I like this piece, but lurking in the background of all of this is America's absurdly strong system of judicial review. Some judge somewhere would find fault with every single policy prescription listed here and block it- then the issue would be tied up in court for years if not longer. It's very under-discussed how our current problems with homelessness all stem from judicial review- court decisions in the 70s that blocked panhandling & vagrancy laws, court decisions that made institutionalization much more difficult, and so on all the way up to Grants Pass. I've grown much more skeptical about judicial review in recent years, especially the power of 1 local judge to block literally anything they choose to, and I think that part of the solution is paring back the power of the judiciary
Here here. This is one of the worst problems, and those terrible one percent of judges all seem to live in a handful of state. We need less culture war, and stopping this is the first step.
Deinstitutionalisation happened more or less everywhere but the outcomes you describe occurring in America with respect to people with serious mental illness (SMI) didn’t happen everywhere, ergo, deinstitutionalisation is not the problem nor re-institutionalisation the answer. In the UK we have community treatment orders (CTO) for non-compliant (and potentially risky) SMI patients and such patients are usually prescribed long-acting intra-muscular anti-psychotics. If they disengage and become non-compliant with treatment, they can be recalled to hospital.
The issue is that the US may not have the ability for all kinds of reasons to manage deinstitutionalization as well as other countries, so re-institutionalization may be a good solution for us. Especially given the lack of anything resembling stable community support for so many patients.
Why would America not have the ability to do what many other countries have done? America is the richest country in the world, so this cant simply be due to financial constraints, not to mention the fact that re-institutionalisation would actually be more expensive than community-based alternatives anyway.
NIMBYism isn’t just an American thing. As for civil liberties, the type of conservatorship that Britney Spears was famously on indicates that America can enact laws which are quite authoritarian, as regards mental illness, when it wants too.
It is easier when the state has no financial liabilities. Remember, no one gets elected on this. Our largest, old cities are like walking advertisements for Republican Party extremism, with programs claiming to help everyone, yet never helping anyone. They are jobs programs for connected jerks. I should know, as I work in such an agency. Much of public transit in large corrupt cities suffers from this as well. The schools are literally a corruption all-you-can-eat with overpaid consultants who not only steal from poor children, but ruin their educational experience as well (the best sign of this is to see easy-to-game metrics such as "How many students go on to college").
I love the American city, but corruption is so deep that I am not sure they can reform anymore. My Chicago neighborhood is full of pot holes, but the city staff reliably water the flower pots hanging off of light posts every week. It is insane. Chicago has a forestry service, but they are clearly not doing anything, save for removing dangerous trees, but even there, not very well. The department is well-staffed, but what do they do?
It is terrifying. In another era we could hope that the Republicans would come around, but they apparently are too concerned with tax cuts and silly social issues that have no bearing on people's lives. It is easy to feel helpless.
You are incorrect. It did happen everywhere. Those who with this new found "freedom" rationally converged on better locations with homeless services and good drugs. I can always tell people who have never known anyone who is homeless, or been homeless, because they make these kinds of statements. Homeless people go where it is better. Furthermore, many municipalities will buy them a bus ticket there. For some reason, journalists refuse to write about this, but plenty of places literally buy a bus ticket and often will give cash or a VISA gift card to local homeless to get them out. It is the standard municipal policy in most of the US.
If someone with SMI was NFA and was on a CTO and needed to be recalled to hospital but refused to comply then its likely that the Police would need to be involved in apprehending the individual and conveying them
I think this misses the context. Alexander isn't arguing against some changes on the margins, the background was a Noahopinion (I think) piece that basically said we should adopt forced institutionalization at a level sufficient to remove the mentally ill from the street. And many of his points are made in the context of the size of the changes needed to realize this outcome.
For instance, on the point about liberty, I don't think his issue is so much how inclined should we be to institutionalize someone with X degree of mental illness but about the fact that we presumably don't want to undermine fundamental legal constraints that prevent the government from locking people up without proof -- for instance getting a relative or spouse locked up for your benefit by lying or even bribing doctors.
And this plus constitutional constraints do mean a certain amount of process really is required. And doing that at scale required to *solve* homelessness is very very difficult.
Start with a plan to lock up in pleasant rural asylums not all 140,000 mentally ill homeless, but just the 14,000 most likely to attack passers-by at random.
