Slate Star Codex

[Content warning: mental illness, forced institutionalization, anorexia. As always all patient anecdotes are obfuscated composites of multiple cases with all the details changed in order to protect people’s privacy]

I.

After I wrote about Prison And Mental Illness, a reader recommended I read My Brother Ron by Clayton Cramer, a recent book/memoir arguing against deinstitutionalization. Cramer tells the story of his schizophrenic brother Ron, who was poorly treated because of the lack of an institutional system and so ended up dealing with homelessness and violence, then surveys the history and current state of mental health care in America and the various reasons why deinstitutionalization was a bad idea.

I found the book interesting and engaging, and its arguments intellectually honest and well-written. But in the end I just wasn’t convinced.

But first, his brother Ron. Smart guy, joined the military, did well, finished his tour of duty, went to college, studied electrical engineering. Around 22 – the usual age for this to happen – he started acting weird, dropped out of college, obsessed over weird things like nickels, started thinking random people were plotting against him, et cetera. He ended up in a psych hospital where he got Thorazine and improved quickly – which meant, ironically, that when it came time for his commitment hearing two weeks later, the judge thought he looked pretty normal and released him.

Then he went to live with his family – including his brother the author – where he stopped his medication, started acting violently, smashed windows, screamed at people, and was otherwise a poor housemate. His parents asked him to leave, and he wandered around until he ended up in Santa Monica. There the government gave him a monthly disability check, which he spent on alcohol and a room in a disgusting hotel; when the money ran out around the middle of the month, he spent the next few weeks on the street until he got his next check, after which the cycle repeated itself.

Every so often he would break some law or annoy somebody enough to get arrested, at which point the police would bring him to a psychiatric hospital, he’d be placed on drugs, and he’d get better. Usually he’d leave after a few days to a few weeks. Occasionally he would keep taking the drugs after getting out, become pretty with-it, and try to go back to college. Sometimes he’d stay stable for months, even a year or two. But eventually he would stop taking the drugs for one reason or another, decompensate, and end up back on the streets, his previous progress ruined.

So the author asks: how did we get to this point? He answers with a fascinating history of American mental health care.

II.

Mental health care during the colonial era was surprisingly non-terrible. Mental illness seemed to be pretty well-understood and nobody was accusing psychotics of being witches or trying to beat the demons out of them or anything. Most of the mentally ill lived with families or in their own houses, where other members of the community supported them as best they could. Some were given jobs, with the understanding that they needed the support and their idiosyncrasies would be excused. Some would wander off, and there was a general understanding among colonial towns that if they found a mentally ill person wandering they would return them to their town of origin, who had the ultimate responsibility of caring for them. A few very violent people were locked away, usually in the basements of general hospitals or in prison cells. Getting somebody committed for mental illness was an informal process usually involving finding the friendly local magistrate and explaining why it was a good idea. But this option seems to have been used judiciously, and the incarcerated individuals managed to avoid most abuse and torture. Cramer describes it as “gloriously idyllic…mental illness appears to have been rare, and small town life tolerated all but the ‘furiously mad’ to live in the community.”

The part I found most interesting here was Cramer’s theory about why this system ended. Part of it was the end of small town life; a little village where all the families know each other is more likely to tolerate someone’s eccentricities than a large city of atomized individuals. But a bigger part may have been an unmanageable increase in the mentally ill population.

Urbanization may not simply have been a factor in making Americans more wary of their mentally ill neighbors; it may have increased mental illness rates as well. While we do not know if this was true in the eighteenth century, some recent studies suggest that being born or growing up in an urban area increases one’s risk of developing schizophrenia and other psychoses. in the twentieth century, comparison of insanity rates revealed that urban areas had much higher rates of mental hospital admissions for schizophrenia and bipolar disorder – almost twice as high for New York City compared to the rest of New York State…older statistical examinations of mental hospital admissions argue that at least in the period from 1840 to 1940, while mental hospitalizations increased (because of increased availability) there was no large and obvious increase in insanity. A more recent study of mental illness data shows, much more persuasively, that psychosis rates rose quite dramatically between 1807 and 1961 in the United States, England and Wales, Ireland, and the Canadian Atlantic provinces. A study of Buckinghamshire, England shows more than a ten-fold increase in psychosis rates from the beginning of the seventeenth century to 1986. In 1764, Thomas Hancock left 600 pounds to the City of Boston to build a mental hospital for the inhabitants of Massachusetts. The city declined to accept the gift on the grounds that there were not enough insane persons to justify building such a facility. Massachusetts had a population between 188,000 and 235,000 in 1764; if the population of the time suffered the same schizophrenia rates as today, that would mean that there were about 2000 schizophrenics in the province. Even accounting for the greater tolerance of small town life for the mentally ill, this lends credence to Torrey and Miller’s claim of rising psychosis rates. Urban life today is not the same as urban life then, and even the scale of what constitutes “urban” is dramatically different – but it is an intriguing possibility that the increased rates of mental illness at the close of the Colonial period were the results of urbanization.

