"Every day I fear I’ll get The Call. A well-funded state hospital run by well-paid professionals could save my sibling’s life. Deinstitutionalization and the anti-psychiatry movement infuriate me."
I got this knock on my door in the middle of the night several years ago. The fact that it never needed to happen will gall me forever. A few months later, I got into an argument with a friend about deinstitutionalization. I chose to disengage rather than have to end the friendship, which would have happened otherwise, because despite knowing everything my family had been through and lost, she based her position on some nonsensical fucking feeling that people just amorphously need autonomy...or something? I honestly can't even steelman the thing because it was clearly not based in material reality. It's just feel-good (because it's not their problem) bullshit.
Yes! I was reading something about profoundly mentally I’ll homeless people in SF. And the “advocate” was going on and on about “we must preserve their agency!” Um he has a giant puss oozing sore on his leg and he just shit on the sidewalk. I don’t think his agency should be our top priority .
I would argue that his agency is a top priority and that it is obviously being hindered by debilitating circumstances and conditions that we have a responsibility as society to address. I don’t really understand looking at a person lying passed out in a street in their own feces and thinking “there’s a person with agency.”
If someone can say, out loud, "I do not want to be in this institution," we should default to them not being put in it. Maybe they should be institutionalized, but it's basically prison and we need due process to lock them up.
I suspect that Phoebe may have misread and thought the knock was to say your loved one had been admitted to a hospital. I am sorry that wasn't the case for you.
Hard agree. My partner manages an assisted living facility for people with severe developmental issues and who are profoundly disabled. The only month she had someone at a job fair rant at her about how they're taking away these people's agency and shouldn't they just be left to live freely etc. Some of her customers regularly try to eat things that would poison them and do not know how to safely cross the road. Instead, they get compassionate care and are taken out on holidays and other activities they would simply be unable to do alone (many of whom having been abandoned by family or have families unable to look after them).
Thank you for bringing attention to the deinstitutionalization problem. It sends people to the jails and prisons (LA County Jail claims to be "the nation's largest mental health facility" -- http://shq.lasdnews.net/pages/tgen1.aspx?id=TTC ), but also to the streets. An enormous amount of the "homeless problem" on the West Coast is a mental health problem and/or a self-medication with hard drugs problem.
great article. it is pulled from the author's fantastic book on the topic, which goes into much greater depth and breadth https://www.amazon.com/dp/1635574358/
It's best to view some of the claims made in that article with a high degree of skepticism. Some of it is just straight-up Reefer Madness sensationalism, and it relies heavily on anecdote and speculation to make the (very dubious) case that this "new meth" in some kind of extra-toxic variety that's making people instantly go crazy.
Worth pointing out - especially given the topic of the OP - that meth is nearly indistinguishable, in action and chemistry, from Adderall. Basically all of the horrors of meth use come from the very high, chronic doses some addicts can self-administer, along with the ravages of being homeless, dealing with untreated mental illness, etc. All this stuff about P2P meth being somehow uniquely malign is, from what I can tell, misinformation, and damaging.
For anyone interested in the de-institutionalization era of the 60s and 70s, I recommended The Great Pretender by Susan Cahalan. She set out to write about a famous study (published in Science Magazine as On Being Sane in Insane Places) where a psychologist, David Rosenhan, and some other students he recruited, got themselves admitted to mental institutions although they had no existing or documented mental health problems. The results of the study showed that after having to “prove themselves sane” in a Kafkaesque nightmare to be able to leave, they came out with more mental health issues than they went in with and horrific stories of their treatment. The problem? As she researched, she found out the whole thing, a study that greatly influenced the move to deinstitutionalize, was almost certainly faked and that most of the pseudo patients it was based on never even existed.
I wonder if there’s a kind of reinstitutionalization by another name going on in the permanent supportive housing movement. It’s become the solution to chronic homelessness touted by all the big researchers in my (geographic) area, and our state legislature has started earmarking funding specifically to build it. The idea is, somebody who for reasons of disability or mental illness simply cannot hold down housing on their own lives in a place that ostensibly feels like a “home,” not a hospital, has their rent paid, and has medical, psychiatric, and social services support services in-house. This is considered the gold standard in chronic homelessness solutions right now and is lifted up as humane and necessary. I definitely don’t disagree - I think the sooner we just start paying to house those who will never be able to house themselves, the better. But I hadn’t thought about it in the de-institutionalization historical context before.
Yes, I believe this will happen. The first wave of PSH resulted in some terrible outcomes since they gave apartments to people who couldn't care for themselves. They found people living in squalor, off their meds, completely isolated... not "integrated in the community" to say the least.
So states said "Okay, we can't just put people in apartments. They need services." Often this means a professional visits the home daily (or more) to ensure the person completes basic tasks, plus psychiatric care, addiction intervention, and so on.
A group home can be a good solution for some people, but the federal government pushes independence (the "least restrictive" setting). So the temptation is to cluster PSH units for efficient monitoring and service delivery. And then you've got something like a facility but they're calling it apartments.
What a heartbreaking article. And honestly how infuriating that ideologically-motivated lawyers got to set the terms of people’s independence.
There’s some interesting stuff in there about how this is being tried in different places, too. For instance, my town has a homelessness program called “scattered site response,” like the program in New York, but it’s not scattered housing units in regular buildings - it’s scattered homeless encampments, with the idea that if most people who can’t presently be housed are concentrated among 3-5 larger encampments, those sites can receive city services like water and garbage and social services visits without losing track of people quite so often. It’s new, so unclear how people are responding to it, but at any rate very different from the same term used in the article.
We’ve also got PSH housing in the works, but it’s definitely on the model of “a facility but they’re calling it apartments.”
