FUCK UNLEASHED DOGS. Like, I know that's not the central point of your article, but god. Fuck. Unleashed dogs are a menace, mostly because my youngest sister is terrified of even the most well-behaved service dog across the room.
Slightly more responsive to the point of the article: "severely mentally ill" and "severely mentally disabled (but don't call it illness because it's DEVELOPMENTAL)" seem to be, like, things that need to be considered similarly. "Oh, just put your sister in a group home!" That would be unkind to her *and* to everyone in the group home, roommates and staff alike. At least at home she can have whatever weird-ass sleep schedule she wants and we'll bitch about making her food at 3 am but we will, in fact, get her food. I don't trust institutions to care about my sister *as a person* instead of as a "violent flight risk".
I do think that people being deeply unpredictable in their actions adds another level to being disruptive and threatening in a public place. The most scared I've been in public has always been of people who were being both disruptive and unpredictable in a way I think was likely linked to mental instability, because I had no way of modeling "is this person just muttering" or "will they decide to randomly stab me because I'm standing next to them on a BART platform", like happened a few weeks ago.
I realize that making people deeply uncomfortable and unsafe isn't cause for institutionalization, but at least for me, there is a very real qualitative difference in how unsafe I feel when mental instability combines with disruptiveness or aggression in public.
The problem is that the government can’t reasonably provide love. Alex lives a nice life because he has people who love him who have decent resources. Similarly, children who are abused in their home of origin are genuinely a difficult problem to solve because what they need, what they require, is love and government trying to arrange for that is hard even though humans are hardwired to love children we get to know (also difficult because of effects of trauma of course - which makes them both harder to love and harder to take care of.) Similarly elders with just a little dementia or even just general total technological inability - a loving family renders them “not a problem” for society… but government can’t scare up that loving family if it doesn’t exist. Rotating social workers are an inadequate solution. We should make institutions as nice as possible, we should fund social workers and work hard to reduce turn over but I don’t see how it’s possible to avoid institutions - we can’t create loving caretakers for the vulnerable where they don’t exist. It is a privilege to have people love you and it’s not a privilege it’s easy to equalize.
This is an interesting if tangential point. Governments can encourage love and care by making public spaces more hospitable such that people can more easily meet and spend time together. There are a lot of ways to do that. What abused children need (what any abuse victim needs) is not necessarily just love but true autonomy and support, which is antithetical to the structure of our society. Family Abolition by M.E. O'Brien digs really deep into the family as a site of both care and coercion/abuse and how we can build better, less privatized societal structures of care.
I don’t have a strong opinion on this either way, but, there’s no rule of the universe that institutions have to be the way you describe? They generally aren’t in Denmark where I’m from. They’re not good, mainly because there’s too few of them; but residents who aren’t considered a threat to themselves or others can typically go on walks alone, they’re not gender segregated, never heard of romance/sex being banned, there very often are “communal” pets in these institutions (I’ve even seen horses!), people can cook for themselves (even prisoners in Scandinavia cook for themselves). I’ve never ever heard of people not being allowed on the internet or not having smartphones or computers. Typically people decorate their rooms with a lot of their own stuff probably including entertainment. This is free, or tax funded if you’re anal about it.
Why can’t people do that at American institutions? Is it the fear-of-getting-sued culture over there? Is it illegal for them to invest in some cooler board games on someone’s request??
Fear of getting sued almost certainly plays an outsized role for sure. I had family that ran a bakery, and the amount of regulation preventing them from donating to the local soup kitchens was wild. They could sell 35$ pies all day but try giving them away for free so the downtrodden could have a treat, no way.
But, also, a million other cultural differences and the feedback loops generated from them. Low-trust, low-cohesion, 'bootstrap' society.
One of those differences causing and generated by a lot of nasty feedback loops, Americans have much higher rates of violence than any other 'Western' society. Those that support institutionalization are in favor of a different balance in a tradeoff: the proverbial Alex couldn't fall in love if he's 24/7 institutionalized, but neither could he snap and kill someone. The status quo is something of a "worst of both worlds" situation, largely from polarization IMO.
You suggested in this piece that if one advocates treating people differently who are the sorts of non-disruptive mentally ill people that aren't institutionalized it's because the thing they are optimizing for is minimizing disruption rather than caring for the interests of the mentally ill. But it's not hard to see how one would think a policy like that is in the best interests of the mentally ill.
For a person like Alex, being a bit psychotic seems better than being institutionalized. Alex's quality of life is higher than the quality of life of the average institutionalized person. But I think it's not at all obvious whether the average mentally ill homeless person on the street, constantly in terror and threatening people is of higher quality of life than the average institutionalized person. Seems reasonable to think that, while this doesn't perfectly carve things up, generally the people who are sleeping outside and being disruptive are more likely to be bettered by being institutionalized than the people who aren't.