Irish immigration may also have played a role in the increasing development of mental hospitals in America. It was widely believed in the 1830s that Irish immigrants were disproportionately present among the insane. More recent analysis shows that throughout the nineteenth and twentieth centuries, Ireland’s rates of insanity were twice or more than that of the United States, England, and Wales. Irish immigrants were also overrepresented in insane asylums in the United States, England, Australia and Canada at the end of the nineteenth century.

To this I would add that even today immigrants get schizophrenia at rates up to four times those of non-immigrant populations, though nobody agrees whether this is because the genetically vulnerable are more likely to immigrate or because immigration is a very stressful experience. Even today, developing countries seem to have less schizophrenia than developed countries do (although of course this is hard to prove with certainty). The idea of a tenfold increase in psychosis over the past few centuries is jarring but not entirely outlandish, and does a lot to explain why the mental health system is so much larger and more relevant now.

Faced with these problems, the early Americans created big mental institutions that attracted prestigious clinicians (I interviewed for a job at one of these a few years ago; they boasted that they were in the “Psychiatric Ivy League”, which was a pretty good window into how they thought of themselves). These could never really figure out whether their job was custodial (ie warehouse mentally ill people so they didn’t cause trouble on the streets) or clinical (treat mentally ill people and cure their psychosis), and the nineteenth century vacillated wildly between people making big claims about how they were dedicated to treating all their patients, versus admitting that it was the nineteenth century and nobody had the slightest idea how to do this. While they argued the institutions grew and grew. Along with the schizophrenics, they became the dumping ground for syphilitics (remember, before penicillin syphilis was a common incurable disease that usually caused insanity in its final stages) and old people with Alzheimers (not officially recognized at this point; before the invention of nursing homes they figured they might as well stick crazy old people in with all the other crazy people). Finally, after the obsolescence of the “poorhouse” but before the beginning of welfare, there were a bunch of poor people just completely unprepared for normal life, and some of them ended up in the mental institutions too for lack of a better place to put them. This sort of put a damper on a lot of the curability discussion; not only could 19th century doctors not cure mental illness, but most of the people there weren’t even mentally ill in the traditional sense.

(not that some people didn’t try. Cramer describes a Dr. “Henry Cotton, who removed teeth, tonsils, and parts of the intestine from hundreds of patients at the Trenton State Hospital in New Jersey. Cotton claimed that there were foci of infections in these organs that were causing the insanity and that removal of the infectious would cause clinical improvement.” And then there was Dr. Wagner-Jauregg, whose bold strategy of deliberately infecting psychiatric patients with malaria actually paid off: many of them had syphilis, and the high fever induced by the malaria killed the syphilis bacterium. Wagner-Jauregg received the Nobel Prize for this insight; his later strategy of sterilizing schizophrenics on the theory that the disease was caused by masturbation was perhaps somewhat less Nobel-worthy.)

The institutions continued to grow. In 1954 the national mental health budget was $568 million; in 1959 it was $854 million. In 1951, states spend on average 8% of their budgets on psychiatric hospitals; New York spent one third of its budget on psychiatric hospitals (or not? see dispute in comments). Compare to today, when New York spends only about 20-30% of its budget on education. Psychiatric hospitals (which, remember, also subsumed the function of modern nursing homes) were a huge part of the infrastructure of government.