I’m really concerned about “a facility but they’re calling apartments” one of which is planned in my neighborhood. Originally we were told it would have county social services on the first floor to help the people, now we’re told that’s not happening because they… need the space for other things. It’s a high rise building with almost no parking but when the neighbors questioned that and the impact on local parking for everyone else (because it was pitched as affordable housing for working people, not as a very high-density warehouse for the homeless and/or mentally ill without appropriate support), neighbors were accused of bigotry and elitism and hating the poor. Sure. It doesn’t help that the developer seems to want to slap any old thing up, to cash in on various programs and incentives. Who will be the biggest losers? Pretty sure it will be the people living there.
How infuriating! I’m all for PSH and honestly have been frustrated by Think Of The Children campaigns suing to prevent any homeless person from ever being housed anywhere where a housed person might have to sometimes look at them. (That’s presently happening with a big county housing project in the suburbs of Seattle, which has one of the worst visible homelessness issues in the country but which gets tied up in a years-long lawsuit every time they try to designate any specific building or plot of land for fully-funded shelter.) But that’s a far cry from promising permanent supportive housing and then ripping the “supportive” part out from under it. I think experts would agree that that’s pretty integral to the whole idea!
I worked in a state psychiatric hospital as an aide for about two and a half years from 1987 through 1989 while I was going to college.
At that point, the first wave of deinstitutionalization had passed. The hospital was a huge, sprawling campus with separate buildings for different classes of patients. There were still thousands being cared for there (or locked up, if you prefer), but it was nothing compared to what it was like before the 1970's.
A lot of the old timers liked to tell me stories of what the place was like back in the day. It was its own little town, with a lot of patients working regular jobs to keep the infrastructure of the place running.
Eventually, well after I left to pursue other opportunities, the final wave of deinstitutionalization swept through and the place was completely shuttered. It still remains empty and unused decades later, environmental issues and local NIMBYs keeping from being properly developed.
When I think of the place, I think of some the patients I worked with, many of whom could never function outside of a locked ward.
"prison, which is exactly where they went, as the graph above shows."
It's an elegant graph, but not so.
it falls apart once you consider gender. The inmates filling those asylum beds were disproportionately female (and to a lesser extent, older). The prison population is decidedly not.
It looks like we freed a bunch of folks from the asylums only for them to go to the prisons. But that's not the case. We freed a majority female and skewing-older population, and then shortly after jailed a similar number of young men, disproportionately minorities.
Yeah, that's a fair critique of that graph. But I think there is, nonetheless, quite a lot of evidence that prisons are absorbing many people who would or should otherwise be in mental health care.
And some of that appears to be due to the loss of institutional capacity. E.g., this study, which concluded that 4-7% of the growth in the prison population from 1980-2000 could be attributed to transinstitutionalization:
Their findings indicate that the transinstitutionalized population skewed male, which is true of prison generally, and white, which matches your observation above.
And while that study did not find evidence of transinstitutionalization in earlier periods (1950-1980), a close study of changes in Pennsylvania policies DID find a transition from mental health institutionalization to prison institutionalization during the 1960s and '70s:
And there's this 1972 study, noting that the year after California passed a law banning indefinite involuntary commitment, the number of people with mental illnesses in the San Mateo County criminal justice system doubled.
And there's this 1984 study, which did not find an increase in PRISON incarceration driven by deinstitutionalization, but did note a likely increase in JAIL incarceration. (In other words, the mentally ill were being arrested and held, but not necessarily sentenced.)
This 1984 study finds a similar pattern of former mental patients showing up in the jails. One interesting finding is that 44 percent of arrestees with a history of mental illness had no one to call after their arrest, compared with 18 percent of arrestees with no history of hospitalization -- suggesting that those with a history of hospitalization were more socially disconnected.
That doesn't mean there weren't other, much larger factors at play in skyrocketing incarceration rates (longer sentences, a cultural and economic vicious circle in underclass communities, the evolution of the drug trade into progressively more ruthless and inhumane forms). But it does seem that some of the growth in incarceration, especially in jails, is traceable to a lack of effective mental health care, including the loss of institutional mental health care.
“ I still interact with many people who defend deinstitutionalization”
I’d be interested to hear their justification. One perhaps minor issue I’ve come across is “advocates” taking what the profoundly mentally ill at face value. Whereas if they knew the truth they would have a far more realistic understanding.
I suspect people are uncomfortable with giving the state that much power over an individual. Where do you draw the boundaries and who decides what they are? There's potential for so much abuse of power. Being involuntarily committed is no small act. When we had a family member enter a psychiatric hospital, a family friend told us to ensure it was a voluntary. Once it become involuntary, the state stepped in and then we'd be fighting with doctors and bureaucrats about whether she should stay or go.
New Jersey. We didn't know what the law said but in the middle of a crisis, we took a very cautious approach and trusted what the family friend said. No time to find and consult an attorney and the family friend was a disinterested party.
It terms or public policy part of the difficulty is that the public isn’t even aware that people can’t be “committed” anymore. Until they are dealing with a 20 year old with schizophrenia or a stubborn 80 year old with dementia.
Long-term involuntary commitment is next to impossible. Short-term (a few days or weeks) happens all the time and is honestly pretty trivial and basically just means some psychiatrist heard someone say there might be a problem and didn't want to get sued for not committing you.
I'm sincerely torn on the issue. On the one hand, many people clearly aren't able to take care of themselves, and they will only accept help if forced to. (And selfishly, as a city dweller, something has got to give.) But on the other, I find the prospect of the state being able to essentially imprison somebody indefinitely who hasn't committed a crime to be frightening. The Rosenhan experiment showed that doctors really can't accurately determine who's insane or not, and will in fact hold sane people in institutions.
I remember a decade or so ago, an international student in New York complained that she was being spied on in her home. It escalated until her college forced her into a mental institution if she didn't want to be expelled--so she did, but it turned out her landlord was a pervert who was spying on her via hidden cameras. This wasn't a "state commitment" situation, but a similar dynamic.
