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Book Review: My Brother Ron

[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]


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.


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.


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.


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.


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.

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427 Responses to Book Review: My Brother Ron

  1. Douglas Knight says:


    5x committment → commitment

    ruban → urban
    That’s the one sent me off looking for these because I read it as rural!

    idiosyncracies → idiosyncrasies ; hav → have ; fo → of ; disproporationately → disproportionately ; whateterver → whatever ; sympthathetic → sympathetic ; COmmunity → Community ; treament → treatment ; contigent → contingent ; frefused → refused ; behaviora → behavior ; homseless → homeless ; prohitibing → prohibiting

    • Julie K says:

      Also: 40$ had -> 40% had

    • John Ohno says:

      Also “many untreated or unsuccessfully schizophrenics” should probably be “many untreated or unsuccessfully treated schizophrenics”.

    • Steve Sailer says:

      “Thomas Szaszszsz”

      Once you start hitting those keys, it’s hard to stop!

      • Tracy W says:

        Obg Pratchett: “She knew how to spell banana. She just didn’t know how to stop.”

      • Anonymoose says:

        I thought this was a joke, I’ve seen him make it before.

        • Julie K says:

          Obviously it’s a joke.
          Personally, having grown up with a surname that was always being spelled and pronounced wrong, I don’t think it’s a very funny joke. (I won’t go SJW and call it ethnocentric…)

          • Nita says:

            I don’t even understand what’s so odd about Szasz’s name, to an English speaker. English also has these weird two-letter consonants, like “th”, “ck”, “gh”, “sh” and so oh. Is “Thoth” also funny? Thoththththth?

          • FullMeta_Rationalist says:

            {“th”, “ck”, “gh”, “sh”, etc} are all common digraphs. They correspond to a single sound. And they’re used frequently enough that English speakers have become desensitized to them.

            “sz” does not map to any cached digraph. So my first instinct is to imagine the “s” and “z” as distinct consonants “s-z-a-s-z” . The resulting awkwardness of alternating between the two (distinct but similar) consonants feels little jarring.

            Furthermore, my second instinct is to imagine a prolonged sibilance. The end result is to pronounce Szasz as an unnecessarily long buzzing sound “z-z-z-z-z-z-z-z” with a random {intonation?} somewhere in the middle where the “a” is.


            “Mental illness is but a fiction” said Thomas with pizzazz.

          • Steve Sailer says:

            “Is “Thoth” also funny?”


        • Vaniver says:

          Yeah, he edited the previous post to go from spelling it a different way every time to spelling it this way (with the repeated ‘sz’ the first time, then normally thereafter).

    • There’s also an instance of CHMC for CMHC.

  2. Wilj says:

    “…a population that has a high (though less than 50 percent!) risk of committing some kind of crime in the future.” — wait, the mentally ill (or just schizophrenics?) have anywhere near a 50% chance of commiting a crime? That sounds pretty high.

    I’m betting a few particular illnesses account for most of this, though I wonder if this is counting, e.g., shoplifting, and what kind of crimes are most represented.

    A quick Google suggests that about 30% of all Americans probably have some kind of police record and ~9% have a felony, so maybe that number isn’t so high after all, if it’s not felonies. (If it is, that number for African-Americans is 30%, which might be ammo against the institutionalization argument.)

    • Scott Alexander says:

      Not implying that it’s near 50%, just that it’s less than that.

    • Lambert says:

      There exists positive association between schizophrenia and criminality, but P(criminal|schizophrenic) is still well under 50% due to P(criminal) being low.

      • Earthly Knight says:

        This inference is fallacious, P(A|B) can be high even when P(A) is low, or zero. E.g. the unconditional probability of Ted being from Kiribati is negligible, while the conditional probability of Ted being from Kiribati given that his island home is being reclaimed by the sea is high. Remember that P(A|B) is (loosely) the proportion of B which is also A, so knowing what proportion A is of the whole probability space is unhelpful.

        • Jon M says:


          “This inference is fallacious, P(A|B) can be high even when P(A) is low, or zero.”

          P(A|B) by definition cannot be high if P(A) is zero unless P(B) is also zero.

          P(A) >= P(B)P(A|B)

          Otherwise agree with your point though.

    • Deiseach says:

      My experience with paranoid schizophrenia is the social housing client I have mentioned here before. On her meds, she’s a perfectly nice woman. Off her meds, she’s still a perfectly nice woman but she is not rational. She’s not violent, she’s not criminal, but she is not right in the head.

      This leads to multiple phone calls per day (she had to be banned from coming in to the offices) about things like the neighbours stealing her keys, breaking into her house and ripping up her clothes and smearing chocolate on the walls, we the council putting cameras down the drain that come up in her bathroom to spy on her for the government, etc. She lost her job because her illness made her unable to keep to it. I don’t know much about her family circumstances apart from they can’t cope with her (whether it’s because she won’t let them help or not, I don’t know).

      She has to then go to the local psychiatric hospital for a respite stay until she gets back on her meds and evens out. This is a regular cycle and it does make me wonder if something like half-way houses or supported accommodation or something would be better than simply leaving people back into the community with “Here’s your prescription, keep taking the tablets, there you go, good luck with life!” Letting people rely on the support of their community is a great idea in theory, but what if there’s no support because (as above) you’ve burned all your bridges by accusing your neighbours of being spies and vandals and thieves? How many people on here could cope with regular accusations of breaking into someone’s home and damaging their property, even if the cops only made that one visit that time and now they know the score?

    • Chris says:

      Well, according to this book, the population of people who commit three felonies a day is everyone.

      • John Schilling says:

        That book correctly notes that the United States (and probably most developed nations) has more laws than anyone can keep track of, with the result that there are lots of people committing nominally serious crimes without anyone noticing. And that this can be abused by prosecutors who want to lock up people that nobody but their political enemies wants to see locked up. But it does not support and I suspect the author completely made up the bit about “three felonies a day”. Or saw it on the internet or heard some guy say it in a talk or whatnot.

      • Anonymous says:

        From one of the amazon reviews:

        “The product description of this book on (the US site) starts by claiming that “The average professional in this country wakes up in the morning, goes to work, comes home, eats dinner, and then goes to sleep, unaware that he or she has likely committed several federal crimes that day”. So I was keen to find out what crimes these might be, that ordinary people were unconsciously committing in such profusion. Sadly, that is something you cannot learn by reading this book. As far as I can ascertain, there is literally no mention of “three crimes a day” or anything similar on any of its pages, from the foreword by Alan M Dershowitz to the index. The quotes published on the book’s jacket are much more accurate: “Now comes veteran defense lawyer and civil libertarian Harvey A. Silverglate… exposing… a pattern of serious abuses and convictions of innocent people in some of the most famous (as well as obscure) federal cases of recent decades”… “…Silverglate has written a work peerless in revelations about the mad expansion of federal statutes whose result is to define, as criminal, practices no rational citizen would have viewed as illegal…”…”…federal prosecutors have conceived of something truly frightening – punishment without crime…””

        That’s pretty heinous false advertising 🙁

  3. Two comments:

    Thomas Szasz was not a leftist, he was a libertarian. What you say about him is not consistent with what I know of his views–if you haven’t read any of his books you probably should find one. His view, as best I can tell, was not that there were no crazy people but that mental illness was a misleading metaphor. I doubt that he would have substantially disapproved of the policy you recommend.

    The wife of an old friend of mine, an attorney, at one time was working for the mental health department of a southern state. Her job, as she described it, largely consisted of preventing people who wanted to transfer the cost of taking care of an elderly relative to the state by getting the relative committed.

    • Wilj says:

      (Great blog, btw!)

      From my reading (admittedly, largely of excerpts), Szasz did deny the existence of the mentally ill, in large part. He didn’t deny their abnormal behavior, but rather their illness, proclaiming that they’re “badly mistaken, ignorant, stupid, misled, upset — but […] not sick like with pneumonia.”

      So no one’s bipolar or depressed, for example; they’re just responding to the stresses of their situation, or dumb or confused. There are no mentally ill people, just normal(?) people who have other problems.

      He didn’t deny the existence of brain tumors or the like, I think, but his stance is still very puzzling to me. “So you would treat [this depressed woman] with drugs? Is feeling miserable […] a form of illness?!” Well… yeah, if it’s consistent. Why wouldn’t the brain be subject to abnormality and illness as much as the lungs?

      • Deiseach says:

        R.D. Laing appeared on an Irish chat show in the mid-80s and was in a state that led the interviewer to accuse him of being drunk.

        It’s hard to say whether he had drink taken, was merely tired and stressed, or this was his normal way of behaving (as he claimed); I remember watching this with my parents (back int the days when everyone in Ireland watched “The Late Late Show”) and he certainly did seem a bit “off”.

        “Intelligent but troubled” was the impression I got 🙂

      • Deiseach says:

        Okay, so depression is not an illness as such, it’s a sensible reaction to the stresses of the circumstances you find yourself under. Just as nobody would say to someone with, for example, hayfever “You’re ill, you’re diseased” but rather “You’re perfectly normal, you just are over-sensitised to this particular environmental factor”.

        Fine and dandy. But you’d still give anti-histamines to someone with bad hayfever so they could see and breathe and stop coming out in big itchy hives on their skin, even if that is only treating the symptoms and not the cause (eradicate all grasses and pollen-bearing plants!)

        So why the hell wouldn’t you give depressed people anti-depressants, even if that is only treating the symptoms and not the cause?

        • Wilj says:

          This seems spot-on to me.

        • caryatis says:

          One criticism would be that giving people anti-depressants (or talk therapy for that matter) tends to focus their attention on themselves and their “illness,” when a change in life circumstances might leave them happier and more sustainably better off.

  4. suntzuanime says:

    Isn’t institutionalizing the poor something they used to do, with like workhouses &c.?

    • Sviga Lae says:

      I recall this being covered somewhat in Foucault’s ‘A History of Madness’.

      See also The Last Psychiatrist’s many topical rants about the modern-day role of psychiatry as an overflow mechanism for insoluble social and economic problems.

      • bbartlog says:

        Foucault is a good read but not at all reliable as a historian. The most well-known instance is his complete fabrication of the ‘ship of fools’ as an actual method of dealing with the deranged (in ‘Madness and Civilization’), but this is just the most obvious example of a tendency to regard the truth as less important than the overall story.

  5. While there’s still a chance of you seeing this, I wanted to note that the folks I know from Appalachia consider “Hillbilly” a rather offensive slur. I don’t know if everyone does or what the general consensus is, but I consider you the kind of person who wouldn’t want to use slurs, and I recall the word coming up in a recent post.

    On topic: If cities are potentially making people mentally ill, has anyone tried moving mentally ill people to places with more nature/out in the countryside?

    • Z says:

      People from the Ozarks also tend to see the word “Hillbilly” as a slur, at least when used by outsiders. Although the tone with which the word is used is much more important than the word itself. I typically hear it from urbanites in a context which is explicitly meant to be insulting.

    • Garr says:

      I’ve used the word when referring to Carter-Family-type music (which I really like a lot) because “Folk Music” suggests Phil Ochs or Joanie Mitchell and “Old-Timey” doesn’t necessary mean anything specific to people. People might know what you’re talking about when you say “Hillbilly Music”. But that would annoy the guys whose grandparents played it?

    • stillnotking says:

      The sports teams of my mom’s high school in Man, West Virginia are known as the Hillbillies. Several businesses in my own home town had “hillbilly” in their names. It’s not an offensive term in WV, though it is sometimes used ironically. (“I’m just a dumb hillbilly, what do I know?”)

      The offensive version — as of about twenty years ago, anyway; I don’t know what the kids are saying now — is “grit”, which connotes “dirty, uneducated, inbred asshole”, and would never be self-applied.

    • Deiseach says:

      On topic: If cities are potentially making people mentally ill, has anyone tried moving mentally ill people to places with more nature/out in the countryside?

      Geel (formerly spelled Gheel) in Belgium, due to the links with St Dymphna, Irish saint who is patroness of the mentally ill (“St. Dymphna is the patron saint of the nervous, emotionally disturbed, mentally ill, and those who suffer neurological disorders – and, consequently, of psychologists, psychiatrists, and neurologists. She is also the patron saint of victims of incest.”)

      People came on pilgrimage to her shrine, including a lot of people who were looking for (or their families on their behalf were looking for) a cure for their mental illness. This led to a religious foundation being established to house them, and gradually to the model of “care in the community”.

      From the article on St Dymphna:

      In 1349 a church honouring Saint Dymphna was built in Geel. By 1480, so many pilgrims were coming from all over Europe, seeking treatment for the mentally ill, that the church housing for them was expanded. Soon the sanctuary for the mad was again full to overflowing, and the townspeople began taking them into their own homes. Thus began a tradition for the ongoing care of the mentally ill that has endured for over 700 years and is still studied and envied today. Patients were, and still are, taken into the inhabitants of Geel’s homes. Never called patients, they are called boarders, and are treated as ordinary and useful members of the town. They are treated as members of the host family. They work, most often in menial labour, and in return, they become part of the community. Some stay a few months, some decades, some for their entire lives. At its peak in the 1930s, over 4,000 ‘boarders’ were housed with the town’s inhabitants.

      From the article on Geel:

      Geel is well known for the early adoption of de-institutionalization in psychiatric care. This practice is based on the positive effects that placement in a host family gives the patient, most importantly access to family life that would otherwise have been denied. The legendary 7th-century Saint Dymphna, who had moved to the Geel area from Ireland, is usually credited for this type of care. The earliest Geel infirmary and the model where patients go into town, interact with the community during the day, and return to the hospital at night to sleep, date from the 13th century.

      Originally, this practice was religiously motivated and organized by a chapter of canons, attached to the church of Saint Dymphna. By the 18th century, however, the placement of patients was mostly done directly, without the intervention of the canons. The number of patients grew in proportion to the growing city’s reputation abroad and the economic benefits flowing to the city provided further motivation to the inhabitants. Attracted by the gentle care of patients, Vincent van Gogh’s father considered sending his famous son to Geel in 1879. The high point came in 1938, with a total of 3,736 placed patients, compared with only 700 a hundred years earlier.

      This novel type of psychiatric care was evaluated by various other institutions around the world (see for instance Eastern State Hospital in Virginia), but often seen as too revolutionary to implement. It is only in the early 20th century that the idea of deinstitutionalization was adopted more widely elsewhere. Today, a modern psychiatric centre stands on the place of the old infirmary, and close to 500 patients are still placed with inhabitants.

      • TheAncientGeek says:

        I’ve heard of this in connection with my beer obsession. When I was living in Belgium, I used to beer-hunt in my spare time, using a trusty and tattered copy of the Guide compiled by NHS psychiatrist Tim Webb in *his* spare time (shrinks and their copious free time..). Anyway, he mentioned Geel’s unique arrangement as a side note to its beer cafe.

    • Gbdub says:

      I guess I’d always thought of “hillbilly” as more like “redneck”, potentially insulting but not necessarily a slur, and potentially even a label of pride, depending on context.

      For those that take it as a slur, what is the non-slur preferred term? “Hillbilly” does seem to capture a certain culture that’s worth having a name for.

      • stillnotking says:

        “Redneck” is definitely more derogatory than “hillbilly”. The New South has (sort of) reclaimed “redneck” as defiant cultural signaling, often by people who would not have been regarded as rednecks in previous generations, but “hillbilly” has always meant freedom and self-sufficiency as well as rural isolation.

        • Held in Escrow says:

          So I have a lot of friends who live in the Appalachian area and would fit under the traditional idea of a “hillbilly.” They go by redneck. It’s just what you refer to their culture by; there’s no slur involved and its used in a completely neutral fashion (such as when we go camping we call it going rednecking as I’m a dirty city slicker).

          I mean, you don’t just go in and call them a bunch of rednecks with a slur to your voice and a New York accent, but you wouldn’t do that with most ethnic groups either

        • nydwracu says:


          I believe the Blue Tribe term is “reclaimed slur”.

      • Agronomous says:

        …what is the non-slur preferred term?

        “Sons of the Soil” — but it ain’t gonna happen.

      • houseboatonstyx says:

        @ gbdub
        “Hillbilly” does seem to capture a certain culture that’s worth having a name for.

        Couldn’t say for sure, but Suzette Hayden Elgin’s blog might could be a pretty good place a person could take a look.

      • “Appalachians” seems to work.

    • Scott Alexander says:

      Did I use “hillbilly”? A search doesn’t find it in the text above.

      • Vaniver says:

        A search on the whole site finds it here most recently, as well as earlier posts. Perhaps they were assuming that commenting on the most recent post was the best way to reach you, even if the prompt was elsewhere?

      • Sorry for the confusion. As Vaniver said, not this post, just recently. I just didn’t think a post buried near the end of a 300+ comment thread would get read.

  6. J says:

    Glad to hear your OCD has gotten better. I’ve heard that keeping a hair dryer in the car with you can really help. (And speaking of OCD, I still worry about that poor man who slipped in the shower and now has chest pain. Did he pull through?)

  7. Douglas Knight says:

    remember, before penicillin syphilis was a common incurable disease that usually caused insanity in its final stages

    This is an example where the mental illness really was iatrogenic.

    • Mary says:

      The treatments could be unpleasant and harmful, but no, syphilis really does cause insanity in its final stages.

    • Scott Alexander says:

      How so?

      • Douglas Knight says:

        Mercury, I guess. But you have to establish the general before you can explore the specific.

        • Scott Alexander says:

          I’m confused. What does mercury have to do with neurosyphilis?

          • bean says:

            I think he thinks that syphilis itself doesn’t actually drive people mad, and was instead suggesting that the treatments used were responsible.

          • John Schilling says:

            From about 1500 to as late as 1915, if you were diagnosed as suffering from syphilis (neuro or otherwise), there was a good chance that some well-meaning physician would dose you with mercury vapor or various mercury compounds on account of it being common medical knowledge that this was helpful. And you’d eventually go insane, but it was common knowledge that syphilis causes insanity and, trust us, it would be worse without the mercury.

          • Deiseach says:

            John Schilling is right about mercury as a treatment for venereal disease. It did have some efficacy, problem was, like all New Wonder Drugs, it got over-prescribed for everything (because hey, if it cures X could it be any use for Y?) and naturally nobody knew much about heavy metal poisoning.

            I found this out reading about Paracelsus – I’m surprised you never heard that, Scott, is there no general ‘history of medicine’ class where they tell baby doctors in training about the predecessors in the field? Alternately, this just reinforces my opinion that STEM types need more exposure to history/humanities 🙂

          • bean says:

            Where did you get the impression that doctors were STEM types? Pre-med may or may not be STEM, but med school definitely isn’t.

          • wysinwyg says:


            is there no general ‘history of medicine’ class where they tell baby doctors in training about the predecessors in the field?

            Nope, and scientists don’t get exposed to the history of science, as adequately demonstrated by e.g. Kuhn or Feyerabend.

            And there’s a reason for it. Med schools and STEM grad schools are cultures, and part of culture is mythology. It becomes much harder to buy into such a mythology when your history class exposes you to hard evidence that the mythology is false in some important respect.

          • nil says:

            The history of psychology was a pretty significant part of my undergrad psych education, fwiw

          • JayT says:

            I was in school about 15 years ago getting degrees in computer science and math, and I had to take at least four semesters worth of science history and/or ethics. I went to a mediocre state university, so I would have a hard time believing that it was particularly progressive on that front.

          • JayT says:

            Possibly, but my friends that were physics or engineering majors had to take similar classes. My wife was a biology and chemistry student (at a different University) and she also had similar classes. I’m not sure what STEM field doesn’t require at least some history and ethics study.

            That said, all of my experience is with California schools, so perhaps on the East Coast or Midwest it is different.

          • Nornagest says:

            It becomes much harder to buy into such a mythology when your history class exposes you to hard evidence that the mythology is false in some important respect.

            I kinda have the feeling that I’m getting trolled, but what hard evidence would that be?

          • hlynkacg says:

            That ancient peoples did not have the technology to build the pyramids, clearly they had help form aliens.

          • Nornagest says:


  8. God Damn John Jay says:

    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

    Differential Diagnosis is hard, Lets go Complaining!

  9. drethelin says:

    I feel like an important point in discussing the growth of mental illness as a proportion of people is the ENORMOUS growth in complexity of every day life. There are deficiencies that would barely matter (or even be an advantage) 2 or 3 centuries ago that are near-crippling illnesses in a modern workplace. Many of what we would consider even the most menial/easy jobs require strict timekeeping, maintaining a very consistent schedule, and driving yourself or navigating a transit system miles every day. Not only that, but the density of modern living means there is a lot less room for acting out even outside the context of needing a job. With paranoia, you go from a situation where you need to know and trust maybe a few dozen people to potentially meeting and getting into altercations with hundreds in one DAY. There are behaviors that are annoying in a village with horses that become downright deadly in a city with cars, which necessitate far more interference from police/mental institutions.

    Whether or not cities make people mentally ill, I definitely think they would bring a lot of mental illnesses to the fore.

    • Ari says:

      I agree with cities part. I hate travelling long distances and not that eager to interact with a lot of people I don’t know. The more older I get wish for more of a community and smaller place to live. Sadly a lot of job opportunities are in big cities which I so dread.