>Long-term supervision programs that combine regular check-ins on compliance with minor punishments for non-compliance have yielded substantial reductions in problem drinking behavior
The link is to a program for alcohol offenders (the article implies it's mostly drunk drivers and domestic abusers) in South Dakota. South Dakota, as far as I am aware, does not have a huge homelessness problem. Therefore, I must conclude that this program is being applied largely to people who have fixed addresses and own automobiles. I must also assume that approximately 95% of the people subject to this program are not seriously mentally ill. Thus, the program is being applied in the main to people who can be easily found by authorities, have sufficient wherewithal and executive function to show up for their twice-daily tests, and almost certainly perceive themselves as having something to lose if they don't comply.
How, then, do you figure that this kind of compulsory outpatient treatment would have anywhere near the same rate of success on a population of persons who do not have a fixed address, usually don't own an automobile or much of anything else, and are (I'll just quickly remind you) seriously mentally ill?
The real solution would be long-term mental health institutions in places with a low cost of care. Basically, New York and San Francisco send their long-term mentally ill to less expensive locations in Mississippi or Alabama. This would provide lower costs and establishing communities with large facilities would allow for a concentration of labor so staffing would be reasonable. I picked those states because they have low labor costs, but other may states may work as well.
What we do not need are huge, expensive facilities in the most expensive cities. That will never happen, nor should it. In my experience, most homeless people concentrate in cities with the best services and the best drugs. It would be brutal to live in Salt Lake City or Fargo as a homeless drug addict, but LA is quite nice. New York has winter, but they also have massive services. There is a reason homeless people congregate where they do.
The safest path would be internment in massive, concentrated mental health facilities operated with the smallest budgets imaginable. Individuals who are not new to the police or health providers. These places should be cheaper than prisons and sufficiently miserable as to encourage the unhoused to avoid behavior leading up to involuntary confinement, if they are capable. I suspect that the number of individuals engaging in anti-social behavior will drop dramatically once such behavior has swift consequences. Some unfortunately will clearly be unable to stop themselves, and mental health confinement would seem to be more humane than imprisonment. Once the rump of bad actors is gone, the threat of permanent internment will make city life bearable again.
The real question is how to get more housing built in the hard-core exclusionary cities (New York, San Francisco, Los Angleles, Washington, Boston, ...). I think we are at the point where the Federal government needs to step in and ban any and all zoning restrictions in unreasonably expensive municipalities. My hope would be that once this is imposed on New York and San Francisco, the other cities might rush to reform before uncle Sam forces them to. There is no reason why every empty lot in the five boroughs cannot have high-rise housing on it, ideally cheap towers full of studios and one-bedrooms, the housing in highest demand, and the layouts the city refuses to allow. The other housing hack would be to ban "affordable" units, because any housing outside of market housing is useless, and should not be a tax on everyone else. "Affordable units" are nothing more than disguised corruption. The practice needs to end.
I'd add that you could do a lot of good for big city life just by sending off to peaceful asylums in the countryside not all 140,000 homeless mentally ill, but just the 10% most dangerous.
When Jordan Neely died, I guesstimated that he was one of the 500 craziest people roaming the streets and subways of NYC. It then turned out he was on an authoritative list of the 50 scariest crazymen in New York!
If we just sent to asylums the worst 10% of the mentally ill homeless, we'd still have a depressing number of people sleeping on the street, but we wouldn't have have as many psychos punching Rick Moranis at random and the like.
That seems highly doable: building asylums for 14,000 is hardly beyond America's capacity. When we see that that works, we can expand from there.
Scott was simply gaslighting. His argument amounted to "the outcome that existed as recently as 6 years ago, and that is currently happening in every city outside the West Coast is impossible".
IMO more intensive caseworker strategies I think should be used more broadly across healthcare/CJ. And they don't require any large scale capital investment or changes to laws. (I think these should probably be state civil service workers though, too much waste in outsourcing to various non-profits.)
$300k does not surprise me at all Charles (I mean there are fixed costs to building/maintaining and then there are marginal labor costs per person served, the fixed costs are killers for big institutions that I just don't see happening, even ignoring current laws on being detained would need to be amended).