So basically, how many sane (or mentally ill, but functioning to an extent that they should still be free) people are worth erroneously committing to improve the lives of other people who genuinely need the help? And on the other hand how many mentally ill people will be condemned to lives of homelessness and squalor to prevent unjust commitments? I don't think there are easy answers.
Honestly I think there are easy answers. If you’re too crazy to hold down a job and are homeless then that’s the criteria. If you’re either employed or have a home then you’re good. If you have no home and no job living on the street is not a legal option.
Oh, I don’t want to go to the shelter there are too many rules. Then get a job! If you wont or can’t then you’re being committed and they will try to get you sorted out.
What do you think we should do with those who refuse to (or can’t tolerate) being medicated and therefore can’t care for themselves?
And then there are those who can’t care for themselves due to a profoundly disabling personal disorder.
I was just reading that the treatment for borderline personality disorder can involve coming to terms with something being fundamentally wrong with oneself as a person.
How does that work? What about those who don’t respond to treatment?
If they're just a little weird, leave them be. If they're genuinely dangerous but would benefit from long-acting injectable antipsychotics, court-ordered long-acting injectable antipsychotics.
Keep in mind that the median borderline is "your friend's crazy ex-girlfriend". There are borderline schoolteachers, programmers, mayors, therapists (soooooo many borderline therapists!) et cetera. I am very in favor of all these people getting treatment, but I don't think the ones who refuse should all be locked up forever (or even for a few months).
They can be any amount of weird they want in the privacy of their own home. If they have it together enough to stay housed - great! It’s when they are so weird they can’t stay employed or housed that we have a problem.
I want to emphasize that deinstitutionalization is more than a historical movement -- it's the law in 2022, and one the Department of Justice enforces aggressively throughout the country. Many states have been sued under the Americans with Disabilities Act for not providing services in the "least restrictive" and "most integrated" setting possible.
The federal government has a website where they log their lawsuits and other legal activities to force states to move people out of institutions, including mental institutions. As you can see, they are active in court: https://www.ada.gov/olmstead/olmstead_cases_list2.htm
When they get sued, states typically enter a settlement agreement. Then DOJ lawyers and reviewers are in their business for a decade or more, and they are aggressive in forcing the state to close institutions and move people to independent housing and group homes. States really don't have the option of institutions anymore.
Deinstitutionalisation here is viewed from a moral or ethical ground it seems. I had always had it described, at least here in Ontario where care is publicly funded, as a cost cutting measure.
Over this series of articles I can’t get over how our discussion and interpretation of mental illness is so deeply cultural and bound to our current moment.
You’ve said a couple of times now that there isn’t good evidence for SSRIs. I know there is controversy over their effectiveness in treating depression – but I think it’s important to note that antidepressants are also widely prescribed for anxiety, and there is evidence that these medications are effective for generalized anxiety and panic disorder.
This fits my wife’s clinical experience as a psychiatrist, along with my anecdotal experience (self, family, and friends). Zoloft changed my life. It took a few months and a high dose, but I don’t have panic attacks or anxiety spirals unless something is really wrong – and even then, I’m able to keep functioning.
I don’t know as much about depression, because I’ve never had it. (FWIW, my wife says medication works.) But if you have severe anxiety, an SSRI could help. They don’t work for everyone—some people get more anxious or even manic—but they work for a lot of people.
Here is an example of a meta-analysis found SSRI / SNRI drugs are more effective for anxiety than all sorts of therapy. This fits my experience too—I was in and out of therapy for years, but the therapist who helped me the most is the one who finally referred me to a psychiatrist: https://pubmed.ncbi.nlm.nih.gov/25932596/
I also find it validating to see the lower effect sizes for everything they tell you to do (relaxation, exercise, FUCKING MINDFULNESS…)
To be fair to FUCKING MINDFULNESS, it does come out decently in that meta-analysis, at least in the pre-post studies. It's not for everyone, and for sure most of the drugs have higher effect sizes. But if the condition is mild, it might be all someone needs, and without the side-effects.
I suspect mindfulness works better for some personalities than for others. I know people who bounce right off it and I get why. Even if it works for you, it takes daily time and effort and it can be hard to find that consistently. But for some of us, at least, it works wonders.
That’s true, some people benefit... I just meant that it’s **really** not for me (I suspect because I have ADHD too) and I’ve had it suggested over and over.
I have ADHD too, but as someone for whom SSRI's don't do a damn thing on any front, fucking mindfulness (love that) helps some, when I can get myself to stick with a daily routine that includes meditation. I think it's just a YMMV kinda thing.
I used to make this argument too, but studies have found about the same effect size for SSRIs for anxiety as for depression. Either they both work or they both don't.
(as you say, many people who take SSRIs for anxiety report very strong effects. But many people who take them for depression also report very strong effects! Either the patients are having placebo responses, the studies are wrong, or we're misunderstanding what the studies are telling us - I think it's a little bit of each)
I wouldn't be so quick to pile dirt on "outdated and empirically unjustifiable psychoanalytic techniques." I agree that it would be amazing to be able to fully understand the brain and therefore treat peoples' mental illnesses accordingly, but as a mental health professional it's become more and more clear to me that we probably do not have the ability as a species to understand our own brains. They are simply too complex. It's not that much different from expecting a dolphin, chimpanzee, or octopus to fully understand their own nervous systems. I would love for my belief to be proven wrong, for the record.
There are at least a couple very low-hanging fruits for depression and PTSD: psilocybin and MDMA, respectively. Both are currently being studied in various places and are (hopefully) on the path to being approved as treatments like ketamine has been, but such progress is infuriatingly slow. I've used these two substances numerous times to quickly and completely end "treatment-resistant" forms of mental illness in other people. I must do so off the books and at great risk to my career, of course, because they're still considered highly illegal drugs...but the evidence for their efficacy is far, far too strong for me not to suggest them to those who are struggling so badly and who can be cured so easily.
