In the United Stated, disproportionate numbers of homeless people and criminal offenders suffer from mental illnesses. There is good reason to believe that there is a causal relationship between mental illness and certain socially problematic behaviors. Social scientists have uncovered evidence for this relationship; you may do the same, in the comfort of your own mind, by asking “Why might a person who believes that everyone around him is plotting his demise find it difficult to hold down a job and keep an apartment? Also, why might such a person resort to property crimes in order to survive?” For these reason, if no other, people who take an interest in public policy (the better kind of people) should also take an interest in mental illness as a public heath problem. After all, both homelessness and crime are issues that have attracted attention from innovative and earnest public officials. Not to be outdone by the state legislature in Utah—which established a program to provide housing to homeless people, a program which is entirely too linear in its logic to garner broad appeal—other political jurisdictions (especially municipalities) have established policies that deal with the problem of the homeless by making it illegal to feed them or by funding artistically sophisticated architectural installations that make it more difficult for homeless people to sleep. However, while one might hope that starving the homeless or preventing them from sleeping would make them go away, they remain with us. Meanwhile, the number of people incarcerated in jails and prisons in the United States has continued to climb, imposing tremendous fiscal burdens on federal, state, and local governments. It is widely known that a disproportionate percentage of these prisoners are mentally ill—according to a 2017 Urban Institute Study, 55% percent of male inmates and a staggering 73% of female inmates.
How did we get ourselves in this situation? Have things always been this way? They have been similar, at times, but there have also been times when things were somewhat better. From my childhood, in the early 1980s, I remember numerous news broadcasts about rising rates of homelessness. At the time, many people seemed to assume that increasing homelessness was the result of a weak economy. Many news broadcasts even focused on homeless families who had lost their employment and other means of support. Now we know, however, that most of this increase in the number of homeless Americans was due to a process known as deinstitutionalization.
Through the nineteenth century, American states constructed ever larger numbers of insane asylums or mental hospitals. The primary motivation for the construction of these facilities was a movement to provide care for individuals with mental or developmental disorders, people who were previously left defenseless. While good intentions drove the origin and expansion of these institutions, they were terrible. The care was poor and often did nothing to help patients recover. Patients were abused and neglected—it was not uncommon for patients in these hospitals to starve to death. They were also placed is positions of dependency to an extent which was often unnecessary. Furthermore, they were usually isolated from family, friends, and community, especially since the institutions were often in remote locations where land was relatively cheap. Perhaps most significantly, these institutions were very expensive to run and many poor states found them to be a great fiscal burden. By mid-century, there was a broad consensus that something needed to be done. Deinstitutionalization was the answer the political class converged upon.
When John F. Kennedy, the US Chamber of Commerce, and the American Civil Liberties Union agree on something, you might believe that an outstanding policy coup is about to be performed. In this particular case, at least, you would be bitterly wrong. The proposal was to largely phase out state hospitals and, in their place, to establish community mental health services that would be funded through a patchwork of federal and local programs. State hospitals were indeed cut back, and drastically so, especially in the 1970s. At first, funding for community mental health services were secured. However, when Ronald Reagan became the president of the United States in 1981, he did not make funding for mental health services a priority. Block grants to community mental health services evaporated and the armies of mentally ill Americans being turned out of state hospitals had no psychiatric services to fall back upon.
One might fairly ask, starting from perspective of American individualism, why mentally ill people need to rely on the government or charities for support and treatment. Certainly, not all people with mental illnesses need extra help (outside of medical treatment, counseling, familial support, and community support). Indeed, a large percentage of Americans will suffer from a medical illness at sometime in their lives. In a given year, about one in five Americans suffer from a mental illness of some kind, most of which can be managed without inpatient treatment or other disruptions to employment and family life. Anxiety disorders, including PTSD, OCD, and specific phobias are particularly common, with over 18% of Americans experiencing an anxiety disorder in a given year. Major depressive disorder is also very common, affecting around 7% of Americans in a year. Bipolar disorder, which can be somewhat more complicated to treat, is less common but still affects around 2.6% of Americans at any given time. By comparison, schizophrenia, which (without treatment) is typically even more debilitating than bipolar disorder, “only” affects a little over 1% of Americans right now. Most of the affected people keep their jobs, continue to care for their families, and continue to function in most aspects of their lives (though this is much less common for people with, for example, schizophrenia). This means that many of these individuals will retain medical insurance and will have access to behavioral health treatment, should they seek it. However, the more that individuals with psychiatric disorders need medical treatment, the less access they are likely to have access to this treatment.
