Details That You Should Include In Your Article On How We Should Do Something About The Mentally Ill
I. Suppose that you, an ordinary person, open your door and start choking on yellow smoke. You think “there should be less pollution”, and call up your representative. The technical expert hears “there should be less pollution” and immediately has dozens of questions. Do you just want to do the obvious things, like lower the threshold for hexamethyldecawhatever? Or do you want to ban tetraethylpenta-whatever, which is vital for the baby formula food chain and would cause millions of babies to die if you banned it? The expert has a point. Any pollution legislation must be made of specific policies. In some sense, it’s impossible to be “for” or “against” the broad concept of “reducing pollution”. Everyone would be against a bill that devastated the baby formula supply chain for no benefit. And everyone would support some magical bill that managed to clean the skies without any extra hardship on industry. In between, there are just a million different tradeoffs; some are good, others bad. So (the technocrat concludes), it’s incoherent to support “reducing pollution”. You can only support (or oppose) particular plans. On the other hand, ordinary people should be able to say “I want to stop choking on yellow smoke every time I go outside” without having to learn the difference between hexamethyldeca-whatever and tetraethylpenta-whatever. I think you’re supposed to imagine the environmentalists’ experts and the industries’ experts meeting policy-makers and hammering out some compromise, then moving one direction or another along the Pareto frontier based on how loudly normal people protest pollution. But if you’ve been demanding an end to pollution for years, and nothing has happened, then it might be time to hit the books, learn about hexamethyldecawhatever, and make sure that what you’re demanding is possible, coherent, and doesn’t have so many tradeoffs that experts inevitably recoil as soon as they have to think about the specifics. II. I’m not a pollution expert, but I’m a psychiatrist, and I’ve been involved in the involuntary commitment process. So when people say “we should do something about the mentally ill”, I naturally tend towards thinking this is meaningless unless you specify what you want to do - something most of these people never get to. Let’s start with a summary of the current process for dealing with disruptive mentally ill homeless people:
This isn’t going to win any of the people involved Doctor Of The Year awards. I’m sympathetic to attempts to change the system. But it’s hard to find the right point of leverage. If your plan is to change the case law around involuntary commitment - to expand the definition of “dangerous to themselves or others” - it probably won’t matter, because most of these decisions are based on vibes that only loosely connect to the written law. But also, even if you find a way to make doctors commit many more people, it still won’t matter, because those people will stay in the hospital for a few days, then come out with antipsychotics which they will immediately stop taking. If your plan is to change the law around guardianship and get all of these people state-sponsored guardians, that could help around the edges. But guardians can’t directly physically confine people or force drugs down their throats, so this won’t get them “off the streets” or “medicated” without additional steps. If your plan is to “lock them up long-term”, keep in mind that (for now) there are almost no institutions equipped to do this. Each state usually has one center with a 3-digit number of beds for the most recalcitrant patients. Getting into these is like getting into Harvard, only in reverse - you need a spectacular anti-resume proving that you’re among the worst of the worst in the country. If you want tens of thousands of people in institutions like these, then you’ll need some kind of vast nationwide building program (do you expect San Francisco to be good at this?) But okay, suppose you build those institutions. How long are you keeping people there? Remember, someone’s going to come in, start taking antipsychotics, and (if the drugs work) appear significantly saner within 2-4 weeks. Best-case scenario, they’re completely sane. Now what? Do you keep a completely sane person locked in the mental institution forever? Or do you let them out, at which point they will inevitably stop taking the drugs and become psychotic again? Okay, sounds like you need some kind of social services to keep patients taking their drugs. There are lots of these, all around the country. The problem is, if the person isn’t taking the drugs (and sometimes even if they are), they won’t attend appointments with social workers. And the social workers can’t show up at their door, because these patients are homeless and hard to track down. Okay, sounds like you need to get them homes. But there’s not enough government-subsidized housing. And anyway, now we’re back to Housing First, the solution that all of these “We Should Do Something About The Mentally Ill” articles treat as their foil. Okay, then can you threaten people into attending appointments and taking drugs? There are Involuntary Outpatient Commitment orders, which say basically “go to your psychiatrist and follow their recommendations, or else we’ll put you in jail”. But remember, a lot of the problems happen when these people fail, through bad luck and bad executive function, to get refills. Typical cases might be:
(Am I just being gullible? Are these people just making fake excuses? I don’t think so. I used to work at a clinic where visits were free with insurance, but missed appointments incurred a $200 fine that insurance didn’t cover. My low-income patients would miss a visit, then freak out because they couldn’t afford the $200 fine. Then I would talk to people, get permission to waive the fine once, and tell them okay, we won’t charge them this time, but they had to show up the next time. Then they would miss their next appointment too, their bill would go to collections, and I would never see them again. I asked the clinic director why we had such a punitive policy, and she said that without the policy, patients would miss so many appointments that the clinic couldn’t make money or pay staff.) There are an infinite number of ways that semi-psychotic homeless people can miss appointments. The half-life of these people’s contact with the medical system is a month or two. So they’ll miss their appointment and get off the drugs. The police aren’t going to start