I think therapy helps a lot of people. But there's an immense diversity in what therapy is, and some techniques have a better research record. I'm sure some people get a lot out of "let's talk about your day" style therapy, but there's so many people doing so at such expense and there just isn't great evidence that it works.
I love that and I'm confident it'd be more effective than traditional therapy for many people...but I'm not sure that it's even possible to truly demonstrate that effect via any kind of impartial study. This seems to be the case with so much of psychology/psychiatry.
I had a similar experience with a wonderful psychiatrist I saw for several months to treat my post-partum depression. Every week she gave me an assignment--for example, to join a mom’s group, or to make a list of specific actions I performed to help my baby son, or to throw away a particular book (by Penelope Leach, may her name be blotted out) that was, in my doctor’s words, “torturing you.” At the start of each session I reported on what I had done to fulfill the assignment, and how it went. As a bonus, every assignment was something helpful and concrete I could do to make things better. It was so much more useful than just sitting there ruminating over how bad I was feeling.
Ibogaine has great promise, but I am concerned by the many reports of its effects wearing off after several months. Supposedly there is a metabolite that sticks around for a very long time after the initial trip experience, and the therapeutic effect may be mediated by that metabolite rather than self-discovery during the actual trip. We need to study it far more intensively, in any case!
I've done therapy (for depression/anxiety) with a lot of different people, due to bad reactions to all the drugs, plus moving around a lot. The solely "talk about your day" kind didn't help, but Cognitive Behavioral Therapy and EMDR did help. I know, everyone's different, data point of one, blah blah blah.
I started therapy and medication last year to relatively good success. I’d been feeling bad and finally spoke to someone who was alarmed at how deep my depression was (I don’t like to brag but I got a very high score on the depression test).
After a year I can say I’m definitely better than I was. I tested out various pills until I found one that seemed to help (an SSRI, incidentally) The talk therapy, though, I’ve found to be a waste of time. My therapist is very nice and our conversations are pleasant, but I can’t see any way they actually help me. He spends time getting me to identify my feelings, their source, and how I respond to them. But, I know all that already. What I don’t know is how to feel better.
I do feel better now so it’s possible the therapy has helped in ways I don’t notice, but I doubt it. I think it’s mostly the lexapro.
I’ve got a very opinionated psychiatrist and I find him enormously helpful for pointing out when I’m going off the rails. He actually has not that much interest in the source of feelings, it’s all about the thought processes.
Does everyone here hate Lost Connections? I don't, but I didn't read it for the drugs part (the first third) because all the drugs make me sick in one way or another, but for the "village" part, the last two thirds. And the third third was the solutions part, and it also did not fill me with any kind of hope: We have to change our whole culture and mindset. Which is already on the to do list for basically everything wrong, most obviously the environment, so I guess I hope a lot of people read a lot of books.
I'm actually writing this from a psychward here in Britain where I've been for the past two weeks, though I have leave over the weekend. While bed numbers are often very limited and nurses ludicrously overworked, I feel blessed that despite the Tories' efforts we still have a healthcare system where I was able to go to A&E and say that I was at immediately risk of seriously hurting myself and they had me on the ward that evening with new medication assigned the day following, without me having to panic about this putting me in any debt. If I had been in the position of being scared about the cost I simply wouldn't have gone and would, quite likely, have severely hurt myself or worse.
As for the talking cure, I have OCD (diagnosed as a young child) which is sometimes very intense in terms of intrusive images and thoughts. Talking about these horrible images and thoughts offers light relief but also plays into my compulsive tendency towards confessing (look up scrupulosity in OCD if that doesn't make sense to you as part of the condition). I am already well aware of my childhood traumas and upsets and have a tendency to obsessively brood and ruminate as it is.
However much I agree with all of Mark Fisher's critiques of C.B.T. at least it can actually have some lasting impact on OCD, whereas hundreds and hundreds of hours of talking cure therapy really have only helped me construct new narratives to cling to imho.
Thanks - the NHS isn't perfect by any means (underfunded and subject to a lot of bureaucratic measures and backdoor privatisation over the last couple of decades) but I'm very thankful it exists.
"Every day I fear I’ll get The Call. A well-funded state hospital run by well-paid professionals could save my sibling’s life. Deinstitutionalization and the anti-psychiatry movement infuriate me."
I got this knock on my door in the middle of the night several years ago. The fact that it never needed to happen will gall me forever. A few months later, I got into an argument with a friend about deinstitutionalization. I chose to disengage rather than have to end the friendship, which would have happened otherwise, because despite knowing everything my family had been through and lost, she based her position on some nonsensical fucking feeling that people just amorphously need autonomy...or something? I honestly can't even steelman the thing because it was clearly not based in material reality. It's just feel-good (because it's not their problem) bullshit.
...yep, still angry, I guess.
“People just amorphously need autonomy”
Yes! I was reading something about profoundly mentally I’ll homeless people in SF. And the “advocate” was going on and on about “we must preserve their agency!” Um he has a giant puss oozing sore on his leg and he just shit on the sidewalk. I don’t think his agency should be our top priority .
I would argue that his agency is a top priority and that it is obviously being hindered by debilitating circumstances and conditions that we have a responsibility as society to address. I don’t really understand looking at a person lying passed out in a street in their own feces and thinking “there’s a person with agency.”
If someone can say, out loud, "I do not want to be in this institution," we should default to them not being put in it. Maybe they should be institutionalized, but it's basically prison and we need due process to lock them up.
"The fact that it never needed to happen will gall me forever. " ?? I'm confused. You were glad it happened, right?
Why would I be glad to hear my loved one had died? What kind of knock do you think I got?
