.
Thank you for pushing my brain. Maybe we'll figure out some small steps.
At its most basic level, even if the funding is there you need the kindly butt-wipers and toenail clippers and people who care the way that that Jewish carpenter cared or all the funding won’t make a difference. When you mentioned the mayor trying to encourage communities to take people in, the reality is that people have to do what you’ve done, invited them in, cared for them and GONE OUT OF YOUR WAY for no other reason than you wanted to, and that’s a big ask, as generous as we like to think we all are. Everyone made fun of that Super Bowl commercial with the feet washing but I thought it was pretty right on no matter who paid for the ad..
This is really the gist of Matthews Desmond's book Poverty, By America, which is that we only end poverty by giving up certain things as well. Like maybe having to pay people more means not every business will make it. Or re-orienting ourselves about how we in the upper and middle classes get help - that mortgage tax deduction is a support program from the government, just as welfare is. We are all getting support. A lot of abolishing poverty is going to be adjusting what success means for us personally and our communities and I don't think most people have it in them.
You said no one wants to hear this. I do! I love what you have to say.
That photo at the bottom speaks volumes. Other people might feel afraid to walk down that path, and avoid the area. But here are unhoused people, not criminals and mentally ill people. People blame homeless people for all kinds of things. Even the man you quoted on next door assumed that the guy who urinated was due to homelessness.
Kim, if you haven't read this yet, the nonprofit where I was chair worked with the UN to define poverty. Here was the result of their work. It explains who becomes homeless and why, and it has vastly increased my understanding. https://atdfourthworld-usa.org/map-download-the-report
OOh! Thank you Dianne for these links! This is amazing. I have some reading to do. As for Prop 1, I will be sitting here eating popcorn, watching and hoping for some success for people and something we can replicate (or not replicate) in Nevada. Rooting for you all in California.
The over-medication of hospitalized patients resulted, years ago, in an abhorrence for forcing people to be medicated against their will. As someone who has worked in short-term involuntary psych hospital units, I have seen how difficult it is to give meds to someone who doesn't want to take them--it is a legal and bureaucratic nightmare. Someone who is in a floridly psychotic state does not have the ability to make informed consent, but many hearings must be held and hoops jumped through before the Dr's judgement that they need meds can be accepted. The pendulum swung so far in the diretion of patients' rights, that patients sometimes need to be restrained, or in seclusion to keep them from harming themselves or others, when a shot or a pill will return them to a semblance of reality. The pendulum has to swing back to the middle. Freedom is a very elusive concept when you are trying to help, or manage the symptoms of someone who has no internal capacity for self-control.
Thank you for this thoughtful answer. I see the quagmire here.
This: https://mlf.org/community-first/
I’ve heard about this and really want to check them out in person. Amazing!
Your analysis of how end-stage capitalism has fueled the crisis of homelessness is excellent, but there's more to it, that stems from the closing of state mental hospitals during the Reagan administration. Not only were the community resources for medical care and housing never funded as promised. The entire premise was based on the belief that people with chonic, severe mental illness would be willing to voluntarily take medication, and live in situations where they would be required to follow rules of behavior. As a retired psychiatric social worker, I can tell you that this whole model is a fallacy. A huge percentage of the unhoused and also those housed in prison are not willing to take medications to control the symptoms of their illnesss that cause them to be unable to manage their lives, or who often turn to alcohol or street drugs instead. Nor do they want to live anywhere that requires them to take meds, abstain from alcohol or street drugs, or follow basic rules. To solve a big part of the homeless problem, and the reality that our streets and jails have become de facto psychiatric facilities, mostly unmedicated, we need to re-establish state hospitals--hopefully more humane than those of the past. If the laws were changed to make it easier for a court to require a chronic miscreant to take meds, it might be possible for some to live in the community with adequate support services, and if they refuse, they live in the hospital. Some are simply too sick or disorganized to care for themselves and need to be mandated to live in a state facility. It is less cruel to make sure that the chronic, severely mentally ill are adequately housed, fed, clothed --and required to take medication--than it is to allow them to continue to live in bedlam and befoul the streets of our communities, even if that is what they prefer to do.
I agree with you 100% about the de-institutionalization of care, which began under Kennedy. I think Kennedy was well-intended and his vision was altruistic and probably a response to his sister, Rosemary who was developmentally disabled and required care. But the idea was that families would care for their people, with support from care centers stationed around all around the US. When those care centres never materialized.... well, you know what happened. I agree about the complexity of all this. I think supported residences could be an alternative to psychiatric confinement though, particularly in places where homelessness is not rampant and entrenched yet. UnityHouse in Troy, NY runs a very successful program that houses schizophrenic adults with the goal of living in the community, although many never make it and stay in supported housing. I really appreciate this comment because you really dig into why this is so hard to manage. But I do believe part of the equation is for people to not other people into seclusion outside our communities. I am intrigued by this hospitialization idea because I wonder if we could ever get facilities to be as humane as we need them to be. I wonder if there are examples of this..... Thanks for this great comment! I so appreciate your perspective.
There are other facilities like the one you reference in Troy, NY. They presume a willingness to accept treatment . The bigger problem can only be tackled if psychiatry courts were established that were able to mandate medication to those unwilling to take them voluntarily, and the re-establishment of long-term involuntary treatment facilities, i.e. state hospitals, for those who cannot or will not comply.