I think it's a good idea to offer more supportive housing for psychotic people, but involuntary institutionalization come up *specifically* when people prefer homelessness to institutionalization. And I don't think that preference is unreasonable! People want their romantic partner, or their dog, or to be able to smoke (nicotine reduces negative symptoms in schizophrenia), or to be able to see the sun whenever they want...
Your entire model rests on Alex's UBI Girlfriend who is content to put him up in a private space that contains the negative externalities of his behavior, despite Alex apparently contributing nothing to household finances and only contributing to chores as far as his avolition lets him tear himself away from online games and going to the park. This is, after all, the "community care" model promised by advocates of deinstitutionalizatuon.
But walking the streets of a major West-coast metro will show you that it isn't working. By opposing involuntary commitment, what you are doing is to forcing us all into the role of Alex's girlfriend, to absorb the negative externalities of mentally ill strangers as they take over public spaces, and subsidize their lifestyles even as they refuse to accept the conditions of housing and treatment. Regular exposure to anti-social behavior does not need to be "part of being a citizen in an urban environment."
If you want to imprison people without due process because they are annoying to you, that is between you and your conscience, but don't act like it's for the benefit of the people imprisoned.
Here's the problem: you said that you think 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, etc... who are typically taken to jail by the police.
If laws against public camping, illegal dumping, public drug use, public intoxication, littering, illegal fires, public urination & defecation, and threatening behavior are enforced equally against everyone, then living on the street while mentally ill will no longer be a viable alternative to complying with the requirements of treatment or shelter. The population Lehman is discussing, who cannot or will not comply with those requirements, and do not have an Alex's Girlfriend to take them in, will end up jail.
I do not see how Lehman's proposal to place these people in a place dedicated to treating their illness (even if it also restricts their liberty) rather than throwing them in jail, is not considering the best available option for their well-being/health.
Or maybe they think the people in the institutions are demons coming to kill them. Either way I think the freedom to hurt yourself and potentially hurt others too is probably not worth respecting, but you also can't just act like psychotic people are rational actors
> But I think it's not at all obvious whether the average mentally ill homeless person on the street, constantly in terror and threatening people is of higher quality of life than the average institutionalized person.
The entire reason you have to institutionalize these people is that their revealed preference is to be homeless on the street rather than spending their time in a grey padded cell without anything fun or interesting to do. If they wanted to stay in a grey padded cell without anything fun or interesting to do, then you wouldn't need to override their choices to get them to do it, certainly not after getting them on antipsychotics.
Setting up camp in a public space should not be a viable alternative to going to a homeless shelter or mental health facility simply because a person does not wish to follow the conditions such places impose on residents.
Yeah, I think this essay sets up a false dichotomy between being institutionalized vs being in an idyllic non-institutionalized setting with lots of support, no need to get a job, and loved ones who trust the untreated psychotic person enough to let him babysit their young children??? In fact, lots of psychotic people get trapped in homelessness and can’t find a way out.
Having been in an institution briefly (misguided substance choices inducing psychosis when young) they really fucking suck. I think many people who haven't don't appreciate all the ways they suck because of the nature of bureaucracy.
If institutions were just alternatives to living in a tent with beds, showers and people to watch and give you medication that wouldn't be so bad. Require evidence of severe mental illness, danger **and** living on the street and they now live in a building with people to care for them. Doesn't seem so bad.
Unfortunately, it doesn't work like that. Veteran Vance might really care about carrying his medals around but after some patient stabs another with a medal a rule will be made. Can't just let patients have shoelaces (suicide) or phones with wifi (sent harrasing picks). Inevitably you'll even have difficult rules about what books can be read.
In theory, you should be able to just have the people running the institution make reasonable choices. Vance hasn't shown any violent tendencies so let him keep his medals, let Linda keep a phone etc.. But lawsuits and the tension between preventing abuse and enabling discretion make this unachievable.
The nurses and doctors are overworked and don't want to face a lawsuit saying they were negligent because they knew item X could be harmful and let patients keep it anyway. Employees come and go and rules are the way we can communicate institutional knowledge. Not to mention there are always a few awful people who will use discretion in harmful ways and once some orderly somewhere uses their ability to unilaterally approve or deny privleges to coerce sex then you get extra procedures.
In practice, therefore, they aren't just a homeless encampment with beds, toliets and medicine. They are places where miserable people have to spend days staring at the wall or in supervised activity with people they may not like.
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Having said all this, I do think that we may want to consider creating a voluntary version of this -- just build trailers out on cheap land and create a place that offers the services of an institution but where people aren't actually committed and are allowed to own and manage their own stuff -- but with advice and help. Being able to say "it's not involuntary we can't control everything patients own" would make things much better.