I suspect that Phoebe may have misread and thought the knock was to say your loved one had been admitted to a hospital. I am sorry that wasn't the case for you.
Kfix is correct. I was stumped, sorry! I get it now.
No harm done.
Hard agree. My partner manages an assisted living facility for people with severe developmental issues and who are profoundly disabled. The only month she had someone at a job fair rant at her about how they're taking away these people's agency and shouldn't they just be left to live freely etc. Some of her customers regularly try to eat things that would poison them and do not know how to safely cross the road. Instead, they get compassionate care and are taken out on holidays and other activities they would simply be unable to do alone (many of whom having been abandoned by family or have families unable to look after them).
Thank you for bringing attention to the deinstitutionalization problem. It sends people to the jails and prisons (LA County Jail claims to be "the nation's largest mental health facility" -- http://shq.lasdnews.net/pages/tgen1.aspx?id=TTC ), but also to the streets. An enormous amount of the "homeless problem" on the West Coast is a mental health problem and/or a self-medication with hard drugs problem.
Increasingly it’s a hard drugs leading to mental illness problem, particularly with the new generation of methamphetamines.
https://www.theatlantic.com/magazine/archive/2021/11/the-new-meth/620174/
great article. it is pulled from the author's fantastic book on the topic, which goes into much greater depth and breadth https://www.amazon.com/dp/1635574358/
It's best to view some of the claims made in that article with a high degree of skepticism. Some of it is just straight-up Reefer Madness sensationalism, and it relies heavily on anecdote and speculation to make the (very dubious) case that this "new meth" in some kind of extra-toxic variety that's making people instantly go crazy.
Worth pointing out - especially given the topic of the OP - that meth is nearly indistinguishable, in action and chemistry, from Adderall. Basically all of the horrors of meth use come from the very high, chronic doses some addicts can self-administer, along with the ravages of being homeless, dealing with untreated mental illness, etc. All this stuff about P2P meth being somehow uniquely malign is, from what I can tell, misinformation, and damaging.
For anyone interested in the de-institutionalization era of the 60s and 70s, I recommended The Great Pretender by Susan Cahalan. She set out to write about a famous study (published in Science Magazine as On Being Sane in Insane Places) where a psychologist, David Rosenhan, and some other students he recruited, got themselves admitted to mental institutions although they had no existing or documented mental health problems. The results of the study showed that after having to “prove themselves sane” in a Kafkaesque nightmare to be able to leave, they came out with more mental health issues than they went in with and horrific stories of their treatment. The problem? As she researched, she found out the whole thing, a study that greatly influenced the move to deinstitutionalize, was almost certainly faked and that most of the pseudo patients it was based on never even existed.
I wonder if there’s a kind of reinstitutionalization by another name going on in the permanent supportive housing movement. It’s become the solution to chronic homelessness touted by all the big researchers in my (geographic) area, and our state legislature has started earmarking funding specifically to build it. The idea is, somebody who for reasons of disability or mental illness simply cannot hold down housing on their own lives in a place that ostensibly feels like a “home,” not a hospital, has their rent paid, and has medical, psychiatric, and social services support services in-house. This is considered the gold standard in chronic homelessness solutions right now and is lifted up as humane and necessary. I definitely don’t disagree - I think the sooner we just start paying to house those who will never be able to house themselves, the better. But I hadn’t thought about it in the de-institutionalization historical context before.
Yes, I believe this will happen. The first wave of PSH resulted in some terrible outcomes since they gave apartments to people who couldn't care for themselves. They found people living in squalor, off their meds, completely isolated... not "integrated in the community" to say the least.
So states said "Okay, we can't just put people in apartments. They need services." Often this means a professional visits the home daily (or more) to ensure the person completes basic tasks, plus psychiatric care, addiction intervention, and so on.
A group home can be a good solution for some people, but the federal government pushes independence (the "least restrictive" setting). So the temptation is to cluster PSH units for efficient monitoring and service delivery. And then you've got something like a facility but they're calling it apartments.
PSH failures in NYC: https://www.nytimes.com/2018/12/06/nyregion/nyc-housing-mentally-ill.html
What a heartbreaking article. And honestly how infuriating that ideologically-motivated lawyers got to set the terms of people’s independence.
There’s some interesting stuff in there about how this is being tried in different places, too. For instance, my town has a homelessness program called “scattered site response,” like the program in New York, but it’s not scattered housing units in regular buildings - it’s scattered homeless encampments, with the idea that if most people who can’t presently be housed are concentrated among 3-5 larger encampments, those sites can receive city services like water and garbage and social services visits without losing track of people quite so often. It’s new, so unclear how people are responding to it, but at any rate very different from the same term used in the article.
We’ve also got PSH housing in the works, but it’s definitely on the model of “a facility but they’re calling it apartments.”
I’m really concerned about “a facility but they’re calling apartments” one of which is planned in my neighborhood. Originally we were told it would have county social services on the first floor to help the people, now we’re told that’s not happening because they… need the space for other things. It’s a high rise building with almost no parking but when the neighbors questioned that and the impact on local parking for everyone else (because it was pitched as affordable housing for working people, not as a very high-density warehouse for the homeless and/or mentally ill without appropriate support), neighbors were accused of bigotry and elitism and hating the poor. Sure. It doesn’t help that the developer seems to want to slap any old thing up, to cash in on various programs and incentives. Who will be the biggest losers? Pretty sure it will be the people living there.
How infuriating! I’m all for PSH and honestly have been frustrated by Think Of The Children campaigns suing to prevent any homeless person from ever being housed anywhere where a housed person might have to sometimes look at them. (That’s presently happening with a big county housing project in the suburbs of Seattle, which has one of the worst visible homelessness issues in the country but which gets tied up in a years-long lawsuit every time they try to designate any specific building or plot of land for fully-funded shelter.) But that’s a far cry from promising permanent supportive housing and then ripping the “supportive” part out from under it. I think experts would agree that that’s pretty integral to the whole idea!