    • TheAncientGeek says:

      Whence the original idea of an asylum as an asylum… as a peaceful respite, rather than a warehouse. They at least understood that lowering stress generally make things better. But you can ruin anything with cost cutting.

      Whence also the blandification of modern life..if you don’t know all the quirks and triggers of all the 1000 people you are going to meet in a day, and you dont, then you need to stick within a narrow window.

      • Murphy says:

        I’m not sure that was ever the original idea.

        The history of the Bethlem Royal Hospital (Bedlam), pretty much the oldest asylum, is probably relevant.

        It made quite a bit of money from paying visitors who came to see the inmates as a form of entertainment or as some kind of moral warning (back then they liked to attribute mental health problems to moral failings)

        “[there is no] better lesson [to] be taught us in any part of the globe than in this school of misery. Here we may see the mighty reasoners of the earth, below even the insects that crawl upon it; and from so humbling a sight we may learn to moderate our pride, and to keep those passions within bounds, which if too much indulged, would drive reason from her seat, and level us with the wretches of this unhappy mansion”

        Depressingly it’s claimed that the people in the asylum were abused far less when members of the public were coming to view them like a freak show. When public visitors stopped so did pretty much all public oversight.

        • There were, however, asylums with treatment philosophies in explicit opposition to that of Bedlam as early as 1796 (e.g. the Quaker-run York Retreat).

        • Addict says:

          Did you read the recently-discovered Hooke monogram on mania and meloncholia, written during his time at bedlam?

          The actual thesis isn’t any good, but there are tons of observations he made of the inmates and staff and policy whenever he got distracted from his research

        • TheAncientGeek says:

          What I was trying to get at was that whether you got the Bedlam treatment or not would depend on your ability to pay. George III certainly didn’t.

    • jaimeastorga2000 says:

      Don’t forget credentialism.

      Maybe the Amish are right after all?

      • FullMeta_Rationalist says:

        Recently, I was skimming Reader’s Digest when I came across a legal case regarding Telemedicine. A retired Texan veterinarian was giving advice over the phone. He lost the case, supposedly because advice-via-web (or telephone) doesn’t establish a doctor-patient relationship.

        I thought Scott might find it interesting. I couldn’t find the original article online, but here’s a much shorter article.

        • wysinwyg says:

          Now there are CPT codes for phone and online consultations. As long as you bill under one of those codes, it would almost certainly establish a doctor-patient relationship.

        • Cliff says:

          I don’t think that’s why he lost. There was a state level restriction on providing veterinary care without seeing the patient. He argued he was just providing information, then that the rule violated his freedom of speech.

      • LeeEsq says:

        There is always a catch. The days in the past, where a person could be hired because the employer liked his moxy rather than because of any particular qualifications, mainly benefited white men. If you weren’t a man and you weren’t white or at least not white enough than getting hired by sheer gumption was unlikely. There was also a much bigger and more official old boy’s network to help those born on the top. Credentials might not have mattered but your birth did and often gave you credentials.

        Another thing is that it is much easier to do background checks these days. Maybe employers had to go by moxy because they couldn’t really investigate potential employees too much without spending a lot of money and time. These days checking up on people is much easier and this leads to more credentialism.

      • onyomi says:

        Given that libertarianism basically just means “always let uber” exist, I still don’t understand why Scott is not a libertarian.

        My theory as to why everyone else, including young people who enjoy things like uber, is not: a kind of bias toward authority and hierarchy: “you can’t just go out and start doing things. You didn’t go through the proper channels!”

        • Samuel Skinner says:

          Probably the same reason he isn’t a feminist- because the term is so broad it isn’t useful for telling people what he actually believes.

        • wysinwyg says:

          My impression is that “libertarianism” denotes a complete rationalistic system of ethics involving a great many premises, some of which seem quite shaky to me.

          While a lot of the pragmatic conclusions of libertarians seem sound to me, the whole philosophy does not.

          Also, “libertarian” can be sort of divided between a philosophical and political position. I don’t think the two are consistent — I think in many cases “political libertarianism” is just “give more power to whoever already has power by undermining the access of the powerless to the government”, which is not necessarily consistent with the philosophy. (If it is consistent with the philosophy, that’s even more reason I want little to do with the philosophy.)

          Your theory is pretty self-serving — “those stupid libs just want someone to tell them what to do because they’re too lazy and morally weak to decide for themselves and take risks”. That should be a good hint to go look for evidence against it.

          • Gbdub says:

            Self serving? Pot meet kettle. I could just as easily describe political progressivism as: “give more power to those that already have it by giving ever more authority to the government, ensuring only the politically favored may succeed”.

            Neither is particularly fair, but I suppose they make handy grass-based anthropomorphs to slaughter.

          • Nita says:

            @ Gdub

            These are not symmetrical:

            (i) I do X, but they don’t, because they have an irrational bias.
            (ii) They do X, but I don’t, because I think it leads to bad consequences.

          • onyomi says:

            Okay, if he agrees with most of the practical conclusions of libertarianism without necessarily buying into the whole undergirding philosophy, I would still think he’d vote for Gary Johnson rather than Hillary Clinton. Unless he is just voting for Hillary to vote against Trump. Though it is not entirely clear to me that Trump is more libertarian than Hillary (I tend to think he is); it is pretty clear to me that Cruz is.

            I’m not trying to say, “Scott, why won’t you vote for the person *I* like???” I’m just saying his stated prediction–something like 90%, I believe–that he will vote for Hillary doesn’t reconcile well–in my head, at least–with his views on issues like economic freedom.

          • wysinwyg says:


            Self serving? Pot meet kettle.

            For the record, “tu quoque” is never a valid rebuttal.

            But in this case, it’s not even justified since I’m not theorizing about the secret unconscious motivations of libertarians — merely about the (most likely unintended) effects of their favored policies.

          • “My impression is that “libertarianism” denotes a complete rationalistic system of ethics involving a great many premises, some of which seem quite shaky to me.”

            There are surely libertarians who see it that way. But different libertarians differ quite a lot on the basis for their conclusions and somewhat on the conclusions themselves.

            There are, after all, both Christian libertarians and atheist libertarians. Ayn Rand attacked libertarians for not having the proper philosophical basis (hers), but I think most libertarians regard Rand and her followers as themselves libertarians, even if she, and some of them, deny it.

            I think it is more useful to define libertarians by the conclusion—roughly speaking wanting a much smaller and less powerful government (or no government) and a society structured primarily by voluntary association with institutions of private property and trade.

            And I think it’s a mistake to think of “libertarian” as a binary category–you are or are not. You can be more libertarians or less, libertarian in some ways and not others. Scott comes across as more libertarian than most, and the most obvious position he holds inconsistent with the views of most libertarians, support for a basic income, is also argued by the bleeding heart libertarians, a group within the movement.

          • gbdub says:

            If you intended your description of libertarianism ( just “give more power to whoever already has power by undermining the access of the powerless to the government”) as an example of an unintended consequence, than I apologize. The tone of your post did not give me that impression – it read to me like you were impugning the motives of political libertarians (e.g. “They claim they care about freedom, but really they just use that as cover to secure their own power!”).

            Anyway “the pot calling the kettle black” is not really tu quoque, which is basically an irrelevant claim of hypocrisy. In this case, you were criticizing onyomi’s argument as self serving. I was merely calling (my apparently flawed reading of) your argument also self-serving. If “self-serving” is a valid critique of a premise, it is fair for me to use it against your logic as well.

          • Vox Imperatoris says:

            It’s not the worst rule in the world, but it’s not a very good rule.

            “You shouldn’t smoke.”

            “But you yourself smoke!”

            “So what? That doesn’t make it a good idea to smoke. As a smoker, I know just how bad it is for you.”

            As Samuel Johnson put it:

            It is not difficult to conceive, however, that for many reasons a man writes much better than he lives. For, without entering into refined speculations, it may be shown much easier to design than to perform. A man proposes his schemes of life in a state of abstraction and disengagement, exempt from the enticements of hope, the solicitations of affection, the importunities of appetite, or the depressions of fear, and is in the same state with him that teaches upon land the art of navigation, to whom the sea is always smooth, and the wind always prosperous… We are, therefore, not to wonder that most fail, amidst tumult and snares and danger, in the observance of those precepts, which they laid down in solitude, safety, and tranquility, with a mind unbiased, and with liberty unobstructed… Nothing is more unjust, however common, than to charge with hypocrisy him that expresses zeal for those virtues which he neglects to practice; since he may be sincerely convinced of the advantages of conquering his passions, without having yet obtained the victory.

          • Said Achmiz says:

            @Mark Atwood:

            What is your opinion on “I don’t practice what I preach because I’m not the kind of person I’m preaching to”?

          • gbdub says:

            @Vox – Your smoker example is fine, but that’s still not what I did, and it’s not pot-meet-kettle either.

            Pot: Look at you kettle! You are covered in soot, and things that are covered in soot are bad. Therefore, I am better than you. Ha ha.

            Kettle: But pot, you too are covered in soot! Does that not also make you bad?

            That’s perfectly reasonable! If being covered in soot is bad, then a pot and a kettle equally covered in soot are equally bad, and neither can be preferred over the other (or if a premise being self-serving is inherently bad, then another self-serving premise is also bad). The point of tu quoque as a fallacy is that it is essentially a specific form of ad hominem when in reality, the personal foibles of the arguer should not affect the truth or falsity of the argument.

            Here’s kettle actually committing tu quoque:
            Pot: Being covered in soot is bad, and if you are, you should clean yourself.

            Kettle: But pot! You’re covered in soot! So being soot-covered must be good.

            I generally agree with you re: Mark Atwood’s point. Failure of someone to follow their own advice doesn’t automatically render their advice without merit. It may just be a virtuous but difficult path. Then again, if someone is hypercritical of others for failing to heed their advice, but conspicuously fails to make any serious effort to follow it themselves – well, at some point I think it does become fair to at least question their motives for bringing up the point so often. True hypocrisy is overdiagnosed, but real (hence the motes and beams – the problem is not that you’re wrong to point out a mote, it’s that you shouldn’t be a jerk about it when you’ve got your own beam).

          • onyomi says:

            The problem with he who expresses zeal for the virtues he himself fails to practice is that, as Wang Yangming put it, knowledge and practice are inseparable.

            For example, I’m going to be skeptical of the advice of an obese nutritionist or athletic trainer. He may say that he knows what do but simply lacks the time, will power, resources, etc. to do it, but in my view, knowing how to get something done is part of knowing how to do it.

            On this view, a formerly obese thin person is actually a better diet guru than a person who was always thin, and this shows in how people get intensely interested in stories like that of the Subway spokesman who shall not be named.

            And I think this is appropriate. It’s just a heuristic, but all things equal, a thin person is more likely to know how to be thin than a fat person and a formerly fat person who is now thin is even more likely to know how to get thin than a person who was always thin. A fat person claiming to know how to get thin may or may not have the right ideas, but lacking the knowledge of how to implement them, his knowledge is, at best, incomplete.

            Thus, preached but unpracticed virtues are rightly suspect: they may be unpracticable, might prove not to be so good if they really were practiced, or, at best, are incomplete.

          • In re obese trainers, they probably aren’t what you want if your intent is to lose weight, but if your intent is to build strength or (assuming the obese trainer doesn’t have a history of exercise injuries) exercise without getting injured, especially if you’re fat, an obese trainer might be at least as good as a lean trainer in the first case, and better than a lean trainer in the second case.

          • Nornagest says:

            My impression is that “libertarianism” denotes a complete rationalistic system of ethics involving a great many premises, some of which seem quite shaky to me.

            Some libertarians would agree — to them, the non-aggression principle is the linchpin of the whole philosophy and anyone that tries to do without it isn’t a libertarian.

            Others question that principle for one reason or another, and espouse the same or similar policy prescriptions for other reasons — usually utilitarian ones. I don’t consider myself a libertarian as such, but I find the latter more convincing: highly derived rights-based ethics invite rationalization and tend to run into all sorts of conflicts with revealed preference, but when you can’t run a taco truck without eight permits, it doesn’t take a very rarified philosophical superstructure to suspect that a lot of areas might be better off with less oversight.

    • Garr says:

      Does paranoia include reading signs of ordinary irritation as signs of infinite contempt and disgust? Or does there have to be some kind of “he’s-conspiring-against-me” thought involved?

      • Garr says:

        Does paranoia include interpreting absence of response to a simple fairly on-topic psychiatric question asked on the comments-page of a blog read by thousands of people daily, at least 115 of whom would be able to provide a clinically authoritative answer, as a sign of the world’s infinite contempt and disgust?

    • Julie K says:

      A century or more ago, there were many menial jobs that included room and board as part of the compensation, which definitely reduced life’s complexity for people in such positions.

      • Mary says:

        And the master was expected to supervise the behavior of his subordinates.

        In the mid-19th century, a newspaper defined the term “boss” for the benefit of its readers — and the new term was partly because of a new sort of relationship, where you had the regular work for wages of a servant but were otherwise independent, like someone hired for a particular task.

    • TK-421 says:

      Burdens makes a similar point.

    • xtmar says:

      Many of what we would consider even the most menial/easy jobs require strict timekeeping, maintaining a very consistent schedule, and driving yourself or navigating a transit system miles every day

      In some ways, menial jobs are more difficult in this respect than more skilled white collar jobs. If you show up to work fifteen minutes late to a law office, or cut out for a doctor’s appointment, nobody is going to yell at you so long as you get the work done eventually. Plus, you can work from home, and the quality of your output is fairly subjective, so if you mail it in occasionally, it might slip through without too much trouble.

      On the other hand, if you work in an auto factory or as a burger flipper, you can’t show up late too often and expect to keep your job, because your output isn’t easily time shifted, and similarly the very objective nature of the product means that it’s less tolerant of screw ups than a more subjective job. Try putting four bolts on a car tire and see how long you stay employed. Also, a lot of service jobs, like child care or home cleaning or even being a cashier, require somewhat more trust than is placed in a low level advertising creator, because they’re inside people’s houses or dealing with cash on a regular basis, while the worst the advertiser can do is steal some pens from the office closet.

      • FullMeta_Rationalist says:

        I remember a story a professor of mine once shared with the class. It was about a newly-hired colleague at the software division of a defense contractor.

        The colleague was fresh out of university. The manager said that the programmers were free to work at the office according to whatever schedule they wanted. However, the manager added the caveat that noobs should generally attend when everybody else was also attending. That way, the noobs could ask for help from seniors when they got stuck.

        Unfortunately, the freedom proved too much. The newly-hired colleague kept coming in during weird hours of the night when nobody was around. As the manager had warned, s/he was generally unproductive and had to be fired after a few weeks.

    • ” the ENORMOUS growth in complexity of every day life. ”

      I am not sure you are correct. There are an awful lot of things in modern life that simplify. For a trivial example, compare getting from one place to another with or without gps and mapping software. A car is a considerably easier and less complicated, for the user, form of transport than a horse. I’ve never done farming, let alone farming under much more primitive conditions, but I suspect it involves a lot of detailed information and paying attention to lots of things going on. Cooking over a fire is a more complicated process than cooking over an electric stove—I’ve done both.

      • Donny Anonny says:

        I’d be willing to bet that the average 2016 rush hour commute in a car is a lot more complicated than the same commute on a horse circa 1864, even if a car is easier to take care of and operate than a horse.

        While a lot of individual things are much easier to do now than back in the proverbial day, I suspect that a lot of mental strain comes from the fact that we have so many more things to see to.

        No matter how good of a juggler you are, eventually you will reach a limit to the number of balls you can keep airborne.

      • Randy M says:

        Yes, but in pre-modern life, how often did one need to get from place to place? Vastly less for the average, right?
        Eating has definitely gotten a lot simpler, but it’s also rarer to find housing that includes board.

      • garr says:

        I would never use a GPS — too complicated. Also, whenever you’re driving a car you have to keep lots of things in mind in order to avoid killing people, and you’re constantly afraid you’ll kill someone. And you’re constantly aware of the possibility that your car will stop working or fail to start for any of 567 reasons. And there are 137 reasons that you might get ticketed. And you have to keep track of where the streets are being cleaned and when, and make sure you move your care in time. As for farming, I suspect it involves very little social information; you don’t have to worry about what the squashes and corn think about you or whether they’re going to get you fired. As for cooking, it’s taken a friend of mine a month to get gas in her new apartment in Brooklyn, and she had to submit lots of different forms and make lots of different calls to do so, and had to miss work to wait around all day today for the gas company to come so that she could use her electric stove. And each piece of “documentation” that she had to submit was procured only after a lengthy process of submitting prior documents.

        • Tracy W says:

          @garr: If you’re raising animals on your farm, you have up know what they’re thinking and feeling. Which cow will step on your foot during milking, if given half a chance. And which one will try to kick over the bucket. Can a sheep get through a whole in this fence? (I hear from friends who grew up on sheep farms that they are basically the Houdinis of the animal world.) Where did the hens lay their eggs? How do you get the bull out of the stream?

          • Garr says:

            Tracy, it’s a lot more stressful trying to figure out what the ladies who run the office are thinking and feeling, and worrying about which thug might smack you on the back of the head during subway-ing, and which one will try to kick you over the platform-edge, and whether a sociopath can get through your apartment building’s often-unlocked front door. How can I speak to that woman in a way that won’t give her the impression that a Creep Is Being Creepy? How do you get the steroid-Prole out of the doorway to the Arab grocery that used to be a bodega?

          • JayT says:

            I would wager that the people that were worrying about those issues were the same type of people that have adjusted to modern society without issue. The ones that have had problems are the people who’s average day was to walk from the bunkhouse to the stable where they shoveled poop all day, and then went back to the bunkhouse for dinner.

          • Tracy W says:

            @garr: people can kill each other in rural areas too. The murder rate has been falling in England over the centuries even as England has gotten more urban. Forget about a sociopath getting through your apartment ,buildings unlocked door and start worrying about the sociopath who the gang head assigned to the bunk opposite you.

            @JayT, hmmm, I’m inclined to take you up on that offer of a wager, if you can think of a suitable objective data source. I read a fair bit of history and I’ve never heard of someone on a farm whose entire job was shovelling manure (may have been some jobs like that in commercial stables in big cities or during military campaigns of course.) I’m about US$10 confident farm jobs that just consisted of shovelling manure were rare.

          • JayT says:

            I was being overly simplistic with that comment, my point was just that the low-level menial labor had very few responsibilities and very few concerns.

            Menial labor workers today also have very few responsibilities at work, but they have the added stress of making sure that they have transportation and room and board lined up.

          • Tracy W says:

            @Jay T, damn, I was hoping you had some cool data source.

            My point basically is that farming is pretty darn complex. At least if you are dealing with animals.

            And farming life has the built in complexity that if anything breaks ducking out to the shops is not an easy option. You have to mend or make do. My granddad could make all sorts of things himself.

      • drethelin says:

        Farming involves a lot of detailed information, but crucially not from everyone involved. There are a lot of jobs available on an archaic farm, like fruit picker or scythe wielder, that are under the direction of a more knowledgable farmer and require little to no initiative, problem solving, or interaction with people.

        In regards to horses: I think you’re underestimating how intuitive horses are and how intuitive cars are. Children regularly learn to ride horses to a competent level, as well as clean and tend them. The needs of animals are fairly intuitive (if more labor intensive for the user than a car’s needs) to people living around them, which far more people did back in the day. Comparatively, almost no one knows how to repair a car, and we make people wait until they’re 16 and spend something like 6 months or more learning how to drive them before they’re allowed. I agree that GPS makes things a lot simpler than maps, but both are way less simple than when there was literally one road in your town, and that road also led to the next town over. And there were a lot more jobs where transportation was nearly irrelevant: People living on the farm they worked, or living in the house or inn where they were servants.

        Cooking may have been more complicated, but it wasn’t a mandatory skill: there were bakers specifically so not everyone had to know how to make bread.

        • Vox Imperatoris says:

          I don’t have a position overall on whether life today is “more complicated” than in the past, but:

          Farming involves a lot of detailed information, but crucially not from everyone involved. There are a lot of jobs available on an archaic farm, like fruit picker or scythe wielder, that are under the direction of a more knowledgable farmer and require little to no initiative, problem solving, or interaction with people.

          The same is true at McDonald’s.

          Comparatively, almost no one knows how to repair a car, and we make people wait until they’re 16 and spend something like 6 months or more learning how to drive them before they’re allowed.

          No one needs to know how to repair a car today. That’s why we have mechanics.

          Cooking may have been more complicated, but it wasn’t a mandatory skill: there were bakers specifically so not everyone had to know how to make bread.

          It is far less of a necessary skill today than it was in the past. At the very least, virtually every woman had to learn how to cook. Now there are many people of both sexes that have never cooked anything in their lives.

          • Stefan Drinic says:

            A schizophrenic has the sheer cognitive ability to work at McDonalds, sure. What he lacks is the ability to hold it down because of his further mental issues, be they freaking out customers or being unable to work for any period of time due to particularly bad episodes; in the archaic farm example, this is much less of a big deal because presumably this person would be farming with people he’d know much better than his coworkers and the clients at McDonalds, and they’d know them to be just kind of a crazy person who it’s best to handle with kid gloves when this sort of thing happens.

            Nobody knowing how to repair a car is an example of life being more complicated in and of itself. It’s complicated enough that only a select bunch of people in our society know how to manage such a thing, whereas taking care of a horse is a fairly simple matter.