“We have no societal response to madness, no therapeutic program, no system of care that honors the fundamental humanity and dignity of the mad. We treat them as a social nuisance. We do not care about the horrors and traumas of their lives, about the dreams and aspirations they have, about what they are capable of if they are provided the right supports. All we care about is that they are out of dangerous situations, medicated, off the streets and the subways, and off our minds.”
Also, I think people imagine that only people who aren't like Alex would ever be involved but I don't think they realize how hard that is to achieve.
Imagine Alex was rich and instead of a loving girlfriend actually had a selfish sister who wanted his money. She could convince him to come live with her, then kick him out sometime during a difficult period and make up a story to tell the police about him attacking her.
Immediately, you've created the scenario where they are homeless (kicked out and sis destroys his cards and wallet and phone), are unlikely to be able to get back on their feet right away in whatever city their sister lives in and the cops will probably dismiss everything he says once they see he has delusions.
And enough process to protect people in this situation tends to make it hard to institutionalize at scale.
Why can't this happen now exactly? What difference does any new proposed policy make here? And isn't this an insanely contrived scenario? (And why wouldn't the police do anything about it?)
Because right now it's virtually impossible to get someone involuntarily committed to a mental institution for any extended length of time. Alex's sister could certainly say that Alex was dangerous and this happened but in the current system Alex gets held for observation for a week while the doctors check his meds then he gets out and can go fly back to somewhere he has friends and access to all the resources to contest an attempt by his sister to get herself declared his legal guardian anyone else does.
Sure, she could try to file criminal charges but the judicial system -- while far from perfect -- is relatively well equipped to deal with that situation and now she needs to convince a jury beyond a reasonable doubt that a specific event occurred and that's what the system is relatively good at and it's not all basically deference to whatever MD gets called in to evaluate. Moreover, even if she gets him convicted that tends to work against her goal of getting declared his guardian. It's going to be hard to argue she has her brother's best interests at heart while pushing to make sure he is criminally convicted.
Why would she be declared his legal guardian in any case, new system or not? He's just confined to an asylum, no legal guardian necessary. And certainly I would like for a more robust legal system to judge if anything like that would come up and require evidence to prove it.
If someone has assets and isn’t mentally competent you can get someone else declared a legal guardian because you need to decide how to manage those assets and use them for their benefit. Hell Britney had someone declared her guardian in that sense and she had way more resources.
This actually used to happen relatively frequently under the old system before they closed the asylums. People wanted auntie’s/grannies money so they get them committed and then they have virtually no ability to fight an attempt to get declared their legal guardian.
> 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 think this is wrong. The Alex in your example made his choices for understandable reasons and has same people who care about him who help him make good choices. The crazy homeless street people have far less options and I'm not at all convinced it's better for them to be on the street even if they resist institutionalization.
(I do also, separately, think that "keep public spaces clear of scary unkempt smelly people shouting at passerby" is undervalued, but that's a separate discussion).
- Alex's ability to babysit seems to stand in serious enough contrast to all his problems and i'm having trouble understanding the complete picture here
- if Alex didnt have a loving family and a dog and a nice home would he prefer living on the street unmedicated w/o support to living in an institution? (or is the problem that institutions wont let you live unmedicated and medication can have terrible side effects)
I find it interesting no one talks about the demographics of typical disruptive homeless people. Seriously. Start there. What is their typical gender, age, race, citizenship, criminal record, do they speak English? It is not about building or maintaining stereotypes, it is gathering information about a problem before you try to solve it. For example, if I would move to a country which language I do not speak and I have no work permit, I might end up being homeless.
I’m not sure I see where there’s a difference between this author’s view and Bentham’s. Aren’t they about different populations?
Alex isn’t like, say, Jordan Neely, or the guys passed out in the tenderloin getting ambulances into EDs 25 times a year. He hasn’t been in and out of the criminal justice system, short-term involuntary detention, taking illicit drugs and screaming at subway passengers for years.
I’m not sure how Alex’s story is relevant at all to the problem Bentham (and Scott?) are addressing, other than to highlight the importance of using long-term institutionalization as a response to disruptive behavior (including repeatedly nodding off and defecting in public areas), and not as a response to diagnoses.
If you believe in lifetime imprisonment for public unconsciousness or defecation, then that's your business, but I certainly hope these policies wouldn't be adopted in a liberal society. (Always fascinating whenever I encounter someone with opinions on drug policies only slightly to the left of Rodrigo Duterte.)
If you’re strung out on fentanyl, schizophrenic and defecate in the sidewalk, you should be briefly institutionalized.