Yes I can’t understand how the “supportive” piece can get moved and then anyone expects it will be a nice, helpful place.
I worked in a state psychiatric hospital as an aide for about two and a half years from 1987 through 1989 while I was going to college.
At that point, the first wave of deinstitutionalization had passed. The hospital was a huge, sprawling campus with separate buildings for different classes of patients. There were still thousands being cared for there (or locked up, if you prefer), but it was nothing compared to what it was like before the 1970's.
A lot of the old timers liked to tell me stories of what the place was like back in the day. It was its own little town, with a lot of patients working regular jobs to keep the infrastructure of the place running.
Eventually, well after I left to pursue other opportunities, the final wave of deinstitutionalization swept through and the place was completely shuttered. It still remains empty and unused decades later, environmental issues and local NIMBYs keeping from being properly developed.
When I think of the place, I think of some the patients I worked with, many of whom could never function outside of a locked ward.
"prison, which is exactly where they went, as the graph above shows."
It's an elegant graph, but not so.
it falls apart once you consider gender. The inmates filling those asylum beds were disproportionately female (and to a lesser extent, older). The prison population is decidedly not.
It looks like we freed a bunch of folks from the asylums only for them to go to the prisons. But that's not the case. We freed a majority female and skewing-older population, and then shortly after jailed a similar number of young men, disproportionately minorities.
Yeah, that's a fair critique of that graph. But I think there is, nonetheless, quite a lot of evidence that prisons are absorbing many people who would or should otherwise be in mental health care.
And some of that appears to be due to the loss of institutional capacity. E.g., this study, which concluded that 4-7% of the growth in the prison population from 1980-2000 could be attributed to transinstitutionalization:
https://gspp.berkeley.edu/assets/uploads/research/pdf/p71.pdf
Their findings indicate that the transinstitutionalized population skewed male, which is true of prison generally, and white, which matches your observation above.
And while that study did not find evidence of transinstitutionalization in earlier periods (1950-1980), a close study of changes in Pennsylvania policies DID find a transition from mental health institutionalization to prison institutionalization during the 1960s and '70s:
https://networks.h-net.org/node/4189/reviews/5778780/brewer-parsons-asylum-prison-deinstitutionalization-and-rise-mass
And there's this 1972 study, noting that the year after California passed a law banning indefinite involuntary commitment, the number of people with mental illnesses in the San Mateo County criminal justice system doubled.
https://ps.psychiatryonline.org/doi/epdf/10.1176/ps.23.4.101
And there's this 1984 study, which did not find an increase in PRISON incarceration driven by deinstitutionalization, but did note a likely increase in JAIL incarceration. (In other words, the mentally ill were being arrested and held, but not necessarily sentenced.)
https://scholarlycommons.law.northwestern.edu/cgi/viewcontent.cgi?article=6430&context=jclc
This 1984 study finds a similar pattern of former mental patients showing up in the jails. One interesting finding is that 44 percent of arrestees with a history of mental illness had no one to call after their arrest, compared with 18 percent of arrestees with no history of hospitalization -- suggesting that those with a history of hospitalization were more socially disconnected.
https://heinonline.org/HOL/Page?collection=journals&handle=hein.journals/ijotcc30&id=234&men_tab=srchresults
That doesn't mean there weren't other, much larger factors at play in skyrocketing incarceration rates (longer sentences, a cultural and economic vicious circle in underclass communities, the evolution of the drug trade into progressively more ruthless and inhumane forms). But it does seem that some of the growth in incarceration, especially in jails, is traceable to a lack of effective mental health care, including the loss of institutional mental health care.
Thanks for writing this. It's great info, and I always appreciate when people take the time to provide source materials.
“ I still interact with many people who defend deinstitutionalization”
I’d be interested to hear their justification. One perhaps minor issue I’ve come across is “advocates” taking what the profoundly mentally ill at face value. Whereas if they knew the truth they would have a far more realistic understanding.
I suspect people are uncomfortable with giving the state that much power over an individual. Where do you draw the boundaries and who decides what they are? There's potential for so much abuse of power. Being involuntarily committed is no small act. When we had a family member enter a psychiatric hospital, a family friend told us to ensure it was a voluntary. Once it become involuntary, the state stepped in and then we'd be fighting with doctors and bureaucrats about whether she should stay or go.
What state are you in? In most states my understanding is that involuntary is next to impossible.
New Jersey. We didn't know what the law said but in the middle of a crisis, we took a very cautious approach and trusted what the family friend said. No time to find and consult an attorney and the family friend was a disinterested party.
It terms or public policy part of the difficulty is that the public isn’t even aware that people can’t be “committed” anymore. Until they are dealing with a 20 year old with schizophrenia or a stubborn 80 year old with dementia.
Long-term involuntary commitment is next to impossible. Short-term (a few days or weeks) happens all the time and is honestly pretty trivial and basically just means some psychiatrist heard someone say there might be a problem and didn't want to get sued for not committing you.
I'm sincerely torn on the issue. On the one hand, many people clearly aren't able to take care of themselves, and they will only accept help if forced to. (And selfishly, as a city dweller, something has got to give.) But on the other, I find the prospect of the state being able to essentially imprison somebody indefinitely who hasn't committed a crime to be frightening. The Rosenhan experiment showed that doctors really can't accurately determine who's insane or not, and will in fact hold sane people in institutions.
I remember a decade or so ago, an international student in New York complained that she was being spied on in her home. It escalated until her college forced her into a mental institution if she didn't want to be expelled--so she did, but it turned out her landlord was a pervert who was spying on her via hidden cameras. This wasn't a "state commitment" situation, but a similar dynamic.