This started to shift in the 1940s due to what the book calls “dynamic psychiatry” (although they use this phrase a bit differently from how I understand the definition). The old, tired psychiatry was a simple dichotomy between sane people (who don’t need psychiatric help) and insane people (who are totally out of touch with reality and need to be locked up for their own good). And it understood this distinction in relatively biological terms – they didn’t know anything about genes or neurons them, but they figured something was going on. But the new, exciting psychiatry thought of mental illness as a continuum, with everybody having a little bit of mental illness – whether it was just neurosis or anxiety or whatever – and psychotics just being the people whose mental illnesses made it hard for them to function. The new school understood this in very psychosocial, Freudian terms. Schizophrenics were people with oppressively close mothers; autistics were people with distant, cold mothers, et cetera. Psychiatrists tended to like this new school, because it meant that instead of spending their time in scary mental institutions full of crazy people, they could spend their time in nice Viennese parlors talking to rich people about their families.

Around the same time, scientists invented Thorazine, which seemed to produce miraculous recoveries in institutionalized psychotic people. This was before anyone knew anything about the long-term side effects of Thorazine, so everyone figured it was a miracle drug with no side effects and now there was no need for mental institutions any more.

Then we got to the Sixties. Cramer mostly manages to avoid being too transparently political, but it’s hard for him to talk about Sixties Leftists without a bit of vitriol. He describes the genesis of the anti-psychiatry movement – a wide variety of traditions all coming together in an agreement that the mentally ill are just Too Cool And Free-Spirited For Society and anybody who tries to treat them is a bad person who hates creativity and wants to make everyone conform. He describes the jettisoning of centuries of accumulated wisdom about the causes and presentation of mental illness in favor of an unexamined dogma that mental illness is caused by oppressive systems of social control. He describes how some people did a few quick studies showing that schizophrenic people mostly lived in bad neighborhoods full of social decay, and concluded that bad neighborhoods and social decay caused schizophrenia without considering any other possible causal structures (of course, we as a society have long since moved beyond that). Others argued that hospitalization was the sole cause of mental illness, turning otherwise happy eccentrics into violent lunatics (again, a position we have long since moved beyond).

He reserves some of his strongest words for anti-psychiatry psychiatrists like R. D. Laing and Thomas Szaszszsz:

You might wonder how a psychiatrist could believe that there was no such thing as insanity. Would not the exposure to psychotic patients during Szasz’s training have shown him the error of his ideology? It turns out that Szasz may not have had any exposure to psychotics. In a 1997 interview, he describes how he consciously selected a psychiatric residency “that did not include work with involuntary patients”. The chairman of the Psychiatry Department told him, “Tom, you have only one year left of your residency, I don’t think it’s right that you should finish without any experience with psychotic patients. I think you should do your third year at the Cook County Hospital.” So Szasz quit and went elsewhere to avoid that experience.

Szasz was drafted into the Navy after completing his training, and his experiences there almost certainly reinforced his already well-developed belief that mental illness did not exist. “The servicemen didn’t want to be in the Navy and played the role of mental patient. I didn’t want to be in the Navy and played the role of military psychiatrist. My job was to discharge the men from the Service as ‘neuropsychiatric casualties’.” Szasz had gone out of his way to avoid seeing psychotic patients, and then took a job that he describes as certifying that sane people pretending to be insane were actually insane as a convenient fiction. Is there anything surprising about Szasz’s projection of this situation onto the entire profession?

I actually had been wondering about that, and that clears up a lot. As for Laing:

In the mid-1960s, British activists gravitated to Laing’s ideas, arguing that schizophrenia was more “properly human”, in a world of hydrogen bombs, than conventional definitions of sanity…Laing argued that schizophrenia was not a breakdown but a breakthrough. By the 1970s, Laing took the position of Huxley’s The Doors of Perception, that schizophrenia was a form of sanity, not insanity. Laing’s position increasingly became a political attack on Western society, and then morphed once again, rejecting the idea of schizophrenia by declaring it as hypersanity. Eventually Laing’s celebrity led him to India and drug abuse, and he became a shell of his former self.

Well then.

Around the time all this was going on, the ACLU was launching an attack of its own on the psychiatric system. Most of what they were saying sounded good – make sure people only get committed if the courts are absolutely sure they’re insane, make sure that they have all of their rights even within the psychiatric hospital – but Cramer references internal memos and discussions purporting to show that the ACLU’s real goal was to make psychiatric commitment so bureaucratically difficult that nobody would ever do it, thus freeing the mentally ill from their oppressors and destroying the psychiatric system. The courts were sympathetic to their cases and established several new rights and standards that made committing people exceptionally difficult.