            It’s also not really relevant, since the vast majority of people would never have owned one, but that’s neither here nor there.

            Cooking is less of a necessary skill in-depth, as in, you need to spend much time learning how to do it to become able to feed yourself, but I’m not convinced schizophrenics are consistently stable enough to reliable feed themselves well. Communal meals and having someone to prepare your meals for you after a day of doing mentally simple work are much harder to get by today than they once were. A paranoid person is certainly intelligent enough to shove something frozen in their microwave and turn it into a meal, but I can also see them skipping dinner because Jesus what if the food is poisoned and the microwave is out to kill me.

          • Tracy W says:


            whereas taking care of a horse is a fairly simple matter.

            This is not my experience of horses. They are animals. They can get overhot or over cold. They can get overworked. They can get stones in their hooves. They can get ticks in their skin. They can eat things that are bad for them. They can’t tell you what’s wrong.
            They can bite you. They can kick a man hard enough to kill. They can get scared and bolt with you on their back. The mares go into heat and stallions take an impressive amount of interest in this. They get sick in as complicated ways as humans do, being a vet is not easy.

            And throughout this, there’s the major risk that a horse can do a lot of damage just by stepping on your foot.

            Looking after horses requires constant awareness and intelligence. I suspect if you think it’s simple you either grew up in a horsey family and don’t realise how much you learnt growing up, or you’re much smarter than me.

          • John Schilling says:

            Apples to apples, please – I think people are not being clear on the distinction between using a horse or car, owning one, and maintaining one. Horses are probably the most high-maintenance draft animal in regular use, in part for the reasons that Tracy has listed. But this mostly doesn’t affect the normal day-to-day user. Children are routinely allowed to ride horses unsupervised at ages that would be reckless and illegal for an automobile. And the sort of riding that requires great skill to avoid injury, is comparable to off-roading or auto racing. I am unconvinced that riding a horse is harder or requires more arcane knowledge than driving a car.

            Nor am I convinced that maintaining a horse is harder than maintaining a car. Seriously, auto maintenance? The things won’t even piss when they need to; you need to get underneath with a socket wrench every time…

            But one critical difference is that anyone who owns a horse must necessarily maintain a horse, even when they aren’t using it. Cars suffer no harm from being left wholly unused and untended for modest periods, and in normal operation the maintenance can be outsourced to a specialist mechanic. Every horse-owning household, while it may have several people with minimal riding skills, needs someone with specialized training in animal husbandry.

            Which is part of the reason we invented mules. Horsemanship was never a necessary skill for prosperity in preindustrial times, any more than airmanship is today.

          • houseboatonstyx says:

            @ John Schilling

            + to this whole post

            Children are routinely allowed to ride horses unsupervised at ages that would be reckless and illegal for an automobile.

            Nitpick: As a ranch girl I did both. Under the same conditions (in the middle of a square mile ranch, with an automatic shift pickup truck and a horse neither of which wanted to go fast anywhere), I’d rate the skill needed for safe use as comparable — and more importantly, as ‘right-brained’, intuitive and muscle memory stuff.

            Go left: pull the reins or turn the wheel left. Go faster: poke harder with your foot. Go backwards is less intuitive: you have to ‘left-brain’ memorize an arbitrary symbol on the gear shift; but at least the Park, Neutral, Reverse, Forward are arranged in an intuitive order
            and (after some learning) you have the muscles of your right arm to remember them with, preceded by the muscles in the neck and eyeballs which look left before you even start to turn left.

          • keranih says:

            I think the horse vs car debate is obscured by a couple of things:

            – the working poor of yesteryear didn’t generally own horses, but those of today generally own cars
            – horses are (for the most part) self replicating, while cars are not
            – in living memory even urban middle class men understood basic mechanics of car repair, while horses have completely vanished from urban working life (excepting very specific careers) for more than three generations

            While the complexity of doing a specific task (ie, plowing a field) is easier with an experienced horse/mule/ox than with an experienced tractor, this is (by revealed preference) almost entirely overcome by the added upkeep in labor required by the animal. And plowing a field with a green mule is a task for an expert, while plowing a field with a brand new tractor is no more difficult than plowing with an experienced, well-broke tractor.

        • Tracy W says:

          On NZ farms children drive tractors, or did in my mother’s day.

          • Richard says:

            On most farms I would think children drive tractors. My kids started at age 5, but that was a bit messy since they were too small to operate both the clutch and the steering wheel at the same time. Once they grow tall enough to reach both, they’re fine.

      • wysinwyg says:

        If you’re limited to at most 15 mph, then the natural human capacity for unconsciously learning geography will be sufficient to tell you where you are and where you need to go next for the most part.

        Learning to ride a horse is significantly easier than learning to drive a car. I’ve only ridden a horse once, but I didn’t need hours of instruction and supervision to learn — it took maybe an hour at most.

        Nothing about farming is terribly cognitively demanding. It’s difficult to farm or garden if you don’t already know how to do it, but if you’ve already learned it, most of it is unconscious.

        The modern world is very cognitively demanding. In earlier times, it was easier to get by on muscle memory.

        • nil says:

          I think you’re right w/r/t to the intuitive mental mapping of geography, but for the record you don’t really know how to ride a horse, and if you try it again it would be pretty dangerous for you to think that you did.

          • Stefan Drinic says:

            The horse thing is kind of a red herring, anyway. It wasn’t common for people at all to have any in most agrarian cultures, let alone use them for riding.

          • nil says:

            @Stefan True. I didn’t really say that because I’m invested in the “modern complexity” debate in this thread, though, but because thinking you know how to ride a horse when you actually don’t is a great way to break a leg and I’m relatively invested in the “breaking legs is bad” debate.

          • wysinwyg says:

            Good point. What I should have said is that David Friedman was understating the difficulty of learning to drive a car and overstating the difficulty of learning to ride a horse and left it at that.

          • Stefan Drinic says:

            I’ll help with your hoping nobody here breaks a leg, then.

          • “Good point. What I should have said is that David Friedman was understating the difficulty of learning to drive a car and overstating the difficulty of learning to ride a horse”

            Having done both I disagree.

          • Agronomous says:


            I’m relatively invested in the “breaking legs is bad” debate.

            Which just goes to show how short-sighted you are: if 3^^3 people laugh so hard at her breaking a leg that their tears wash the dust specks out of their eyes, then the global util total goes up!

            One other simplicity advantage of horses: they know how to get home on their own, so you don’t have to grab a cab when you’re drunk, then get a ride to where you left the horse the next day.

            One advantage of horses if you’re in a horror movie: they know there’s a monster nearby. (This may only work if you never believe them, though.)

            One serious annoyance of horses: I can never seem to find the shifter (or the brakes).

            One social advantage of horses: people don’t look at you funny when you give them names and talk to them.

            One resource advantage of horses: I can’t garage a pickup truck and a minivan together and eleven months later get a free Mini Cooper.

        • Tracy W says:

          Farming is not that easy. Let’s say it’s been dry for a bit, and there’s no sign of coming rain. Should you sell or slaughter some stock now to conserve feed for the remaining stock and before the price or condition of the stock falls further?

          When do you risk using the meadows down by the stream that might flood?

          Are there any weeds growing in this field that might harm your animals if they graze there?

          Which bull do you use for stock duty?

          What do you do when an animal starts looking under the weather?

          I don’t know much about horticulture, but I doubt that that sort of farming is mostly unconscious either.

          • Stefan Drinic says:

            Farming is complicated for sure, but the complicated part needn’t be done by every farmer. As long as the mentally challenged/plain dumb person has a social network of people who are able to take these decisions just fine, they can still get by and be useful by being the person who digs out potatoes or pulls out weeds.

          • Tracy W says:

            And now if you have a social network of people who are able to take these decisions just fine you can be useful by being the person who clears tables or stacks shelves or irons at a laundry.

    • Cadie says:

      There are some people who simply do much better in life with some form of support/supervision that’s more difficult to get nowadays, especially in the cities. This is a downside of modern life and culture; it’s gotten better in many ways, but there are a few people and situations for whom it has significant disadvantages, and the larger level of freedom and responsibility each adult has today is a poor fit for them. Living in a place/era where family members gave them more oversight would be easier for those who find the constant juggling and decision-making incredibly stressful and are more relaxed and happier when someone else does much of that for them.

      Of course, we can’t go back to the family patriarch being in control of everyone (and what if it’s him who needs help managing money/housing/etc. affairs?) nor should we, that would be a net loss even if some people benefited. It does suggest we need other options to replace that instead of pretending it had no benefits and ignoring the whole thing. Some people really need the security and simplicity of someone else managing their major affairs but don’t need anywhere near the level of management and control that would be present in a psychiatric facility or prison. Something like college dormitories, but for single adults with one person per room? More funding for social workers and their training, and allow people needing that far lesser amount of care/oversight let a social worker handle things for them? I don’t know, I just know that the idea of maximum independence is bad for some people, it’s hard for them and they hate it, but there’s little middle ground between fully independent and fully controlled by an institution so they suffer.

      • Acedia says:

        Great post. I’d add that people have tremendous difficulty empathizing with different feelings on this subject. Like, I’ve always personally found the idea of being guided by a benevolent authority figure deeply appealing on a visceral level. But the sort of people who value having maximum liberty and personal autonomy at all times seem to find any submission to another’s will to be contemptible and abhorrent, even tantamount to slavery.

        (On a mild tangent, I wonder if opinions on this subject correlate at all with religiosity).

    • nil says:

      “Not only that, but the density of modern living means there is a lot less room for acting out even outside the context of needing a job.”

      Strongly agree with this. IMO there are really significant stress-relief and overall mental health benefits to a walk through the woods, and maybe, every once in a while, yelling as loud as you can at some poor, innocent trees.

  10. Jack V says:

    Your analysis sounds convincing to me.

  11. Lambert says:

    Malaria kills syphilis.
    Sickle cell anaemia prevents malaria.
    Sounds like two thirds of the way to a game of rock-paper-scissors.

    • Murphy says:

      hmm… just need a version of syphilis that cures Sickle cell anaemia…

    • Ninmesara says:

      This is a common misconception. Sickle cell anemia does not prevent malaria.
      Patients with sickle cell anemia get malaria at the same rate as the normal population and are more likely to die when infected. Sickle cell trait, on the other hand, prevents malaria.
      You can read a longer explanation here.
      There is a great and very accessible review on the subject.

  12. taktoa says:

    Funnily enough, I was listening to The Mind Electric (link) when I noticed this post — a song pretty clearly about someone sent to a mental institution and forced to undergo electroshock therapy.

  13. Lane says:

    Here’s what I always think about when the issue of how to treat the mentally ill comes up:

    There used to be a homeless woman who had a little campsite on my street. She spent all winter sleeping in a playpen she’d insulated with garbage bags. One night I stopped to talk to her about her life. She said she’d been in and out of the hospital and they’d told her she was bipolar (she seemed skeptical about this). She’d spent some time in psych wards, in homeless shelters, and in subsidized housing, but she said she didn’t like any of them because they wouldn’t let her smoke inside, and smoking was her true connection to God. She said smoking under the stars was her form of communion.

    The next time I saw her, I gave her a pack of cigarettes as a present.

    I know this story is fucked up, and I don’t want to pretend that her life was great, but I’m still glad she had the ability to choose the thing that was most important to her. That’s what I would want.

    • rminnema says:

      There’s nothing wrong with a random act of kindness. There’s especially nothing wrong with a random act of kindness towards a person who is living under such rough conditions. Good for you.

    • FullMeta_Rationalist says:

      I agree with rminnema. As a preference utilitarian, I see nothing wrong with giving her cigarettes. Good for you.

      Incidentally. This reminds me of how Scott recently hypothesized that the reason schizophrenics gravitate towards cigarettes is because nicotine mitigates schizophrenia [0]. Maybe it was schizophrenia and not bipolar disorder. Or maybe nicotine has greater medicinal value than we suspect.


      • Donny Anonny says:

        Given that nicotine seems to bind really well with certain receptors in the brain, it wouldn’t surprise me if it turns out that there are medical applications for it that haven’t been explored due to the political stigma of the substance.

        There seems to be a lot of tantalizing information that certain substances can be really helpful in treating certain medical conditions (THC for some forms of epilepsy, psilocybin for PTSD, etc.)

        Speaking as someone who’s not interested in recreational drugs, or drug culture, it’s sad that possible treatments are never explored due to political concerns.

        • Gerry Quinn says:

          It’s supposed to help prevent Parkinson’s disease.

        • Agronomous says:

          Nicotine binds really well with the nicotinic acetylcholine receptors in the brain.

          This is not a coincidence, because nothing ever is.

    • Agronomous says:

      All I can say is Thank God this horrible person isn’t inflicting second-hand smoke on other unfortunates in shelters or subsidized housing. I think we, as a society, have struck exactly the right balance here—well, aside from the fact that we let her have non-biodegradable plastic garbage bags; at some point, I guess we have to accept that some people are just plain evil.

  14. Mary says:

    Hmmm. . . . once upon a time I read of a study that concluded that more structured society was, the more depression and less psychosis you got.

    And then tested it by looking at, IIRC, Mennonites, to find that psychosis was very rare, and depression was so common that they had a name for it — wrestling with an angel — and their low suicide rate was caused by the community support for the depressed.

    That might explain quite a bit about the rising rates.

  15. Kiya says:

    (my hospital charges $1,000/day/patient, 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.)

    $1000/day is for the IOC people on days when they get treatment?
    And you say in the next paragraph that this is once every couple of months, so total cost of $6000/year/patient?

    • Andrew says:

      No, he meant $1000/day is the inpatient “price” (that noone actually pays). IOC would presumably be much cheaper.

  16. Leroy says:

    I have noticed that there is a certain type of person who seems to have some sort of need to take a scene which most of us would view as squalor and misery and proclaim that no, these people are not wretched, but have in fact discovered the true secret to the good life, and it is the rest of us who are living the lives of misery instead.

    This makes solving the squalor and misery very difficult, since you have a faction of people who are often quite persuasive at explaining why the squalor and misery is in fact bliss, and that it is in fact we, the modern west, who are the ones suffering with our excessive hygiene and concern with punctuality, work and money – we are just too brainwashed to realise it.

    This trope is very familiar to anyone who lives in a western country that has a minority population of indigenous people who live in squalor and dysfunction. It seems the mentally ill provide a similar surface for these sort of liberals to project their dissatisfaction with modernity and their own culture upon. It does an awful lot of damage.

    I do not know if bringing institutions back is the answer, but people who cannot look after themselves need someone who is authorized to look after them (against their will if necessary). The best case scenario is that this is a family member, but if that is not an option then it needs to be the state.

    I am all for trying more flexible arrangements, but they have to work. If at the end of the day the person being looked after is not being compliant and adopts a homeless or otherwise anti-social and negligent lifestyle, then maybe institutions need to be there as a last resort.

    • Nita says:

      Yes, declaring that actually miserable people are not miserable is wrong. But this principle applies to locked-up people as much as it does to homeless people.

    • Donny Anonny says:

      A variation on the whole Noble Savage trope.

    • Anonymous says:

      Reminds me of my complaint about a certain kind of person that whenever a group appears to be filled with idiots comes up with some elaborate justification for why their views /actions make sense after all.

      • Soumynona says:

        If you don’t understand why the views or actions of a group make sense to its members, you shouldn’t be calling them idiots.

        • Anonymous says:

          I understand why dogs keep eating until they make themselves sick. They aren’t terribly bright.

    • wysinwyg says:


      I have noticed that there is a certain type of person who seems to have some sort of need to take a scene which most of us would view as squalor and misery and proclaim that no, these people are not wretched, but have in fact discovered the true secret to the good life, and it is the rest of us who are living the lives of misery instead.

      Do you even steelman, bro?

  17. Alex says:

    Anyone read “Crazy like US” ( ?

    Seems to be possibly related.

  18. Vaniver says:

    Against this we have only one counterbalancing consideration

    …only that one?

  19. Deiseach says:

    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.

    I don’t know what America is like, but I imagine the “poorhouse” system was not hugely dissimiliar to that in Ireland and Britain. My grandmother (born in the later years of the reign of Victoria) was terrified of ending up in the “poorhouse”.

    The county homes (the national state nursing homes) which had taken over from the poorhouses/workhouses were seen as the inheritors of the system, and the poorhouses had deliberately been made as unpleasant as possible so that only the very desperate would seek admission as the utmost last resort: the idea of keeping out the “undeserving poor” (I believe Bryan Caplan has the same distinctions between the deserving and undeserving poor) and keeping the drain on the community resources to the absolute minimum by treating the paupers as badly as they could get away with – this wasn’t a holiday camp, after all!

    Well, it succeeded. It terrorised a whole class and several generations so that they would do anything rather than end up in the poorhouse/the county home. My grandmother was bedridden for the last fifteen years or so of her life due to being crippled by rheumatoid arthritis (literally crippled; her knee joints locked so her legs were permanently bent and she had to be lifted into a wheelchair out of her bed to move around) and my mother looked after her (my father moved in when they married and we were all living in my grandmother’s house). She used to beg my mother to promise not to send her to the county home. I remember this, even though she died when I was eleven, so I was quite young when all this was going on.

    So one problem with institutions was that they were deliberately unwelcoming to the people who should have been the objects of help. I think the problem with how “care in the community” worked in practice as against in theory was that first society was happy to shuffle all the inconveniently disruptive mad and poor to large warehouses (as you put it) out of sight and dump the problem on the people running them (because they were often private or voluntary institutions), and then it was happy to dump the problem back on the families (in most cases the ones who would be looking after the newly released and those who would no longer be committed) to look after them, with the putative help of ‘the community’ but with little to no resources made available to help the families or the ill.

    There’s no perfect solution. We’re always going to need somewhere for those in crisis situations or, like the schizophrenics who go off their meds, relapsing to go for short to mid-term stays to be helped get back on track. This appears in practice to mean the psychiatric wards of general hospitals, which then get crises of not enough beds for everyone looking to be admitted, sending people home before they’re ready to be discharged due to pressure on space and resources, and no specialised units for children separate from adults. So maybe a return to something of the model of the dedicated institution would be helpful.

    On the other hand, community care – if it’s done right – is better for the individuals, but it costs. It costs public money for the support and resources, because unfortunate things like this happen.

    A mixture of both, but how do you get the mix right? Are you justified in over-riding someone’s right to bodily autonomy to force them to take medication, if there is a very real risk that without it they could harm themselves and others? We’ve gone from the large institutions, but I don’t think we’ve moved on from the mindset of the stigma attached to them and to mental illness.

  20. Deiseach says:

    Your pillowcase example makes me think that the nurse was being a petty-minded jobsworth.


    It’s a mental hospital. Some of the people there are probably suicidal. Things like sheets, etc. can be made into nooses to hang yourself. So can pillowcases. So the Magic Approved List* is there for the protection of the hospital. The nurse was acting rationally: suppose the patient tried hanging or choking herself with her special pillowcase? The hospital will be sued by the family and the lawyers will crucify the nurse: why did you let her have the pillowcase? Pillowcases are not on the list! It’s your fault! That’s her job gone and probably her career, if the knock-on effects pursue her to the next job interview (“And why did you leave your last job?” “I was fired due to a court case over a patient’s attempted suicide” “Thank you, we’ll keep your application on file, next interviewee please!”)

    So getting a doctor to give her a direct order to let the patient have her goddamn pillowcase gets her off the hook and means if the patient decides to try strangling another patient with her special pillowcase it’s on your head, Scott 🙂

    *Yeah, I know it makes no sense to allow sheets and not pillowcases if they’re worried about suicide attempts, but Lists Of Approved Things are not about patient care, they’re about the hospital lawyers telling the hospital “You won’t get sued into oblivion, or at least not as badly, if you can’t be held liable for negligence due to breach of your duty of care if you have a List for the staff to follow”.

    • Julie K says:

      >*Yeah, I know it makes no sense to allow sheets and not pillowcases

      Scott said the patient stories are composites, so maybe it really was something besides a pillowcase.

    • Murphy says:

      Yep, exactly this, also it’s likely the nurse would lose her pin(struck off) so there would never ever be any other interviews for nursing jobs.

      They’re far far faster to strip nurses of their pins than they are to strike off doctors.

      Doctors on the whole watch each others backs and are self-regulated. Nurses are further down the pile and are more likely to get thrown to the wolves by both the doctors and the other nurses.

      I’ve seen cases where doctors who’ve fucked up and cut an artery open during surgery due to clumsiness have tried to shift blame to the nurses by pointing to a missed hourly-obs entry 2 weeks prior and a late dose of medication 2 1/2 weeks prior. (yes it doesn’t make any sense but they were looking for anything to try to shift any quantity of blame to anyone they could with regards to anything related to the patient)

      They have no shame and will fuck over junior staff in a heartbeat.

      • Devilbunny says:

        In the US, nurses are generally certified by a board of nursing that is independent from the board of medicine that certifies physicians. They do tend to face harsher treatment for certain misdeeds (diversion of controlled substances is considered particularly bad), but their professional licensure is almost entirely controlled by other nurses (my state has one physician and one non-nurse on the nursing board, vs roughly a dozen nurses evenly split between RN’s and LPN’s).