If you’re released and then go back to that behavior immediately, you clearly are in need of a longer-term stay (weeks?), and then supervised release.
If you then go back to that behavior, and are clearly going to go back to that behavior every time you’re released (you have a pattern of doing that and clinical judgement is that you’re probably not capable living a normal-ish life like Alex does), then at that point you should be institutionalized long term. If over several months or years you show progress, and it’s decided that you may have improved enough to try independent living again, you’re released.
This is similar to how criminal justice works. The conversation you’re having with Bentham is like if he said “serial violent offenders should get long prison sentences”, and your rejoinder is “you think a first-time shoplifter should go to jail for life??!!”
No! There are vastly different types of criminality and the justice system reflects that in sentencing. There are also vastly different types of serious mental illnesses and associated behavior, and the psychiatric response, including coercive institutionalization should reflect that.
My opinion of this really depends on whether schizophrenic people, in this system, have access to defense lawyers and a jury of their peers and so on. If schizophrenic people have been committed of a crime through a normal process,* it seems fine to keep them in a separate prison specialized for dealing with severe mental illness. I do not think that schizophrenic people who commit nonviolent drug crimes should have a separate justice system with lower standards.
Is public defecation actually a problem anywhere that has adequate public bathroom access? It really seems like 'bathrooms' might be more ethical and significantly cheaper.
*Or, like, the reformed version of the normal process that should exist, where people's civil liberties are respected.
Unfortunately, I’m not sure anyone’s figured out how to provide public bathrooms to this population without them turning into unsanitary drug and prostitution hubs.
My solution would be to provide lots of public bathrooms, but heavy surveillance of them (photo every time the door opens - if the bathroom is degraded after you use it but not before, that’s destruction of public property and a crime that you’ll actually get in trouble for.)
Like many problems in this space, we can provide many more solutions if we’re willing to surveil and punish people who degrade them for others.
And again we’re back to “what’s the punishment for degrading a public bathroom?) If I do it (repeatedly), I should go to jail. If someone is mentally ill enough that they can’t be held responsible, they should be institutionalized.
This would be an example of “long term institutionalization for nonviolent, minor crimes.”
It seems like Robin Hanson's proposal for mandatory crime insurance vouchers would distinguish between people who can be let out of institutions and amidst society, and people who have to be exiled away from people whose lives they will inevitably made worse. https://www.overcomingbias.com/p/who-vouches-for-youhtml
"But I do not think we should take crimes more seriously if the person perpetrating them has poor hygiene or a serious mental illness. "
Why not?
From any kind of utilitarian perspective it makes sense for crimes to be judged partly on their impact and people who are louder or smellier will often have a significantly worse impact on utility than more normal people.
This is cope of the highest order. I don't think it's a given that you, as a city dweller, are required to accept someone muttering to themselves, and I definitely don't think schizophrenics off their meds should be allowed to wander the streets causing trouble for people. If the few psychotic people you personally know happen to be conscientious enough to avoid causing problems, cool. The large majority of people are not like this, and if they are psychotic, then they are dangerous. (Well, even the highly conscientious ones can eventually do something dangerous - Freddie had an article about one famous case).
I highly recommend you stop! Or at least do so very quietly. But if you're not an off-your-meds schizophrenic or psychotic then it's probably fine. (I notice you didn't address this more substantive part of the comment.)
The rate of homelessness really is lower in red states with cheaper housing than San Francisco or New York. And I don't get the impression people are as often bothered by crazy people in the street in such places.
San Francisco and New York attract mentally ill homeless people by giving them lots of freebies, red states don't do this. People who walk around in public talking to themselves probably can't hold down a job to maintain housing with, and would likely do similar things even if they did have some alternate source of income. The problem is one million percent not "housing" - at least not for these guys. It's a problem for normal people who want to be able to live reasonably.
Huh? Why not? Mobility decreasing over time could be due to any number of factors that don't affect homeless people. Again, you think homeless people won't take a bus to NY because mobility has decreased over time? Get off the copium drip and return to the real world please
There is a misconception about freedom that a lot of people have. Freedom is always a means to an end for the individual. It might be a political end, if you are liberal, but not for the individual. The individual uses their liberty for doing things, agreeing to things, and in doing so their liberty is reduced. If you sign a contract, you make a compromise. Your liberty is reduced. You have to work for your boss, even if at that moment you'd prefer watching Netflix.
So a person who agrees into a program that is "coercive", is not having their liberty taken, but is just exercising their liberty.
FUCK UNLEASHED DOGS. Like, I know that's not the central point of your article, but god. Fuck. Unleashed dogs are a menace, mostly because my youngest sister is terrified of even the most well-behaved service dog across the room.