In exchange, the opponents of institutions promised community treatment. Everybody agrees that community treatment was a good idea. The implementation left a lot to be desired. First, as always, they were seriously underfunded. Second, even the ones that had enough money quickly found that creating outpatient psychiatric centers is fundamentally geographically difficult. Schizophrenics are not known for their ability to go places on an organized schedule, nor for their access to good consistent transportation. The great advantage of the old asylums was that all of the schizophrenics were in one convenient location for the mental health workers to treat. When the new community treatment centers were set up, they tended to serve any schizophrenics who might live within a few blocks of them, and all the rest never made it to their appointments. Third, as per Cramer most of the people operating these new community centers were Sixties Leftists who decided that instead of the “bandaid solution” of actually treating mentally ill people, their real job was to cut out mental illness at the root by protesting capitalism and racism:

One of the officials of the CMHC [Community Mental Health Centers] program later admitted that the CMHCs “were not equipped to deal” with the chronically mentally ill, who were about to be released in large numbers from state mental hospitals. The belief that mental hospitals caused mental illness, or at least made the mentally ill worse off than they were before, combined with an idealized view of how caring communities would be for the severely mentally ill. The activists and bureaucrats who wrote the CMHC regulations were about to start the release of mental patients into caring communities which for the most part did not exist. As one of those involved later admitted, “We were federal bureaucrats on an NIMH campus talking about the community, but really from some conceptual level as opposed to hands-on experience.”

If CHMCs were not primarily serving the chronically mentally ill, then whom were they serving? Two especially notorious examples were Lincoln Hospital Mental Services in New York City and Temple University Community Mental Health Center in Philadelphia. In both cases, the belief that mental illness was somehow an expression of class struggle meant that broader social and political causes – such as landlord/tenant relations, poverty, and oppression – became significant activities of the staff. Racial and ethnic tensions within the staff destroyed both CMHCs, with threats of violence, sit-ins, VietCong flags, posters of Che Guevera and Malcolm X as symbols of the fight.

In the late sixties and early seventies all of these things came together. Psychiatrists wanted to focus on healthy people who were much more pleasant to talk to. Pharmaceutical companies insisted that their new wonder drugs could cure psychosis. Activists wanted to destroy the psychiatric system. Judges were making it much more difficult to commit anybody. And community mental health centers were trying to pick up the slack. The result was the deinstitutionalization strategy called “closing the front door and opening the back door” – that is, making new commitments more difficult, and accelerating the pace at which psychotics already in institutions could be discharged to the new community treatment programs (it didn’t hurt that syphilis had been cured a few decades earlier and the last few chronically insane syphilitics were dying off as well). This went exactly according to plan, the institutionalized population shrunk and shrunk throughout the seventies, and by the time Reagan decided to close the last few psychiatric institutions there wasn’t much left to close down.

III.

Needless to say, Cramer opposes most of these developments. He makes his antideinstitutionalization argument in several parts. But first, some things he doesn’t argue.

Cramer is pretty quick to admit the institutions had their problems:

Many [psychiatric hospitals] remained “snake pits”, to borrow the title of Mary Jane Ward’s very popular 1946 novel about mental hospitals. The American Psychiatric Association created the Central Inspection Board in 1947 to evaluate existing mental hospitals in the United States and Canada. The results were not encouraging. By 1953, it had evaluated 45 hospitals, approved two, given ten a “contingent approval”, and disapproved the rest.

The book frankly discusses the “regimented, often hopeless conditions of state mental hospitals”, talks about a hospital in Alabama where “care was worse than simply inadequate: one psychiatrist for 5000 patients; astonishingly low funding for clothing, food and upkeep of the buildings”, studies showing that institutions never actually got patients’ signatures on the forms that were supposed to waive their rights to court hearings. It describes the case of Edna Long, who was hospitalized for “public drunkenness” and

permanently hospitalized in 1952. As Ennis tells the tale, Long received no treatment during the next fifteen years, but was kept busy working at menial jobs in the hospital. After the death of her husband in 1960, the state hospital had her declared incompetent, and seized her assets to pay for her care. Then, they put what assets remained under the management of an attorney, who made a bit of money from reducing the value of her estate by 86% (according to Ennis, a common practice at the time in New York). Once Long had become too physically ill to continue working, the hospital suddenly found her “competent to manage her own affairs” and released her, to a life of elderly poverty. Most of the money that she and her husband had accumulated had been consumed by attorneys supposedly protecting her assets.