    • Scott Alexander says:

      As Julie said, it wasn’t quite a pillowcase, but I chose the pillowcase/sheet example as one where other things obviously in the same category for suicide risk were still allowed.

      • Randy M says:

        That said, do you think the reason for seeking approval rather than using common sense judgement was fear of litigation or internal discipline driven by such, or some minor bureaucratic power trip or what?

        • CatCube says:

          I’ve noticed that most bureaucratic nonsense happens at the junctions of rulesets, both of which may make perfect sense independently.

          • Deiseach says:

            Probably that and a combination of nobody ever made a big deal about a pillowcase before, so it wasn’t put on the list (what goes on the list is the things people do make a fuss over having), and that gets calcified into “If it ain’t on The List, it’s forbidden”.

        • Tracy W says:

          As I’ve gotten more experienced I’ve seen more and more cases of me using common sense, making a change, and that causing terrible problems down the line. For me.

          I think Chesterton’s fence applies.

        • Gbdub says:

          It’s probably not precisely fear or a power trip. More likely it’s just burnout and a bad incentive structure: make the common sense call and you may make your patient somewhat happier, but otherwise receive no reward or recognition. Make the common sense call and it goes bad, you get bureaucratic hellfire rained down on you and have no defense. Easier just to mechanically follow the rules.

          • Ant says:

            That, and it’s not always a bad idea to distrust common sense. Sometimes, the absurd rule is there for a very good if obscure reason. Asking someone who should know if ignoring is a good idea is the correct path in most of these case.

    • Alexp says:

      I suppose it’s possible to accidentally suffocate by sticking your head in a pillowcase?

    • William O. B'Livion says:

      > You won’t get sued into oblivion

      You ain’t gettin’ sued into me no matter what.

      In fact, you ain’t getting into me at *all*.


  21. Quite Likely says:

    Very interesting. From your description another big improvement would seem to be just improving the social welfare system generally. If all these non-institutionalized psychotics had access to free or near free decent quality public housing for example, their situation would be significantly less dire.

    • Mary says:

      Only if they were willing to stay in them and keep them in decent shape.

    • Deiseach says:

      If all these non-institutionalized psychotics had access to free or near free decent quality public housing for example, their situation would be significantly less dire.

      Speaking from social housing provision viewpoint, not necessarily. The person has to be able to live independently. Sometimes we get applicants where reading their file you go “This person will not be able to cope if we stick them in a house in town/out the country away from their family, which is the only option we have right now” but hey, if their social worker or clinical psychologist says they’re fine, what can we do?

      We can give people housing, and I agree that is a problem solved. A problem. We can’t keep them on their meds, we can’t monitor their day-to-day living arrangements, we can’t replace family and friends and professional support.

    • Scott Alexander says:

      Most of these people have access to social security checks sufficient to afford housing. Many make use of that. The rest are usually too confused to go about obtaining it, which is a slightly different problem. The confused people can be plugged into the system and put in group homes, but they have to want to be, or at least come to somebody’s attention.

      • Maybe it’s just my social circle, but I’ve known smart people who aren’t schizophrenics who’ve had a hard time dealing with the social services bureaucracy. At least one of them basically needed his friends to do it for him. Depression and anxiety can be incapacitating tor getting help, even for people who can manage once they’ve got the housing.

        I look at this, and I shudder to think about what it’s like for people who aren’t as intelligent or aren’t literate.

        • Richard says:

          Smart people may have another handicap too, in that they don’t fit the standard template. I spent a while on the streets after my first startup went rather spectacularly bust in the dotcom bubble, and trying to get any kind of social security was just an endless loop of:

          -We don’t give out checks to rich people
          -I’m actually not rich, I’m bankrupt
          -But you made 5 million last year
          -Yes, it’s all gone now, that’s what bankruptcy means.
          -No, I’m sorry, we don’t give out checks to rich people

          They seemed somehow not to be capable of understanding that last year this year. The year after that, I would probably have qualified, but by then I was more or less back in business.

          • HeelBearCub says:

            That seems more like a feature than a bug.

            If you had 5 Million in income the previous year and plowed all of it back into the business in such a way that none of it could help you the next year, the concept of “privatized profits, socialized loss” seems to come in. (Not that it fits exactly).

            You have to set the enrollment qualifications using some method, and that method will necessarily miss some potentially worth candidates. The number of people who make 5 Million one year and are completely destitute the next seems like it would be quite small.

          • The Nybbler says:

            Which seems to indicate that the common claim that people who do not expect welfare should support it anyway because “there but for the grace of God go I” is misguided.

            Because when the grace of God (or luck, or error, or whatever) fails, in fact the system will not be there for you. The welfare system is for welfare recipients, not just people literally down on their luck.

          • brad says:

            I obviously don’t know all the details, but it may well be that Richard was legally eligible for the benefits he was applying for but the bureaucrats weren’t aware of the laws and regulations that they were supposed to be administering. Their guts told them that he must not be eligible and that was that. I’ve run into similar situations with a different government agency.

            Of course there’s an administrative appeals process and ultimately you can sue in federal court and even recover legal fees, but ideally the people working at these places would follow the law instead of their gut intuition.

          • John Schilling says:

            No bureaucrat knows all the laws and regulations they are supposed to administer. I’m not sure that would be humanly possible; it would certainly be pointless.

            Bureaucrats know how things have always been done, know what their fellow bureaucrats will accept and reject, know what will glide through the system and what will gum up the works, and they know what will get them in legal trouble. All of which are correlated with the laws and regulations, but they aren’t the same as the laws and regulations.

            The laws and regulations for handing welfare checks to ex-millionaires are I suspect sufficiently dusty and obscure that nobody but bankrupt ex-millionaires ever bothers looking them up, and being bankrupt means not being able to hire lawyers to file complaints. So that part of bureaucratic practice probably doesn’t correlate well with the law.

          • gbdub says:

            @HBC if you call that a “feature not a bug” do you think it wise to withhold benefits from otherwise eligible people who are broke because they are addicted to meth? Who are broke because they are mentally ill and stopped taking their meds? Or had too many kids? There are very few broke people who don’t bear at least a little responsibility for their insolvency. Why privilege “lost a lot of money, instead of just a little” as a particularly reprehensible case?

            If Richard actually made $5 million in a year, presumably he paid a goodly chunk of that back in taxes, which ought to cover his benefits for awhile.

            I get the concept of progressive taxes, but saying “We’re going to tax you more to pay for benefits when you’re rich, but we’re also going to deny you benefits if you need them, because you used to be rich” seems just cruel.

          • Vox Imperatoris says:

            Seriously, though: not giving welfare to a guy who made $5 million in the previous year is “Mission Accomplished” for the welfare system. Get out the banner, get out the aircraft carrier.

            I don’t, in general, think the welfare system works very well. But come on, this is absolutely sensible.

          • Anonymous says:

            @Mark Atwood
            How do you even keep track of so many slights and grudges going back decades? Do you keep a diary? And how do you walk around with all those chips on your shoulder? Don’t they get heavy?

          • Said Achmiz says:

            @ Anonymous:

            One man’s “grudge” is another man’s “piece of a puzzle, to be used for accurate pattern recognition later”.

          • LPSP says:

            In a horrible and broken way, the system assumed that you were capable of making your way back up without its help and thus didn’t.

            If only you had been a squeakier wheel!

          • Soumynona says:

            @Vox Imperatoris

            I think we should also seriously consider the possibility of refusing medical care to people who used to be healthy the previous year. Imagine how much money we would save!

          • Vox Imperatoris says:

            @ Soumynona:

            More like refuse to pay for free medical care for people who had the money to buy insurance but didn’t.

            People who make millions of dollars but don’t save enough to keep themselves out of the streets are like the textbook definition of “undeserving poor”.

            Besides, as he said, it rendered him ineligible for one year. If he had still been “down on his luck”, he could have qualified. But he had recovered. So evidently he didn’t need the money.

            That’s not to say that I believe the welfare system is particularly good at allocating money to the people who need it most. But at least in this case, it avoiding giving out money to someone who transparently shouldn’t have gotten any.

          • BBA says:

            [Assuming you’re from the US – other countries have vastly different welfare states with which I’m far less familiar.]

            Were you a salaried employee or a contractor? If the former you were probably eligible for unemployment benefits if nothing else – those don’t have any tests based on assets or previous salary, although the benefits are paltry. My cousin was able to collect unemployment after the hedge fund where he worked went out of business until he was able to get a job at another hedge fund. (And I don’t mean this as a “welfare queen” anecdote – I actually encouraged him to do it. His employer had been paying taxes into the unemployment fund, he lost his job through no fault of his own, and there’s no clause in the regulations that says straight white dudes who work at hedge funds are ineligible.)

          • Agronomous says:

            @Said Achmiz:

            One man’s “grudge” is another man’s “piece of a puzzle, to be used for accurate pattern recognition later”.

            I like this a lot.

            In particular, every time I remember a grudge, I’m going to intentionally try to recast it as “a piece of a puzzle”.

            (Years ago, I googled one guy I had a grudge against from years before that—turns out he’d died a horrible death from cancer. You’d think that would have cured me of holding grudges.)

        • Anonymous says:

          I navigate the system for my mentally disabled sister. I’ve got a JD and I still sometimes fuck up. She’d have zero chance on her own.

          They do have advocates that are supposed to help, but they tend to be: 1) not terribly bright and 2) petty tyrants.

        • nil says:

          It’s really awful. It’s a system that is actively progagandized against and only occasionally properly funded set-up to benefit people with very little political and social power. In a lot of cases the time-surplus of beneficiaries acts as a crutch, and the actual decision-makers are either disengaged paper-pushers or (more often in my experience) high-empathy do-gooders who hate saying no to needy people and therefore semi-consciously prefer to outsource the dirty work of gatekeeping to complex rulesets.

          • Anonymous says:

            The older ones may be do-gooders, but with the rise of public sector unions they are very well compensated jobs. With a high school diploma you can start at GS-5 and make your way up to GS-9. An associates starts you at 7 and allows you to reach 11.

  22. K says:

    Excellent article, and I agree with all of it. One thing I would add though, since you’re advocating individual choices which I completely agree with. I think we need to reduce the stigma of family members of the mentally ill (all kinds of mentally from mild paranoid to more extreme forms of neurosis and psychosis) wanting to abandon their mentally ill family members. People feel pressured to stay and deal with the bullshit because it’s “family” even though often times the mentally ill family member never recognizes their problem and doesn’t realize how much they negatively affect EVERYONE around them.

    A lot of emphasis has been put on reducing stigma on the mentally ill, and I think that’s wonderful to see mental illness as just another illness. However, we also need to be understanding of family members who want to get away. Especially children who never signed up for that kind of lifelong trauma and abuse.

    • Mary says:

      And then you get abuse cases where the family member kept saying, “I can’t cope with this” until, one day, lo and behold, they really can’t.

    • Deiseach says:

      Yes indeed. The example of the commenter’s wife dealing with family members trying to dump Grandma on the state instead of looking after her themselves – sure, there are people who will game the system and shirk their responsibilities. They want to get Grandma put away so they can sell her house and take the cash.

      There are other people who can’t afford to pay to put Grandma in a decent nursing home, they can’t look after her themselves, and the only option the state leaves them is “We won’t give you a decent state-run nursing home, we won’t pay you carer’s allowance so someone can stay home and take care of Grandma, but we will take her in if she’s certified crazy”.

    • Randy M says:

      Pretty much agree. A little stigma may be appropriate, I guess. Microstigma, as an attempt to care should be made, in non-extreme cases. But learning what some illness can cause people to be prone to, and imagining putting up with that indefinitely (as well as all associated costs) pretty much just leaves me with sympathy for everyone involved.

  23. JayMan says:

    One quibble: there is an increase in all mental illness just like there is an increase in autism rates, right?

  24. vk says:

    It seems like a really common theme that comes up in stories like Ron’s is that someone will be taking medication and see substantial improvement, and then immediately stop taking that medication. Is there any consensus about the possible causes? Is this a problem that can be affected in any way?

    • Mary says:

      The leading cause, I’ve heard, is that the patients don’t really think they have a problem.

      • Have a story about lack of insight: I knew someone who became much easier to be around. I asked her about it– she said she’d been taking psych meds (sorry I don’t remember the drug or the diagnosis) and she said she didn’t notice a change in herself, but other people had become much nicer.

        • keranih says:

          Hell, that happens as soon as I pass the peak of PMS hormones.

          Everyone around me becomes more rational and better at handling bumps in the road. And I don’t have to scream at them as much.

    • The side effects are supposed to be very unpleasant, so if you lack the insight to see that they’re what makes you functional (which I think is common among psychotics) then you’re likely to stop taking them. One of Scott’s old posts floated the off-the-wall alternative hypothesis that antipsychotics are anti-addictive.

    • Deiseach says:

      Is there any consensus about the possible causes?

      You take your meds, you feel fine, you gradually drift from taking them (because you feel fine and the side-effects aren’t great and you don’t need them because you feel fine and you’re coping okay), and as you get worse, you don’t recognise you need to start taking your meds again because you know the Chinese government poisoned them because you realised the guy in the garden centre is working for the CIA spying on you and they want to silence you.

    • Murphy says:

      Side effects of anti-psychotics can be absolutely brutal.

      So you’re being required to take some pills and they’re

      ruining your relationship with your girlfriend because they leave you about as interested in sex as in peeling moldy bananas. Alternatively you might also find yourself horny but totally impotent. Even if you don’t have an SO suddenly you can find yourself horny but utterly unable to even masturbate.

      leaving you feeling like your head is full of cotton wool, you can’t solve simple problems which you could handle before being off the meds.

      Giving you headaches.

      making you feel tired all the time.

      Causing spells of confusion or fainting.

      And making you gain a hell of a lot of weight.

      You can’t make yourself concentrate enough to read the books you like and you find yourself losing track of the plots of any TV show you watch.

      And that’s before we touch the rare side effects of just one anti-psychotic.
      Some antipsychotics can also cause diabetes and significantly shorten your life.

      You remember how you felt before you were on any meds and felt far far better, you might sort of remember your episode but you scale back the meds a bit and you feel better and the psychosis doesn’t immediately come back so you scale the meds back more and you can really think again, the headaches go away, your relationship with your girlfriend is getting back to normal, everything is looking more happy.

      It’s all going really well…. and then 2 months later you suddenly go downhill , end up screaming about the aliens at a police officer and wake up in a mental hospital by the end of month 3.

      This isn’t from personal experience but rather from some people I know who have gone through something like this.

    • Scott Alexander says:

      Number one, you’d be surprised how much trouble everyone has taking their meds, whether it’s a mentally healthy person taking meds for heart disease, or what.

      Number two, if people feel badly they figure the meds aren’t working. If people feel good, they figure they don’t need the meds.

      Number three, they often don’t have the organizational ability to remember things, both in terms of taking the meds and getting more meds (which sometimes involves complicated financial/insurance/transportation issues).

      Number four, antipsychotics often have very serious side effects. In theory your psychiatrist can change them around and titrate the dose until they’re bearable; in practice this is hard, and a lot of these people see psychiatrists for like ten minutes a month, and nobody wants to take the risk of changing things around, so they’re just told to deal with them.

      • Matt says:

        I was wondering about this while reading your post. Do you know of any technological breakthroughs on the horizon where a mentally ill person could get some kind of device that automatically releases the drugs they need? I think I remember reading about birth control implants that could be controlled through wifi. I don’t know what the legal environment would be like for that, like a court order for a doctor to have control of your implant…

        • John Schilling says:

          Technically, we’ve been able to make implantable drug infusion pumps for decades; my mother had one for chemotherapy in the 1980s. But there’s an inherent infection risk, particularly around any refill port, that nobody has really found a good answer for yet. Could happen next week, or next century. Probably closer to next week, but as with all technological breakthroughs there’s no guarantee.

          Legally, it’s exceedingly difficult to force medical treatment on someone against their will, and particular surgical body modification of any sort. For good reason.

          Institutionally, I’d be worried about the incentives. This would hand a great deal of power over vulnerable people to doctors, bureaucrats, and judges who might want to do the right thing but aren’t likely to get sued or fired if they turn all of their patients into mindlessly obedient joyless zombies (p- or otherwise) but could if even one patient hurts a third party.

          • Matt says:

            Yeah, the legal part of it is problematic. I wonder if there exists a good hack around it. I was thinking that if people signed a paper saying they voluntarily give control to a doctor they could avoid institutionalization but I think that might be unconstitutional.

            Maybe a company that provides the implants could also bundle their product with legal advocacy. “Use Squirrel Brand implants and we’ll keep you out of the nut house!”

          • John Schilling says:

            The more general concern is that if you have a social problem for which people reluctantly accept incarceration or institutionalization as a solution, and someone proposes some other sort of morally dubious intervention (judicial torture, for example, or various sorts of mind control), they can compete in a vicious cycle. Yes, yes, there are people with moral concerns about the new Stepford Behavior Alteration treatment, but it’s voluntary; nobody’s making the inmates sign up for it and we all agree they deserve to be locked up, right? Having this option available can only improve their lot, Yay Us! Yes, yes, the prisons/asylums have become hellish oubliettes, but really, what sort of inmate doesn’t sign up for Stepfordization and go home the next day? The sensible ones live content, productive lives, why should we waste our money on comforts for people who choose to be locked away for life?

          • William O. B'Livion says:

            @John Schilling:

            Wanna kick back with a glass of milk plus drencrom and viddy some ultraviolence there me droog?


          • John Schilling says:

            You can have my Beethoven when you pry it from my cold, dead frontal lobes.

          • William O. B'Livion says:

            Dude, don’t feed me straight lines like that. This may not be a family channel, but comments about power drills and suction would probably not be appreciated.

        • Scott Alexander says:

          The psych equivalent is to inject a chunk of antipsychotic that gradually dissolves into your bloodstream. We’ve got lots of those that last one month, and I think just recently developed one that lasts three months. It’s very helpful, with the caveat that you still need to follow up with people at least once every three months.

          For legal reasons if nothing else, I can’t imagine filling a pump with more than three months’ worth of antipsychotics anyway.

          • HeelBearCub says:


            Norplant can be implanted and work for 5 years. It can be removed if desired.

            If a person suffering from psychosis is on their meds and decides of their own free will to implant a long lasting anti-psychotic (that worked) why would that be different than Norplant from a legal perspective?

          • John Schilling says:

            A person suffering from psychosis is probably not capable of making an informed decision as to what dose of which antipsychotic is likely to help them. They’ll need to go to someone like Scott for that. And Scott will almost certainly give better answers if he can observe the results at, say, three-month intervals, and adjust the prescribed or recommended dose accordingly. To do otherwise might be construed as negligence or even recklessness.

            With Norplant, it’s not as big an issue because the therapeutic index is pretty broad and you can aim high. So what if the patient is even more infertile than expected for the next five years, when they were planning to have zero babies in that period anyhow? But e.g. making a depressed person even more undepressed than planned and with no “off” switch, you can see how that might cause problems.

        • Anon says:

          My mother (who is schizophrenic) has something kind of like this, except one level removed. Her machine doesn’t automatically release her medication into her body, but it does hold onto all of her pills for her and automatically releases a tiny little plastic cup every morning with the exact pills she’s supposed to take that day in it. The idea is that this removes the burden of trying to figure out how many of each pill and which pills she’s supposed to take at once.

          Every time I go to her apartment, though, I see five or six of these little plastic cups with the pills in them piled up near her machine, so making pill-taking convenient obviously isn’t a sufficient solution. Fortunately for her, my mother isn’t violent or otherwise publicly disruptive. She doesn’t cause problems at the library or anything, even when she’s off her medication.

          I think something that automatically releases medication into a person’s body would be overkill for a gentle, non-threatening schizophrenic like my mom, but would probably be a pretty good solution for violent or otherwise extremely non-functioning schizophrenics.

          • boottle says:

            Automatic pill dispenser’s are very common in the UK, mainly for elderly patients. They’re used for all kinds of medication, since anyone in their 80s probably has a bit of memory loss, and will be on about 5 pills for blood pressure, cholesterol, joint pain etc. There’s also an alarm that can be set to go off. AFAIK they’re pretty sophisticated, can even deal with pills that need to be taken at different times (eg statins taken at night).

        • Anon says:

          Yeah, Scott wrote about that here.

          Quote from Scott:

          But again, one of the most common paranoid schizophrenic delusions is that their electronic devices are monitoring everything they do. If you make every one of a psychotic person’s delusions come true, such that they no longer have any beliefs that do not correspond to reality, does that technically mean you’ve cured them? I don’t know, but I’m glad we have people investigating this important issue.

        • William O. B'Livion says:

          I ran into one of these a couple weeks ago up at Eldora (a ski area outside of Boulder, CO). Out of the blue dude comes up to me and starts talking *really* fast about being selected for the secret service detail for Hillary and turning it down and do I think he can get the chip removed from his arm.

          “You’d probably have to ask a doctor”. No more needed to be said really.

        • Agronomous says:

          a) You’re never going to put anything controlled by WiFi into my body. If you do, I’m digging it out with an X-acto knife.* I’m not schizophrenic: I’m a software developer.

          b) Actual schizophrenics wouldn’t bother getting the knife; they’d just use their teeth.

          c) Didn’t Scott write about some terrible idea just like this last year? (Spoiler: yes; search that post for “chip”.)

          d) I honestly just realized I forgot to take my meds this morning (and took them just before typing this). Weekends really throw off the routine.