Slightly more responsive to the point of the article: "severely mentally ill" and "severely mentally disabled (but don't call it illness because it's DEVELOPMENTAL)" seem to be, like, things that need to be considered similarly. "Oh, just put your sister in a group home!" That would be unkind to her *and* to everyone in the group home, roommates and staff alike. At least at home she can have whatever weird-ass sleep schedule she wants and we'll bitch about making her food at 3 am but we will, in fact, get her food. I don't trust institutions to care about my sister *as a person* instead of as a "violent flight risk".
I do think that people being deeply unpredictable in their actions adds another level to being disruptive and threatening in a public place. The most scared I've been in public has always been of people who were being both disruptive and unpredictable in a way I think was likely linked to mental instability, because I had no way of modeling "is this person just muttering" or "will they decide to randomly stab me because I'm standing next to them on a BART platform", like happened a few weeks ago.
I realize that making people deeply uncomfortable and unsafe isn't cause for institutionalization, but at least for me, there is a very real qualitative difference in how unsafe I feel when mental instability combines with disruptiveness or aggression in public.
The problem is that the government can’t reasonably provide love. Alex lives a nice life because he has people who love him who have decent resources. Similarly, children who are abused in their home of origin are genuinely a difficult problem to solve because what they need, what they require, is love and government trying to arrange for that is hard even though humans are hardwired to love children we get to know (also difficult because of effects of trauma of course - which makes them both harder to love and harder to take care of.) Similarly elders with just a little dementia or even just general total technological inability - a loving family renders them “not a problem” for society… but government can’t scare up that loving family if it doesn’t exist. Rotating social workers are an inadequate solution. We should make institutions as nice as possible, we should fund social workers and work hard to reduce turn over but I don’t see how it’s possible to avoid institutions - we can’t create loving caretakers for the vulnerable where they don’t exist. It is a privilege to have people love you and it’s not a privilege it’s easy to equalize.
This is an interesting if tangential point. Governments can encourage love and care by making public spaces more hospitable such that people can more easily meet and spend time together. There are a lot of ways to do that. What abused children need (what any abuse victim needs) is not necessarily just love but true autonomy and support, which is antithetical to the structure of our society. Family Abolition by M.E. O'Brien digs really deep into the family as a site of both care and coercion/abuse and how we can build better, less privatized societal structures of care.
I don’t have a strong opinion on this either way, but, there’s no rule of the universe that institutions have to be the way you describe? They generally aren’t in Denmark where I’m from. They’re not good, mainly because there’s too few of them; but residents who aren’t considered a threat to themselves or others can typically go on walks alone, they’re not gender segregated, never heard of romance/sex being banned, there very often are “communal” pets in these institutions (I’ve even seen horses!), people can cook for themselves (even prisoners in Scandinavia cook for themselves). I’ve never ever heard of people not being allowed on the internet or not having smartphones or computers. Typically people decorate their rooms with a lot of their own stuff probably including entertainment. This is free, or tax funded if you’re anal about it.
Why can’t people do that at American institutions? Is it the fear-of-getting-sued culture over there? Is it illegal for them to invest in some cooler board games on someone’s request??
Fear of getting sued almost certainly plays an outsized role for sure. I had family that ran a bakery, and the amount of regulation preventing them from donating to the local soup kitchens was wild. They could sell 35$ pies all day but try giving them away for free so the downtrodden could have a treat, no way.
But, also, a million other cultural differences and the feedback loops generated from them. Low-trust, low-cohesion, 'bootstrap' society.
One of those differences causing and generated by a lot of nasty feedback loops, Americans have much higher rates of violence than any other 'Western' society. Those that support institutionalization are in favor of a different balance in a tradeoff: the proverbial Alex couldn't fall in love if he's 24/7 institutionalized, but neither could he snap and kill someone. The status quo is something of a "worst of both worlds" situation, largely from polarization IMO.
You suggested in this piece that if one advocates treating people differently who are the sorts of non-disruptive mentally ill people that aren't institutionalized it's because the thing they are optimizing for is minimizing disruption rather than caring for the interests of the mentally ill. But it's not hard to see how one would think a policy like that is in the best interests of the mentally ill.
For a person like Alex, being a bit psychotic seems better than being institutionalized. Alex's quality of life is higher than the quality of life of the average institutionalized person. But I think it's not at all obvious whether the average mentally ill homeless person on the street, constantly in terror and threatening people is of higher quality of life than the average institutionalized person. Seems reasonable to think that, while this doesn't perfectly carve things up, generally the people who are sleeping outside and being disruptive are more likely to be bettered by being institutionalized than the people who aren't.
