
Dungeons and Back Alleys: The Fate of the Mentally Ill in America - DanBC
https://www.psychiatrictimes.com/couch-crisis/dungeons-and-back-alleys-fate-mentally-ill-america
======
car
What a powerful piece, poignant in its prose.

 _The human brain is the most complicated thing in the known universe and
keeps its secrets well hidden. Genetics and neuroimaging have shown how
remarkably complex and interacting are the biopsychosocial causes of mental
illness and that there will likely never be magic bullets. Drug companies have
stopped looking for them._

This paragraph summarizes the issue of mistreatment of the mentally ill in the
US perfectly:

 _Why is it that the rest of the developed world gets this and what makes us
the laggard outlier? How can it be that the richest country in the world is
most neglectful of its most vulnerable citizens? The simplest answer to this
complicated question is the misplaced US faith that market forces are always
the most efficient vehicle for solving problems. Adam Smith—the father of
modern economics—knew better and strongly supported the role of government in
providing vital public services undervalued by the market. Privatization of
mental health has resulted in too much treatment for the well; cruel neglect
for severely sick._

The path to improvement is a political one, lobbying the ones in power on
behalf of our powerless mentally ill. We need to end their silent suffering.

~~~
sandworm101
>> The human brain is the most complicated thing in the known universe

Really? It is more complicated than the Orca brain? We aren't magic. The
differences between our's and the brains of similarly-sized animals are
slight. I'd say our brain isn't fundamentally any more complex than an ape's
or a dogs. But if you want to compare numbers, Sperm Whales have 18-20lb
brains, far larger and more complex than ours by every measurement.

[https://en.wikipedia.org/wiki/File:Figure_35_03_05_Brain_siz...](https://en.wikipedia.org/wiki/File:Figure_35_03_05_Brain_size_Vertical.png)

~~~
michaelvoz
Correlating brain size to intelligence or complexity is a common amateur
mistake. Let’s for a second pretend all animal’s brains are black boxes, and
we can neither see nor measure them. Instead, let us say we can only judge
brains by their impact on the world. Would you then not put humans so far
above the other animals as to make it almost silly to compare?

~~~
sandworm101
>> can only judge brains by their impact on the world.

So bacteria? Plankton has a massive impact on the world too. Insects ... the
planet is arguably dominated by insects.

Mammalian brains are, plus or minus a few percent, equally as dense/complex.
There are aspects of dolphin brains that are far more complex than ours. A
dog's brain has far more connections dedicated to smell than ours. There is
some evidence that Orca brains have similarly more connections dedicated to
emotions. Each brain is tuned slightly differently, ours perhaps more to
vision and problem solving, but our biology isn't any more evolved or
complicated.

------
nullwasamistake
The problem with deinstitutionalization and modern therapy is the assumption
everyone can be treated. While that's more true than ever, a significant
proportion of the mentally ill do not respond to medicine or therapy.

We need to bring institutions back for those we cannot cure. Jail has become
the treatment center of last resort for those too dangerous to themselves or
others, because we closed all the secure psychiatric centers. There's not
enough room in jail either, and judges aren't keen on incarcerating people
long term to protect them from themselves. So these people end up on the
street.

Besides the drug addicts, of which treatment is also a problem in the US, this
is why you see so many crazy homeless people.

Institutions might not be a "nice" place to live your life, but it's a hell of
a lot better than living on the streets

~~~
jdietrich
_> Institutions might not be a "nice" place to live your life, but it's a hell
of a lot better than living on the streets_

Given the choice between being locked up indefinitely in a quasi-jail with a
bunch of crazy people or taking your chances on the streets, what would you
choose for yourself? Are you certain?

We don't need institutions, we don't want institutions, we need properly
funded community care. People with severe and enduring mental health problems
do far better when they have a stable home, meaningful activity and a sense of
autonomy. We can provide those things far better in the community. Long-term
institutions only offer "out of sight, out of mind" for the rest of us.

~~~
fosk
By labeling the solution as "community care" you are really not proposing a
solution: what are the implementation steps for your solution?

We don't need more money, we don't need more programs. We need an
implementation checklist.

You see, we as a society need to take it step by step and adopt a scientifical
method in dealing with this problem. The first step is to prevent the mentally
ill and drug-addicted from being a danger to the community and to themselves.
So bring back the institutions as that first step.

Then a second step, we need to identify groups of people that we decide to re-
introduce with "community care", monitor their results and keep them
accountable. Each one of them will most likely respond differently to
different implementations of what you call "community care". Give it a time
duration too, and observe the behavior. And so on.

Finally, there will be individuals fully re-introduced into society. There
will also be individuals that need a little bit of extra effort to make that
happen. But like with any group, statistically there will be individuals too
dangerous that must stay in the institutions for their own health.