          (* I mean, I’d sterilize the knife first; and probably check with a veterinarian relative to see if they’d do it instead. But do you really want 4chan to have the slightest chance of mucking around with your physiology?)

          • Wendy Laubach says:

            I have a pacemaker in me that’s controllable by wifi. Your concern resonates with me, but I prefer it to needing surgery every time they need to modify its settings in a minor way.

          • Agronomous says:

            Wait, literally WiFi? Or just some wireless radio communication scheme?

            I like doctors being able to non-invasively tweak implants, but I’d like things set up so that:

            (a) anybody who wants to communicate with the implant has to actually touch me (if they’re that close, there’s lots of other ways to kill me) and

            (b) there’s some reliable authentication involved, at least to the level of a challenge-and-response protocol, with a different key for every single device (it’s cute that lots of people can use their car key to open my car; it’s a lot less cute for pacemakers).

            If I had a pacemaker that literally was controlled by WiFi, I’d be so stressed out that I’d need a pacemaker or something.

      • bean says:

        Number one, you’d be surprised how much trouble everyone has taking their meds, whether it’s a mentally healthy person taking meds for heart disease, or what.
        This cannot be overstated. I’m on ADD medication, and have been for the majority of my life. I take it every day, because I have an alarm on my phone, and the rule is that I do not kill the alarm until I’m on the way to get the pills. Period. Before I started doing this (many years ago), I routinely would forget, even when it was on the table in front of me. And I can’t think of a condition which is better for making sure that I comply with the pills. Unlike a psychotic, I recognize that I need to take them even when I’m off them. I don’t have horrible side effects. (There are some, and occasionally, I’ll skip a day, but the cost-benefit is way in favor most of the time.) I’ve been doing this for years, so I should have habits.
        And yet, before I started setting the alarm, I missed probably once a month. That was back in high school, so not only did I forget, my family forgot to remind me. Take that as a base rate, and assume that it’s common for people who forget one day to decide the next day that they shouldn’t. It’s pretty obvious why you have people drop off their meds.

        Number three, they often don’t have the organizational ability to remember things, both in terms of taking the meds and getting more meds (which sometimes involves complicated financial/insurance/transportation issues).
        Also a serious issue. I moved to a new city recently, and getting a new prescription was a major hassle. I think I had to make four visits before the HMO cleared me. Fortunately, I didn’t run out of pills, but it wasn’t pleasant.

        • Azure says:

          My brother (who was schizophrenic) would titrate down from his recommended dose for the usual reasons (horrible side effects, mental confusion, general misery) and then his symptoms would actively conspire to get him to stop taking them entirely. He once told me that angels would come and tell him that the medication was actually created by The Adversary to numb the soul and blind ones sight of how the world is.

          So he’d stop taking it entirely and then go back into (more) full-on psychosis with stray animals telling him about their allegience in the great struggle between God and The Adversary and sleeping on the streets and so forth.

          A friend of mine who was also schizophrenic was in involuntary outpatient treatment actively ran away from and resisted treatment, partlay because of the side effects. Partly because he had embraced ‘anti-psychiatry’ and thought psychosis revealed some truth that was being denied to him and would talk about group homes he’d read about where mentally ill patients were allowed to live ‘on their own terms’ and had much better outcomes.

          For some bipolar patients there’s a temptation to either titrate down or fail to comply completely to jump back into hypomania. This can work quite well for a while, but if they fall into depression finding the motivatio to get back to treatment can be hard, and if they go into full-on mania with psychosis you have the whole problem of seeing through this fragile, meaningless veil some call ‘reality’ to the truth beneath and not agreeing that there’s anything wrong.

      • Cadie says:

        Yes!#1/#3 are a big deal, even for people whose issues are comparatively mild. I take Effexor (well, a generic instant-release version) and I’m actually starting to like the fact that it causes nasty discontinuation syndrome symptoms very quickly if you don’t taper it properly. Because if it didn’t, I’d forget to take it a lot of the time. But if I completely miss a dose by more than a few hours I feel terrible, reminding me to take it and feel normal again within an hour, and as a result I never have a day where I skip the meds. At worst I forget it in the morning and by early afternoon it’s “uggghhh I feel awful, wtf… oh, whoops, I’d better take my pill.”

        I wonder if there’s a way to encourage people to take their meds by making it unpleasant to stop, unpleasant in a manner that’s safe but sucks and sets in really fast (and goes away fast upon taking the meds) to get the conditioning effect of associating feeling the discontinuation syndrome with forgetting meds and feeling better with taking them. Hmm. Some people take antidepressants and antipsychotics together. I wonder if something like Seroquel/Effexor (or whatever is likely the best combination of AAP and SNRI) as a combo pill would be useful and interesting to a pharma company, the SNRI added to lessen depression, smooth out a few AAP side effects, and introduce discontinuation syndrome if the meds are suddenly discontinued without tapering under physician advice.

        • wysinwyg says:

          I wonder if there’s a way to encourage people to take their meds by making it unpleasant to stop, unpleasant in a manner that’s safe but sucks and sets in really fast (and goes away fast upon taking the meds) to get the conditioning effect of associating feeling the discontinuation syndrome with forgetting meds and feeling better with taking them.

          Pair it with nicotine.

        • Anon says:

          Slightly OT, but I also take Effexor (well, actually, generic venlafaxine), and unlike literally every other person whose account of taking this drug I’ve ever read, I never have any kind of discontinuation symptoms when I miss a dose. I can go from taking my normal 150mg a day dose for months on end to nothing cold turkey and have no noticeable effects whatsoever.

          It makes me wonder if I have some kind of rare genetic variant that makes me immune to Effexor discontinuation syndrome. Perhaps relatedly, it doesn’t work very well for me, though it does work better than Prozac or Zoloft.

          (Actually, come to think of it, I’ve never experienced discontinuation syndrome from any drug. I was able to go off Prozac and Zoloft cold turkey too.)

      • “and nobody wants to take the risk of changing things around”

        A friend of mine finally had the mix of psych meds that work for her (she’s got bipolar 2, restless leg, chronic pain, and ADD– I may have forgotten something) and a new-to-her psychiatrist changed something just because and without telling her. It cost her something like a couple of months of brain fog until she happened to notice that one of the dosages was changed.

        I assume it could have screwed her up for years or for life if she hadn’t been lucky.

        I don’t know how common this sort of story is.

        • Loki says:

          I had a shrink try to add Seroquel to my meds (I wasn’t taking any antipsychotic at the time), without mentioning it to me.

          I manage my own meds, so I noticed and was like hell no I am not taking this without even discussing it, but if it had just somehow been added to my regular meds without me noticing, and if I had experienced some of the many common side effects, I would likely have stopped taking my meds altogether.

          I don’t understand how, for someone who isn’t somehow committed, this would even be legal? I mean surely informed consent is a thing.

      • William O. B'Livion says:

        > Number one, you’d be surprised how much trouble everyone has taking their
        > meds, whether it’s a mentally healthy person taking meds for heart disease,
        > or what.

        I’ve had surgery twice (relatively minor–hernia repair and a C6/C7 fusion), and have a host the sorts of overuse injuries you get when you’ve lead a life like mine–osteoarthritis, tendonitis, rotator cuff injuries etc.

        I’ve forgotten to take my *pain* meds at times, and even the onset of the pain isn’t really enough to remind me because it usually comes back gradually and you don’t notice it right away.

        Heck, by the 7th or 8th day of a run of antibiotics I start to get a little sketchy.

  25. I still don’t think you disagree with Caplan or Szasz. You just misunderstand what they are saying. The argument you are making here is one of the very same arguments that they are making.

    • Exa says:

      If an intelligent and competent person like Scott can read a book written to make a point, and spend enough time thinking about the book to write a well-reasoned blog post about why he disagrees with what he perceives to be the point, and completely fail to see the real point, this indicates that the book has serious problems and should probably have been more straightforward about how it explained things.

    • Scott Alexander says:

      I don’t disagree with them that not everyone should be institutionalized. I do disagree that some people should be institutionalized sometimes, that “mental illness” is a pretty good description of what psychotics are going through, and that psychiatric treatment is pretty valuable.

      For a particular point of disagreement explained in detail, see

      • MondSemmel says:

        I think you left out part of a sentence somewhere, and ended up writing the opposite of what you meant.

        Surely you meant something like “I do disagree [with them in that I think]”?

  26. xtmar says:

    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.

    We didn’t forcibly round them up, but part of the reason why a lot of the post-WWII to 1960s housing projects, like Cabrini Green, were so massive was precisely because it concentrated the poor people. This nominally allowed for easier access to dedicated social services, employment help, job training, and so on, but also had the effect of concentrating poverty and keeping the have nots away from the haves. In other words, we did, and do, institutionalize them.

    • James D. Miller says:

      If this were the motive housing projects would have been built outside of big cities.

      • John Schilling says:

        How so? Housing projects like Cabrini-Green were mostly built during postwar suburban boom, when most of the “haves” were living outside of big cities.

        • James D. Miller says:

          But the haves still worked in cities and took their families into cities for amenities. If the goal was to isolate the residents the housing projects would have been built in rural areas.

          • Vox Imperatoris says:

            Well, with this kind of ulterior-motives theory you can explain anything.

            Easy explanation: they didn’t think they would be able to get away with putting the poor in rural areas, but the urban housing projects had just enough of a superficial veneer of helpfulness to the poor.

          • William O. B'Livion says:

            Most of the “projects” were not sold on being warehouses for the poor. They were part of the post-war notion that we could engineer a better society, and were usually designed and sold as “mixed income housing”, the notion being that you’d have these awesomely beautiful well designed environments where the little poor children would go to school and play with the children from the middle class and the affluent and we’d all be one happy mass of workers leading to the triumphant whatever.

            This is how you got Cabrini Green 4 blocks west of the Gold Coast, and had the welfare recipients buying their groceries at the same place that the Domestics for denizens of the Gold Coast shopped.

            The same notion is what lead to the development of the “scattered site housing” programs.

            Frankly it doesn’t work. Instead of the middle class ethos and habits rubbing off on “the poor” you get the kids of the middle class picking up the poor behaviors (drugs, unprotected sex at earlier ages) from their classmates. Because getting stoned and having sex is a LOT more fun that homework.

            So it turns out that not even working or middle class $MINORITIES like living in close proximity with the poor and criminal (to the extent they are distinct) classes from their own socially designed sub-class, so these “mixed income” places increasingly became worse and worse places to live.

            Now, you can ascribe all sorts of racist and evil motives to the people who designed and implemented these programs, but it wasn’t a couple dozen guys who kept ironed sheets in their closets, it was a bunch of leftist nuckfuts who thought they could build a utopian society.

            It’s the flip side of the the anti-psychiatry folks Cramer and Our Host are talking about. People who thought that poverty was caused by a lack of stuff, and that the behaviors that lead to and keep people in poverty can be ameliorated if you provide The Poor with the accoutrements of Middle Class (this is also what lead to the absolutely insane lending policies of Freddie Mac/Fanny Mae)

            Micheal Crichton coined the term “wet streets cause rain” for this sort of backwards causality when it shows up in newspapers. I submit that it applies equally well here.

          • Agronomous says:

            Because getting stoned and having sex is a LOT more fun tha[n] homework.

            [citation needed]

            Note also that there are plenty of conspiracy theories making the rounds that The Man just wanted the land (four blocks from the Gold Coast) that Cabrini-Green was built on and so exaggerated the problems there in order to get it torn down.

            (I trust Revealed Preference on this one: anybody who could move out of C-G, did (wait: how do I know that? The Man’s propaganda!).)

      • xtmar says:

        It’s similar in motivation, not a 1:1 comparison.

  27. Dr Dealgood says:

    A bit of a sidenote, but the thing with the libraries is not only true but an understatement.

    One of my close relatives was until recently a librarian in one of the somewhat nicer suburbs of Detroit, and according to her the #1 biggest issue they had was with homeless people and/or perverts masturbating and defecating in the library. It drove the staff nuts, because they had no option to deal with it, and drove off the actual patrons which made justifying the budget of a public library that much harder. Eventually the only people who came were people who wanted to steal bibles and / or test prep material, the homeless and public masturbators.

    This sort of thing gets glossed over a bit because a lot of people don’t get that “creepy” is a euphemism when we’re talking about homeless people. It’s not that someone is smelly and makes weird noises every so often, we’re talking about behavior which would get you or I locked up immediately.

    That’s why I take argument about institutionalization for the sake preserving public spaces and lowering crime seriously. Even if these crimes are rare on a population level, they don’t actually need to happen all that often to drive off the people who have anywhere else to go. Then you end up with more “bad neighborhoods” where the only folks living there are the ones who are stuck there and where outsiders justifiably don’t want to visit or do business. We saw that happen in New York until Giuliani came along.

    • AM says:

      I’m curious what the extent of these problems are, and how evenly they are distributed.

      The central library in the area where I grew up (Schenectady, NY, in the 90’s and early 00’s — not in the greatest area) certainly had homeless people, but I don’t remember anything that bothered me (though I’m a mildly oblivious type), nor do I remember any such stories from my friends who had jobs there.

      So I went to look it up on Yelp, where it has 5 recent positive reviews with no mention of homeless folk, and one review from somebody about my age who worked there as a page in the early ’00s, and reported masturbation, drunkenness, etc — so apparently that was a thing — and I’m sure it’s much worse to deal with as an employee.

      (Since then I’ve only really experienced spiffy rich college town libraries.)

      • John Schilling says:

        Small world. The Schenectady public library was one of my refuges growing up, though that was back when all the soon-to-be-homeless were still working at GE.

        Libraries in Lancaster and Palmdale, CA, today, definitely have homeless people hanging about, and lately uniformed security guards at the door. Even before the guards I never had problems with indecency etc, but as you note it’s the people who work there who will face the worst of it.

      • bean says:

        I’ve been to a lot of libraries (at least a dozen) throughout the LA area recently (past 6 months or so), and I can’t say I’ve seen any of this sort of thing. I don’t remember seeing security guards at any of them, or homeless people doing weird things. Some of them are definitely in areas that have homeless people, so it isn’t that. Nor can I recall seeing homeless people in other libraries that I’ve been to over the years in several different cities.
        I suspect that it does happen, but not often enough for even a serious bibliophile (6 library cards and counting!) to notice. And the staff don’t remember the 159 hours a month when nothing happens, they remember the one when it does.

        • Adam says:

          Go to Long Beach Central. Unless something has seriously changed since 2009, the memorial park right next to it and City Hall is a homeless colony. It’s near a VA hospital, though, which always tends to attract homeless.

          • bean says:

            I have a Long Beach card, but I’ve only been to one of the branches. Long Beach Central is on my list at some point, but I’m always headed somewhere else when I go through there.

        • bean says:

          As an update to this, I went to the Santa Monica library yesterday, and did see at least one person who I was reasonably sure was homeless, and a couple of others who might have been. I wasn’t tempted to hang out there, but that was also because it was far away from home and parking in Santa Monica is difficult and costly.

      • Emily H. says:

        I’ve worked in public libraries for 10 years. 2 in a poor, African-American neighborhood of a medium-sized southern city, 4 in a poor, African-American and Caribbean neighborhood of a large northeastern city, 4 in a middle-class Jewish neighborhood of the same large northeastern city.

        Library #1 – we had one homeless alcoholic regular who’d come in every two or three weeks. He was very loud and repetitive but basically harmless. There was also that one lady who I suspect was on some sort of illegal stimulant, who got really angry that she couldn’t put in her mailing address on the web form where it said “email address.”

        Library #2 – We actually didn’t have any regular patrons who were visibly homeless and seriously mentally ill, though we had the occasional fistfight.

        Library #3 – We have one homeless regular and some regulars who are odd but probably harmless. Once I had to deal with a masturbator. But our problems are on the order of “makes weird noises, doesn’t smell good” rather than defecation and masturbation. (Parents are totally willing to let their 10-year-olds come here unsupervised, which either speaks to how bad they are as parents or how safe the library actually is despite some people who make one uncomfortable.)

        We averaged probably less than one serious security incident a year.

        Now, none of these libraries were in areas where there was actually a large homeless population in walking distance of the library — I suspect that makes a big difference — but even in very poor neighborhoods, it’s not necessarily true that the public libraries are overrun with patrons with serious behavioral problems.

      • caryatis says:

        My local (big city) library has a periodicals room (newspapers, magazines, academic journals). I usually enjoy sitting in library periodicals rooms and reading whatever catches my interest. In this library, the room is dominated by homeless people. Terrible smell, risk of harassment, I don’t feel safe going to the bathroom. So I don’t use that library. I commute to the suburban library. There’s a real cost to letting these people take over public spaces.

      • Tyrrell McAllister says:

        I grew up going to the Santa Rosa library (specifically mentioned in My Brother Ron) in the ’80s and ’90s. The most disruptive things that I remember anyone doing were snoring and smelling of alcohol.

        That may be mostly a testament to how good a job the staff did at keeping things tolerable for the patrons.

      • James Kabala says:

        I grew up in a non-affluent-but-non-destitute small town in New England and went to the library frequently and never saw anything remotely like this. (Since then, like you, I have mostly only been inside college libraries, but my parents still live there and still go to the library, and I have not heard reports of such behavior.)

        • Nornagest says:

          I grew up in a small town in upstate California and used the library all the time without any problems. Later I moved to a large town in the Bay Area, tried to use the public library, and found it full of homeless people. Not always disruptive homeless people, but often enough to make it unattractive as a hangout.

          It’s probably a geographic thing. But that doesn’t really help much, since a lot of the people we’d most like to have access to free public educational resources are in big urban areas.

      • keranih says:

        I’m curious what the extent of these problems are, and how evenly they are distributed.

        I worked as a part time library page in the local county library while in college for my second degree. A close friend got a library science degree and currently works a branch of a county system in a southern city. (Not the one I used to work in.)

        From the perspective of the library staff there are three types of issues: deviant adults, homeless adults, and youths.

        (Please to bring to mind your mental construct of a librarian. Do you form the image of a socially adept, charismatic, persuasive person? If so, congrats, you are one in a million, and so is your mental librarian.

        Deviant adults come into most interaction with the library staff when they log onto a library comp, open up a whole host of porn on a score of screens, and then walk away from the terminal so that one of the kids – spying an empty seat – slides into the seat at the computer and then sees the images on the screen. The DA is lurking around the corner to get off on the kid staring bug-eyed at the screen. Also an option – actually sitting at the computer desk with their hands down their pants.

        Homeless people are aromatic, attempt to wash their clothes in the restroom sink (whilst denying entry to anyone else) (and with a predictable spread of liquid all over the counter) fall asleep (aromatically) in the newspaper reading area and (more rarely) converse with people who are not physically present. Additionally, they attempt to converse with people who *are* physically present, but are attempting to read to their child, study for a test, or find a book on the shelves. When rebuffed by one, they go to the next.

        The most benign homeless are not actually homeless – they are living alone, and expect the library personnel to be their emotional support staff. Even if they’re working part time to finance an engineering degree.

        Youths are a mixed bag. Some are clearly patterning after the DAs, others are just selfish little shits who need a good spanking. (You ain’t living until you’ve been called a white bitch by a ten year old who wants to keep using a comp to access webgames after his time is up and the comp is now someone elses for an hour.) Most are just continuing their school hours disruptive loud behavior in another setting. Others are transitioning from (relatively well behaved) school hours actions to disruptive after-school behavior.

        All of them will sneak in food/snacks, eat it noisily (in front of you) deny that they have consumed anything, and then leave their crumbs, cans, and wrappers lying about.

        Libraries that don’t have on-site security guards have the local pd or sheriff on speed dial. Most have rules about how everyone leaves the building together at the end of the day. Most also have rules about how telling off a customer/patron means two people – one to shush, one to observe.

  28. FullMeta_Rationalist says:

    The book itself mentions my preferred answer to this conundrum: involuntary outpatient commitment (IOC). This is exactly what it sounds like.

    Maybe “what IOC might signify” is obvious to you as a psychiatrist. But I didn’t have any idea what IOC might signify (until now) since I was not familiar with the words “outpatient” and “commitment”. </pedantry>

    +1, great review. Would read again.

  29. Deiseach says:

    God help us if we ever systematically decide that people should not be allowed their freedom if the decision carries any discomfort or risk.

    Obesity epidemic. The Sugar Tax, a vital necessity that will be introduced in the island next door to prevent child obesity because of the social costs in actual real money – all the reports quote figures like “save the NHS £576 million a year”, none say anything about “help the obese to live happier, healthier lives”. (Never mind that, contra Jamie Oliver’s petition, Type 2 diabetes is slightly more complicated than “You ate too much junk, you got fat, you gave yourself diabetes”).

    Professor Vaeed Sattar, Professor of Metabolic Medicine, University of Glasgow, said: “to tackle obesity we must do much, much more [than just reduce sugar intake]. In fact, plentiful evidence still points towards excess fat as a major contributor to excess calories (more so than sugar) so we cannot become distracted by this ‘sugar battle’. Equally, ready access to cheap calorific foods is pervasive and tackling such issues will be difficult. These are difficult issues. Cutting excess calories requires a broader approach and will take many years, but we do have to start somewhere, and ultimately the government needs to take the lead.”