Against this tale of woe, Cramer can say only that it “leads me to wonder if there was a bit more to the story”. Judging from my own conversations with patients and nurses who used to live in / work at these hospitals – who generally report similar stories – I doubt there was.

So what is this book’s argument against deinstitutionalization?

First, it points out that very many deinstitutionalized schizophrenics slipped through the community mental health system and never got further treatment. This was in part due to the problems with CMHCs – poor funding, difficult to get to, sometimes not that interested in mental health at all (though they got a lot better after the Sixties). But it was also due to schizophrenics just generally not being too interested in engaging with the psychiatric system (especially, one might imagine, the ones who had just gotten out of institutions) and no one being able to make them. I 100% acknowledge that this argument is correct.

Second, it points out that many untreated or unsuccessfully treated schizophrenics ended up homeless on the street.

“Of 179 homeless men and women who received psychiatric examinations in a Philadelphia shelter in 1981, 40% were found to have “major mental disorders”. One-third of those examined were diagnosed as schizophrenic, and another one-fourth had a primary diagnosis of substance abuse. A Boston shelter study of 78 residents in 1983 again found that 40% had major mental disorders, and another 51% had less severe psychiatric problems…a survey of 345 subjects seeking food assistance in 1983 Phoenix found that about 30% had spent some time in a mental institution.

A quick Fermi calculation from the book’s numbers suggests that maybe 10% of schizophrenics are currently homeless. Again, I 100% acknowledge that this argument is correct and that these are probably accurate statistics about the percent of the homeless who are mentally ill.

Third, it points out that many of these people die of preventable causes. Many freeze to death on cold nights. Cramer notes that deinstituionalization corresponded with a doubling of US hypothermia deaths (although never above 1/500,000 people = 500 people per year) and that anecdotal evidence suggests many of these were mentally ill. Still others commit suicide or otherwise die of their own predictable poor choices. For example:

In another case, a woman with anorexia was admitted to a hospital after she had been involved in a family disagreement and refused to eat. She had lost a great deal of weight but refused to submit to a psychiatric exam, and since a judge felt her condition was not dangerous in an immediate sense, she was allowed to go home. She died from starvation three weeks later.

Again, I 100% acknowledge this sort of thing probably happened and happens quite often.

Fourth, it says that these people are generally weird and scary and can push everyone else out of public places. Many, for example, end up in libraries, the rare sort of public place you can enter without an admission charge. He tells the story of some such library “patrons”:

Mick is having a bad day. He hasn’t misbehaved but sits and stares, glassy-eyed. This is usually the prelude to a seizure. His seizures are easier to deal with than Bob’s, for instance, because he usually has them while seated and so rarely hits his head and bleeds, nor does he ever soil his pants. Bob tends to pace restlessly all day and is often on the move when, without warning, his seizures strike. The last time he went down, he cut his head. The staff has learned to turn him over quickly after he hits the floor, so that his urine does not stain the carpet.

A friend worked at the main branch of the Santa Rosa, California public library in the 1980s and 1990s. She was awash in similar stories of mentally ill people who would urinate in the corners of the library, make frightening noises, sleep at the tables, and generally create an environment that would have been grounds for at least expulsion, if not arrest and commitment, in any American public library in 1960. The library staff was obligated to work with such “patrons” until their actions became clearly criminal. She recounted what happened when she observed that one of these mentally ill patrons was sitting at a table with his pants down to his knees. Her supervisor was obligated by library rules to attempt to first resolve the problem without the police. He approached this exposed “patron” and diplomatically asked “Sir, are you appropriately attired for the library?”

Why was it necessary for librarians to take such a kid glove approach? Attempts to resolve behavioral problems led to lawsuits, such as happened in Morristown, New Jersey. The behavior and offensive smell of a homeless person named Kreimer led to the adoption of a code of conduct prohibiting loitering, “unnecessary staring”, following others around the library, and requiring those using the library to conform to community standards of cleanliness. The ACLU filed suit against this discriminatory code. At trial, Judge Sarokin ruled that the rules were discriminatory, and that the ban on annoying other patrons violated Kreimer’s right to freedom of speech.

This ruling was later overturned on appeal, but apparently the whole series of lawsuits had cost so much money that the mere possibility of a suit from the ACLU led libraries to adopt a policy of tolerating everyone, no matter how filthy, loud, or threatening they might be. Once again, this sounds like the sort of thing that probably happens and I have no doubt the book is telling the truth. One need not blame the homeless and mentally ill for their behavior to acknowledge that this is a potential argument in favor of institutionalizing people so they have less inconvenient places than libraries to spend their time.