I like this piece, but lurking in the background of all of this is America's absurdly strong system of judicial review. Some judge somewhere would find fault with every single policy prescription listed here and block it- then the issue would be tied up in court for years if not longer. It's very under-discussed how our current problems with homelessness all stem from judicial review- court decisions in the 70s that blocked panhandling & vagrancy laws, court decisions that made institutionalization much more difficult, and so on all the way up to Grants Pass. I've grown much more skeptical about judicial review in recent years, especially the power of 1 local judge to block literally anything they choose to, and I think that part of the solution is paring back the power of the judiciary
Here here. This is one of the worst problems, and those terrible one percent of judges all seem to live in a handful of state. We need less culture war, and stopping this is the first step.
Deinstitutionalisation happened more or less everywhere but the outcomes you describe occurring in America with respect to people with serious mental illness (SMI) didn’t happen everywhere, ergo, deinstitutionalisation is not the problem nor re-institutionalisation the answer. In the UK we have community treatment orders (CTO) for non-compliant (and potentially risky) SMI patients and such patients are usually prescribed long-acting intra-muscular anti-psychotics. If they disengage and become non-compliant with treatment, they can be recalled to hospital.
The issue is that the US may not have the ability for all kinds of reasons to manage deinstitutionalization as well as other countries, so re-institutionalization may be a good solution for us. Especially given the lack of anything resembling stable community support for so many patients.
Why would America not have the ability to do what many other countries have done? America is the richest country in the world, so this cant simply be due to financial constraints, not to mention the fact that re-institutionalisation would actually be more expensive than community-based alternatives anyway.
NIMBYism isn’t just an American thing. As for civil liberties, the type of conservatorship that Britney Spears was famously on indicates that America can enact laws which are quite authoritarian, as regards mental illness, when it wants too.
It is easier when the state has no financial liabilities. Remember, no one gets elected on this. Our largest, old cities are like walking advertisements for Republican Party extremism, with programs claiming to help everyone, yet never helping anyone. They are jobs programs for connected jerks. I should know, as I work in such an agency. Much of public transit in large corrupt cities suffers from this as well. The schools are literally a corruption all-you-can-eat with overpaid consultants who not only steal from poor children, but ruin their educational experience as well (the best sign of this is to see easy-to-game metrics such as "How many students go on to college").
I love the American city, but corruption is so deep that I am not sure they can reform anymore. My Chicago neighborhood is full of pot holes, but the city staff reliably water the flower pots hanging off of light posts every week. It is insane. Chicago has a forestry service, but they are clearly not doing anything, save for removing dangerous trees, but even there, not very well. The department is well-staffed, but what do they do?
It is terrifying. In another era we could hope that the Republicans would come around, but they apparently are too concerned with tax cuts and silly social issues that have no bearing on people's lives. It is easy to feel helpless.
Reading these kind of articles makes me thankful for the UK mental health system, despite its faults
My thoughts exactly
As the UK is getting more like the US (in policies and atomization), the UK mental health system is getting there too, don't worry
You are incorrect. It did happen everywhere. Those who with this new found "freedom" rationally converged on better locations with homeless services and good drugs. I can always tell people who have never known anyone who is homeless, or been homeless, because they make these kinds of statements. Homeless people go where it is better. Furthermore, many municipalities will buy them a bus ticket there. For some reason, journalists refuse to write about this, but plenty of places literally buy a bus ticket and often will give cash or a VISA gift card to local homeless to get them out. It is the standard municipal policy in most of the US.
If someone with SMI was NFA and was on a CTO and needed to be recalled to hospital but refused to comply then its likely that the Police would need to be involved in apprehending the individual and conveying them
No Fixed Abode
https://www.mind.org.uk/information-support/legal-rights/police-and-mental-health/sections-135-136/
I think this misses the context. Alexander isn't arguing against some changes on the margins, the background was a Noahopinion (I think) piece that basically said we should adopt forced institutionalization at a level sufficient to remove the mentally ill from the street. And many of his points are made in the context of the size of the changes needed to realize this outcome.
For instance, on the point about liberty, I don't think his issue is so much how inclined should we be to institutionalize someone with X degree of mental illness but about the fact that we presumably don't want to undermine fundamental legal constraints that prevent the government from locking people up without proof -- for instance getting a relative or spouse locked up for your benefit by lying or even bribing doctors.
And this plus constitutional constraints do mean a certain amount of process really is required. And doing that at scale required to *solve* homelessness is very very difficult.
