Contra Charles Fain Lehman On Mentally Ill Homeless People

The importance of liberty

By Shannon Badiee, CC BY-SA 2.0.

I.

Scott Alexander wrote an excellent, empathetic article about the many implementation details and ethical dilemmas involved with Getting Tough On Mentally Ill Homeless People. Writer Charles Fain Lehman replied, and I think his response is not excellent or empathetic. He writes:

The title of this post is “serious mental illness is an optimization problem.” What I mean by this is that it is an attempt to find the optimal balance between two conflicting policy priorities. In this case, the priorities are the freedom of individuals to do what they please unimpeded by coercion, which is to say liberty; and the freedom of individuals not to suffer the debilitating effects of unchosen illness, which is to say health…

The answer to the question “do you keep a completely sane person locked in the mental institution forever?” is yes, of course. For some people, the institution is the only context in which they are able to live free from profound psychosis. This strikes me as obvious. If a person will only remain sane and functional in a 24/7 residential setting, then granting him the liberty to live in the community is not merely foolish but cruel.

The fact that Alexander finds this a hard question to resolve implies that he sees the optimization problem as trying to maximize health while holding liberty constant. This is, in fact, much of what drove deinstitutionalization (of which the IMD exclusion is a part). The idea is that living in an institutionalized setting is intrinsically dehumanizing, because it deprives people of liberty. Therefore, we should discourage their use as much as possible, or even abolish them altogether.

But what if instead of trying to maximize health while holding liberty constant, we instead tried to maximize liberty while holding health constant? If instead of trying to do what we can consistent with respecting the autonomy of the sidewalk psychotic, we did whatever we needed to to keep him sane, even if it meant long-term confinement?

Over the course of my life, I’ve had numerous psychotic friends. All of my psychotic friends have had homes, but that isn’t necessarily relevant to Lehman’s point: presumably if people have a right not to suffer the debilitating effects of unchosen illness and to live free from profound psychosis, they continue to have that right if they have an apartment.

Let’s make up a composite of many of my psychotic friends. Call him Alex.

Alex lives with his girlfriend, who financially supports him. He believes himself to be one of the strongest holy warriors in the eternal war between demons and angels for the fate of the world. He receives messages related to the war coded in television shows and conversations. He hallucinates demon attacks, which causes him a great deal of distress. Creating protective sigils, exorcising demons, and healing angels takes a great deal of time. He uses various self-help techniques, such as limiting his involvement in the holy war to prevent burnout and checking with his girlfriend whether she can also see what he’s seeing.

Antipsychotics at a dose sufficient to suppress his psychosis give Alex severe akathisia, a constant urge to move that sufferers often describe as “intense mental and emotional torture.” In consultation with his loved ones, Alex decided to go off antipsychotics: the demon war was less painful than the akathisia.

Alex suffers from avolition, which means he spends a lot of time lying under a blanket or staring at the wall. However, his beloved dog can often poke him to get up. They enjoy long walks together, especially through the beautiful local park. When his girlfriend comes home, they like cuddling and watching their favorite shows on Netflix. When his avolition lets him, he enjoys baking and gardening. He loves board games, and often plays them online with a group of friends who are tolerant of his eccentricities. Alex’s brother lives nearby and helps Alex’s girlfriend when she needs a break. In return, Alex often babysits his nieces, who adore him.

Here are some points about Alex.

First: it is far from obvious that Alex would be healthier (in the common-sense definition of the word) if he were not psychotic. Akathisia is pretty unhealthy! Antipsychotics often have horrifying side effects, and it’s often reasonable to prefer psychosis to the side effects of antipsychotics. Traditionally, this sort of difficult tradeoff is made by the individual patient.

Second: if Alex were in an institution, he wouldn’t have a girlfriend. He wouldn’t have a dog. He wouldn’t go on walks alone through a beautiful local park. He wouldn’t have Netflix. He wouldn’t be able to bake. He might be able to garden, if the institution has a garden and the recreational therapists didn’t decide everyone should paint or play basketball instead. It’s a matter of luck whether his institution had board games, and they definitely wouldn’t have Dominion or Pandemic or Settlers of Catan. He would be completely cut off from his online friends. He wouldn’t be able to babysit his nieces.

Most of these facts are true even in nice institutions. You can’t let people in institutions have access to fire. You can only offer so many supervised activities, and people with unpopular preferences are shit out of luck. If you let people go on walks alone, they’ll escape. If you let everyone have a dog, no one would have a right not to own a dog. Institutions typically ban romantic or sexual activity because of the difficulties making sure it’s consensual, and anyway they’re usually gender-segregated for privacy reasons.

And it is… far from obvious that it is better for Alex to be sane, and to never again fall in love or play with his dog or bake or garden or babysit his nieces or go on a long walk by himself. Many perfectly neurotypical people would, in this situation, gladly enlist in the demon war.

Lehman writes:

My thoughts on this topic are in part influenced by the work of Neil Gong, a UCSD sociologist who has done extensive ethnographic work on mental health care in Los Angeles. (Buy Neil’s book here.) In his work, Gong compares the mental health treatment experience of Los Angeles’s seriously mentally ill homeless with that of the city’s richest denizens. Conventionally, sociologists assume that the poor are the most tightly controlled while the rich can do what they please. Gong finds that, in fact, the opposite is true. The poor are subject to a paradigm that he calls “tolerant containment”: light-touch services aimed at providing them care only insofar as it is consistent with their autonomy. The rich, by contrast, actively pay for a strategy that Gong calls “concerted constraint”: therapeutic restriction aimed at prioritizing their health over their liberty.