I think it's a good idea to offer more supportive housing for psychotic people, but involuntary institutionalization come up *specifically* when people prefer homelessness to institutionalization. And I don't think that preference is unreasonable! People want their romantic partner, or their dog, or to be able to smoke (nicotine reduces negative symptoms in schizophrenia), or to be able to see the sun whenever they want...
Your entire model rests on Alex's UBI Girlfriend who is content to put him up in a private space that contains the negative externalities of his behavior, despite Alex apparently contributing nothing to household finances and only contributing to chores as far as his avolition lets him tear himself away from online games and going to the park. This is, after all, the "community care" model promised by advocates of deinstitutionalizatuon.
But walking the streets of a major West-coast metro will show you that it isn't working. By opposing involuntary commitment, what you are doing is to forcing us all into the role of Alex's girlfriend, to absorb the negative externalities of mentally ill strangers as they take over public spaces, and subsidize their lifestyles even as they refuse to accept the conditions of housing and treatment. Regular exposure to anti-social behavior does not need to be "part of being a citizen in an urban environment."
If you want to imprison people without due process because they are annoying to you, that is between you and your conscience, but don't act like it's for the benefit of the people imprisoned.
Here's the problem: you said that you think 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, etc... who are typically taken to jail by the police.
If laws against public camping, illegal dumping, public drug use, public intoxication, littering, illegal fires, public urination & defecation, and threatening behavior are enforced equally against everyone, then living on the street while mentally ill will no longer be a viable alternative to complying with the requirements of treatment or shelter. The population Lehman is discussing, who cannot or will not comply with those requirements, and do not have an Alex's Girlfriend to take them in, will end up jail.
I do not see how Lehman's proposal to place these people in a place dedicated to treating their illness (even if it also restricts their liberty) rather than throwing them in jail, is not considering the best available option for their well-being/health.
Or maybe they think the people in the institutions are demons coming to kill them. Either way I think the freedom to hurt yourself and potentially hurt others too is probably not worth respecting, but you also can't just act like psychotic people are rational actors
> But I think it's not at all obvious whether the average mentally ill homeless person on the street, constantly in terror and threatening people is of higher quality of life than the average institutionalized person.
The entire reason you have to institutionalize these people is that their revealed preference is to be homeless on the street rather than spending their time in a grey padded cell without anything fun or interesting to do. If they wanted to stay in a grey padded cell without anything fun or interesting to do, then you wouldn't need to override their choices to get them to do it, certainly not after getting them on antipsychotics.
Setting up camp in a public space should not be a viable alternative to going to a homeless shelter or mental health facility simply because a person does not wish to follow the conditions such places impose on residents.
Yeah, I think this essay sets up a false dichotomy between being institutionalized vs being in an idyllic non-institutionalized setting with lots of support, no need to get a job, and loved ones who trust the untreated psychotic person enough to let him babysit their young children??? In fact, lots of psychotic people get trapped in homelessness and can’t find a way out.
Having been in an institution briefly (misguided substance choices inducing psychosis when young) they really fucking suck. I think many people who haven't don't appreciate all the ways they suck because of the nature of bureaucracy.
If institutions were just alternatives to living in a tent with beds, showers and people to watch and give you medication that wouldn't be so bad. Require evidence of severe mental illness, danger **and** living on the street and they now live in a building with people to care for them. Doesn't seem so bad.
Unfortunately, it doesn't work like that. Veteran Vance might really care about carrying his medals around but after some patient stabs another with a medal a rule will be made. Can't just let patients have shoelaces (suicide) or phones with wifi (sent harrasing picks). Inevitably you'll even have difficult rules about what books can be read.
In theory, you should be able to just have the people running the institution make reasonable choices. Vance hasn't shown any violent tendencies so let him keep his medals, let Linda keep a phone etc.. But lawsuits and the tension between preventing abuse and enabling discretion make this unachievable.
The nurses and doctors are overworked and don't want to face a lawsuit saying they were negligent because they knew item X could be harmful and let patients keep it anyway. Employees come and go and rules are the way we can communicate institutional knowledge. Not to mention there are always a few awful people who will use discretion in harmful ways and once some orderly somewhere uses their ability to unilaterally approve or deny privleges to coerce sex then you get extra procedures.
In practice, therefore, they aren't just a homeless encampment with beds, toliets and medicine. They are places where miserable people have to spend days staring at the wall or in supervised activity with people they may not like.
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Having said all this, I do think that we may want to consider creating a voluntary version of this -- just build trailers out on cheap land and create a place that offers the services of an institution but where people aren't actually committed and are allowed to own and manage their own stuff -- but with advice and help. Being able to say "it's not involuntary we can't control everything patients own" would make things much better.