So basically, how many sane (or mentally ill, but functioning to an extent that they should still be free) people are worth erroneously committing to improve the lives of other people who genuinely need the help? And on the other hand how many mentally ill people will be condemned to lives of homelessness and squalor to prevent unjust commitments? I don't think there are easy answers.
Honestly I think there are easy answers. If you’re too crazy to hold down a job and are homeless then that’s the criteria. If you’re either employed or have a home then you’re good. If you have no home and no job living on the street is not a legal option.
Oh, I don’t want to go to the shelter there are too many rules. Then get a job! If you wont or can’t then you’re being committed and they will try to get you sorted out.
Would you agree that all homeless people should be sent to prison? Psych hospitals aren't much better.
Mass-rounding-ups of poor people is the kind of thing Dickens villains would shudder at, I get nervous when people think of it as the "easy answer".
What do you think we should do with those who refuse to (or can’t tolerate) being medicated and therefore can’t care for themselves?
And then there are those who can’t care for themselves due to a profoundly disabling personal disorder.
I was just reading that the treatment for borderline personality disorder can involve coming to terms with something being fundamentally wrong with oneself as a person.
How does that work? What about those who don’t respond to treatment?
If they're just a little weird, leave them be. If they're genuinely dangerous but would benefit from long-acting injectable antipsychotics, court-ordered long-acting injectable antipsychotics.
Keep in mind that the median borderline is "your friend's crazy ex-girlfriend". There are borderline schoolteachers, programmers, mayors, therapists (soooooo many borderline therapists!) et cetera. I am very in favor of all these people getting treatment, but I don't think the ones who refuse should all be locked up forever (or even for a few months).
They can be any amount of weird they want in the privacy of their own home. If they have it together enough to stay housed - great! It’s when they are so weird they can’t stay employed or housed that we have a problem.
You can see my justifications at https://slatestarcodex.com/2016/03/07/reverse-voxsplaining-prison-and-mental-illness/ and https://slatestarcodex.com/2016/03/31/book-review-my-brother-ron/
I'm so chuffed by the Rats of NIMH reference that I can't read any further without communicating my utter delight.
Utter delight!
I want to emphasize that deinstitutionalization is more than a historical movement -- it's the law in 2022, and one the Department of Justice enforces aggressively throughout the country. Many states have been sued under the Americans with Disabilities Act for not providing services in the "least restrictive" and "most integrated" setting possible.
The federal government has a website where they log their lawsuits and other legal activities to force states to move people out of institutions, including mental institutions. As you can see, they are active in court: https://www.ada.gov/olmstead/olmstead_cases_list2.htm
When they get sued, states typically enter a settlement agreement. Then DOJ lawyers and reviewers are in their business for a decade or more, and they are aggressive in forcing the state to close institutions and move people to independent housing and group homes. States really don't have the option of institutions anymore.
I believe SSRIs work, but skepticism about their efficacy has been durable enough that I always feel duty bound to mention it.
That makes sense. (This is probably meant to be a reply to my other comment... sorry I made 2 because I have so many thoughts on this post)
Deinstitutionalisation here is viewed from a moral or ethical ground it seems. I had always had it described, at least here in Ontario where care is publicly funded, as a cost cutting measure.
Over this series of articles I can’t get over how our discussion and interpretation of mental illness is so deeply cultural and bound to our current moment.
You’ve said a couple of times now that there isn’t good evidence for SSRIs. I know there is controversy over their effectiveness in treating depression – but I think it’s important to note that antidepressants are also widely prescribed for anxiety, and there is evidence that these medications are effective for generalized anxiety and panic disorder.
This fits my wife’s clinical experience as a psychiatrist, along with my anecdotal experience (self, family, and friends). Zoloft changed my life. It took a few months and a high dose, but I don’t have panic attacks or anxiety spirals unless something is really wrong – and even then, I’m able to keep functioning.
I don’t know as much about depression, because I’ve never had it. (FWIW, my wife says medication works.) But if you have severe anxiety, an SSRI could help. They don’t work for everyone—some people get more anxious or even manic—but they work for a lot of people.
Here is an example of a meta-analysis found SSRI / SNRI drugs are more effective for anxiety than all sorts of therapy. This fits my experience too—I was in and out of therapy for years, but the therapist who helped me the most is the one who finally referred me to a psychiatrist: https://pubmed.ncbi.nlm.nih.gov/25932596/
I also find it validating to see the lower effect sizes for everything they tell you to do (relaxation, exercise, FUCKING MINDFULNESS…)
To be fair to FUCKING MINDFULNESS, it does come out decently in that meta-analysis, at least in the pre-post studies. It's not for everyone, and for sure most of the drugs have higher effect sizes. But if the condition is mild, it might be all someone needs, and without the side-effects.
I suspect mindfulness works better for some personalities than for others. I know people who bounce right off it and I get why. Even if it works for you, it takes daily time and effort and it can be hard to find that consistently. But for some of us, at least, it works wonders.
That’s true, some people benefit... I just meant that it’s **really** not for me (I suspect because I have ADHD too) and I’ve had it suggested over and over.
I've wondered if I have some anti-placebo effect against it because it just feels like such nonsense
I have ADHD too, but as someone for whom SSRI's don't do a damn thing on any front, fucking mindfulness (love that) helps some, when I can get myself to stick with a daily routine that includes meditation. I think it's just a YMMV kinda thing.
My objection to mindfulness is most descriptions feel like they were written by an mom trying to calm down a 4 year old.
I used to make this argument too, but studies have found about the same effect size for SSRIs for anxiety as for depression. Either they both work or they both don't.