The paradigm that obtained after deinstitutionalization, and that inspired the IMD exclusion, and that Alexander seems to think is the best we can do, is one of “tolerant containment.” I think the fact that people pay to have their liberty taken away when they can suggests that our order of priorities is backwards.

I haven’t read Gong’s book, so it’s definitely possible that I’m misrepresenting things, but the summary on Amazon says:

Across town in West LA or Malibu, wealthy people diagnosed with serious mental illness attend luxurious treatment centers. Programs may offer yoga and organic meals alongside personalized therapeutic treatments, but patients can feel trapped, as their families pay exorbitantly to surveil and “fix” them.

It seems to me that an individual person paying to have their liberty taken away from them is good evidence that they’d like their liberty taken away from them. But a person’s family members paying to have their liberty taken away from them is much less good evidence. Surely sometimes families are doing what their doctor recommends whether or not it’s good for their relative, are embarrassed that their relative is severely mentally ill and are paying for the problem to Go Away, or or are simply exhausted and burned out and in need of a break.

Even if a person decided herself to go to an expensive institution, she opted in to concerted constraint. There are other people—like Alex—who don’t want concerted constraint and express that preference by not going to an institution. And finally—as I hesitate to point out to a conservative—services bought on the free market generally reflect the preferences of those purchasing them. Severely mentally ill people who pay for their own concerted constraint generally have their liberty constrained in ways they like and approve of. Severely mentally ill people detained against their will by the government have their liberty constrained in whatever way is most convenient to those in charge—never mind what it does to their health and well-being.

Liberty sounds like some high-fatulin philosophical concept about the right of all rational beings to self-determination of their own lives. But in this context it’s not. Liberty is the ability to bake cookies and go on walks and have a dog—and it’s very hard to have a life worth living without it.

II.

Okay, but it’s not actually about health. Lehman is quite clear that he would like to institutionalize treatment-noncompliant severely mentally ill disruptive homeless people, and is silent on the subject of institutionalizing treatment-noncompliant severely mentally ill people with stable homes and loving family members.¹ The difference between these two groups is not their level of “objective health.”

Lehman’s problem has nothing to do with the wellbeing of psychotic people. Lehman’s problem is that he doesn’t like it when he encounters an unkempt, smelly person behaving in an unpredictable and scary way.

I am very sympathetic to this complaint. I, too, don’t like it when I encounter unkempt, smelly people behaving in unpredictable and scary ways.

The problem is that, if you’re bluntly honest, the thing you’re saying is “I think that people accused of the crime of behaving in an unpredictable and scary way, while unkempt and smelly, should have no rights to a robust defense and the presumption of innocence and due process of law, and the potential punishments they face should include lifetime imprisonment without parole.”

People recoil from saying that frankly, because it’s evil. Much better to pretend you have a purely altruistic desire motivated solely by the properly understood welfare of psychotic people.

I do, actually, think it is a reasonable public policy goal for public spaces to be pleasant, which means minimizing the amount of threatening behavior, frightening yelling, and harassment that people experience. But I do not think we should take crimes more seriously if the person perpetrating them has poor hygiene or a serious mental illness. The problem of disruptive or threatening severely mentally ill homeless people should be treated with exactly the same seriousness as the problems of disruptive or threatening drunk people, disruptive or threatening drivers, disruptive or threatening people who don’t like gay people very much, and disruptive or threatening people with unleashed dogs—all of whom are groups whom, as an Oakland resident, I’ve had far more problems with than with severely mentally ill homeless people.²

Conversely, people do have a right to act weird in public. It’s all right to be bothered by someone with Tourette’s repeating “bitch”, or someone muttering to themself, or someone pacing in circles for hours. But most such people are harmless. Accepting a certain amount of discomfort is part of being a citizen in an urban environment. Severely mentally ill people are people too; banning us from the streets is as unjust as banning everyone who uses a wheelchair.

To be clear, I’m not against all coercive treatment of mental illnesses. If you have Yells At Small Children In Graphic Detail About How You’re Going To Torture Them Disorder, you should be in court-ordered outpatient treatment; in extreme cases, I could be talked into long-term institutionalization. But I think most of the problem of severely mentally ill homeless people could be solved with:

• More housing in general, which gives the Alexes of the world the stability they need to live lives worth living for themselves and nondisruptive to others.

• Better access to rental assistance.

• More homeless shelters, halfway houses, etc. for people to take advantage of if they want to.

• Better social services for psychotic people (as would be necessary in Lehman’s plan as well).

• Less tolerance of threatening or disruptive behavior in public by anyone (housed or unhoused), including diversion programs which target the root causes of this behavior.

• More tolerance of harmlessly weird people.

• Did I mention more housing?

These would meet the needs of both severely mentally ill people and people who would like not to encounter disruptive and threatening behavior in public.

1. Huge fan of this as a formerly treatment-noncompliant severely mentally ill person with a stable home and loving family.

2. Honestly, it probably makes the most sense to prioritize the drunk people and the people with unleashed dogs. Dealing with severe mental illness is hard and expensive! Fines for unleashed dogs and a heavy alcohol tax are revenue earners.