Do you feel like it would be a hard sell for the public to embrace committing people back into institutions? Are there any models of this kind of institution that would work? (I can think of none) What are the ethics of force-medicating people? (We do that routinely for the incarcerated mentally ill so they can stand trial and there is a lot of shady ethics there. I'm going to be thinking about this for awhile.... Thanks for raising it as a discussion point.
So difficult. In particular, I remember one homeless person I called Rabbit Woman. She was tall, beautiful, dirty, walking constantly, and usually moaning. She was prey, and from what I heard raped too many times. A chef friend said Rabbit would come into her restaurant sometimes, relatively early. They'd sit her away from anyone else there because she did smell. After ordering and eating she'd pull out a wad of money and pay, tipping well. Another friend said Rabbit came from a wealthy family, who'd had her involuntarily institutionalized through the years. She'd get on meds in the facility, and her mind would get to a right place. She'd then sue to get out, winning every time. Once out, she'd stop the meds, end up on the streets striding and moaning. The family finally gave up, finding good people in my city who'd watch out for her, hand her a wad of money periodically. I have a few other similar tales like that. What to do? Oliver Sacks in one of his books talked about the old institutions with farms and other work attached. He said many enjoyed the work and liked getting outside but still in a safe, enclosed space. The fans were shut down after lawsuits stating the people were forced to work. Sacks said that was not true; all work was voluntary. I don't know, but I could see someone - not all - liking a place where the schedule remained the same, and they had something to do each day, not just sit in a room with a t.v. on, or old magazines, or even books (as much as I like to read). We really need to figure this out, how to help those mentally challenged, who might benefit from a facility of kind people.
Agree. We have to get this right. And love the Oliver Sacks mention. I like this idea of an enclosed village that would be built to provide a sense of purpose and leisure and community and context. But it's still incarceration right? It's still guards and gates even if they are nice guards and gates. It is a big deal to take someone's freedom away even if we think it's the best thing for them. I mean Esme Weijung Wang writes in her book (The Collected Schizophrenias) that the most terrifying moments of her life happened when she was involuntarily committed. I suspect that the answer partially has to come from communities impacted by this kind of confinement and what alternatives might be.
Agree, but in we're confined in so many ways in society. Some people cannot adjust (I think of one homeless "neighbor" a women's group helped, but showed up later saying he'd been on the street too long, it was home). I think a fair amount want it, it's almost like coddling - or would welcome it if it didn't feel institutional. Then there are degrees of mental issues, and times when it is worse, times almost non-existent. There are people who just had a bad economic time, and homelessness is temporary. What are the statistics? I think it's that the majority of those homeless are housed again after two to four months, or that was so in the past. It's mainly the mentally ill who need some permanent solution, or semi-permanent. New York City lost around 2000 psychiatric beds in the last two years. Texas has not quite 2300; the whole state! (It would be around 2900 but staff shortages reduced it by 700.) We need to look to other nations, see how they handle it. The US is 29th in ranking out of 167 countries in the category of living conditions (prosperity.com should be seen by all; we're number . . 19 overall). I've had homeless as neighbors; both cities where I've lived had too many. I was acquaintances with a fair amount in my home city, but not here. Hurts my heart.
Thank you for pushing my brain. Maybe we'll figure out some small steps.
At its most basic level, even if the funding is there you need the kindly butt-wipers and toenail clippers and people who care the way that that Jewish carpenter cared or all the funding won’t make a difference. When you mentioned the mayor trying to encourage communities to take people in, the reality is that people have to do what you’ve done, invited them in, cared for them and GONE OUT OF YOUR WAY for no other reason than you wanted to, and that’s a big ask, as generous as we like to think we all are. Everyone made fun of that Super Bowl commercial with the feet washing but I thought it was pretty right on no matter who paid for the ad..
This is really the gist of Matthews Desmond's book Poverty, By America, which is that we only end poverty by giving up certain things as well. Like maybe having to pay people more means not every business will make it. Or re-orienting ourselves about how we in the upper and middle classes get help - that mortgage tax deduction is a support program from the government, just as welfare is. We are all getting support. A lot of abolishing poverty is going to be adjusting what success means for us personally and our communities and I don't think most people have it in them.
You said no one wants to hear this. I do! I love what you have to say.
That photo at the bottom speaks volumes. Other people might feel afraid to walk down that path, and avoid the area. But here are unhoused people, not criminals and mentally ill people. People blame homeless people for all kinds of things. Even the man you quoted on next door assumed that the guy who urinated was due to homelessness.
Kim, if you haven't read this yet, the nonprofit where I was chair worked with the UN to define poverty. Here was the result of their work. It explains who becomes homeless and why, and it has vastly increased my understanding. https://atdfourthworld-usa.org/map-download-the-report
Re Proposition 1, yes it is good, but it also forces people into programs, which is not cool. See https://www.aclunc.org/blog/don-t-be-fooled-proposition-1-s-false-promises
OOh! Thank you Dianne for these links! This is amazing. I have some reading to do. As for Prop 1, I will be sitting here eating popcorn, watching and hoping for some success for people and something we can replicate (or not replicate) in Nevada. Rooting for you all in California.