Fifth, Cramer argues the deinstitutionalized mentally ill are responsible for a disproportionate amount of crime, including some of the flashiest mass shootings. He notes that of a New York Times list of the 100 most famous rampage killers, 47 had a past history of mental health problems, and 20 had been previously institutionalized. Former psychiatric inpatients are 55 times more likely than the general population to be arrested for murder, and about five times more likely to be arrested for lesser crimes like robbery, rape, and aggravated assault. He cites Bernard Harcourt’s work showing a strong negative correlation between the institutionalization rate and the crime rate – although as I’ve mentioned before, I think these numbers are seriously off and that this is more likely related to lead levels. Nevertheless, the general point that deinstitutionalized mentally ill are at high risk of criminality stands – although Cramer admits that the overwhelming majority will never get in trouble.

IV.

So I agree with almost all of Cramer’s empirical claims. Yes, many deinstitutionalized schizophrenics are not receiving adequate treatment. Yes, many are homeless, either broke or unable to manage their disability money in a rational way. Yes, many are dying of preventable causes like freezing to death. Yes, many are going around public places and threatening people and freaking people out. And yes, many of them (though by no means most) are committing terrible crimes. So how can I disagree with his assessment that deinstitutionalization was a mistake, that Reagan and the hippies and Thomas Szasz were in the wrong, and we need to bring back a strong system of long-term state-run psychiatric hospitals?

Well, let me ask a related question. Should we round up everybody from the ghetto and stick them in prison? This policy would have a number of advantages. Many people in the ghetto are desperately poor and living in terrible conditions. Many die before their time. They often make middle-class people who come across them profoundly uncomfortable. And their crime rate is much higher than that of the non-ghetto population. All the advantages of institutionalizing the mentally ill also apply to institutionalizing people in ghettos.

Against this we have a counterbalancing consideration: it is a horrible idea and it would be really mean and everybody involved would hate it and you have no right to even consider such a thing. This is also how I feel about institutionalizing the mentally ill.

First, a digression. Many of the people Cramer mentions – his brother Ron, his case studies of homeless people who freeze to death on the streets, some of the mass killers – have in fact been institutionalized. Ron was institutionalized the better part of a dozen times. Usually they’re in the hospital for a few weeks to a few months, stabilized on medications, and then released. After their release for one reason or another they come off their medications and then experience whatever catastrophe makes them suitable for inclusion in this book.

So if we want to solve all of the problems Cramer brings up – homelessness, crime, library-bothering, etc – we can’t do it by just having people in institutions for a few months or a few years. The second they set foot out of a hospital in this counterfactual world, they’ll encounter the same problems they encounter in our real one. In other words, this isn’t really about treatment, at least in the sense of “we need better commitment laws so hospitals can treat patients and then help them reintegrate into society.” What Cramer is talking about, if he’s really serious about solving these issues, is lifetime institutionalization.

Making someone spend their entire life in an institution is a pretty big deal, especially if, as Cramer freely admits, they often include “regimented, hopeless conditions” where “care is worse than simply inadequate”. Sometimes we as a society decide that criminals need to spend their entire life in an unpleasant institution because they murdered somebody or something, but it seems excessive to say that somebody should be institutionalized for life merely because they are from a population that has a disproportionate (though still not high!) risk of committing some kind of crime in the future. Once again, if we were in that business we should just imprison people for being born in bad neighborhoods. Yes, it’s a tragedy when an anorexic starves themselves to death. But should we lock up all anorexics forever to prevent that one case?

What about the humanitarian argument that we need to institutionalize schizophrenics so that they don’t end up starving on the street? Here we get into some really thorny moral issues. I tend to go by revealed preferences – schizophrenics have voted with their feet to not be in mental hospitals. If there were voluntary mental hospitals, and schizophrenics chose to live in them, that would be great and I would support them in that choice. If you are contradicting schizophrenics’ expressed preference that they prefer not being in mental hospitals – freezing weather and all – to being in mental hospitals, then you have no right to say you’re doing it for their own sake.

I can see a counterargument: psychotic people are not very good at making decisions. What if they would be happier in a nice warm institution, but they are too crazy to realize this? For example, maybe when the person asks them “Would you like to go to the hospital?” they believe that person is a CIA spy who will be leading them to the firing chamber instead?