    We’re gradually moving from “information campaigns” to “Something Must Be Done (We Need A Law)”.

    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.

    From what I’ve seen of reported recent cases, the ACLU is not noted for its chill 🙂

    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)

    It’s also a common way for mentally ill people to end up dead. Even in my own country, we had one reported shooting and in the US, I see by Google that “I called 911 for help with a mentally ill family member, the police turned up and shot him like a dog” happens a lot. (Okay, now I’m waiting for the corrections to pour in about “actually, it doesn’t happen a lot, it’s only 0.01% of all reported interactions of the mentally ill and police). I still imagine that “trespassing on government property”, with the heightened fear of terrorism, never mind appearing to threaten armed police officers, will get you shot more likely than not.

    • FacelessCraven says:

      @Deiseach – “(Okay, now I’m waiting for the corrections to pour in about “actually, it doesn’t happen a lot, it’s only 0.01% of all reported interactions of the mentally ill and police).”

      Can’t speak much to the rates, but this is actually a problem of some note in America, as a subset of the “our police think they are Delta Force” problem.

    • John Schilling says:

      Tresspassing on government property will almost never get you shot, and “0.01% of interactions of the mentally ill and police” is probably on the high side. But we’ve got a lot of cops interacting with a lot more mentally ill, so it adds up to a real problem. Better training may help; some high-profile departments are moving in that direction, and we’ll see.

      • Hlynkacg says:

        Agreed, shooting people nets you a lot of paperwork, and often a disciplinary hearing.

        Though the “0.01% of interactions” stat has me wondering just how many interactions are happening “off the books”.

      • Squirrel of Doom says:

        There are 1.1 million cops in the US.

      • William O. B'Livion says:

        I realize that the readership here is probably 2 standard deviations higher than normal, but let’s lay something out here:

        * Cops are usually drawn from the middle and lower middle class.
        * They are *usually* younger men who join the force either for a steady paycheck, or to “catch bad guys”.
        * The corollary of that is they generally do not join the force to be social workers.
        * They deal with a WIDE range of humanity on a daily basis, from “normal” folks to the sort of criminal who thinks that sticking a knife in a cop is a good way to get street cred.
        * Those in bigger cities spend much of their careers/work days dealing with the wreckage of 60 years of social programs. Adults who never finished highschool, have no marketable job skills (even in the absence of “real” mental illness) and who engage in petty crime to supplement whatever government largess they receive. These people are often violent (not particularly *effective* with their violence, but an elbow in the nose is never pleasant) and nasty (you remember this scene in Silence of the Lambs: Not Fiction. Worse in Real Life).
        * They want to go home at the end if their shift, and they care more about going home to their family at the end of their shift than they do about you. You are their job, their wife and kid are their *life*.

        Thus if you wave a 10 inch knife[1] at a cop you are VERY likely to get shot.

        We expect the police to show up at 2 in the morning ready to rumble[2] when we report a couple people trying to break into our house. We expect them to be polite and courteous to us when they pull us over for infringing on traffic regulations. We expect them to handle minority problems with sensitivity and concern, and we expect them to handle psychiatric patients with care and kid gloves.

        Wrong tool for the job.

        I you have a family member you care about, or a friend with the sorts of mental illness that spirals down into violence do not expect the police to care more about them than you do. You live with them and YOU need to monitor their behavior and adherence to their medical regime. You need to help them track, and help them get their meds “fixed” to balance effectiveness with side-effects. You need to work with them to reduce the drama and stress in their lives and to provide a place where they feel safe.

        The government *CANNOT* do this. It has too many demands on it, is being pulled too many ways, has too many pressure groups pulling it too many different ways, and often has folks with COMPLETELY different agendas.

        [1] In the mid 2000s the San Jose police shot a mentally ill woman who was ‘waving a potato peeler’ at them from behind the kicthen counter. “Potato Peeler” gives a specific mental image, right? She was Vietnamese. It was a Vietnamese potato peeler. Search term “Cai Bao”.

        [2] I don’t expect the police to be there in time to stop the problem. I expect them to be there in time to take me “down town” to discuss what I did to stop the problem.

        • bbartlog says:

          Even after you make various allowances for US demographics (i.e. more minorities), greater gun ownership, and some cultural factors, we still have more police shootings than is reasonable. Germany for example ends up with about one person per year being shot to death by the cops. After looking at our larger population and the other factors mentioned above, someone might conclude that our number should be higher by nearly two orders of magnitude; maybe sixty or eighty per year would be expected. Instead we have about a thousand.

          • John Schilling says:

            Germany for example ends up with about one person per year being shot to death by the cops.

            If by “about one” you mean seven, perhaps.

            After looking at our larger population and the other factors mentioned above, someone might conclude that our number should be higher by nearly two orders of magnitude;

            Could I trouble you for your math, please? Why “nearly two orders of magnitude” instead of three or four?

            American police are shot at more frequently than German ones, to the tune of 143 deaths per year. The only comparable information I can find for Germany come from a Reddit thread indicating an average of 0.21 dead cops per year.

            If we were to assume that police in both countries were perfectly trained, perfectly virtuous professionals who only fired their weapons as a last resort when under unprovoke murderous assault, we would expect American police to shoot (143/0.21) = 681 times more people than do German police. With German police killing ~7 people per year and American police killing rather less than ~4800, the American police are looking rather restrained just on the numbers.

          • Douglas Knight says:

            John, that Reddit post says 3 German police murdered in 2012, not 1998-2012. So they kill about 2-3x as much as they are killed.

            As for American police, your link says 143 deaths in the line of duty, but only about 57 have causes that make them sound like murder. I am surprised to learn that more officers are shot than die in car crashes.

            But how many do American police kill? It is hard to know. Here is a list of 1200 people killed by police in 2015. That was a special year: more police died in car crashes (47) than were shot (35).

        • Having googled for “Cai Bao” and looked at pictures, I find it hard to see any reason why a woman waving one from behind the kitchen counter would be threatening enough to warrant shooting her. I can imagine someone thinking it was a medium sized kitchen knife, hence dangerous at very close quarters, but not anything worse than that.

        • TheAncientGeek says:

          Proves took much. Other countries manage to run more social-worker-like police forces under the same broad constraints.

          • keranih says:

            Examples, please?

            (Not taking the shit, here. I really would like to know who you have seen do it better.)

  30. Donny Anonny says:

    Tangentially related, but this post certainly explains why there is such a huge collection of spooky Internet stories/memes/image galleries about exploring abandoned mental asylums after dark.

  31. Vox Imperatoris says:

    Great article!

    I agree with you completely, as far as I can tell.

    • suntzuanime says:

      Your praise would be more persuasive if you were like “Great article! You’re wrong about basically everything, as far as I can tell.”

      • MugaSofer says:

        Why? Part of writing a good article is that it persuades the reader they agree with you, or providing and factually accurate information and clear insights.

        • The praise is less convincing if you agreed with the article’s thesis in advance. Vox Imp doesn’t say if that’s the case or not.

        • Vox Imperatoris says:

          Yes, I’m not trying to persuade other people that they should read this article. Presumably they already have, if they’re reading the comments. But if I were, the recommendation would be more “persuasive” from someone who disagreed.

          But in fact, I was giving positive feedback to the author, letting him know that it is appreciated. I wasn’t trying to persuade anyone of anything.

      • Randy M says:

        Lol. How about if I just didn’t have much idea before but now agree?

  32. Donny Anonny says:

    The description of mental illness in colonial America being kind of idyllic reminded me of something I heard in the news a few months back where an anthropologist found that the voices heard by mentally ill people in places like Africa and India tended to be benign or playful, vs the ones heard by similarly ill people in the US, where they are overtly hostile.

    I wonder if there are perhaps cultural similarities between colonial America and Ghana and India that could account for mental illness being evidently somewhat benign?

  33. Pvk says:

    Love your blog.

    I’m a pastor of a small church in a low property value part of a California city. Because housing is cheaper group homes proliferate. I deal with a variety of homeless males with serious mental illness and substance issues every day. The history was helpful. The description of the life, accurate.

    Those with more sanity sit in my office to just to have someone listen. The schizophrenics just mill around trying to do their thing. Some days its like the walking dead with shells of men shambling down the street. Getting hit by cars happens frequently.

    “not hurting anyone” is where I kvetch. This population burdens an already burdened community dealing with drugs, neglect, etc. The two populations enable each other. Homelessness and alcohol/drug use litter a neighborhood with feces, urine, panhandling, drug dealing and chaotic street incidences. These things aren’t tolerated in more affluent areas of town. The police understand “everything in its place”. People gotta go somewhere.

    I agree that institutionalization should be highly selective, but what is offered now isn’t close to adequate. My friends on the street go through cycles in and out of the ER. I can’t imagine what this costs the state. IF they get admitted they get patched up, detoxed, medicated, and released, only to have it all repeat again.

    This population NEEDs institutions, the question is what kind. One friend comes back from the ER with a host of paperwork. Reading through his “home care” instructions is tragic/comical given his living in a park, eating from a dumpster and getting his stuff rifled through when another hears he’s just gotten some new meds.

    Thanks for the piece. It’s an important conversation

    • Scott Alexander says:

      Is the problem lack of money, or lack of sanity necessary to use the money wisely?

      • pvk says:

        Most of the time both. I have in my “parish” of sorts a paranoid schiz who used to live with his parents until they died, lived in the family home held in trust for him. It became a place where others moved in to take advantage. Together with his sisters we got the sheriff to kick out the low lifes. After that he burned it down. I found a guy who wanted a tenant and could handle him. What keeps him housed is his sisters, the disability payments and the insurance money from the home. This is his last stop though. After that money runs out he’ll surely be homeless unless a car or another homeless guy ends his life.

        Just a few minutes ago another friend from the streets bragged about how he beat the first guy up last night for lying and stealing. This second guy is bipolar, poly addicted, suicidal. He has more sanity but less resources.

        In any case on my corner it’s really the law of the jungle.

      • William O. B'Livion says:

        > Is the problem lack of money, or lack of sanity necessary to use the money wisely?

        I think it’s the lack of wisdom to use the money sanely.

        It is an incredibly complex problem, made even more difficult by the last 120 years of progressive government intervention into society.

        Which is to say that no matter *what* solution you propose a significant portion of the electorate, or a significantly powerful government employee or politician will oppose it.

        The funny thing is that I just finished reading a book called “Extreme Ownership” that was intended as a tome on leadership and management in business by a couple of Navy SEALs who’d been in Ramadi during the worst of the fighting there.

        It’s really a treatise on how to live well. Take ownership of what you can, and lead those both “above” and “below” you in life.

        IMO the right answer is a spectrum of solutions:

        * Where possible provide not just the patient, but the patients family and social circle with information and education on what to watch for and how to assist the patient in managing their condition. In this case it’s hard to charge the patient with ownership of their own situation, but their wives/husband/SOs need to own it.

        * Find a way to make it easier for Doctors to manage doses of medication to minimize “side effects” while maximizing intended effects.

        * A good shoe manufacturer realizes that not only do feet come in different lengths, but different widths. Bloody PAYLESS to does a better job of this than the crapmeisters at HUGO BOSS. Why do we have to have only three sizes (outpatient, group homes, inpatient)?
        ** This implies a mix of outpatient, group home care, possibly the creation of emergency clinics *just* to deal with psychiatric issues located in the places where the police and social service agencies are more likely to find those sorts of people.

        * See Tracy W’s comment on Common Sense and Chesterton’s Fence. The bureaucrat relies on process and procedure to guide their decisions and keep their job. Thus it is difficult as heck to get reliable, flexible results out of a bureaucracy, however the mentally ill *require* that sort of flexibility because the combination of problems they have, genetics, family support and such each case in some ways a precious snowflake. But OTOH there is a lot of money (in aggregate) in this, and there are always family pressures one way or another that might not be in the best interests of the patients.

        * In general the further away you are from the problem the less likely you are to be able to fix it. Experiments should be done at local or county levels with the understanding that they will never get the right answer, but will only do their best to make a bad situation less bad.

        * Employing people in the US is very expensive, and there’s a lot of menial jobs that *could* be done by someone who requires a more flexible work environment coupled with intelligent supervision that either go undone, or are done in other ways. Fix THAT and you can start to chip away at a whole host of other social ills, benefit the economy and create or free up more funding for the “truly” ill.

        I may have told this story here before, but it is relevant. At one in the 1950s or 60s my father, a traveling medical salesman, made a sales call on a catholic hospital in the midwest. It was in a small town and was *literally* run by Nuns. As in the “CEO” was a Sister who had taken orders and was wearing the full getup. He was attempting to sell her single use disposable dressings and bandages. She stated that she would not buy them, and when pressed said “Come, let me show you”. She took him to a room in the basement that had a long table around which sat a bunch of old women. They were very carefully cleaning, boiling, and rolling bandages.

        The Nun explained that this was these ladies only form of income, and in their community this was their only *likely* source of income, and that by buying the single use bandages most of these women would be left without that income.

        There have been massive changes in the medical market since then, driving by technology, Medicare/Medicaid reimbursement policies, the legal industry and broader social shifts. Most of those local religious charity hospitals were either forced out of business or bought up by “not for profit” (not for profit is not the same as charity) corporations. I suspect we as a nation are poorer for that.

        • Garrett says:

          My full time job is as a software developer. I volunteer as an Emergency Medical Technician (EMT).

          In my full-time job, I am always expected to use my judgement to achieve the goals outlined. If there are uncertainties, I’m either to clarify (if major), or pick something reasonable (if it’s small). I have broad latitude in all aspects of my job.

          As an EMT, I have little latitude in what I do or *don’t* do for a patient. If I elect to not do something, I need to document it or multiple levels of quality assurance will flag the charts I write up and insist that I write more stuff to document why I didn’t do what I was supposed to do.
          If I do something I’m not supposed to do, I have to write up lots of extra paperwork, in addition to a likely meeting with my medical director and various other people where I will be interrogated and who will insist that mistakes are not allowed.
          My conclusion from having spent a bit more time looking at the healthcare system as a whole is that the sole responsibilities of doctors at this point is to have a huge liability insurance policy, and to slowly develop ulcers from worrying about things.

  34. Donny Anonny says:

    Hey, Scott, in regards to your recent nootropics survey, about a half-dozen people reported use of, and positive effects from NSI-189.

    I’d be curious to hear your thoughts on NSI-189.


    • Scott Alexander says:

      Never used it, don’t know much about it.

    • Vita Fied says:

      >>NSI-189 is an experimental, novel potential antidepressant that is under investigation

      Probably garbage. Perhaps a one-off usage for military servicemen under specific circumstances with corrections to race, gender, and biometric testings, like how some of these seem to be.

      The nootropic crowd has about 20 IQ points above the average idiot bodybuilder taking new random shit to get buffed, but falls for the same bullshit.

      Let the athletes experiment with this stuff, with pro-gamers being the ones willing to experiment with the brain stuff. Don’t do it yourself.

  35. Hollyluja says:

    Your penultimate paragraph invalidates your whole argument. You believe in involuntary commitment, you’re just haggling about the price (in this case, the criteria).
    A supportive continuum of care is a nice idea (and one I’d gladly pay tax to support!), but until it is a reality I’m tired of my kids and I being harassed out of public parks, libraries, transit, etc by screaming spitting weirdos.

    • Scott Alexander says:

      Isn’t that kind of like saying “If you believe in imprisonment, you can’t be against locking up random people in concentration camps, since you’re just haggling over the price”?

      Or “If you believe war is sometimes morally justifiable, you can’t be against mass shootings – you already agree you can shoot people with guns, you’re just haggling over the price”?

      What you call “haggling over the price” I call “doing a cost-benefit analysis”, and it’s pretty much the basic unit of human decision-making.

      I don’t think I’ve ever been harassed out of something by a mentally ill person. I’m not sure how I am different than people who say this is a typical occurrence (unless it’s that I live in nicer areas?) But I would rather have this solved by better security than by imprisoning anyone who might do it.

      • ReluctantEngineer says:

        I’m not sure how I am different than people who say [being harassed out of something by a mentally ill person] is a typical occurrence

        I’d guess that not having kids is a big part of it.

        • Scott Alexander says:

          Because mentally ill people disproportionately harass kids, or some other reason?

          • ReluctantEngineer says:

            Because stuff you might tolerate or even not notice when alone can seem like a much bigger deal when you’re with kids. That filthy homeless guy ranting to himself in the subway car may not have you concerned for your own safety, but what about the safety of your hypothetical four year old?

          • Dr Dealgood says:

            Have to agree with ReluctantEngineer.

            No kids myself, but when my (now ex) girlfriend started living with me I definitely started paying more attention to crime and shady characters wandering around. There’s a big difference between the level of risk you’re willing to expose yourself to and the level that you would expose someone you love to.

          • Hollyluja says:

            ReluctantEngineer is right – this is stuff that didn’t bother me as much before I had kids. The drive to keep them safe is unexpectedly intense.

            So now, with the police and social services either underfunded or toothless, I see “warehousing” as the next best option.

            Don’t worry, you’ll still get to sit in the Star Chamber. It’ll just be positioned at the back door of the institution instead of the front.

            ETA: this happened yesterday, not far from where I live.

          • Anonymous says:

            More evidence for the breeding induced sociopathy hypothesis.

          • Hlynkacg says:

            the breeding induced sociopathy hypothesis.

            Could you elaborate?

          • William O. B'Livion says:

            > Could you elaborate?

            I suspect that it’s a theory that can be translated to say “When you have kids you become more callous to those you think would hurt them.”

            Calling that sociopathy displays the arguers fundamental dishonesty.

            I have a 9 year old. You present a reasonable threat to her in my presence and I will do my damnedest to stop you. If this means you die right there, YOU made the choice to threaten someone.

            Thing is, that wasn’t caused by my having a child, before I had kids if I saw you threaten a child I would do what I thought I could to stop you. The only difference is that since it’s my kid I’m willing to go further, faster than if it’s a stranger’s kid where I’d be less certain about the environment.

            This is how tribes work, we watch out for other people’s kids when their parents aren’t around. Doesn’t matter whether the jackal slinks in on 4 legs or two, you don’t let it take the kid.


            That we have people these days that articulate that as “sociopathy” says far, far more about them than the rest of us.

          • Anonymous says:

            If it was about reasonable threats to the life or health of their children, sociopathy would indeed be a massively inappropriate descriptor. But that’s the small motte surrounded by a gigantic, continent sized bailey.

            Ordinary, well socialized adults are willing to make trade-offs for strangers. Not one to one, no one is demanding sainthood, but they’ll take a speck of dust in their own eye to save a stranger’s life. Especially when it is right in front of them, rather than some abstract EA argument. Someone that refuses to do so is rightly seen as a sociopath and shunned. Bring uncertainty into the situation and a similar result obtains. People are expected to bear tiny risks in order to benefit other people.

            But parents are a whole other story. Homeless people are to be kept out of sight not because they pose any appreciable danger to little precious but because they smell bad or because there very existence upsets a child whose parents haven’t bothered to teach him that poor people exist. The tinyest risks and the smallest inconviences trigger complete disregard for basic human decency.

            Public policy arguments based on pure self interest, with not even a nod in the direction of the veil of ignorance are routinely made about e.g. schools, where the same person wouldn’t dream of making such an argument without the excuse of a nominal third party.

            That’s breeding induced socioapthy and isn’t something to be proud of.

          • Walter says:

            I play a lot of wargames/card games. Magic the gathering, warhammer, etc.

            The rules lawyering is INFINITELY worse when you are playing team games. People who may feel like they are getting the raw end will usually smile and nod in the name of good sportsmanship. But let them stand up on behalf of their teammates?

            I’m not remotely joking. Adding people to an activity (mega battle, free for all) makes something take longer, but, like, at a linear rate. Adding people to a SIDE of an activity, such that I can be a defender? Such that I can be angry without looking selfish? It’s incredible. Everything instantly takes forever.

            Similarly, bros and sisters who have kids become incredible jerks on their kids behalf. Behavior that they’d recognize as crazypants is utterly ok if it is “for the children”.

      • Said Achmiz says:

        I don’t think I’ve ever been harassed out of something by a mentally ill person. I’m not sure how I am different than people who say this is a typical occurrence (unless it’s that I live in nicer areas?)

        Um, yes. Obviously this is a big part of it.[1] That’s… that’s actually one of the big things that makes an area “nicer”.

        But I would rather have this solved by better security than by imprisoning anyone who might do it.

        Quick poll, for Scott or anyone else: would you rather live in an area where you can walk around and be safe anywhere (on the streets, in parks, any public places at all) but where libraries and such have less security; or, an area where public buildings etc. have very good security and are super vigilant against anything that might bother visitors, but where every other part of the area is unsafe?

        I know which one I prefer.

        [1] Meta-level comment: I see this pattern in your writing a lot, Scott. You go “I just can’t see any plausible explanation for this! It’s a mystery to me! So weird… Unless somehow maybe it’s [insert explanation X]?? That’s the only thing I can think of …”, where explanation X is, yes, duh, obviously the reason, and cue comments from incredulous readers going “… uh, yeah? Of course it’s X!”