(as you say, many people who take SSRIs for anxiety report very strong effects. But many people who take them for depression also report very strong effects! Either the patients are having placebo responses, the studies are wrong, or we're misunderstanding what the studies are telling us - I think it's a little bit of each)
I wouldn't be so quick to pile dirt on "outdated and empirically unjustifiable psychoanalytic techniques." I agree that it would be amazing to be able to fully understand the brain and therefore treat peoples' mental illnesses accordingly, but as a mental health professional it's become more and more clear to me that we probably do not have the ability as a species to understand our own brains. They are simply too complex. It's not that much different from expecting a dolphin, chimpanzee, or octopus to fully understand their own nervous systems. I would love for my belief to be proven wrong, for the record.
There are at least a couple very low-hanging fruits for depression and PTSD: psilocybin and MDMA, respectively. Both are currently being studied in various places and are (hopefully) on the path to being approved as treatments like ketamine has been, but such progress is infuriatingly slow. I've used these two substances numerous times to quickly and completely end "treatment-resistant" forms of mental illness in other people. I must do so off the books and at great risk to my career, of course, because they're still considered highly illegal drugs...but the evidence for their efficacy is far, far too strong for me not to suggest them to those who are struggling so badly and who can be cured so easily.
I think therapy helps a lot of people. But there's an immense diversity in what therapy is, and some techniques have a better research record. I'm sure some people get a lot out of "let's talk about your day" style therapy, but there's so many people doing so at such expense and there just isn't great evidence that it works.
I love that and I'm confident it'd be more effective than traditional therapy for many people...but I'm not sure that it's even possible to truly demonstrate that effect via any kind of impartial study. This seems to be the case with so much of psychology/psychiatry.
I had a similar experience with a wonderful psychiatrist I saw for several months to treat my post-partum depression. Every week she gave me an assignment--for example, to join a mom’s group, or to make a list of specific actions I performed to help my baby son, or to throw away a particular book (by Penelope Leach, may her name be blotted out) that was, in my doctor’s words, “torturing you.” At the start of each session I reported on what I had done to fulfill the assignment, and how it went. As a bonus, every assignment was something helpful and concrete I could do to make things better. It was so much more useful than just sitting there ruminating over how bad I was feeling.
Talk therapy is an easy job with high pay, and my three psychiatrist friends think many are in the field to fix themselves.
I've been impressed by ibogaine.
Otherwise, I'm unqualified.
Ibogaine has great promise, but I am concerned by the many reports of its effects wearing off after several months. Supposedly there is a metabolite that sticks around for a very long time after the initial trip experience, and the therapeutic effect may be mediated by that metabolite rather than self-discovery during the actual trip. We need to study it far more intensively, in any case!
I've done therapy (for depression/anxiety) with a lot of different people, due to bad reactions to all the drugs, plus moving around a lot. The solely "talk about your day" kind didn't help, but Cognitive Behavioral Therapy and EMDR did help. I know, everyone's different, data point of one, blah blah blah.
CBT is good. I don't think it fits under Freddie's "traditional and unproven therapy" category.
I started therapy and medication last year to relatively good success. I’d been feeling bad and finally spoke to someone who was alarmed at how deep my depression was (I don’t like to brag but I got a very high score on the depression test).
After a year I can say I’m definitely better than I was. I tested out various pills until I found one that seemed to help (an SSRI, incidentally) The talk therapy, though, I’ve found to be a waste of time. My therapist is very nice and our conversations are pleasant, but I can’t see any way they actually help me. He spends time getting me to identify my feelings, their source, and how I respond to them. But, I know all that already. What I don’t know is how to feel better.
I do feel better now so it’s possible the therapy has helped in ways I don’t notice, but I doubt it. I think it’s mostly the lexapro.
I’ve got a very opinionated psychiatrist and I find him enormously helpful for pointing out when I’m going off the rails. He actually has not that much interest in the source of feelings, it’s all about the thought processes.
I'm occasionally a film lecturer. I have given way too much money to therapists who seem to often want to talk about films at/with me.
You write so well that if you wrote a phone book, I would read it.
Does everyone here hate Lost Connections? I don't, but I didn't read it for the drugs part (the first third) because all the drugs make me sick in one way or another, but for the "village" part, the last two thirds. And the third third was the solutions part, and it also did not fill me with any kind of hope: We have to change our whole culture and mindset. Which is already on the to do list for basically everything wrong, most obviously the environment, so I guess I hope a lot of people read a lot of books.
Also documentaries.
I'm actually writing this from a psychward here in Britain where I've been for the past two weeks, though I have leave over the weekend. While bed numbers are often very limited and nurses ludicrously overworked, I feel blessed that despite the Tories' efforts we still have a healthcare system where I was able to go to A&E and say that I was at immediately risk of seriously hurting myself and they had me on the ward that evening with new medication assigned the day following, without me having to panic about this putting me in any debt. If I had been in the position of being scared about the cost I simply wouldn't have gone and would, quite likely, have severely hurt myself or worse.
As for the talking cure, I have OCD (diagnosed as a young child) which is sometimes very intense in terms of intrusive images and thoughts. Talking about these horrible images and thoughts offers light relief but also plays into my compulsive tendency towards confessing (look up scrupulosity in OCD if that doesn't make sense to you as part of the condition). I am already well aware of my childhood traumas and upsets and have a tendency to obsessively brood and ruminate as it is.
However much I agree with all of Mark Fisher's critiques of C.B.T. at least it can actually have some lasting impact on OCD, whereas hundreds and hundreds of hours of talking cure therapy really have only helped me construct new narratives to cling to imho.
I’m sorry you are having a difficult time, but glad you were able to get and are continuing to get help. I hope things are on the upswing for you.
Thank you. I hope and tentatively think they are.
Thanks for sharing. I'm glad to hear you're doing better. It's so interesting to hear how things work in different countries (I'm in the USA).
Thanks - the NHS isn't perfect by any means (underfunded and subject to a lot of bureaucratic measures and backdoor privatisation over the last couple of decades) but I'm very thankful it exists.