I agree this is a possibility and a strong argument. Against it I can only say that many of the psychotic people who don’t want to go to mental hospitals are dragged there anyway, and usually continue to not want to be in the mental hospital after they get there and learn what it is like.

An example from my own life might serve to clarify the odd mix of rational and irrational decision-making I think characterizes these choices. When I was a child, my OCD was much worse. I would do things like close every shutter in my room nine times. I won’t say this was the most rational thing to be doing. But if you with your superior rationality had come in and chained me to my bed so that I couldn’t close my shutters, I would have spent the entire night freaking out because my shutters hadn’t been closed the appropriate nine times and that meant the world was unbearably wrong. Given a mind that will freak out for a whole night if the shutters aren’t closed, and supposing for a second that curing the underlying OCD is not an option, then spending a minute closing the shutters is a perfectly rational decision. Likewise, given the weird collections of fears and sensitivities that characterize the typical psychotic, staying out of a psychiatric hospital may be a perfectly rational decision. And this is even granting the extremely dubious premise that the hospital is not abusive, is not disgusting, is not dictatorial, doesn’t involve drugs with terrible side effects, or any of the other hundred ways a psychiatric hospital can be bad even when your judgment is perfectly intact.

I recently learned many of the homeless in nicer cities have laptops. This makes sense – laptops are really cheap these days, way cheaper than houses, and you can carry them around with you on your back. Psychiatric hospitals, in contrast, do not have laptops. Even if you own a laptop, you may not bring it in, since it is theoretically Usable As A Weapon. You may not bring a cell phone, a tablet or any other form of communication device. Some of the very nice psychiatric hospitals, including the one I work at, have a single computer for thirty residents, which you may use for fifteen minutes a day, with a nurse watching you the whole time to make sure you don’t go on any sites that seem likely to make you upset or emotional. This fact alone makes me, personally, with my as far as I can tell totally intact mind, prefer the thought of homelessness to the thought of lifetime institutionalization. My computer is my only lifeline to most of my friends and the only way I have to express myself, and the thought of trading that away just so I can have a warm bed seems – pardon the expression – insane.

And for me it’s the computer. For other people it’s other things, reasonable by our standards or not. A few weeks ago I was woken up by a call in the middle of the night. A newly admitted patient at the mental hospital where I work was making a scene. She had this thing about using her special pillowcase, and pillowcases weren’t on the hospital’s Special List Of Things It Is Okay To Bring In. Sheets? Absolutely. Blankets? Totally fine. Pillows? Knock yourself out. But nobody had thought about pillowcases, so they were officially banned. And I made it to the hospital, still half-asleep, and for a second I couldn’t figure out who was the crazy person, the woman making a William Wallace-esque stand for the right to bring her pillowcase into a hospital, or the woman telling her absolutely not, because it wasn’t on the Magic List. Eventually I asked the nurse if maybe we could just sort of pretend the pillowcase was a very small sheet, and she said that if I specifically ordered her to do so she wasn’t able to contradict a doctor’s orders, and the problem was solved. By which I mean that by the time she figured out something else she needed, my shift would be over and it would be someone else’s problem. Because everything in a mental hospital is like this all the time.

So am I okay with this causing some people to freeze to death? Yes. I don’t think we can be sufficiently sure that institutionalizing schizophrenics is in their own best interest to overcome the burden of proof necessary for overriding someone’s revealed preferences. So if respecting people’s revealed preferences mean some of them go homeless or die, so be it. God help us if we ever systematically decide that people should not be allowed their freedom if the decision carries any discomfort or risk.

I want to stress just how important a decision this is. Back before deinstitutionalization, there were about 500,000 people in US psychiatric institutions, with varying degrees of permanency. Given the increase in the population and mental illness, I expect there are up to a million potentially institutionalizable individuals today. If institutionalization costs the average psychotic 1/3 of a QALY per year (eg moving from poverty to imprisonment on this table) then we’re taking away 300,000 QALYs every year indefinitely. On the other hand, if institutionalization were better for psychotics, they could potentially gain a similar number of QALYs. That makes policy decisions in this area potentially more important than crime, more important than terrorism, more important than education, potentially more important than everything except health care, not starting too many wars, and mass incarceration full stop. These kinds of decisions are the ones you want to be really, really sure about. So far, nothing in My Brother Ron has given me the level of certainty I would need.