“We have no societal response to madness, no therapeutic program, no system of care that honors the fundamental humanity and dignity of the mad. We treat them as a social nuisance. We do not care about the horrors and traumas of their lives, about the dreams and aspirations they have, about what they are capable of if they are provided the right supports. All we care about is that they are out of dangerous situations, medicated, off the streets and the subways, and off our minds.”
https://www.psychiatrymargins.com/p/the-tragedy-of-jordan-neelys-death
Also, I think people imagine that only people who aren't like Alex would ever be involved but I don't think they realize how hard that is to achieve.
Imagine Alex was rich and instead of a loving girlfriend actually had a selfish sister who wanted his money. She could convince him to come live with her, then kick him out sometime during a difficult period and make up a story to tell the police about him attacking her.
Immediately, you've created the scenario where they are homeless (kicked out and sis destroys his cards and wallet and phone), are unlikely to be able to get back on their feet right away in whatever city their sister lives in and the cops will probably dismiss everything he says once they see he has delusions.
And enough process to protect people in this situation tends to make it hard to institutionalize at scale.
Why can't this happen now exactly? What difference does any new proposed policy make here? And isn't this an insanely contrived scenario? (And why wouldn't the police do anything about it?)
Because right now it's virtually impossible to get someone involuntarily committed to a mental institution for any extended length of time. Alex's sister could certainly say that Alex was dangerous and this happened but in the current system Alex gets held for observation for a week while the doctors check his meds then he gets out and can go fly back to somewhere he has friends and access to all the resources to contest an attempt by his sister to get herself declared his legal guardian anyone else does.
Sure, she could try to file criminal charges but the judicial system -- while far from perfect -- is relatively well equipped to deal with that situation and now she needs to convince a jury beyond a reasonable doubt that a specific event occurred and that's what the system is relatively good at and it's not all basically deference to whatever MD gets called in to evaluate. Moreover, even if she gets him convicted that tends to work against her goal of getting declared his guardian. It's going to be hard to argue she has her brother's best interests at heart while pushing to make sure he is criminally convicted.
Why would she be declared his legal guardian in any case, new system or not? He's just confined to an asylum, no legal guardian necessary. And certainly I would like for a more robust legal system to judge if anything like that would come up and require evidence to prove it.
If someone has assets and isn’t mentally competent you can get someone else declared a legal guardian because you need to decide how to manage those assets and use them for their benefit. Hell Britney had someone declared her guardian in that sense and she had way more resources.
This actually used to happen relatively frequently under the old system before they closed the asylums. People wanted auntie’s/grannies money so they get them committed and then they have virtually no ability to fight an attempt to get declared their legal guardian.
> 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 think this is wrong. The Alex in your example made his choices for understandable reasons and has same people who care about him who help him make good choices. The crazy homeless street people have far less options and I'm not at all convinced it's better for them to be on the street even if they resist institutionalization.
(I do also, separately, think that "keep public spaces clear of scary unkempt smelly people shouting at passerby" is undervalued, but that's a separate discussion).
hm things i'm curious about:
- Alex's ability to babysit seems to stand in serious enough contrast to all his problems and i'm having trouble understanding the complete picture here
- if Alex didnt have a loving family and a dog and a nice home would he prefer living on the street unmedicated w/o support to living in an institution? (or is the problem that institutions wont let you live unmedicated and medication can have terrible side effects)
I find it interesting no one talks about the demographics of typical disruptive homeless people. Seriously. Start there. What is their typical gender, age, race, citizenship, criminal record, do they speak English? It is not about building or maintaining stereotypes, it is gathering information about a problem before you try to solve it. For example, if I would move to a country which language I do not speak and I have no work permit, I might end up being homeless.
I’m not sure I see where there’s a difference between this author’s view and Bentham’s. Aren’t they about different populations?
Alex isn’t like, say, Jordan Neely, or the guys passed out in the tenderloin getting ambulances into EDs 25 times a year. He hasn’t been in and out of the criminal justice system, short-term involuntary detention, taking illicit drugs and screaming at subway passengers for years.
I’m not sure how Alex’s story is relevant at all to the problem Bentham (and Scott?) are addressing, other than to highlight the importance of using long-term institutionalization as a response to disruptive behavior (including repeatedly nodding off and defecting in public areas), and not as a response to diagnoses.
If you believe in lifetime imprisonment for public unconsciousness or defecation, then that's your business, but I certainly hope these policies wouldn't be adopted in a liberal society. (Always fascinating whenever I encounter someone with opinions on drug policies only slightly to the left of Rodrigo Duterte.)
I didn’t say that at all.
If you’re strung out on fentanyl, schizophrenic and defecate in the sidewalk, you should be briefly institutionalized.
If you’re released and then go back to that behavior immediately, you clearly are in need of a longer-term stay (weeks?), and then supervised release.