a nationwide manhunt for a psychotic homeless person who’s indistinguishable from all the other psychotic homeless people. So realistically what will happen is they’ll be back on the street, a year later they’ll get arrested for some other reason, the police will notice they violated the treatment order, and the judge will try to add an extra year to their sentence for the treatment order violation. Then if their lawyer is really good, he’ll spend his 0.01 minutes on the case arguing that his patient has one of the excuses above, which will always be true. Then the judge will either give them a year in prison or not, and everyone will feel kind of dirty and ashamed of themselves either way. (Also, even in the best case where you successfully treat somebody, I’m afraid that “1995 - 2024: psychotic homeless person” doesn’t look good on a resume, so they probably won’t be getting high-powered jobs. Meanwhile, cheap apartments in SF are $1000/month. So the connection between “no longer psychotic” and “no longer homeless on the street” is tenuous unless you also have some plan to provide free housing.) Okay, then can you just make it a crime to be mentally ill, and throw everyone in prison? According to NIMH, 22.7% of Americans have a mental illness, so that’s a lot of prisoners. “You know what I mean, psychotic homeless people in tents!” Okay, fine, can you make homelessness a crime? As of last month, yes you can! But before doing this, consider:
I admit that if you’re willing to be arbitrarily cruel and draconian (life sentence for someone and their entire family the moment the bank forecloses on their home!) you can make this one “work”. But anything less than that and it becomes just another confusing bad option. In practice, the government tries some combination of these things, each of which works a little. Sometimes they fiddle with the law around inpatient commitment around the edges. Sometimes they give people free houses. Sometimes they threaten them with Involuntary Outpatient Commitment orders. Sometimes they throw them in prison. Most of these things work a little. Some of them could work better with more funding. Nobody thinks the current system is perfect. I respect people who want to change it. But you’ve got to propose a specific change! Don’t just write yet another article saying “the damn liberals are soft on the mentally ill”. The damn liberals are soft because some of them are the people who have to develop an alternative plan, and they can’t think of a good one. If you’re going to write yet another article like this, and you want to change minds, you should skip the one hundred paragraphs about the damn liberals, and go straight to the part where you explain how you plan to do better. If your plan is “be arbitrarily cruel and draconian”, then that will work, but please admit it. Don’t mumble something about “I just want these poor people to be able to get the treatment they deserve yet don’t know how to ask for” before going back to railing against the damn liberals. If your plan is something else that will solve everything with no tradeoffs, then you owe it to your readers to explain what that is. You're currently a free subscriber to Astral Codex Ten. For the full experience, upgrade your subscription. |
Older messages
Open Thread 337
Monday, July 8, 2024
... ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏
Your Book Review: Don Juan by Lord Byron
Friday, July 5, 2024
Finalist #3 in the Book Review Contest ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏
Prediction Markets Suggest Replacing Biden
Tuesday, July 2, 2024
Mantic Monday 7/1/24 ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏
Open Thread 336
Monday, July 1, 2024
... ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏
Your Book Review: Dominion
Friday, June 28, 2024
Finalist #2 in the Book Review Contest ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏ ͏
You Might Also Like
In Waning Senate Days, Kyrsten Sinema Screwed Workers and Spent Campaign Cash on Stay at French Castle
Monday, December 23, 2024
The Arizona senator's prodigious campaign spending in global wine hot spots can't possibly be related to the campaign she's not running, says an ethics complaint. Most Read Indiana's
Monday Briefing: Al-Assad’s final days in power
Sunday, December 22, 2024
Plus, tell us about your most successful New Year's resolution. View in browser|nytimes.com Ad Morning Briefing: Asia Pacific Edition December 23, 2024 Author Headshot By Gaya Gupta Good morning.
Gift of the Day: For the (Battery) One-Percenters
Sunday, December 22, 2024
“They'll never have to turn on low power mode again.” The Strategist Gifts Every product is independently selected by editors. If you buy something through our links, New York may earn an affiliate
GeekWire's Most-Read Stories of the Week
Sunday, December 22, 2024
Catch up on the top tech stories from this past week. Here are the headlines that people have been reading on GeekWire. ADVERTISEMENT GeekWire SPONSOR MESSAGE: Improve focus and memory with Thinkie:
Speckled Curiosa
Sunday, December 22, 2024
Today, enjoy our audio and video picks. Speckled Curiosa By Caroline Crampton • 22 Dec 2024 View in browser View in browser The full Browser recommends five articles, a video and a podcast. Today,
10 Things That Delighted Us Last Week: From Gap’s CashSoft to Airplane Footrests
Sunday, December 22, 2024
Plus: A design-y divider to make room for guests in small spaces. The Strategist Logo Every product is independently selected by editors. If you buy something through our links, New York may earn an
LEVER WEEKLY: Nurses And Other Superheroes
Sunday, December 22, 2024
Financial technology startups could ruin Christmas and more from The Lever this week. Nurses And Other Superheroes By The Lever • 22 Dec 2024 View in browser View in browser This is Lever Weekly, a
The Sunday — December 22
Sunday, December 22, 2024
This is the Tangle Sunday Edition, a brief roundup of our independent politics coverage plus some extra features for your Sunday morning reading. Our Sunday newsletter is typically a feature for
What I give my 5 (!) siblings every year
Sunday, December 22, 2024
Plus: Our favorite board games View in browser Ad The Recommendation December 22, 2024 Ad I gave my big family the present of a new tradition. Maybe you can, too. A sheet pan of holiday shaped sugar
☕ Clipped wings
Sunday, December 22, 2024
Is the F-35 worth the money? Morning Brew Presented By Timeline December 22, 2024 | View Online | Sign Up | Shop Skating at the Grand Palais in Paris. Stephane De Sakutin/AFP via Getty Images BROWSING