Start with a plan to lock up in pleasant rural asylums not all 140,000 mentally ill homeless, but just the 14,000 most likely to attack passers-by at random.
That would do a lot for urban life.
If that works, it can be expanded.
Excellent post
>Long-term supervision programs that combine regular check-ins on compliance with minor punishments for non-compliance have yielded substantial reductions in problem drinking behavior
The link is to a program for alcohol offenders (the article implies it's mostly drunk drivers and domestic abusers) in South Dakota. South Dakota, as far as I am aware, does not have a huge homelessness problem. Therefore, I must conclude that this program is being applied largely to people who have fixed addresses and own automobiles. I must also assume that approximately 95% of the people subject to this program are not seriously mentally ill. Thus, the program is being applied in the main to people who can be easily found by authorities, have sufficient wherewithal and executive function to show up for their twice-daily tests, and almost certainly perceive themselves as having something to lose if they don't comply.
How, then, do you figure that this kind of compulsory outpatient treatment would have anywhere near the same rate of success on a population of persons who do not have a fixed address, usually don't own an automobile or much of anything else, and are (I'll just quickly remind you) seriously mentally ill?
The real solution would be long-term mental health institutions in places with a low cost of care. Basically, New York and San Francisco send their long-term mentally ill to less expensive locations in Mississippi or Alabama. This would provide lower costs and establishing communities with large facilities would allow for a concentration of labor so staffing would be reasonable. I picked those states because they have low labor costs, but other may states may work as well.
What we do not need are huge, expensive facilities in the most expensive cities. That will never happen, nor should it. In my experience, most homeless people concentrate in cities with the best services and the best drugs. It would be brutal to live in Salt Lake City or Fargo as a homeless drug addict, but LA is quite nice. New York has winter, but they also have massive services. There is a reason homeless people congregate where they do.
The safest path would be internment in massive, concentrated mental health facilities operated with the smallest budgets imaginable. Individuals who are not new to the police or health providers. These places should be cheaper than prisons and sufficiently miserable as to encourage the unhoused to avoid behavior leading up to involuntary confinement, if they are capable. I suspect that the number of individuals engaging in anti-social behavior will drop dramatically once such behavior has swift consequences. Some unfortunately will clearly be unable to stop themselves, and mental health confinement would seem to be more humane than imprisonment. Once the rump of bad actors is gone, the threat of permanent internment will make city life bearable again.
The real question is how to get more housing built in the hard-core exclusionary cities (New York, San Francisco, Los Angleles, Washington, Boston, ...). I think we are at the point where the Federal government needs to step in and ban any and all zoning restrictions in unreasonably expensive municipalities. My hope would be that once this is imposed on New York and San Francisco, the other cities might rush to reform before uncle Sam forces them to. There is no reason why every empty lot in the five boroughs cannot have high-rise housing on it, ideally cheap towers full of studios and one-bedrooms, the housing in highest demand, and the layouts the city refuses to allow. The other housing hack would be to ban "affordable" units, because any housing outside of market housing is useless, and should not be a tax on everyone else. "Affordable units" are nothing more than disguised corruption. The practice needs to end.
Thanks.
I'd add that you could do a lot of good for big city life just by sending off to peaceful asylums in the countryside not all 140,000 homeless mentally ill, but just the 10% most dangerous.
When Jordan Neely died, I guesstimated that he was one of the 500 craziest people roaming the streets and subways of NYC. It then turned out he was on an authoritative list of the 50 scariest crazymen in New York!
If we just sent to asylums the worst 10% of the mentally ill homeless, we'd still have a depressing number of people sleeping on the street, but we wouldn't have have as many psychos punching Rick Moranis at random and the like.
That seems highly doable: building asylums for 14,000 is hardly beyond America's capacity. When we see that that works, we can expand from there.
Scott was simply gaslighting. His argument amounted to "the outcome that existed as recently as 6 years ago, and that is currently happening in every city outside the West Coast is impossible".
IMO more intensive caseworker strategies I think should be used more broadly across healthcare/CJ. And they don't require any large scale capital investment or changes to laws. (I think these should probably be state civil service workers though, too much waste in outsourcing to various non-profits.)
$300k does not surprise me at all Charles (I mean there are fixed costs to building/maintaining and then there are marginal labor costs per person served, the fixed costs are killers for big institutions that I just don't see happening, even ignoring current laws on being detained would need to be amended).