I agree kids should have a right to use public libraries without having mentally ill people urinate on them or scream at them. I think the solution in this case is to tell the ACLU to take a chill pill and then let librarians enforce common-sense decency rules, not to lock up a million people for the rest of their lives.

V.

So that leaves the question – what do we do with all of these psychotic people starving on the street? Saying “leave them alone” is all nice and well, but what if they start seeming violent or threatening? Do we leave them alone until the point at which they commit a major crime and they end up in prison for the rest of their lives? What if they’re clearly acting recklessly and about to die? What if we have evidence (maybe from past experience) that they would prefer to be sane and medicated but they’re too far gone to realize it?

The book itself mentions my preferred answer to this conundrum: involuntary outpatient commitment (IOC). This is exactly what it sounds like. If you, let’s say, start trespassing on government property and yelling at police officers (a common way for mentally ill people to come to the attention of the system), and you get brought before a sympathetic judge who wants to help you and doesn’t want to lock you up but would prefer you not do that anymore, he can order an outpatient commitment. This means you’re legally required to see a psychiatrist every so often and maybe get injected with long-acting antipsychotic medication (usually once per month, although I think they’ve recently invented a once-every-three-months version now).

I have seen psychotic patients involved in such programs and they usually do very well. They get the same level of treatment they would in a psychiatric hospital, people will come hunt them down to make sure they don’t miss their appointments or medication dosings, and in the interim they can live wherever they want in whatever conditions they want. If the medications work, which they usually do, then they are hopefully clear-headed enough to either hold down a job or use their disability payments responsibly. If they can’t do that, then it’s probably for the same reason that normal poor people can’t, and nobody says they need to be institutionalized.

Cramer notes that people in IOC programs have half the suicidality rates, half the crime rates, and “substantial reductions in hospitalization, homelessness, arrest, and incarceration.” They are half as likely to be hospitalized, half as likely to be victims of crimes, and “enjoy improved quality of life”.

This isn’t as good as, say, one-tenth the suicidality and hospitalization rates would be. But psychiatry isn’t a discipline with very many miracles. Sometimes the drugs work and sometimes they don’t. Long-term psychotics are notoriously difficult to treat and this is probably about as well as they would be doing in a long-term institution anyway.

Cramer brings this up as part of his political polemic – apparently the same hippies who oppose everything else opposed IOCs, so their success is part of the Grand Narrative Of Hippies Being Proven Wrong. I like hippie-bashing as much as anyone else, but I don’t understand why he doesn’t take this further, say that this is the alternative to reinstitutionalization that he secretly knows we need. He points out that the main reason IOCs are underused is that psychiatrists don’t know about them – I would add that at least in my county there isn’t enough funding to refer enough patients to the program and monitor their medication compliance and so on. But I guarantee you that publicizing the option to psychiatrists and expanding the program is a lot cheaper than reinstitutionalizing people would be.

(my hospital charges $1,000/day/inpatient, though goodness only knows how much of that insurance companies actually pay. Cramer notes that the prison system usually costs $50,000/year/mentally ill prisoner. My guess is that the costs of institutionalization are somewhere around that order of magnitude.)

So in my ideal world, psychotic people who aren’t bothering anybody can do what they want – preferably with the option of voluntary psychiatric hospitalization available, and with some pressure to at least try it once and get a feel for what it’s like. Psychotic people who are bothering other people can get outpatient treatment once every couple of months and remain medicated and monitored by professionals. Preferably there would also be some kind of concept of a psychiatric living will – that is, some way for people who are not yet mentally ill, or who are currently being managed on drugs, to express a wish to be stabilized if they ever become mentally ill so that they can make their long-run choices from a position of sanity.

I acknowledge this is not the ideal world. I acknowledge there are some people who really need institutionalization – people who are constantly violent, who have zero concept of social rules and will scream at anyone they meet, people who are catatonic or need extraordinarily complicated medication regimens that can’t be handled in a normal environment. I’ve referred some of these people to involuntary long-term institutions (which still exist for these kinds of extreme situations), I don’t feel guilty at all, and in most cases I am pretty sure the general public would be pretty grateful to me if they knew the gory details.

But for a million people, most of whom aren’t bothering anybody and just want to be able to live a half-decent life outside the walls of a locked facility? There has to be a better solution than that.