        (I don’t really know what to make of this; just something I’ve noticed.)

        • caryatis says:

          “That’s… that’s actually one of the big things that makes an area “nicer”.”

          Good point. Also because Scott is male and therefore less worried about rape and less likely to be sexually harassed or masturbated at. Not sure how many sexual harassers are actually mentally ill, though.

          • houseboatonstyx says:

            @ caryatis
            Not sure how many sexual harassers are actually mentally ill, though.

            What about better security everywhere in the area, streets included? And anyone filmed at (objectively defined) harassment behavior, gets banned from the area — even the mayor’s honor student kid.

          • Said Achmiz says:

            @ houseboatonstyx:

            What about better security everywhere in the area, streets included? And anyone filmed …

            Ok, so let’s take that suggestion seriously and roll with it. Now we’re placing cameras in literally all of our public spaces? Maybe guards? Or both? Streets, parks, alleys, bridges… everywhere. Right?

            A practical-minded person might bring up the question of cost. It’s the taxpayers who’re paying for this, right? And an idealistic-minded person might object that perhaps the citizens of this are aren’t ok with being filmed and watched everywhere they go, from the moment they step out of their house.

            And suppose our new pervasive security measures catch the unsavory homeless fellow doing a forbidden thing. Then, what? We exile him from the area? Ok, fair enough, but did we really need to turn our neighborhood into the Panopticon in order to do that? If the punishment for an infraction is exile, the surveillance state seems like overkill.

            Is this really the sort of area you’d want to live in? I don’t think I would.

            … (objectively defined) harassment behavior, gets banned from the area — even the mayor’s honor student kid.

            Do you really think that this will make an area meaningfully safer, in actual practice? This sort of no-tolerance no-contextual-judgment approach? Like, actually in practice safer?

            In short: your suggestion — what will it cost us, and what do we actually get out of implementing it?

          • caryatis says:

            @ houseboatonstyx: It’s never “objectively defined.” You seem to be assuming perfect implementation, which will never happen. Plus I think “banned from area” –the town? the neighborhood?–would be too harsh.

          • houseboatonstyx says:

            @ Said Achmiz April 2, 2016 at 6:41 pm

            My Selective Demand for Rigor detector starts humming when my “Try Means X to improve Problem Y” is answered with “To completely totally 100% forever everywhere solve Problem Y by Means X alone blah blah Orwellian Police State.”

            (Or maybe that should be “Selective Demand for Carrying to Absurdum.”)

            Briefly, maybe we need an Orwell’s Law: “To completely totally 100% forever everywhere solve any problem by any one thing blah blah Orwellian Police State.” That would fit “Pre-emptively lock up all mentally ill people before they misbehave anywhere” rather more closely than my “Let everyone go everywhere till some one does get filmed misbehaving, then ban him [temporarily and after warnings, from whatever area the taxpayers and police are willing to enforce it in].”

            Big Brother is here already, just not all tax supported. Everyone’s cell phone, dash cams in parked cars that turn on by motion detection, security cameras in big box parking lots and restrooms, etc.

          • John Schilling says:

            Good point. Also because Scott is male and therefore less worried about rape and less likely to be sexually harassed or masturbated at.

            But much more likely to be violently assaulted. Can we please stop pretending that violence is only frightening or problematic when it is directed at a woman for sexual reasons?

          • keranih says:

            With John Schelling on this.

            That men are subject to violence in different ways than women does not mean that they are not subject to violence at all.

        • Wendy Laubach says:

          “But I would rather have this solved by better security than by imprisoning anyone who might do it.” This appealed to me when I first read it, but it poses the same dilemma as anti-terrorism measures: we risk imprisoning ourselves in order to avoid imprisoning the people who threaten to make life unbearable for us. Nevertheless, I take our host’s point about what a terrible idea it is to lock up people because of what they might do. Mostly we’re stuck with the unpleasant task of waiting until they do something pretty bad before we intervene, then we have to live with the fact that forcible intervention looks and feels a lot like punishment, whether we feel guilty about punishing the mentally ill or not.

      • nydwracu says:

        Scott, you should ask lambdaphagy about Baltimore sometime.

      • Robert St James says:

        What form would this “better security” take? A continuous police presence? Better response times after someone has been stabbed or shot? Or a cavalier attitude of “it doesn’t bother me so why should it bother you?”– a protective shield of indifference.

        Ride the Portland Blue Max line with a guy walking up and down the car talking to himself and swinging a baseball bat. Do the cost benefit analysis of not getting out at the very next stop.

    • Randy M says:

      Some prices merit haggling.

  36. MugaSofer says:

    “These kinds of decisions are the ones you want to be really, really sure about, so we should go with my prior.” Really?


    • Vox Imperatoris says:

      How about “so we should not default to the maximally coercive option”?

      • MugaSofer says:

        I’m not saying you should. I’m saying that pointing out all the harm either option will do, then going “eh, let’s go with the prior” is disappointing.

        There’s no attempt to even search for the correct solution, just laying out the fact that there are arguments for both sides. Which is fine, just worse than I’d hoped for.

    • suntzuanime says:

      Scott has a principle. That principle is that society should exercise caution in committing gross breaches of the liberty of individuals. Many people share that principle, including, full disclosure, me. If you don’t understand the principle, I can understand that you might not be persuaded, but that doesn’t mean the principle is wrong or worthy of this sort of meta-level scorn.

      • William O. B'Livion says:

        Thing is, if we’re going to say that society must respect the decisions of mentally ill people, then we should also be able to hold them *fully* responsible for the ramifications of their decisions.

        Having it both ways (we have to set unreasonably high bars for commitment, but we can’t punish them to the full extent the law allows because they’re mentally incompetent) is VERY problematic.

        I should add that I agree we should avoid gross breaches of liberty, but frankly the actions of a few of these mentally ill are used as a reason to breach the rights and liberties of large numbers of non (or less ) mentally ill people. When your right to live sleep in doorways, defecate in alleys conflicts with my rights NOT to have to walk in that stuff, and when the murder sprees of a few mean society goes after the rights of non-mentally ill, well, you’re going to get some pushback.

        • hlynkacg says:

          Having it both ways (we have to set unreasonably high bars for commitment, but we can’t punish them to the full extent the law allows because they’re mentally incompetent) is VERY problematic.


  37. aanon smith-teller says:

    >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 only one counterbalancing consideration: that 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.

    Debtor’s prisons are a thing. Workhouses used to be a thing. Community housing is currently a thing.

    You keep doing this thing where you compare mental healthcare to jail, and then say “but they’ve committed no crime!” But this is patent nonsense; the reason we don’t send people to jail who’ve committed no crime is that jails are set up for the purpose of imprisoning criminals, not because criminals matter less.

    Everyone agrees that there are some situations where we need to put the mentally ill in permanent care! Pretending like this is some crazy idea no-one’s ever proposed before just makes it seem like you don’t have any arguments and are trying to slip one past us.

    I see that you do in fact have some arguments. So write the post about them! But they’re nowhere near as strong as you seem to present them as, and you seem to spend most of the time acting like even these arguments are totally unnecessary because it’s self-evident that we should never imprison anyone unless they’ve committed a crime.

    I don’t really have an opinion on whether we’re institutionalizing too many or too few people, but this post has caused me to update a bit toward “too few”.

    • Scott Alexander says:

      I am trying to cut through the mystique surrounding psychosis and say “Hey, you know our general belief that being in jail is much less pleasant than not being in jail? That’s pretty close to the principle we should be applying here too.”

      • Vaniver says:

        I think the main objection is to paragraph 3 of part IV. It seems out of place in a section that’s mostly performing a cost-benefit analysis; it says ‘regardless of whether A would actually make sense, you’re a bad person for even considering it, much less putting it into practice.’

        But that rests on the cost/benefit analysis! If you led with “there’s potentially a huge swing in QALYs here” (your paragraph IV.14) and then worked through it and thought you ended up with institutionalization being worse off, especially compared to IOC, then you could conclude with “and thus IOC is way better than institutionalization.” As is, it seems like a huge admission of bias that taints the CBA that follows.

        • Vox Imperatoris says:

          I see how it could be taken multiple ways, but I took that paragraph to be an expressive shorthand for “all the background evidence from similar situations points towards rounding up everyone in the ghetto having obviously terrible consequences”, not “rounding up and imprisoning everyone in the ghetto would be terrible regardless of whether it made their lives 24/7 bliss”.

          Especially considering the author’s previous writings, the intended meaning seems clear.

          • Vaniver says:

            I see how it could be taken multiple ways, but I took that paragraph to be an expressive shorthand

            This is an explanation for why you did not write aanon smith-teller’s comment, or my shorter comment earlier. This is not an explanation for why the structure of that section is productive instead of counterproductive.

          • Vox Imperatoris says:

            @ Vaniver:

            It’s productive for a reasonable person interpreting it charitably.

            If not, not.

          • Vaniver says:

            I think you want to use “reasonable” in the sense of “agreeable” when I want to use it in the sense of “actually thinks through propositions and inferences.”

            The argument in that paragraph is most easily read as a deontological argument about rights. My emphasis:

            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.

            This is not how someone would write about “let’s do the math and then follow it”; this is how someone would write about a taboo tradeoff. And so then the obvious inference is that everything afterwards is motivated reasoning that follows that conclusion instead of preceding it.

            This isn’t a commentary on the argument as a whole–this is a commentary about that paragraph, its placement, and its implications. One can agree with an argument while seeing its deficiencies.

          • Nita says:

            Known fact: Scott likes to spice up his writing with a bit of “microhumor”.
            Observation: “you have no right to even consider such a thing” could be replaced with “WTF, dude?” with no significant change in effect.

            Conclusion: It’s a funny bit, not a part of the argument. “Everybody involved would hate it” is the argument-ish part.

          • Jiro says:

            I generally don’t take that sort of thing to be humor because interpreting it as humor allows for plkausible deniability: someone makes a bad argument but when called on it claims it was just a joke, and you can’t prove it isn’t.

          • Vox Imperatoris says:

            @ Jiro:

            I generally don’t take that sort of thing to be humor because interpreting it as humor allows for plkausible deniability: someone makes a bad argument but when called on it claims it was just a joke, and you can’t prove it isn’t.

            Assuming bad faith is the very essence of uncharitable interpretation.

            The question isn’t “What is the worst thing this statement could have been a dishonest cover for?” It’s, “What is the best thing the author could have meant?”

            It reminds me of something Scott has complained about before in the context of his arguments with Hallquist:

            This is the one case where I feel instead like I am a politician, and whatever I say is going to be combed through for quotes that can be taken out of context in order to publish more widely and make me look bad, without any engagement with the broader message at all. It’s like those black-and-white attack ads: “Scott Alexander once said that ‘monarchy…has certain…advantages. Wrong on Moloch, wrong for America.”

          • Jiro says:

            The question isn’t “What is the worst thing this statement could have been a dishonest cover for?” It’s, “What is the best thing the author could have meant?”

            If you do that you create bad incentives. The more you take people at their word when they say “honest, that wasn’t a bad argument, that was a joke”, you encourage the strategy of pretending that bad arguments are jokes.

            (Also, note that Scott never said it’s a joke anyway. People are just assuming it is.)

          • Vox Imperatoris says:

            @ Jiro:

            If you do that you create bad incentives. The more you take people at their word when they say “honest, that wasn’t a bad argument, that was a joke”, you encourage the strategy of pretending that bad arguments are jokes.

            The question is not whether someone in general could pass off a bad argument as a joke.

            The question is whether you think Scott Alexander, in this particular instance, is engaging in deliberate dishonesty and equivocation by strategically positioning a bad argument in such a way that it could be taken either seriously or as a joke. Do you or do you not think that?

            If you think that he is not being dishonest, you should interpret him charitably.

            If you think that he is being dishonest, you should interpret him uncharitably. But then there is no point in engaging with him because you can’t have an honest discussion with someone who is trying to use dishonest argumentative tactics.

            Also, it’s not a joke as in “funny anecdote” or “something you should completely dismiss”. It is humorous way of getting across a point, approximately: “Imprisoning everyone in the ghetto is such an obviously awful idea that I don’t need to spell out for you why that is”. He combines this with humorous understatement (“we have only one counterbalancing consideration”; “it would be really mean”) and a run-on sentence structure to enhance the “breathless” effect.

            He is not arguing that imprisoning everyone in the ghetto would be bad. He is taking that as a premise for the argument that imprisoning all the mentally ill would be bad. As he himself said:

            I am trying to cut through the mystique surrounding psychosis and say “Hey, you know our general belief that being in jail is much less pleasant than not being in jail? That’s pretty close to the principle we should be applying here too.”

            If your principle is: no honest person should ever use humor in the process of making an argument because a dishonest person could use humor to disguise a bad argument—well, I think that is a bad principle.

          • Jiro says:

            The question is whether you think Scott Alexander, in this particular instance, is engaging in deliberate dishonesty and equivocation by strategically positioning a bad argument in such a way that it could be taken either seriously or as a joke.

            Scott himself didn’t claim it’s a joke at all. His defenders did that.

            Do I think his defenders are claiming it was a joke dishonestly? Probably not. But they could be mistaken, since they’re not really in a position to know.

        • stargirlprincesss says:

          @Jiro taken on 100% face-value Scott is saying he has a “sacred value” of “not throwing everyone in the ghetto into involuntary treatment.” This does not really seem like something worst criticizing!

          I am also not a big fan of “its just a joke.” But Scott isn’t covering for any insults and he isn’t mis-representing anyone here.

  38. Anonymous says:

    On the subject of why there are more mentally ill people now than in past centuries, I think society may actually be the reason. Japan has an abnormally high suicide rate because of cultural reasons, right? I think with the pressures of society and the various horrors we observe on an almost daily basis, the brain is just more likely to break down than ever before. Public schooling may be responsible for a number of festering psychoses, and I’m not sure if I’m joking.

    • FacelessCraven says:

      @Anonymous – “Public schooling may be responsible for a number of festering psychoses, and I’m not sure if I’m joking.”

      I was public schooled for a few years, up till about fourth grade. I *hated* my classmates with a burning passion, and my quality of life improved immensely after being pulled out into homeschool. My sibling stayed in through high-school, and for about three years they’d walk through the front door in the afternoon, and within five minutes start a screaming match with my parents that would last hours. This would happen several days a week, for about three years straight. my parents eventually pulled them out as well near the end of high school, and they transformed into a decent human being within months, and have remained so since.

      Lord of the flies, all the way.

      • nydwracu says:

        I certainly hope it isn’t news to anyone that government schools are Satan’s tools and should be cleansed from this earth with holy fire.

        • Stefan Drinic says:

          Speak for yourself, America. The world is a very large place, and you’re not alone on it.

          • Nita says:

            Seconded. The school I went to did have some flaws, but the net value was definitely positive.

          • Said Achmiz says:

            I went to a public high school in America and it was some of the best years of my life. #notallpublicschools

            (it was a magnet school, of course)

          • sweeneyrod says:


          • gbdub says:

            There are plenty of good schools (although even the best can be rough on the socially awkward, and I suspect that that’s true everywhere). And there are a growing number of alternatives for those that want/need them.

            The problem is that the bad schools are clustered in the places that serve the people with the least ability to seek alternatives.

        • Spaghetti Lee says:

          Fourthed. I went to a perfectly safe public school full of smart kids and smart teachers. Calm down with the rhetoric.

        • Anonymous says:


        • The Nybbler says:

          Well, since you’re getting piled upon here, I’ll agree with you; school is hell. Most schools probably aren’t hell for most of their students, but for some of them, they are. And many students will remain within that group for their entire school career.

        • William O. B'Livion says:

          We homeschool my daughter (at considerable expense–my wife made approximately the same salary as I did before she quit her job to stay home) because, as one wit put it “It takes a village to raise a child, and I’ve *seen* your villiage”.

          That said, it’s not the schools that are the problem (IMO), it’s that everything from the curriculum to the food in the lunch room is tied to federal money, and driven out of a highly ideological department of the federal government and the system is largely owned by an ideologically driven union.

          Break *that* and school comes less a tool of Satan (which I presume you mean metaphorically).

          However it will always be hell for most kids because about 1/2 if it occurs while you’re also going through puberty and adolescence.

        • William O. B'Livion says:

          What You Say?

          I DISTINCTLY remember Reagan giving you guys 5 minutes to leave before he started bombing.

          Or was that only the Soviets?

        • Anonymous says:

          @nydwracu When I see comments like this, I have to remind myself that you’re a pretty intelligent kid of pretty intelligent parents who were college-educated, and therefore probably would have done better out of (public) school than in it. (Also, you’re much younger than I am and would have been subject to a lot of the pedagogical crapola that came into vogue around your time, but that I thankfully missed.)

          For me, with my non-English-speaking, barely educated parents, some sort of school, public or otherwise, was really the only option. I could not have taught myself calculus or college-level biology. In hindsight, I’m grateful for much of the education that I got, and that’s with most of my K-12 years being a living hell.

    • Psmith says:

      Japan has an abnormally high suicide rate because of cultural reasons, right?

      Paging Jayman, Jayman to the white courtesy phone….

    • stargirlprincesss says:

      My mental health was disturbingly bad while I was in elementary/middle school. It was a terrible situation and I could not handle it at all.

  39. Jacko says:

    Blaming the “hippies” for de-institutionalization of the mentally ill is a bit of a stretch. Hippies (which I assume means lefty idealists who grew up in the 1960’s) had many naive and impractical policies, but it was only when they coincided with the political establishment’s desire to cut expenditure/reduce taxes that they gained any traction.
    Politician: “Hey – I can stop wasting money on these crazy bums who don’t vote AND claim to be virtuous/caring at the same time!”

    • suntzuanime says:

      Giving virtue-signalling cover to “the political establishment” is causal in that they have a harder time doing things without cover. Sounds blameworthy to me.

    • William O. B'Livion says:

      There is this perennial arguement between activists (of all stripes) of whether it is better to work inside the system, work outside the system to pressure it, or blow the system up and replace it.

      The latter generally don’t succeed at much of anything because they’re better at polemics than implementation.

      However with the former you occasionally wind up in this situation where enough people *joined* the institution that they comprise either majority or a significant minority, and and there are still enough people outside the institution that it looks like the outside pressure groups were “forcing” this change.

      See also recent reports of EPA officials using personal email accounts to converse with environmental NGOs.

      Which isn’t to say your thesis has no weight, when you line up things up just right such that *everyone* thinks they can win, you will often get what you want, and the activists, the chemists and the government all thought they had win-win solution.

      • Agronomous says:

        See also recent reports of EPA officials using personal email accounts to converse with environmental NGOs.

        The problem here isn’t that they’re using personal email accounts to conduct official business—everyone does that, even the Secretary of State.

        The problem is that they’re basically saying, “Hey, NGO: why don’t you sue to get us to enforce this thing? We promise we’ll totally roll over in court and everybody’ll be happy.”

        That is, the “adversarial” posture is a complete lie (which seemed to me to be your point earlier).

  40. Dmitriy says:

    I too would prefer to live outdoors with a few personal possessions/freedoms than to be offered a warm shelter in an institution that takes those things away. Perhaps schizophrenics are making the same, apparently rational choice? This seems like something that there would be papers on.

    Are there any institutions that treat their patients with a level of dignity we would find acceptable? To me this includes allowing them to occasionally drink or smoke, own their own private computer, etc.

    • I’m been wondering whether there’s very nice institutionalization for at least some rich people.

      • Anonymous says:

        I knew the teenage child of double digit millionaires that ended up in ordinary hospital locked psyche ward. A very nice one physically–with hallways that looked like the administration building of a good college–and in terms of the attitude and deportment of the staff at least during visiting hours, but still and all recognizably a locked hospital psyche ward in terms of policies and procedures.

        Maybe in the stratosphere beyond that there are other options. I don’t know.

      • William O. B'Livion says:

        Of course there are.

        Also, “rich” starts (in my world) at about 400k a year, or about 5 mil in investments (aside from property unless it’s income producing property). That sort of place may well be within reach for the “lower upper class”.

        But for the “truly rich” there is always the guest house out back with a personal physician on call.

        • Anonymous says:

          Click through the links, it’s all drug and alcohol treatment centers. They aren’t for schizophrenics experiencing psychotic breaks.

          Believe it or not, being able to type a few words into google doesn’t make you an expert or knowledgeable about, well, anything.

  41. Anaxagoras says:

    You talk a lot about the decision-making in going into hospitals, and make a good case that there’s rational reasons why even the severely mentally ill would prefer to avoid this. If we had a perfect magical cure for schizophrenia, how okay would you be with involuntarily applying this to schizophrenics, even if they have a strong preference that you don’t because they wrongly believe you’re NSA injecting them with mind control robots?

    • Jiro says:

      If a magical cure caused no harm whatsoever, not even the harm of making someone be involuntarily locked up a couple of days while he was forced to take the cure, my answer would probably depend on whether it was possible for this to slip towards forcing people to take cures for other things that are only 99% perfect, and then others that are 98% perfect, and then others that are 95% perfect and almost everyone agrees that the illness is a mental illness, etc. I wouldn’t want us to allow forced cures for schizophrenia and in 30 years find that it slipped so far that people are forced to take medication because having political position X is obviously bigotry and thus obviously insane.