If you then go back to that behavior, and are clearly going to go back to that behavior every time you’re released (you have a pattern of doing that and clinical judgement is that you’re probably not capable living a normal-ish life like Alex does), then at that point you should be institutionalized long term. If over several months or years you show progress, and it’s decided that you may have improved enough to try independent living again, you’re released.
This is similar to how criminal justice works. The conversation you’re having with Bentham is like if he said “serial violent offenders should get long prison sentences”, and your rejoinder is “you think a first-time shoplifter should go to jail for life??!!”
No! There are vastly different types of criminality and the justice system reflects that in sentencing. There are also vastly different types of serious mental illnesses and associated behavior, and the psychiatric response, including coercive institutionalization should reflect that.
My opinion of this really depends on whether schizophrenic people, in this system, have access to defense lawyers and a jury of their peers and so on. If schizophrenic people have been committed of a crime through a normal process,* it seems fine to keep them in a separate prison specialized for dealing with severe mental illness. I do not think that schizophrenic people who commit nonviolent drug crimes should have a separate justice system with lower standards.
Is public defecation actually a problem anywhere that has adequate public bathroom access? It really seems like 'bathrooms' might be more ethical and significantly cheaper.
*Or, like, the reformed version of the normal process that should exist, where people's civil liberties are respected.
Unfortunately, I’m not sure anyone’s figured out how to provide public bathrooms to this population without them turning into unsanitary drug and prostitution hubs.
My solution would be to provide lots of public bathrooms, but heavy surveillance of them (photo every time the door opens - if the bathroom is degraded after you use it but not before, that’s destruction of public property and a crime that you’ll actually get in trouble for.)
Like many problems in this space, we can provide many more solutions if we’re willing to surveil and punish people who degrade them for others.
And again we’re back to “what’s the punishment for degrading a public bathroom?) If I do it (repeatedly), I should go to jail. If someone is mentally ill enough that they can’t be held responsible, they should be institutionalized.
This would be an example of “long term institutionalization for nonviolent, minor crimes.”
It seems like Robin Hanson's proposal for mandatory crime insurance vouchers would distinguish between people who can be let out of institutions and amidst society, and people who have to be exiled away from people whose lives they will inevitably made worse. https://www.overcomingbias.com/p/who-vouches-for-youhtml
"But I do not think we should take crimes more seriously if the person perpetrating them has poor hygiene or a serious mental illness. "
Why not?
From any kind of utilitarian perspective it makes sense for crimes to be judged partly on their impact and people who are louder or smellier will often have a significantly worse impact on utility than more normal people.
>more housing
This is cope of the highest order. I don't think it's a given that you, as a city dweller, are required to accept someone muttering to themselves, and I definitely don't think schizophrenics off their meds should be allowed to wander the streets causing trouble for people. If the few psychotic people you personally know happen to be conscientious enough to avoid causing problems, cool. The large majority of people are not like this, and if they are psychotic, then they are dangerous. (Well, even the highly conscientious ones can eventually do something dangerous - Freddie had an article about one famous case).
I mutter to myself in public! As a matter of purest self-interest, I support policies that mean I get to live in my own city.
I highly recommend you stop! Or at least do so very quietly. But if you're not an off-your-meds schizophrenic or psychotic then it's probably fine. (I notice you didn't address this more substantive part of the comment.)
The rate of homelessness really is lower in red states with cheaper housing than San Francisco or New York. And I don't get the impression people are as often bothered by crazy people in the street in such places.
San Francisco and New York attract mentally ill homeless people by giving them lots of freebies, red states don't do this. People who walk around in public talking to themselves probably can't hold down a job to maintain housing with, and would likely do similar things even if they did have some alternate source of income. The problem is one million percent not "housing" - at least not for these guys. It's a problem for normal people who want to be able to live reasonably.
I don't think crazy people all have the gumption to move to SF/NYC.
Gumption? They're homeless, it's as simple as buying a bus ticket
Mobility has declined over time among Americans, and the homeless don't strike me as more mobile than average.
Huh? Why not? Mobility decreasing over time could be due to any number of factors that don't affect homeless people. Again, you think homeless people won't take a bus to NY because mobility has decreased over time? Get off the copium drip and return to the real world please
There is a misconception about freedom that a lot of people have. Freedom is always a means to an end for the individual. It might be a political end, if you are liberal, but not for the individual. The individual uses their liberty for doing things, agreeing to things, and in doing so their liberty is reduced. If you sign a contract, you make a compromise. Your liberty is reduced. You have to work for your boss, even if at that moment you'd prefer watching Netflix.
So a person who agrees into a program that is "coercive", is not having their liberty taken, but is just exercising their liberty.