The most American expectation imaginable is that those who are down on their luck pick themselves up by their bootstraps, dust themselves off, and address the problems that lie before them. As appealing as this expectation is, it is not always helpful or realistic. It is hard to pick yourself up by your bootstraps when you believe that your bootstraps are snakes—genetically modified NSA snakes that are coiled and ready to strike, thereby injecting mind-control venom into your eyes. This is directly analogous to the situation in which many individuals experiencing psychotic symptoms may find themselves. Please note that usage of many terms from psychiatry by the general public is characterized by the same degree of technical precision as science journalist's usage of terms from biology (which is to say, almost none). Just as schizophrenia has nothing to do with “split personalities” or dissociation but rather refers to a disorder characterized by a “shattering” of the relationships between sensory experience, thoughts, emotions, and behaviors, psychotic symptoms have nothing to do with psychopathy or goal-directed antisocial behavior and bear no necessary relationship to violence. Instead, they are characterized by an untethering of the affected person from reality. Common psychotic symptoms include hallucinations, delusions, catatonia, and disorganized thoughts. Some psychotic symptoms—including delusions of grandeur (incorrectly believing that you are a person of unusual importance, like a famous scientist or Jesus of Nazareth)—can be quite exhilarating, they are seldom adaptive. Terrifying delusions and hallucinations appear to be more common. Psychosis is the bread and butter of schizophrenia, but it also affects people at the extremes of depression and mania (extremely elevated mood) as well. This means that people living with bipolar disorder and even major depressive disorder can also experience psychotic symptoms at times. And people who are experiencing them tend not to make decisions that serve their long-term welfare. They seldom have the presence of mind to seek out psychiatric care, even if the have access to it. Psychosis is by no means the only class of highly debilitating psychiatric symptoms (anxiety can make it all but impossible to leave one's home, or do anything else), but it can serve as a useful example.
In a simpler, more brutal time, people experiencing psychosis were often forcibly detained and sent to an insane asylum or state hospital. They might stay there for a considerable length of time. Though there was little greater chance of them recovering in a mental hospital than on the street—since little attention was often paid to therapy and the available therapies (both pharmacological and psychotherapeutic) were not particularly effective—patients were usually given shelter, protection, and food (except when they were not). With the advent of deinstitutionalization, it became much more difficult to involuntarily commit people experiencing psychosis for a long period. Typically, it must be demonstrated that mentally ill persons are dangers to themselves or to others. Even when this is the case, individuals typically do not remain institutionalized for a long period of time. The closure of the old state hospitals and the psych wards in many general hospitals means that there are too few beds to accommodate even the individuals who are committed under the current, more restrictive criteria or who enter hospitals voluntarily. Economic facts mean that inpatient psychiatric care is not profitable for most healthcare providers and, even when patients have insurance, insurers generally impose stringent restrictions on hospitalizations. This means that mentally ill people may be required to leave a hospital before they have sufficiently recovered. In other words, a person experiencing psychotic symptoms (or other debilitating psychiatric problems) is now often placed in a remarkably precarious situation.
If the United States has not excelled in constructing psychiatric hospitals it has excelled in constructing institutions of a different kind, and these have picked up the slack from psychiatric hospitals in a manner that is inefficient, ineffective, and cruel. The largest psychiatric institution in America, in terms of psychiatric patients house, is Cook County Jail in Chicago, Illinois (which is also the largest single-site jail in the country). One third of the inmates in Cook County Jail are estimated by jail administrators to be mentally ill. Certainly, not all of them are psychotic. Many of them are suffering from run-of-the-mill depression or an anxiety disorder. Confinement to a network of tunnels with no natural light is highly conducive to mental illness. However, it is clear that the incarceration of many individuals is linked directly to their mental illness. It is not known exactly how many mentally ill Americas are incarcerated during their lifetimes, but estimates range from 25% to 40%—far higher than the rate for the population at large. Old fashioned insane asylums were terrible places to recover from mental illness; jails and prisons will see you the stress, isolation, and poor treatment of the state hospital and raise you violent fellow inmates, hostile guards, and crippling stigma upon release. While many correctional facilities attempt to provide some psychiatric treatment, especially in the form of psych meds, prisons are designed to detain and punish criminals, not to help mentally ill prisoners to achieve better mental health. As a body politic, we are acting as if we believe that—if only we were a bit more punitive—offenders suffering from mental illnesses would learn to stop acting so crazy. The available evidence better supports the reduction of symptoms, in this population, as a way of reducing recidivism.
There are many productive changes that could be put into place to help Americans who are severely impacted by mental illness. Some of these would only offend fiscal conservatives. These include actually funding community mental health services as was originally envisaged, insuring that indigent patients suffering from mental illness have access to psychiatric care (including prescription medication), and providing access to free housing and employment counseling for jobless and homeless individuals living with mental illness. Programs like these would be expensive, though this expense would be offset (to some extent) by savings in the policing, adjudication, and incarceration of mentally ill populations. They would be hard to sell to the political right since the current system of incarcerating the most mentally ill people in the country seems to adequately insulate middle class society from uncomfortable contact with them. Harder still to sell is the construction of new government-funded inpatient mental health facilities. This jargon-heavy description would be remarkably hard to reformulate in terms of conservative buzzwords.