    • Scott Alexander says:

      If post-cure schizophrenics say they’re very happy to have been cured, I’d be pretty okay with using it. I think the exact system would be something like “you need to take this to receive any government support or if you come in contact with the legal system” to make it look better, but yeah, pretty okay.

      • Jiro says:

        I think that is a bad idea regardless of whether the main idea is a bad idea.

        If you set a precedent that you can force people to do things by saying “well, we’re not actually forcing them, we’re just denying you benefits unless you accept them”, that becomes a precedent that lets you not-force people to do anything at all. The loophole you created to force people to take medication will not just be used to force people to take medication.

        • houseboatonstyx says:

          @ Jiro
          If you set a precedent that you can force people to do things by saying “well, we’re not actually forcing them, we’re just denying you benefits unless you accept them”, that becomes a precedent that lets you not-force people to do anything at all.

          Now that’s a point that could be used against offering the benefit/s in the first place.

        • gbdub says:

          Don’t we already do that (attach strings), like, all the time with benefits? The only place I’ve seen pushback to the general concept is in drug testing welfare recipients.

          Personally, I don’t really have an issue with the concept in general (certainly there’s some place down the slope you don’t want to go beyond, but I think the friction coefficient is relatively high). Generally, my thought process is that once you start relying on the government largesse for your survival, the government (and by extension the taxpayers paying the bills) have the right to weigh their cost and preferences against yours. Want to be crazy and self-supporting? Fine, have fun, don’t hurt anybody. But if we’re taking care of you, we’re going to do it in the most cost-effective way that gets you functional.

          • Jiro says:

            Generally, my thought process is that once you start relying on the government largesse for your survival, the government (and by extension the taxpayers paying the bills) have the right to weigh their cost and preferences against yours.

            I don’t buy that because since those things are paid by taxes, the “largesse” just consists of the government giving you back some of the stuff it took from you in the first place. Taking things and giving them back shouldn’t create a moral obligation for the “gift”.

            (Note that this is true even if the government gives things to someone who didn’t pay that much in taxes. Think of it as the government taking money and buying insurance with it. Some people receive more than they lost and some people receive less, but that’s true for all insurance.)

          • gbdub says:

            But insurance comes with strings! You don’t get a blank check, you get a negotiated fee for an approved list of services. Use this repair shop. Take the generic med. Etc. And mostly we’re okay with that because the insurance buyers recognize that the benefits of “blank check” don’t outweigh the additional cost. If you choose to buy a cheap insurance plan and then complain after you’re sick that the coverage isn’t good enough, my sympathy is minimal.

            My main point is that (as with insurance) public benefits are a collective system, and the costs and benefits apply to the whole system. So everybody buying into the system should have their say about how the benefits are distributed and what costs they are willing to bear.

          • Vox Imperatoris says:

            @ gbdub:

            My main point is that (as with insurance) public benefits are a collective system, and the costs and benefits apply to the whole system. So everybody buying into the system should have their say about how the benefits are distributed and what costs they are willing to bear.

            Public. Choice. Theory.

          • gbdub says:

            @Vox – Your attempted pithiness has obscured your point. Can you elaborate?

          • Vox Imperatoris says:

            @ gbdub:

            I was merely trying to express in a broad way that when you want “everybody buying into the system” to “have their say about how the benefits are distributed and what costs they are willing to bear”, it’s not going to produce good results.

            The people paying in are ignorant of how the system works, have virtually no ability to change what the system will do, and are systematically biased in their opinions about what will make it better. And when you combine that with the collective-action problems and principal-agent problems of actually implementing policies, you end up with a “collective decision” that’s not only bad—it’s not even what anybody wants.

            Your statements like “once you start relying on the government largesse for your survival, the government (and by extension the taxpayers paying the bills) have the right to weigh their cost and preferences against yours” suggest that the actual costs and preferences of the taxpayers are being weighed in some kind of semi-rational way. When no such thing is the case.

            Anyway, I’m not arguing that the government ought to give out tax money unconditionally. I don’t think they should give it out at all. But I trust them even less to try to figure out who’s the “deserving poor” and who’s the “undeserving poor” and use the welfare money as a tool of social control.

            I would like things to be in the hands of private charity, who are much better at figuring out who’s deserving and who isn’t. As David Kelley argues in his book A Life of One’s Own.

          • gbdub says:


            I actually agree with everything you just said! And I too am generally skeptical of big central one-size-fits-all programs and prefer private charity.

            But let’s get back to the specific case: if a person is so mentally ill as to be non-functional in society, such that they impose a significant net cost on their neighbors, does that person, when offered treatment, have an inherent right to say “NO, I prefer to be crazy! You must continue to accomodate and provide for me in my current state!”.

            I say they do not, because I don’t believe they have a right to impose that preference on others with no regard for cost. (I DO think he has an inherent right to say “I prefer to be crazy, so I’m going to do it over here, where I’m bothering no one, and pay for my preferred treatment and living arrangement on my own”. But I doubt many actual people able to make that rational choice exist).

            We must weight their personal freedom against the impingement on the freedom of others. The fact that it’s very, very difficult to actually implement that weighting rationally across a country doesn’t mean we need to throw up our hands and say “just let him do what he wants”.

            I get that assuming this is all rational collective action is a hopeless idyll etc. But there are a lot of problems with “just let everyone follow their personal preference” too, and I think in this particular case it’s okay for the collective to impose on the individual, given the cost of not doing so.

          • Vox Imperatoris says:

            @ gbdub:

            I say they do not, because I don’t believe they have a right to impose that preference on others with no regard for cost. (I DO think he has an inherent right to say “I prefer to be crazy, so I’m going to do it over here, where I’m bothering no one, and pay for my preferred treatment and living arrangement on my own”. But I doubt many actual people able to make that rational choice exist).

            We must weight their personal freedom against the impingement on the freedom of others. The fact that it’s very, very difficult to actually implement that weighting rationally across a country doesn’t mean we need to throw up our hands and say “just let him do what he wants”.

            I agree that the person has no right to be accommodated at the expense of others.

            But I think giving the government the power to decide when certain people need drugs to make them more well-behaved is a bad idea. I think the amount of money saved is not worth the risk of abuse.

            If the person is going around stabbing people, there’s not much choice other than to give him the choice between taking drugs or being locked up. But if he’s just sitting around using the welfare money very improvidently, I think they ought to rely on his consent. Or at least something involving the family.

        • Acedia says:

          If you set a precedent that you can force people to do things by saying “well, we’re not actually forcing them, we’re just denying you benefits unless you accept them”, that becomes a precedent that lets you not-force people to do anything at all.

          How’s that different from “we’re not actually forcing you to spend most of your life at a shitty job you hate doing, we’re just denying you access to food and shelter and any of the things that make life worth living if you don’t”?

          In most countries including America, the whole society operates on presenting people with the sort of “choice” you’re talking about. People largely seem to accept it, and a great many even get quite angry at suggestions that things ought not to work that way.

          • Vox Imperatoris says:

            A disastrous intellectual package-deal, put over on us by the theoreticians of statism, is the equation of economic power with political power. You have heard it expressed in such bromides as: “A hungry man is not free,” or “It makes no difference to a worker whether he takes orders from a businessman or from a bureaucrat.” Most people accept these equivocations—and yet they know that the poorest laborer in America is freer and more secure than the richest commissar in Soviet Russia. What is the basic, the essential, the crucial principle that differentiates freedom from slavery? It is the principle of voluntary action versus physical coercion or compulsion.

            The difference between political power and any other kind of social “power,” between a government and any private organization, is the fact that a government holds a legal monopoly on the use of physical force.

          • Acedia says:


            Your quote is not relevant, since the comment I replied to was explicitly criticizing economic coercion (denial of “benefits”), not physical coercion.

          • Vox Imperatoris says:

            @ Acedia:

            The coercion is obviously in the form of taking the money to fund the benefits, which among other things crowds out other private sources of benefits.

          • Jiro says:

            How’s that different from “we’re not actually forcing you to spend most of your life at a shitty job you hate doing, we’re just denying you access to food and shelter and any of the things that make life worth living if you don’t”?

            The main difference is that when the government denies you access to things you don’t get to deny it the taxes that it uses to pay for the things it is denying you. If you’re trying to get someone to give you food and they won’t, you don’t have to pay them.

            Also, government has a monopoly on force. If someone wants to get food from you without working, and you refuse, he can go try someone else. If everyone denies him food without working, he starves, but (in the absence of conspiracies and prejudice) that only happens if there are practical reasons to deny him free food (which of course there are). Government can deny you something without practical reasons.

  42. nydwracu says:

    I can’t believe there are almost 200 comments right now and not a single person has pointed out the real story here:

    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.

    ’60s courts were not the most civilization-friendly institution.

  43. gattsuru says:

    Glad to see a review of this. I’d encountered Cramer through gunblogging (and, uh… fighting some anti-gay stuff he’s put out), and thought this was a pretty well-written book; I’m glad to see it survives scrutiny from professionals in the field. I would give a few caveats, though:

    A lot of the reason modern institutionalization is so stupidly restrictive and stupidly expensive reflects that it only includes the very most mentally ill people. There are so many rules about things that are Theoretically Usable As A Weapon because there’s an unspoken assumption many institutionalized individuals have shanked someone recently. That’s not something that would necessarily follow if the majority of in-patient individuals were merely bad about drug compliance.

    The ghetto comparison isn’t wrong, in the sense that you’re correct that just mass-institutionalizing every single mentally ill person would be a massive offense to liberty. But it seems a bit like a strawman: even during the worst heights of institutionalization, they weren’t throwing everyone in, and Cramer didn’t (seem to, I admit it’s been years since I read the book) advocate doing so fully. I don’t mean to understate the problems long-term care institutions had: buildings taking in individuals who were not seriously ill or treating everyone poorly date back to at least the late 1800s and 10 Days In a Mad House. But even in those situations, the stated goal was to limit activity to only the seriously ill. Cramer’s point was to have the option available to any serious extent, as he doesn’t feel is the case today. There are meaningful ways to separate chronically non-compliant patients like his brother from individuals who handle themselves better. This isn’t jailing everyone from the ghetto, but jailing those who have serious infractions.

    I’m not sure that’s any more monetarily or practically viable, but it seems a more meaningful position to attack.

    • Scott Alexander says:

      I’m not sure Cramer explicitly wants every mentally ill person institutionalized. But then he loses a lot of his strongest points about eg crime – most of the mass shooters he profiles aren’t necessarily the sort of people you’d consider for permanent institutionalization if you’re only institutionalizing the worst 10% or something. And if you’re not institutionalizing them permanently, what’s to stop them from mass shooting when they get out? Even Cramer’s brother Ron isn’t that ill by schizophrenic standards – and he *was* short-term institutionalized several times – so I’m not sure what he expects to change short of large-scale permanent institutionalization.

      Most people committed today are not psychotic and violent. I would say in my institution at least half are depressed people who made suicidal threats, and only 5-10% are really scary.

    • JayT says:

      Perhaps we don’t throw everyone in the ghetto into jail, how about just black males between 17 and 30? They account for something like 20% of all murders in the country while only accounting for about 3% of the population. Would comparing mental institution to putting those people in holding cells be a strawman?

  44. ReluctantEngineer says:

    I just read on op-ed related to this topic (note that it’s the New York Post, so it has a right-wing slant and devotes about a third of its column inches to criticizing NYC mayor Bill de Blasio). It mentioned something that I’d like to ask our host about. From the article:

    It may be hard to fathom, but many of those people lying on the floor in Grand Central Station actually have family who would like to care for them, but their parents and siblings have been rendered helpless by our laws at the local, state and federal levels. DJ Jaffe, the director of the think tank Mental Illness Policy Org, says that many families “can’t keep mentally kids at home because they’re powerless to help them.”

    The Health Insurance Portability and Accountability Act (HIPAA) prevents doctors from giving families the most basic information about their mentally ill relatives’ conditions or even their whereabouts. They can’t get a diagnosis or even information about medication or appointments.

    So, two questions for Scott (or anybody else with relevant knowledge/experience):

    1) Is this (families of patients wanting to help them, but being unable to because of privacy laws and so forth) a common problem? Is it ever a problem?

    2) If it is a problem, is there an obvious solution? Or would any changes to e.g. HIPPA to try to address this create problems of their own?

    • Scott Alexander says:

      It’s true that HIPAA is very restrictive and sometimes bans things that are common sensically good ideas.

      I haven’t seen this being a big problem in real life, though. First of all, if a patient signs a form saying it’s okay to give away info, then we can give away their info. Any patient who refuses to consent to sharing information about their condition with a family member is probably going to have other problems with being cared for by family members too.

      Second, it’s pretty common for the courts to name a family member as a legal guardian, in which case we can give them a lot of information. I think a lot of doctors are kind of willing to fudge this, like if a family member is the one bringing the patient in and sits in on some of the appointment without the patient complaining, then that’s okay. If somebody isn’t a guardian, and the patient doesn’t want them knowing their history, and the patient refuses to let them sit in on the appointment, then it does seem like there’s a hostile relationship between the patient and the family member trying to care for them and it makes sense that we can’t give away private information.

    • Jaskologist says:

      I suspect regulations are hitting from another angle, too. We have a situation with an elderly family member who has lost the ability to urinate (a medical emergency). Treatment involves catheterization several times a day. This is considered a medical procedure, and thus can only be performed by a registered nurse or a family member, nothing in between. The procedure itself is simple enough, but the frequency with which it needs to be done makes it incompatible with the jobs of said family members. It sure would be nice if we could hire somebody to help, but a full-fledged nurse is too expensive, so our only option at this point is to put them in a home.

      I would bet that there are similar regulations in the psych field which prevent families from taking a hybrid approach of remaining involved but not turning it into a full-time job.

      • Stefan Drinic says:

        Now I’m left wondering how hard it’d be to pretend this is Rome and just adopt the damn worker into your family. It shouldn’t be necessary, but..

      • gbdub says:

        In Michigan there was until recently a law that anyone medically caring for an adult (family included) while receiving Medicaid was considered home health care worker and employee of the state. They therefore were automatically enrolled in, and had to pay dues to, the union that represented home health care workers at the state level. These dues were automatically skimmed from their Medicaid checks and sent to the SEIU.

        This continued for 6 years until ended by law and then defeated in a ballot petition. Still, the SEIU made about $30 million off the deal that they’ve thus far not had to return. Unsurprisingly, something like 80% of Michigan home health care workers did not renew their union membership (since most were family who hadn’t wanted to be unionized in the first place).

      • Garrett says:

        On a related note: I volunteer as an EMT.

        If a friend asked me to help them dig a splinter out (usual home-remedy fashion), I would not do so. This is because I am now a Medical Professional, and using a sewing needle to dig out a splinter is technically Practicing Medicine (surgery), and since I Should Know Better, could theoretically face criminal charges or loss of my license for this.

        This means that I am now more educated to tell you why you, as someone less educated, should perform a procedure that is going to happen anyways, with possibly less dexterity, should do it yourself (or go to an ER!) rather than help.

  45. The Nybbler says:

    Having had some experience with people who were not in contact with reality, I had thought Szasz’s position was a triumph of ideology over observation. I guess the idea that he never had experience with such patients is not really a surprise… did he avoid them because he was afraid it would destroy his beliefs?

  46. Bram Cohen says:

    It doesn’t take much cynicism to read your take on things as basically saying that drugs work and everything else doesn’t. Which isn’t that far from what you said about suboxone recently.

    • Douglas Knight says:

      Scott has a post that addresses the general question of drugs vs therapy.

      psychotic disorders were more susceptible to medication and the anxiety disorders to psychotherapy…in all conditions drugs seem more effective at preventing relapse than at stopping acute episodes

      I don’t see why you see this post as having anything to do with drugs vs therapy. If you want to force treatment on people, it’s a lot less coercive (and cheaper) to do so in the framework of IOC than institutionalization. That’s true whether the treatment is drugs or whether it is therapy. If you wanted to give the patient therapy every single day, it would be pretty difficult outside of an institution (though a halfway house might do), but that’s a lot narrower category than therapy in general.

    • Wilj says:

      To be fair, that position is extremely well-supported in the case of opioid addiction. Non-drug programs of any type have abysmal long-term sobriety rates, but the various maintenance therapies are amazingly successful — from very few succeeding in the former to very few failing in the latter.

      From my experience, both personal and professional, it is truly one in a hundred who gets out without satiating the receptors; it’s like trying to deny yourself food, comfort, and sex, for a “regular” person: not something many can keep up very long. You’re gonna cave and try to sleep in a real bed or sneak a brownie or look at porn “just one time” eventually.

      The hardware issue adds quite a heavy burden to the already-hefty psychological addiction.

    • Scott Alexander says:

      Therapies and psychosocial help work pretty well for mood disorders and anxiety disorders, but this post focuses on schizophrenia and psychosis and in those cases yeah, I think nearly all psychiatrists would agree drugs are the only things that really work. And even the drugs aren’t that great.

      But see also

  47. Faradn says:

    I like the idea of making voluntary commitment more accessible. I hope you talk about it more sometime.

  48. Anatoly says:

    >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 (!). Compare to today, when New York spends only about 20-30% of its budget on education.

    Are these numbers coming from the book? They seem to be somewhat misleading. Historical NY state budgets; the earliest is 1954-55, but shouldn’t differ very much from 1951. In it, total budget:education:mental health are approximately 1100:300:140 in $millions.

    The budget is split in two parts – “local assitance” and “state purposes”, and mental health does take up about a third of “state purposes”, but it seems misleading to say that it’s a third of the budget. More like 13%. And education (almost all of it in “local assistance”) is more than twice as high. In fact, comparing to the most recent budget, it seems that education was and remains ~25% of the state budget in 1954 and now; while mental health went from 13% down to 3%, and health from ~5% up to ~23%, most of it Medicaid.

    • Scott Alexander says:

      Yes, they’re coming from the book. I don’t know his source, but I’ll add a note in the post.

  49. Agronomous says:

    @Scott or whoever maintains this site:

    Any chance of adding some JavaScript that automatically hides/collapses comments from the common-Anonymous email? Everybody wins.

  50. Agronomous says:

    I, too, would like to see broad freedom for the mentally ill—except for paranoid schizophrenics.

    Because they keep killing people I know: one acquaintance stabbed to death, a good friend of the family bludgeoned to death. I literally know more people killed by paranoid schizophrenics than by firearms.

    It angers me beyond belief that psychiatrists could let a paranoid schizophrenic walk around without any means whatsoever of keeping him on his medication. If they’d done their job, my friend would be alive.

  51. SJ says:

    Thanks for writing this review.

    To my knowledge, no one else has written much about the de-institutionalization movement of the 1960s and 1970s.

    After reading Cramer’s book, I came away with the impression that there was no easy answer. Though I am shocked by the stories he presents, I worry that the critics of de-institutionalization may be capitalizing on a small number of outrageous stories.[1]

    Homelessness has been a big political problem for most of my life. Cramer’s history did help me understand when and where that problem began. [2]

    Yet few people have attempted to measure the mentally-ill-homeless as a subset of the total number of mentally-ill. The value of this ratio is exceedingly important, in terms of figuring out the scope of the problem.

    It is also important to figure out the scope of the impact that mentally-ill-and-homeless have on the rest of society. After all, if you are measuring QALY for the mentally ill, you should also be measuring QALY for those who share public space with the mentally ill.

    With mass-shootings, it is easy to claim that most such shooters might have been diagnosed and committed before the shooting, if stricter laws were in effect.

    Yet the total number of people who show signs of mental illness and later go on to shoot up a public location appears to be much smaller than the number of people who show similar signs of mental illness…and never go on a shooting rampage.

    So, now I have two discussions relating to mental-illness which could be improved by a much clearer set of numbers.

    [1] Food for thought: were the critics of the previous system of institutionalization capitalizing on small number of similarly outrageous stories?

    [2] Aside: during the Great Depression, a large number of people lived a vagrant lifestyle. Many would do a short stint of work in a famer’s field for a meal; these were “Hoe-Boys”, or “Hobos”.
    They were the homeless of their time. How many were mentally unstable, or struggled with depression? It is hard to tell.
    But the social ethos of the time managed a different way of dealing with those homeless.

  52. With this many comments anything I say is likely to be buried, but perhaps I can be of some small service. New Hampshire has the most comprehensive and longest-lived Conditional Discharge (outpatient commitment) laws in the country, at least as of a few years ago. There have been some modifications but the basic pieces have been intact since the 1980’s. The ACLU and Disabilities Rights have hated those laws and worked continually to undermine them. Until a few years ago I was one of the main instructors from the state hospital to the CMHC’s on how to use these laws efficiently and fairly, and how to avoid the missteps that would get revocations overturned on procedural grounds. The CD law has limitations, but it has been generally quite useful . The architects of those laws are still going concerns, and if you want to know more, Dr. Alex DeNesnera, Associate Medical Director at the state hospital, and Barbara Maloney (now a judge in NH), previous counsel for NHH know a great deal. More than I do, even.

    This post reawakened so much of what has angered me over the years about advocates who believe they are helping psychiatric patients while they make our improving their lives more difficult. Their preening self-righteousness as they help yet another person leave the hospital while still psychotic and helpless is one of the main reasons that I, a social worker and 70’s hippie freak, am no longer a liberal.