~~~
jdietrich
_> By labeling the solution as "community care" you are really not proposing a
solution: what are the implementation steps for your solution?_

I'm not proposing anything new, I'm proposing the model that is used by most
other developed countries and is being successfully used in some parts of the
United States. If you think that "community care" is some vague pie-in-the-sky
notion rather than an established approach to care with a proven track record,
then there's very little point in continuing this discussion.

[https://en.wikipedia.org/wiki/Community_mental_health_servic...](https://en.wikipedia.org/wiki/Community_mental_health_service)

~~~
briancleland
As a resident of the UK, I can state that community care is exactly the same
ideologically-driven agenda with exactly the same real-world failings that are
being ascribed to the US model. The only difference is that there are still
remnants of a benefit system that provide some protection for the least
fortunate, although the government is in the process of dismantling those as
well.

~~~
hackermailman
It's a failure in most of Canada too, every successive provincial government
decides to slash it's budget or 'reorganize' community care to the point it's
just a weak pill dispensing model with no oversight and thus you get mentally
ill in the street at all hours running wild with drug and alcohol addictions.

I think Andrew Yang style UBI is really the only solution, a guaranteed
monthly living income that's illegal to take loans against or illegal to
withhold because of debts. That or some kind of accountability where we are
able to personally sue politicians who have turned our cities into poorly run
asylums.

------
nabla9
Large part alcohol and drug abuse can be attributed to self-medication.
Alcohol is the most available tranquilizer and sedative. If you are homeless
with mental problem, what else there is?

After the WWII many veterans simply drank themselves into grave because PTSD
was not a thing and they could not get other help.
[https://academic.oup.com/aje/article-
abstract/109/6/687/1121...](https://academic.oup.com/aje/article-
abstract/109/6/687/112124?redirectedFrom=fulltext)

------
mindgam3
So... not to undercut the message of anyone who is trying to reform the
catastrophically broken mental health system, but - there is a massive
elephant in the room in this discussion, and that is trauma.

It is nearly inconceivable to me that a leader in the field, a guy who wrote
an earlier version of the DSM aka bible of modern psychiatry, manages to talk
about the pros and cons of meds but never mentions the experiences that are
known to drastically harm mental health.

We don’t need a “moon shot” as Dr. Frances suggests. At least in terms of
expensive research into completely novel technologies or drugs to determine
the root cause or treat much of this suffering. We may need a moonshot in
terms of getting over our stigma around talking about trauma and abuse, so
that trauma-informed care becomes the rule and not the exception.

The closest thing the DSM has to a trauma diagnosis is PTSD and complex PTSD.
Dr. Bessel van der Kolk (author of The Body Keeps The Score, incredible
resource on trauma) has proposed the diagnosis “Developmental Trauma Disorder”
but this has not yet been widely adopted by mainstream psychiatry.

As far as I’m concerned, adding this single diagnosis and training mental
health professionals to screen for trauma will do a lot more to help people
than writing doomsaying articles like this one.

Source: grew up with developmental trauma from abusive family environment.
Lost my little sister to suicide after her severe trauma was not screened for
and was misdiagnosed as “bipolar”.

------
charlescearl
> It is hard to be complacent when 600,000 people who should be our patients
> are instead languishing as prisoners or sleeping on streets.

Any success stories of decriminalizing — or normalizing given it’s
pervasiveness — mental illness?

One of the most poignant “policing” incidents I saw was at a Charlotte bus
stop where the officer with compassion and humbleness was helping out a
gentleman who was going through an episode — my lay person’s interpretation. I
don’t know whether the officer had any training, but he was doing the best he
could with whatever training he did have, in a way where the person, his
meager belongings and his integrity were respected. So why do we depend on the
kindness of police rather than mental health givers?

~~~
yeahitslikethat
Americans don't treat it as a health problem, so the only public force with
authority is the police force. There's no fire. There's no car accident. Is
not in a national park.

We are cold isolated people.

------
mmjaa
I have been a regular visitor to the USA, and lived there for some time in
between, and seen it over most of my life as a visitor. A time period of 45
years, almost.

Whenever I'm 'back in Cali', one of my favourite places to visit is Skid Row.

From here, you truly see what is rotten in the state of Kansas.

Of course, we can go to all of the major American cities, but there is nothing
more sobering from the glitzy side of downtown than to go work in a soup
kitchen, if they still have them, just a few short blocks away from the
wealth.

It is a sad memory of America. But always an honest one.

------
Torwald
> Why is it that the rest of the developed world gets this and what makes us
> the laggard outlier?

Has a lot to do with playing world police. A lot of this is tied to veterans
with PSD.