However I contend that civil libertarians also present an obstacle to an effective and human policy for the mentally ill. It happens that psychiatric hospitals—even well run psychiatric hospitals—are not popular with their patients. Even when it is in the best interest of an individual to stay in a hospital rather than return to the streets (or some other suboptimal situation), it is not uncommon for such an individual to favor discharge from the hospital. Indeed, hospitals are generally not ideal settings in which to recover from acute symptoms of mental illness. Talk therapy, which is very important in treating most types of mental illness, is often difficult to carry out in a hospital since many of the denizens of these institutions do not function at a high level (or that is my experience). They can be disruptive and even frightening (also my experience). Furthermore, psych hospitals can sometimes take clients away (geographically) from their families, social networks, and support systems. They are certainly not unmitigated boons, but they are nevertheless valuable. In my experience, what psych hospitals are good for is keeping clients safe from themselves and others, ensuring that clients are receiving appropriate meds and are taking them as prescribed, and making sure that the basic physical needs of clients are taken care of (food, drink, shelter, etc.). Starvation is now very uncommon in psychiatric hospitals and it is my impression that hospitals are now better at achieving these goals than they were prior to deinstitutionalization. Furthermore, even if this is all they achieve, a dramatic improvement in the quality of life of acutely mentally ill people is entailed. However, many of the individuals who could benefit greatly from being in an institution will not enter one because they do not want to be “imprisoned” in a psychiatric hospital and do not meet the rather stringent requirements for being committed against their will.
I contend that an expansion of community mental health services, and an expansion of the number of beds in psychiatric institutions, needs to be coupled with legal reforms that make it easier for law enforcement officers and mental health professionals to initiate the process by which mentally ill individuals experiencing acute symptoms are involuntarily committed to institutions. Of course, a serious commitment to individual liberty will rightfully make us skeptical of changes of this kind. Nevertheless, consider again (for example) the plight of people experiencing psychotic symptoms. It is not uncommon for those who are experiencing delusions, hallucinations, and disordered thinking to believe that psychiatric treatment is part of a ruse designed to harm them. Since their experience of the world is filtered through psychosis, if they make decisions based on the evidence available to them, they will often make choices that are objectively not in their own best interest. Clearly, as a society, we cannot criminalize stupidity or legally require that members of society only make rational decisions that promote either their own best interest or the best interest of their community. However, just as parents are granted guardianship over their minor children on the grounds that such children cannot be relied upon to make decisions that will safeguard their own welfare, I suggest that adults who are experiencing certain extreme psychiatric symptoms can be justifiably protected from their misinformed choices by a kind of guardianship exercised by family members, law enforcement, and behavioral health professionals.
Does this sound to you like some kind of paternalistic, nanny-state, Big Brother racket? My first instinct is to gently suggest that you have no idea what you are talking about. My second instinct is to consider that, perhaps as a person with a mental illness, you do know of what you speak but are so misled by paranoid delusions that you believe a legislative development capable of improving the lives of people like you is in fact some kind of sinister plot. However, once I move past knee-jerk reactions and try to see things from your perspective, I am forced to admit that any arrangement of this kind is potentially prone to a variety of abuses. In this respect, it is like local law enforcement. Or federal law enforcement. Or joint stock companies. Or wiffle ball bats. Certainly, one can imagine a hypertrophied state having political enemies labelled as insane and forcibly institutionalized. Indeed, various foul regimes have done exactly this. They have also ordered law enforcement officers arrest enemies of the state and put them in jails or prisons. I do not believe that this means we should not support municipal police departments or correctional facilities and I do not believe that this is a reason to place disproportionate restrictions on involuntary institutionalization.
No meaningful improvements in quality of life are brought about without costs. I am not saying that increasing the availability of inpatient mental health services and prudently facilitating involuntary hospitalizations can be done without costs, either fiscally or in terms of individual autonomy. I am saying that making these changes is worth the costs. Implementing this plan will reduce incarceration rates, reduce homelessness, and reduce human suffering. I am also saying that—if I should ever again be so impaired by delusions or other psychological symptoms that I cannot look after my own welfare—I hope services and policies are in place so that I can receive effective inpatient psychiatric care, whether or not I am eager to volunteer for it. I would want the same for friends and loved ones that also suffer from mental illnesses. So please, let my people go back to state hospitals if and when we need it. And do not call them loony bins, since that is juvenile.